Every finding on record at Optalis Health and Rehabilitation of Troy

This citation pertains to intake: 3040204.Based on observation, interview and record review the facility failed to ensure adequate supervision for a resident with dementia, failed to timely implement adequate elopement interventions and failed to ensure all staff received adequate elopement training for residents that wear a monitoring device, for one (R307) of three residents reviewed for elopements, resulting in an Immediate Jeopardy (IJ). The facility failed to ensure the safety of R307 when the resident was allowed to leave the facility unnoticed wearing a monitoring alarm device, without staff knowledge of the elopement, until notified by the family. The resident entered into the car of a stranger and was transported approximately 11 miles away from the facility placing the resident at risk for serious harm, injury, and/or death.The IJ was identified on 6/16/26.The IJ began on 5/30/26.The Administrator was notified of the IJ on 6/16/26 at 2:52 PM, and a plan of removal was requested.The IJ was removed on 6/9/26 based on the provider's implementation of removal and verified onsite on 6/16/26. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with the potential for harm that is not immediate jeopardy.Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) documented in part, . On 05/30/2026 at approximately 7:20 PM, (Licensed Practical Nurse - LPN A name) was unable to locate Resident (R307 name) during shift change. Within approximately five minutes, the residents daughter. called the facility to report that (R307 name) had arrived at her former home address. (R307 name) had exited the facility without staff awareness. 5:34 PM. camera footage shows Resident (R307 name) pushing the elevator button. 5:34 PM. camera footage shows Resident (R307 name) exiting the elevator onto the first floor headed towards the front door. it is presumed that Resident (R307 name) exited via the front door while the two visitors were entering (tailgating through an already open door. Resident was wearing a (monitoring alarm device) upon return. The device alarmed appropriately when she entered the building. Contributing Factors. Thorough elopement education of front desk staff possibly not provided at time of hire. Testing confirmed the (monitoring alarm device) is functioning properly.A review of the medical record revealed R307 was admitted to the facility on [DATE] with diagnoses that included: dementia and unsteadiness on feet. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition.A review of the preadmission hospital documents provided to the facility upon R307's admission documented in part . Hospital Problems. (Principle) Altered mental status. dementia w (with)/superimposed delirium 2/2 (secondary to) change in environments (pt (patient) has been recently staying w/daughter and now in hospital). s/p (status post) sitter, restraints. Present to EC (emergency care) with worsening of over all dementia symptoms. The patient lived with her husband who was taking care of her. One week ago the house got on fire due to the old furnace, and the couple had to move in with their daughter. Pt's husband had to be hospitalized which made a change in pt's life even more traumatizing. Her dementia now has more episodes of aggression, she stopped sleeping. For her safety and well being she would need to be placed in a place providing care for people with advanced dementia. Impression/plan. Pt with worsening dementia requiring placement in a Memory care.On 6/16/26 at 8:09 AM, R307 was observed sleeping in bed and was unable to be awakened by verbal stimuli. Certified Nursing Assistant (CNA) B was observed sitting in the room. When asked, CNA B explained they were assigned to watch over both residents that resided in the room. An observation of R307 revealed a monitoring alarm device around their right ankle.A review of a facility document titled Physician Statement of Capacity for Medical Treatment and Decisions with the attending Physician signature noted on the date of 2/19/26, noted the resident . lacks the capacity to make reasoned medical decisions and/or provide informed consent for their medical affairs. The specific cause and/or contributing diagnosis to support this decision: Dementia. The lack of capacity activated the resident's Durable Power of Attorney for Health Care that documented R307's husband and two daughters as their patient advocates.On 6/16/26 at 8:48 AM, an interview was conducted with R307's Daughter C. Daughter C reported around approximately 6:30 PM on 5/30/26 their mother was in the living room of their uncle's home. Daughter C stated their uncle called their dad and said . Your wife is in my living room. Daughter C stated their sister and dad went to their uncle house to get their mother. Daughter C explained their uncle resided on the same street that their parents' home was before the fire. Daughter C reported their sister called the facility to inform them that they had their mother around 7:00 PM. Daughter C confirmed that neither themselves, their sister or father was informed by the facility staff of their mother to have been identified as missing. Daughter C said when their sister called the facility staff had not realized that R307 was missing. Daughter C reported that a female stranger picked their mother up from the side of the road and drove her to the street of her mothers old address. Daughter C reported when their sister (Daughter J) brought their mother back to the facility and R307 walked through the front door the monitoring alarm device previously placed on the resident by the facility staff triggered the alarm.On 6/16/26 at 10:12 AM, an interview was conducted with R307s daughter - Daughter J. Daughter J explained that her and her dad were leaving a funeral when they received a call from her uncle informing them that her mom was in their uncle's living room. Daughter J stated at approximately 7:00 PM, they called the facility and talked to the Nurse and asked them if they were missing a patient. Daughter J stated . they had no idea that she was missing at that time. When asked Daughter J believed it was the Nursing Supervisor they had talked to. Daughter J stated the Nurse told them they would check on it and call them back. Daughter J said they brought their mom back to the facility at 7:30 PM. Daughter J stated . I just want to know how she got out with a (name of the monitoring alarm device) on. What if she would have got hit by a car? A passer by picked her up. I mean, come on. She has no safety awareness. Daughter J went on to explain that their parent's had a house fire in January and her parents started living with her. Daughter J stated their mother (R307) was not sleeping at night and her dementia had gotten worse. Daughter J stated they took their mom to the hospital for help to find placement for a secure facility that could care for her properly.On 6/16/26 at 8:15 AM, a request to Nurse Manager (NM) D was made to provide the surveyor with one of the facility's monitoring alarm device. Once provided, a walk through the second unit hallway to the elevator revealed no triggering alarm. Upon exiting the elevator onto the first floor hallway, towards the facility front door, no alarm triggered. The Front Door Receptionist (FDR) F was asked to buzz the front door open to allow Maintenance Director (MTD) E to walk through. MTD E was observed to have walked through the front door and the surveyor followed with the monitoring alarm device in hand, which triggered the facility's alarm system to go off. MTD E returned back into the facility and was observed to input a number in the keypad which silenced the alarm system.On 6/16/26 at 10:45 AM, Receptionist (RT) G (the receptionist that was on duty at the time of R307's elopement on 5/30/26) was called. RT G answered the phone and asked if they could call the surveyor right back. A returned phone call was not received by the end of the survey.A review of R307's medical record revealed an admission elopement assessment completed on 2/10/26 at 5:11 PM, that deemed the resident to not be an elopement risk.A review of the progress notes revealed the following:A Nursing note dated the day after admission on [DATE] at 10:54 PM, documented . Resident confused. Stated she wants to go home. Wandering through the hallway.A Psychiatry Note dated 2/26/26 at 3:08 PM, documented in part . Prior to admission, the patient was hospitalized with complaints of altered mental status, worsening dementia, insomnia and agitation. She was treated for worsening dementia requiring placement, was stabilized, and transferred for subacute rehabilitation.A Nursing note dated 2/28/26 at 5:47 PM, documented in part . Husband visited, shortly after he left resident started sundowning having behaviors, resident verbally expressed she doesn't want to be here and wants to go home.A Nursing note dated 3/2/26 at 3:49 PM, documented in part . resident started sundowning having behaviors, resident verbally expressed she doesn't want to be here and wants to go home.A Nursing note dated 4/17/26 at 2:23 PM, documented . Patient noted with increased agitation about being in facility keeps stating she wants to go home, and why is she here writer and family explained to patient several times about her stay. Patient noted walking in and out off <sic> room, and wandering the second floor hallways. Patient is hard to re-direct, and keeps asking to leave.A review of a facility policy titled Elopement - For Facilities With a Wander Alert Bracelet System review date 6/3/26, documented in part . The purpose of this policy is to provide guidelines to evaluate residents for risk of elopement, implement risk reduction strategies for those identified as an elopement risk. An Elopement Risk Evaluation is available to be completed under the resident's assessment tab in (Electronic Medical System name) as needed when a resident has a new or increased verbal or physical behavior of wandering and/or exiting seeking.The facility staff failed to complete a new Elopement Risk Evaluation for the multiple . new or increased verbal or physical behavior of wandering and/or exiting seeking. as noted above.A late entry note created on 6/4/26 at 10:48 AM and back dated to 5/8/26 at 12:30 PM, documented in part . At 12pm writer observed resident wandering and pacing the hallway, saying she wants to go home. Resident. with confusion, easily redirected, Resident like to play cards, writer played a few hands with resident to decrease elopement risk, writer placed (monitoring alarm device name) bracelet applied to right ankle, verify and working, update care plan and elopement assessment completed, Order placed for psychiatric to reevaluate medication list, IDT (Interdisciplinary team) notified and MD (Medical Doctor), Daughters notified of current status and safety measure implemented, Staff update to monitoring resident for wandering, Will continue with POC (Plan of Correction).On the date of 5/8/26 the facility staff completed a new Elopement Risk Evaluation that deemed R307 to be an elopement risk and implemented interventions for a care plan titled Exit seeking / elopement risk.A review of the medical record revealed no documentation on why the ankle monitoring alarm device was placed on the resident on 5/8/25 despite the same behaviors to have been observed and noted multiple times. Further review of the medical record revealed no documentation of the incident regarding the elopement on 5/30/26 to have been documented.On 6/16/26 at 12:11 PM, the Administrator and Director of Nursing (DON) were asked to provide all attempts and actual elopement incident reports for R307. Two incident reports were provided for 5/8/26 and 5/30/26.A review of the 5/8/26 incident report, noted the same documentation as noted in the 5/8/26 progress note.On 6/16/26 at 12:46 PM, the facility's camera footage was reviewed (with the DON in attendance) for the date of 5/30/25. At 4:34 PM, R307 is seen wandering the hallways of the second floor and going towards the second floor elevator. At 4:35 PM, the resident is observed getting off the elevator on the first floor walking in the direction of the facility's front door. Four minutes later at 4:39 PM, visitors are observed walking on to the first floor hallway from the direction of the front door.The facility's front door is locked and requires the receptionist to press a button to allow people in or out. The front door will unlock after 15 seconds of pushing on it, an alarm will be triggered which would require a staff member to input a code to silence the alarm. The wandering alarm device (bracelet) that was located on R307's ankle would have triggered the alarm as they exited through the front door and again would require a staff member to input a code to override the alarm system and silence the alarm.A second attempt was made to interview the Receptionist - RT G at 11:27 AM, but was unsuccessful. The DON was asked to reach out to RT G and have them return the surveyor's call. The DON was asked again at 11:57 AM - with no response. At 12:14 PM, the Administrator and DON was again asked to reach out to RT G and have them return the surveyor's call.On 6/16/26 at 11:00 AM, LPN A (the nurse assigned to R307 at the time of the 5/30/26 elopement) was interviewed and asked how they were made aware of R307 to have been missing from the facility. LPN A reported that the CNA came to them and asked if they had seen R307. LPN A stated they then began to take steps to locate the resident. When asked if they received the call from R307's daughter on 5/30/26 asking if they were missing a resident, LPN A stated . she called the supervisor work phone. When asked who the weekend supervisor was, LPN A stated the name of Weekend Nurse Supervisor (WNS) H.On 6/16/26 at 12:17 PM, WNS H was interviewed and asked who first informed them of R307 to have been missing from the facility on 5/30/26 and WNS H stated LPN A 's name. When asked if they talked to R307's daughter, WNS H confirmed they had. When asked about R307's daughter to have called them on 5/30/26 to ask if they were missing a resident and for them (WNS H) to have replied to the daughter that they would look into it and call them back, WNS H denied that it was them that the daughter initially talked to. WNS H stated they did not speak to R307's daughter until after LPN A spoke to the daughter.On 6/16/26 at 12:37 PM, an attempt to interview Registered Nurse (RN) I the oncoming nurse that was relieving LPN A, who was also assigned to R307 and was present at the facility when the staff was notified by R307's daughter of the resident to have been found at their uncle's home, was called. A voicemail box was not set up, however a text message was sent to RN I with no return response or return phone call by the end of the survey.On 6/16/26 at 1:30 PM, an attempt to contact CNA K (the aide assigned to the resident at the time of the 5/30/26 elopement) was made. A voicemail was left to return the call. A return phone call was not received by the end of the survey.On 6/16/26 at 12:54 PM, the DON was interviewed and asked about the delayed implementation of R307 to be deemed an elopement risk and the delayed interventions for the elopement behaviors. The DON stated they were unaware of the prior documented incidents in R307's record. The DON said they were made aware of the 5/8/26 incident when the monitoring alarm device was placed on R307. When asked, the DON confirmed the monitoring alarm device would not be triggered by the resident leaving the second floor on to the elevator, however stated it would have triggered when the resident left out the front door. The DON was asked about the video footage to show the resident to have last been seen in the facility at 4:35 PM, despite the facility to have reported to the SA that the resident was last seen on the video footage on 5:34 PM. The DON explained they came to the facility on 5/31/26, the day after the elopement incident and identified the camera system to be off by an hour. The camera footage was discussed with the DON regarding the likelihood of RT G to have let R307 walk out the front door, the alarm to have been overrode and silenced and the visitors to have been let in four minutes after. The DON was asked whose responsibility it was to train RT G on the facility's elopement residents and protocol and the DON responded . She should have been trained by the girl that's sitting up there now. The DON was referencing another facility's receptionist. The DON was asked if they were able to get in touch with RT G to have them return the surveyor's call and the DON stated they informed the Administrator to have RT G call the surveyor.On 6/16/26 at 1:36 PM, the Administrator was interviewed and asked about the 5/8/26 incident and why the monitoring alarm device was applied to the resident this incident despite the multiple documentation of the same wandering behavior and verbalization of wanting to leave the facility. The Administrator stated that this incident was different because the resident actually attempted to go out the facility's front door but was unsuccessful. The Administrator was asked why that was omitted from the progress note and incident report and the Administrator again stated the resident was unsuccessful. The Administrator was asked about the camera footage that revealed the resident to have likely exited out the front door, with the receptionist present at the front desk and four minutes later a family observed walking on to the first floor. The Administrator was asked about the education provided and if the receptionist was aware of what a monitoring alarm device purpose is, how to identify the residents in the facility that are deemed an elopement risk and what to do when the alarm is triggered in the facility. The Administrator replied that it was the facility's presumption as well that the chain of events occurred as discussed above. The Administrator reported they interviewed the receptionist on two different occasions with similar questions and the receptionist denied hearing an alarm or seeing a resident go out. The Administrator then stated in part . She (Receptionist RT G was newly hired on May 6th (2026) and May 30th was the first weekend on her own. (RT G) said the resident looked like a visitor. It was discussed with the Administrator that RT G statement to them verbalizing that . the resident looked like a visitor. confirmed that RT G did observe R307 and likely allowed them to walk out the front door which likely triggered the alarm system with no further intervention. The Administrator was asked how it was possible for the Receptionist to think that R307 was a visitor if their picture was on the desk and in the elopement binder at the receptionist desk as one of the residents categorized as an elopement risk and the Administrator replied . It should not have been possible with the binder and pictures. The Administrator was asked if they were able to get ahold of RT G to have them return the surveyors call and the Administrator replied . Yes, I reached out to her.A return phone call was not received by RT G by the end of the survey despite multiple attempts.The Immediate Jeopardy that began on 5/30/26 was removed on 6/9/26 when the facility took the following actions to remove the immediacy:On 5/30/26, the facility identified an Immediate Jeopardy situation related to resident elopement risk. Immediate actions were implemented to protect Resident [NAME] and all other residents identified as being at risk for elopement.Resident was safely returned to the facility and a 1:1 staff member was initiated on 5/30 for continuous supervision.The resident's wander guard placement and functionality were assessed and tested with no malfunction identified. The resident's elopement assessment, physician orders, and care plan interventions were reviewed and verified.A facility-wide audit of all residents identified as being at risk for elopement was completed by 6/2/26 to verify assessments, physician orders, care plans, wander guard placement, and functionality.Elopement binders were updated and verified at all nursing stations and the front desk. Exit doors, alarm systems, and resident monitoring systems were tested. Facility-wide elopement drills were conducted on 6/1/26 and 6/2/26.Re-education began on 5/30 to all staff regarding the Elopement - For Facilities With a Wander Alert Bracelet System policy, which also encompasses education on the wander alert system, i.e., placement, functionality and alarms. Elopement education included risk assessment, care planning, interventions, identification, physician and guardian notification, elopement binders, change of condition, transfer, supervision, reporting, assessments, and alarm response. In addition to the above receptionist were educated on review of the elopement binder, informing nursing staff of elopement behaviors, , sign in/out procedures and the LOA (leave of absence) process. Education concluded on 6/5. Ad Hoc QAPI meetings were conducted on 6/1/26 and 6/2/26 to review the event, identify root causes, and implement corrective actions.

Based on observation, interview and record review the facility failed to implement an effective infection control surveillance program, including transmission-based precautions (for R146), and to maintain an active water management program which had the ability to affect all 112 residents who resided in the facility. Findings include: Transmission Based Precautions R146 On 3/9/26 at 10:10 AM, a signage observed on R146's room door noted Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms. Requires the use of gown and gloves for high-contact resident care activities). An interview was conducted with the resident at that time. A review of the medical record revealed R146 was re-admitted to the facility on [DATE] with diagnoses that included: Influenza A virus, respiratory failure, heart failure and chronic kidney disease. Further review of the medical record revealed the following: A Physician's order dated 3/6/26, for EBP for MRSA (Methicillin-Resistant Staphylococcus Aureus) sputum. A review of the CDC (Centers for disease control and prevention) Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities (dated 6/27/25) documented in part, . CDC recommends Contact Precautions (requires the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident)for patients with MRSA. MRSA is responsible for more than 70, 000 severe infections and 9,000 deaths per year. Healthcare providers. Follow Contact Precautions when caring for patients with MRSA (colonized or carrying and infected). CDC recommends the use of Contact Precautions in inpatient acute care settings for patients colonized or infected with MDROs (Multi Drug Resistant Organisms), including MRSA. Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities | MRSA | CDC. On 3/10/26 at 2:22 PM, an interview was conducted with the Director of Nursing (DON) in the absence of the facility's Infection Control Preventionist (ICP) who was not present for the survey duration. The DON was asked what guidance the facility was following in regard to the precautions placed for R146. The DON stated initially the resident was on contact precautions and they had recently discontinued that and placed the resident on EBP. When asked why, the DON replied they would look into it and follow back up. On 3/11/26 at 1:20 PM, the DON returned and stated they read the CDC guidance and identified the resident is supposed to be on contact precautions and would fix that immediately. On 3/9/26 at 2:44 PM, a request was made for all the infection control surveillance books to review for the Infection Control Task. On 3/9/26 at 3:03 PM, the Director of Nursing (DON) brought several surveillance books. On 3/10/26 at 4:06 PM, Licensed Practical Nurse (LPN) D, who served as the Infection Preventionist, was interviewed by phone and asked if there had been any infection control trends or outbreaks in the facility. LPN D explained there had been an Influenza outbreak in the facility in February 2026. LPN D was asked where that was documented, as there was nothing found regarding an outbreak in the surveillance books provided. LPN D explained she had a separate book devoted to the outbreak. On 3/10/26 at approximately 4:30 PM, the DON was asked to provide the surveillance book for the Influenza outbreak. Review of the February 2026 Influenza outbreak surveillance revealed line listings and mapping for the facility's first floor. However, there was no documentation for residents residing on the second floor of the facility. Review of resident medical records who resided on the second floor revealed evidence some residents had Influenza in February 2026. On 3/11/26 at approximately 10:30 AM, the DON was asked if there were residents on the second floor who had Influenza in February 2026. The DON explained there were. The DON was asked to provide surveillance documentation for the residents on the second floor. No documentation was provided prior to the end of the survey. On 3/9/26 at 2:15 PM requested Water Management Program (WMP) documentation for review. A WMP binder located at the front desk was provided for review. Maintenance Director (MD) E was not available at this time. Record review of WMP Plan binder indicated the following elements: -cover page title: Water Management Program Plan: [facility name] dated 2/19/24 -no documentation that the WMP had been reviewed or updated since 2/19/24 -Page 2- Water Management Team (WMT) information stated team member names that are no longer employed at the facility -Page 4 and all additional program pages after that were dated 2/14/2019 with no updates or revisions noted -water system description was text only with no flow diagram and not current (e.g. facility is no longer using water softeners per MD E interview on 3/10/26 at 8:20 AM) -section 5 Control Measures includes requirements for monthly monitoring of residual disinfectant and flushing protocols for unused fixtures -monitoring data recorded on logs from 2020-2021, with no recent monitoring records -last quarterly WMT meeting sign in sheet was dated 2/22/22 -program flushing protocol included lists of the following area/fixtures: service hall wash room sink, sorting room sink, supply closet sinks, 100 and 200 unit therapy tubs, soiled utility room toilet basins, supply room sinks, 200 unit dining room -blank monitoring logs were available and unused in the binder for multiple WMP control monitoring tasks including: disinfectant residual, water temperatures, flushing protocols, WMT meetingsOn 3/10/26 at 8:15 AM, when interviewed about his experience with WMP requirements and any related training, MD E said he's been in this role about a year and previously at another facility and he has not completed training specific to WMP requirements. MD E stated he recently reached out to the company they contract with for annual legionella testing to see if there was other sampling they should be doing. When asked about any additional WMP related documentation. MD E showed weekly logs of hot water temperatures taken at points of use in resident rooms throughout the building. When asked about any meetings of the Water Management Team (WMT), he indicated there has not been any WMT meetings in the past year and they will be looking to get this started. When asked about any flushing of low use or unused fixtures, he indicated the eye wash stations and the soiled linen room hoppers get routinely checked and flushed. On 3/10/26 at 8:20 AM Observed components of the building water system on a tour with MD E including the Riser Room, hot water heaters, storage and distribution. During this tour MD E stated that water softener system was no longer in use and is no longer connected to water supply but is too costly to have system components removed. On 3/10/26 at 8:30 AM Observed 1st floor central shower room therapy tub connected to water supply. During this observation, MD E stated it is shut off at the wall access panel, and no water is run to the unit. On 3/10/26 at 8:40 AM Observed 2nd floor central shower room therapy tub connected to water supply. During this observation, MD E stated it is shut off at the wall access panel, and no water is run to the unit. On 3/10/2026 at 9:15 AM When asked for any additional updated WMP documentation from MD E and the Administrator, they provided only the Emergency Preparedness Water Outage Policy dated 9/1/2017 and nothing additional specific to the WMP.

This citation relates to Intake 2718224.Based on observation, interview, and record review, the facility failed to provide a safe, home-like environment by ensuring comfortable water temperatures for residents who used the central shower rooms (including R79) for showers. Findings include:A complaint was received by the State Agency on 1/15/26, which alleged the facility did not have enough hot water for at least three months for operating the facility properly. The complainant indicated their understanding was that the facility had been unable to purchase the needed part to repair the water heater because the facility had to go through their corporate company. On 3/09/26 at approximately 1:25 p.m., R79 was asked about hot water in the facility. R79 reported the water temperature was too cold for their showers and was uncomfortable. R79 said they liked hot water for their showers, and the water was cold or barely warm. On 3/10/2026 at 11:05 AM Observed hot water temperatures on the first floor in vacant rooms and central shower room using digital thermometer, letting water run at fixture 1-3 minutes until maximum hot water temperature was reached and recorded. room [ROOM NUMBER]- sink 102Froom [ROOM NUMBER]- sink 104Fcentral shower room sink 102F, shower 94F On 3/10/2026 at 11:30 AM Observed hot water temperatures on the second floor in the dining room using digital thermometer, letting water run at fixture 1-3 minutes until maximum hot water temperature was reached and recorded. 2nd floor dining room- sink 112F. On 3/10/2026 at 11:35 AM during interview in the second-floor dining room with R79 about shower temperature concerns, R79 stated the dining room sink always gets hot enough, but not the shower area- it fluctuates but does not stay hot enough for a shower. On 3/10/2026 at 11:44 AM Observed hot water temperatures on the second floor in the central shower room using digital thermometer, letting water run at fixture 1-3 minutes until maximum hot water temperature was reached and recorded. Shower 1- at 3 minutes 103F, at 5 minutes 96FShower 2- at 3 minutes 101F, at 5 minutes 97F On 3/10/2026 at 11:55 AM during interview with Staff M at the Nurse station adjacent to the central shower room, when asked about any resident concerns with shower temps, Staff M said just 1 or 2 residents regularly complain about showers not being hot enough. Staff M said they suggest to the residents that they shower earlier or later in the day to get a hotter shower and also stated that they put the concerns in the electronic maintenance system (TELS). On 3/10/26 at 2:35 PM Observed weekly hot water temp monitoring logs with Staff E. At this time, when asked about any central shower temperature monitoring logs he said he does not record on a log but does check regularly and responds to complaints and is often making hot water temperature adjustments. A record review of the Safe Water Temperatures policy dated 11/1/2020 indicates: 5. Water temperatures in resident areas will be set to a temperature of no more than 121F, not less than 105F or the state's allowable maximum water temperature.

This citation relates to Intake 2718224. Based on observation, interview, and record review, the facility failed to ensure consistent activity programming with meaningful individualized activities to promote domains of wellness for five Residents (R79, R60, R29, R97, and R42) of five residents reviewed for activities. Findings include: A complaint was received by the State Agency on 1/14/26, which alleged the facility was short staffed and R79 was not always treated with dignity and respect. On 3/09/26 at 1:12 p.m., there were no activities observed in the activity room or dining room. Activities had not been observed earlier in the morning; an activity calendar was requested. The activity calendar was requested from Activity Aide, Staff J, who was seated, not providing activities. Staff J provided the activity calendar, which showed, Chair Exercise at 1:00 p.m. on this date, and BINGO at 2:00 p.m. On 3/09/26 at 1:13 p.m., the Activity Director, Staff H, was asked about the activities in the building. Staff H said to go by the activity calendar, however, said most residents had been sick the last couple of weeks, the activity calendar was subject to change. This was shown to Surveyor by Staff H. Staff H said BINGO would be happening as scheduled at 2:00 p.m. R79 On 3/09/26 at approximately 1:15 p.m., R79 was interviewed in the dining room, where there were no activities being held. R79 reported there were not enough activity staff and said they and the other residents were missing activities most mornings and on the weekends. R79 said a good activity staff member left their position a few months before and had not been replaced. R79 stated this made them feel upset and frustrated, as they wanted to participate in more activities. R79 said they used to have nice crafts, such as painting on a T-shirt, like the one they were wearing, which they showed Surveyor. R79 said they were also bored with the same repetitive activities and they wanted more variety, like they had before the unnamed activity staff member suddenly left a few months prior. R79 said the only activity they mainly participated now was BINGO, which they appreciated, and a few seasonal parties. R79 shared they ran businesses prior to having a medical condition when they needed to live in the facility, and had some good ideas to run the activities program more smoothly. R79 said running a restaurant and a successful business gave them insights into how to organize and run a department, such as activities, more smoothly. R79 said they would welcome the opportunity to lend their expertise and work collaboratively with the facility to offer suggestions for the activity programming and staffing, to not only benefit them but the other residents, as they wanted the best for everyone there. On 3/09/26, the printed March (2026) activity calendar was viewed, along with the large, posted activity calendar on the units. The posted March activity calendar on both floors appeared to match the printed activities calendar, which was provided by the Activity Director, Staff H . It was observed activities were scheduled seven days a week. The last scheduled activity each day was at 3:00 p.m., other than Self-recreate - Supplies in the Dining Room, which was scheduled at 6:00 p.m., two weeknights. There was a place in the activity room which had colored pencils and coloring pages. R79 said this was for the residents to use for the self-recreating activities in the evenings, and said they wished they had more access to other evening activities, as in the activity room. On 3/10/26 at 10:29 a.m., R79 was in the facility dining room, and said there had been no activities so far offered to them or observed. None had been observed during Surveyor thus on the unit as of yet. It was noted on the March activity calendar the activity, Coffee and Chat, was scheduled at 11:00 a.m. six days a week, with a spiritual service on Sundays. Review of R79's activity log, with a 30-day look-back, revealed R79 participated in five BINGO activities, four dining room games, and two special activities, for a total of 11 activities for the past 30 days (about 36% participation). There were no refusals or declinations marked on R79's task log. On 3/10/26 at 10:53 a.m., a copy of the daily newsletter was observed on a table in the activity room, which had been passed. Two activity aides were observed in the second-floor activity room, Staff I and Staff J , along with Staff H , who indicated they were about to start the scheduled, Coffee and Chat activity. The room had three square tables pushed together, with games and activities on the shelves. On 3/10/26 at approximately 10:55 a.m., Staff H was asked about the schedule and activities. Staff H reported the activities were held mainly in the second-floor dining room or in the activity room across the hall. Staff H explained they brought up residents who were interested in activities from the first floor as well as any residents interested from the second floor, where the activities were generally held. On 03/10/26 at 11:11 a.m., the second-floor activity room had two residents present for Coffee and Chat at the table. The residents had just eaten a snack and beverage. 03/10/26 at 11:17 a.m., a third resident had arrived, with R79, a fourth resident, observed across the hall in the dining room, watching TV. It was observed the Activity Director, Staff H , had transported the residents to the activities, and ran the activity also. The activity aides were not observed participating or assisting Staff H . During the coffee chat time, a few residents were observed at the nurse's station in Geri chairs or wheelchairs, not engaged in activities. The facility census was 108 residents. It was confirmed this was the only activity occurring at that time by activity and nursing staff. On 3/10/26 at approximately 1:45 p.m., Social Worker (SW) K was asked about the facility activities program, and residents' participation. SW K' indicated there were few to no activities in the mornings, which concerned them, or only a few residents participated, other than BINGO or parties. SW K said they wished the activity program was more engaging and more residents participated, especially the residents from the first floor, as the activities were held with residents mainly on the second floor. On 3/10/26 beginning at approximately 2:50 p.m., BINGO was observed ending with residents leaving the room. Staff H reported there had been about 15 residents present and said the scheduled tea party was happening next. The smaller activity room was observed decorated for the tea party, which was scheduled to begin shortly after. During observations at approximately 2:51 p.m., Staff H was observed transporting residents to the tea party, which began shortly after, and was also run by Staff H . The two activity aides were not observed participating in the activity or assisting Staff H . Six residents were observed in attendance during the tea party activity after it started. R60 On 3/10/26 at 4:30 p.m., R60 asked to speak with Surveyor about facility activities and a living room being unavailable to facility residents on the second floor, as well as the activity room being unavailable after 4:00 p.m., and on the weekends. R60 asked to email Surveyor their concerns for a meeting regarding their activity concerns. Review of an email received from R60, on 3/10/26 at 4:28 p.m., revealed a letter they had written which detailed how they and the other residents felt on the second-floor unit when one of the two living rooms they used for activities, family visits, games, reading, and personal space was taken over by staff as an office in the past month. R60 said this occurred without the residents' collective input, most of whom had used the room frequently for personal activities and leisure off-hours, in the evenings, and at night especially. The letter described when the living room the second-floor residents regularly and frequently occupied was taken over by staff, this felt disrespectful to them, and made them feel like a child or an inmate even. The letter continued to describe residents' activity programming concerns as well. During an interview on 3/10/26 beginning at 4:30 p.m., R60 said if the staff had included themselves or other residents in the decision, they could have at least requested to have kept the living room on the second floor with a scenic outside view and some sunshine, as it brought themselves and the residents' daily tranquility and encouragement because of the sunlight and view. R60 said they and the resident council members had vocalized concerns afterwards, and by vote, they were going to be getting the better of the two rooms back. R60 said they still felt sad that they and the other residents were not included in a decision which impacted their daily lives and psychosocial well-being. R60 said they and the other residents used the room for family visits, quiet time, made calls or got their work done, since they and a few of the residents were younger or who had worked especially. R60 clarified they were in a small, shared room with a roommate, which was confirmed, so they worked outside their room. R60 said they had been told they did not qualify for their own room at this facility, where they planned to stay as a long-term care resident due to a chronic medical condition. R60 understood there were other rooms available on the first floor, however said they found the second floor living room was most convenient for most of the second-floor residents, although they could themselves go downstairs if needed. During further interview, per their request, R60 expressed appreciation for the feedback from Administration they had received afterwards. R60 clarified since this was their home, they would welcome the opportunity to collaborate more with management in the future on ideas about their facility home, to make it feel as homelike as possible. R60 shared they had worked professionally and had consulted prior to having a disability, and had collective years of diverse work and life expertise to lend to the facility and activity programming. R60 said they hoped to work across the aisle with the health care team to promote optimal wellness not only themselves but for the other long-term care residents, their peers, who they cared about. R60 said they had some ideas which they believed would benefit the facility and activities program for continued growth. R60 felt bored and excluded with the current programming, as it did not meet their activity needs as a younger resident who had required long-term care unexpectedly. On 3/11/26 at 5:59 a.m., an email was received from R60 to further elaborate regarding their activity participation and concerns. This email summarized how the residents who were primarily served in a building were moderately functional residents, and the lower-functioning and higher-functioning residents (like themselves, R79, and R29) were left high and dry in terms of activity programming. R60 described the facility activities were extremely repetitive, including BINGO, teatime, and manicures, which did not interest them, and said they were always held in the exact same upstairs location, a few steps from Staff H's laptop, likely so could complete their documentation during the activities. R60 was concerned the activities were never downstairs for those residents or delivered in an adequate variety. R60's letter continued to explain there were absolutely no true physical activities, such as games that involved (gross motor) movement, no balloons, balls, or pool noodles. Staff H said there was just a lot of sitting around during activities. R60 shared they were artistic and conveyed they tried to bring in an art teacher from the community however this was not met with assistance by Staff H or activity staff for set-up and clean-up, so the art instructor was unable to continue, which was sad to them. R60's email also described since the activity director ran the resident council meetings, it was unlikely, uncomfortable and difficult to have any sort of discussion among residents about the activities program itself, and several residents did not have the ability to self-advocate (likely due to cognitive impairment). R60 shared a few months prior they had a compassionate, caring activity aide who had positive activity-centered relationships with each of them, who was invested in them, and was not adequately replaced. Since that time, R60 said no one was really collecting residents from their rooms for activities, and they felt like the current program was like a part-time adult daycare. R60 suggested for the high functioning folks like such as themselves, R79, and R29 could collaborate with Staff H on a different quarterly activity, such as a trip to the mall every six months or a regularly scheduled outing. Per Surveyor understanding, there were no facility outings. R60 continued, for the lower functioning residents who were still mobile, perhaps they could be more involved in activities, such as making premade crafts that they can take back to decorate their rooms. R60 emphasized they would like to see the department assist in gathering more residents for events, as had occurred in the past, for a more robust, engaging and inclusive activities program, as the facility was their home. R60's email further described the area in front of the second-floor nurses' station looked sad most days, with residents lined up in the aisleways for hours at a time. R60 described sometimes half a dozen residents were seated there, likely bored out of their minds. R60 alleged they had not seen Staff H interact with these lower functioning residents although their former activity aides had, who had left months before. R60 described since no one went to get residents anymore for the most part, attendance at activities was minimal, since even being announced overhead about 30 minutes before the activity, staff were not taking residents to activities, or a select few. R60 was also concerned there were few activities in the mornings, and said the last activity day was at 3:00 p.m., so there was a small activity window, and questioned why this was occurring. R60 said there had been concerns with the fish tank upkeep and said they would be happy to assist by directing the fish tank upkeep/cleaning, since they and the other residents enjoyed spending their time watching the fish for relaxation. R60 described it had not been kept up on routinely, although they appreciated having a fish tank and wished they had more fish as prior.Review of R60's activity logs for the past 30 days (look-back period) showed R60 participated in individualized activities only (their own activities). R42 On 3/11/26 at approximately 8:35 a.m., Certified Nurse Aide (CNA) L was observed feeding R42 in the dining room. R42 was awake and eating their breakfast. R42 made eye contact and said they were doing fine when asked, and was observed talking appropriately with CNA L while they were being fed. On 3/11/26 at 9:02 a.m., Certified Nurse Aide (CNA) L was asked about the facility activities. CNA L shared, They do BINGO and a little coffee and chat. Nothing much else. They probably could do more (activity participants) than six residents (at a time). It can be (more) interactive, and (have) dementia activities. They mainly put the papers (newsletters) in the rooms (every morning). It (the activities programming) is mainly done in the afternoon. There is nothing done in the (residents) rooms (who do not attend activities). CNA L was asked if R42 participated in any activities. CNA L responded, He (R42) just sits there sleeping. (R42) could probably participate if he was engaged. You can bring residents into this dining room, with activities such as with balls as it would be bigger in there (than the smaller activity room across the hall with tables). CNA L was asked about activities programming on the weekends. CNA L said they worked some weekends and responded, I don't think they have activities on the weekend. When asked to clarify, CNA L said they had not seen any activities occurring when they worked on the weekends, including recently in the last months. On 3/11/2026 at 9:11 a.m., three residents were observed in the common area outside the nurse's station, including R42. None of the residents were engaged in activities. On 3/11/26 beginning at approximately 11:02 a.m., R42 was observed outside the nurse's circle in their recliner geriatric wheelchair. The coffee activity was going on around the corner. R42 was asked how they were doing and said they would like some coffee or tea, with the clerk notified at the desk. No one took R42 to the coffee activity. On 3/11/25 at approximately 11:10 a.m., the activity room was viewed during the coffee and chat activity. Six residents were present. An unnamed resident was heard to say, I didn't know you had activities .I am so glad I came out of my room. There were six residents in the activity room at that time during the coffee activity. Staff H was solely running the activity and had been observed transporting resident to and from the activity. No activity aides were observed. Staff H said they were the only activity staff working in the building on that date. Staff H confirmed they were doing all the transporting and running the activities on their own. On 3/11/25 at 1:02 p.m., 1:13 p.m. and at 1:26 p.m., R42 was observed at the nurse's station without any activities or things to do, such as a sensory activity or looking at a magazine. During this observation, one resident was observed in the activity room with Staff H in the chair exercise activity. Staff H was asked afterwards why there was only one resident in the activity. Staff H acknowledged they were the only staff who was transporting residents to activities, and R42 was ready to begin the activity. Observations of R42 during the three-day survey showed R42 seated in the aisleway outside the nurse's station in their specialized geriatric chair with no activity engagement, with only a few social interactions with nursing staff checking in, along with a few other residents in geriatric positioning chairs or wheelchairs. R42 never had reading materials in front of them or was placed in an area where they could have watched television or heard the news. It appeared they were being supervised by staff at the nurse's station and was not observed in the activity or dining/day room with or without staff, other than at breakfast on 3/11/226. No sensory activities were observed being completed with R42 or the other dependent residents outside the second-floor nursing circle. There was no sensory room or quiet place where residents went for relaxation or to calm them. They were subjected to the busy nursing interactions there. Review of R42's Care Plan showed they liked to participate in watching the news, reading the Indian Bible, watching news, tending flowers and vegetables, cooking, music, mass, BINGO, attending mass, and social activities. R29On 3/11/26 at 10:20 a.m., R29 was observed propelling their manual wheelchair in the facility hallway. On 3/11/26 at 10:26 a.m., R29 was asked about their activity participation in the facility. R29 responded, There is nothing I can do here. R29 said the activities were not enticing. I am 41 ([AGE] years old). Maybe I could try BINGO. They do BINGO twice a week and that is about it.They should put another TV in the activities room or put a video game system in with games R29 said they would do games; they have board games but they are not playing board games. R29 clarified no one came to invite them to attend activities. R29 said, Why don't they play other games; that is perfect for everybody.They do well on a few parties and put food out but I am bored all the time. I am constantly bored. R29 said they would do puzzle books, read magazines, or check out something to read it were made available to them. R29 explained the activity staff were not coming to residents and seeing what they wanted to do. R29 said there was an internet cafe but most of the computers were broken down or locked down and unavailable for use. R29 was asked about individual activities as some were logged for him. R29 said, I get no help for individual activities; I am on my own. such as when they were marked for watching tv, on their phone, or on their computer. R29 explained the only socialization they were getting was talking to their nurses in the evenings or at night but not anyone from activities. R29 continued, People are not engaging us or spending time w us. R29 said they wished Staff H would talk with them on the side while residents were eating, and ask them, What would you like to do? What would interest you guys? And he (Staff H) could come up with things that don't cost money and maybe someone would be willing to donate for the residents. Outings would make a huge difference. R29 said there was a park right up the road they would love to go to. R29 said it made him feel bad when they (the residents on the second floor) lost their day room and they gave us the sh#t##r of the rooms (of the two available). Review of the March activity calendar (2026) showed there were some games scheduled in the activity room during the month, so it was unclear if R29 may not have been aware if they were not invited or taken to the activities. Activities were heard announced by Staff H anywhere from about 10 to 30 minutes prior to the activities. Review of R29's Care Plan said they enjoyed music, games, crafts, food, spiritual, pet activities, computer activities, materials in room, outdoor, and other activities. Review of R29's activity log showed they participated in individual activities. On 3/11/26 at 11:21 a.m., Licensed Practical Nurse (LPN) O was asked about the activities programming in the facility. LPN O confirmed there was no private resident room in the facility for R60 and said they had offered R60 a transfer to another sister facility with their own private room which they declined. LPN O said the residents on the second floor would be getting back the activity room with the sunlight for their own individualized activities, per their understanding from the Administrator, who had addressed the residents' concerns, and denied any involvement in the room change. About the activity programming, LPN O said there needed to be more engagement and more training on what to do in activities and said they had educated Staff H already and said Staff H needed the activities aides to do more. LPN O said they had told all of them (in activities) to engage the residents more, as they saw residents sitting there especially by the nurse's station and not participating in activities. Staff H explained they even offered activities to the residents themselves when they could. Staff H wondered why they were not doing more exercise activities such as balloon or soft ball toss (gross motor activities) or have an exercise class every day, which they did not see occurring. Staff H stated there could be more activities going on in the dining room and found some of the staff (activity aides) were not doing activities with the residents, which concerned them. Staff H understood they needed a more robust engaging activities programs for the facility residents, and wanted the best for the residents. R97ON 3/11/26 at 2:52 p.m., R97 was observed in their bariatric hospital bed in their room. A crossword puzzle book was observed on their nightstand and a few crafts on their bulletin board in their room. On 3/11/26 at 2:54 p.m , R97 was asked about their activity participation. R97 said they were mainly in their room in their bed, and said the activities staff used to bring them more activities. R97 said, I think they could do more. R97 said yesterday (3/10/26) Staff H had brought them a newsletter and a treat and said most days the activity staff brought them a morning newsletter, but that was about it as far as activities for them. R97 said they liked to read and stated, I would like a couple books. R97 said the activity staff had also stopped bringing them a newspaper months ago. R97 said they liked BINGO but they could not attend anymore as their legs were weaker but missed it since the fall. R97 said they loved to read magazines but were never brought any and would like more word puzzle books. R97 said their family member had brought the crossword puzzle book on the nightstand and the crafts posted were from last year and said they would love to do more crafts in their room, but none were offered to them. R97 said they were bored sometimes. R97 said there was a good activity staff member who used to do their nails and massage their hands in their room but said this had not been done since the fall when the activity staff member suddenly left their position. R97 was alert and oriented to themselves, their surroundings, situation, and could tell time. Review of R97's Care Plan showed they liked newspapers, crafts, cards, food activities, playing cards, 1:1 activities (since they were in bed), television, radio, reading materials, and BINGO.On 3/11/26 at 1:27 p.m., Staff H was asked about the activities programming in the facility, initially about the residents with dementia and or cognitive impairment observed frequently outside the second-floor nurses circle in the aisleways without activities, attempts, or other activity interventions. Staff H acknowledged the concern and observations and said they had planned to begin a sensory and dementia program the next week for the residents. When asked about them being the only staff observed completing and participating in the residents' activities during the survey, Staff H' explained that Staff J had returned to work since they were on work restrictions except where they could sit, and said they could do little, other than they helped participate in BINGO on 3/10/26, and had called off on 3/11/26, which left them with no assistance. Staff H said the other Activity Aide, Staff I, had not been feeling well yesterday so could not do much but came to work. This confirmed Surveyor observations of Staff H solely completing the observations of transporting and completing activities with the residents during the survey. Staff I acknowledged they had to complete the transporting of residents and the activities on their own for the most part this week, and recently. Staff H said they thought the activity aides were doing the room visits and taking the activity cart around, when asked about R97. Staff H said they would need to talk with them. When asked about R60 and R29, Staff H said they did not know both wanted higher level activities and would follow-up. When asked about weekend activities, per R79's and staffs' descriptions, Staff H confirmed there were not enough activities occurring on the weekends. Staff H said there had been no activities on Saturdays recently, as they had not had any activity staff on Saturdays to assume the work. It was noted the activity calendar this month showed Saturday activities. Staff H said Staff J was there on Sundays, but earlier acknowledged Staff J could not transport residents generally due to their work restrictions, so it was unclear what occurred on Sundays. Staff H said they could not open up the activity room on the evenings or weekends per residents' request, as items had been stolen when they had opened it up prior without them present. Staff H acknowledged concerns with more additional 1:1 activities needed, per R97's input, and said they would follow up with the Administrator, who was their direct supervisor. Staff H said they were not involved in the decision to take one of the living rooms on the second floor as a staff office and confirmed the residents were getting back the living room of their choice per their understanding. Staff H said they were certified and invested in the activity programming but had not had enough assistance transporting and completing the activities consistently by the activity staff, since the former activity aide left their position. On 3/11/26 at approximately 2:15 p.m., the activity programming concerns from observations, staff and resident interviews, email input, and residents' records were shared with the Nursing Home Administrator (NHA). The NHA said they generally understood the concerns and were invested in providing optimal care and programming related to the activity needs of the facility residents. The NHA confirmed the residents would be getting back their living room of choice on the second floor of the facility. Review of the policy, Activities, dated 4/01/22, revealed, It is the policy of this facility to provide an ongoing program of activities designed to meet the interest, choice, and preferences as well as meet the interest of and support the physical, spiritual, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.2. Activities will be designed with the intent to: a. Enhance the residents' sense of well-being. b. Promote or enhance physical activity. c. Promote or enhance cognition. d. Promote or enhance emotional health. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence.4. Activities may be conducted in different way: a. One-to One programs - sensory stimulation. b. Person-appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.8. To the extent possible, activities provided will: a. Reflect residents'' interest and age. b. Be enjoyable. c. Help the residents to feel useful. d. Provide a sense of belonging. e. Reflect cultural and religious interests of the residents. f. Reflect the residents' choice. 9. Activities will include individual, small and large group activities as well as: a. Indoor and Outdoor activities. b. Activities away from the facility (outings). c. Religious programs. d. Exercise programs. e. Community activities. f. Social activities. g. In-Room activities. h. Individualized activities. i. Educational programs. j. Sensory Stimulation. 10. All staff will assist residents to and from activities when necessary. This policy was referenced from the Centers for Medicare and Medicaid State Operations Manual, Appendix PP. F679 Activities to Meet Interests/Needs of Each Resident.

Based on observations, interview and record review the facility failed to ensure proper storage and supervision was provided for medications left at bedside for four (R93,102,146, and 147) of five residents reviewed for medication storage. Findings include.R147 On 3/9/26 at 10:23 AM, R147 was observed in their room watching tv lying in the bed. R147 was observed having two large round tablets in a medication cup located on their bedside table. R147 was asked if they knew what the medications were and reported the medications were an antacid medication that they were not ready to take yet and would take them when they were ready. A review of R147's medical record revealed a self-administration assessment was not completed for R147. R102 On 3/9/26 at 12:2 PM, R102 was observed lying in their bed reading a book. An observation of the room was made and it was noted in their opened night side table drawer were inhalers (Flonase) and antifungal powders in the drawer. R102 was asked about the medications in the drawer and they reported that the medications came from the Hospital . A review of R102's medical record revealed a self-administration assessment was not completed for R102. R146 On 3/9/26 at 10:10 AM, an observation and interview was conducted with R146. Observed at bedside was a yellow bottle of Desenex. When asked, R146 stated they were unsure of what the medication was for. At 10:31 AM, Licensed Practical Nurse (LPN) C (the nurse assigned to R146) was asked about the Desenex in R146's room. LPN C entered the room and obtained the bottle and stated the bottle should not have been left in the resident's room and should be locked in the treatment cart. A review of R146's medication record revealed a self-administration assessment was not completed for R93. R93 On 3/9/26 at 12:30 PM, R93 was observed lying on their back in bed. Observed in the bed with R93 were two tubes of diclofenac sodium 1% gel. When asked, R93 stated they try to put the gel on their body but have a hard time reaching their body parts. A review of R93's medical record revealed a self-administration assessment was not completed for R93. On 3/9/26 at 2:59 PM, the Director of Nursing (DON) was interviewed and asked about the medications observed at the bedside. The DON replied medications/treatments should be stored in the medication carts and that the nurses are responsible for each medication. A review of a facility policy titled Medication and Treatment Storage dated 8/7/23, documented in part . It is the policy of this facility to ensure. safe and secure storage (including proper temperature controls, appropriate humidity and light controls, limited access, and mechanisms to minimize loss or diversion) of all medications and treatments. All medications and biological will be stored in locked compartments. Non-biologicals for treatments will be stored in medication rooms and in treatment carts.

Based on interview and record review the facility failed to maintain an effective antibiotic stewardship program to ensure appropriate infection criteria was met for five (R17, R38, R95, R116 and R153) residents identified which had the ability to affect multiple residents who were prescribed antibiotics while residing in the facility. Findings include: On 3/9/26 at 2:44 PM, a request was made for all the infection control surveillance books to review for the Infection Control Task.On 3/9/26 at 3:03 PM, the Director of Nursing (DON) brought several surveillance books and explained Licensed Practical Nurse (LPN) D, who served at the Infection Preventionist, was still working on February 2026 surveillance and she would provide the surveillance when it was finished.Review of the December 2025 antibiotic surveillance revealed:No line listings were documented.A McGeer Criteria Worksheet for R153 documented in the Urinary Tract Infections Without Indwelling Catheter section the following: leukocytosis was circled and the box next to .At least 2 of the following: fever or leukocytosis; acute costovertebral angle pain or tenderness; suprapubic pain; gross hematuria; new or marked increase in incontinence, urgency, or frequency. AND One of the following microbiology criteria is present: The box was marked next to, at least 10 [to the fifth power - 100,000] cfu/ml [Colony Forming Units per milliliter] of no more than 2 species of microorganisms in a voided urine. A Lab Results Report for a Urinalysis/Culture and Sensitivity [UA/C&S] for R153 with a collection date of 12/22/25 revealed in part, .Bacteria None. Urine Culture No Growth. Review of R153's December 2025 Medication Administration Record [MAR] revealed an order for, Ciprofloxacin [antibiotic]. 500 MG [milligrams]. one time a day for UTI [urinary tract infection] for 3 Days. The MAR documented the medication was administered 12/24/25-12/26/25.Review of the January 2026 antibiotic surveillance revealed:An Order Listing Report dated 3/9/26 at 9:17 PM.R95A McGeer Criteria Worksheet for R95 documented the following for a UTI without indwelling catheter: the box was marked next to, .Acute dysuria or actue pain, swelling, or tenderness of the testes, epididymis or prostate. AND At least 10 [to the fifth power- 100,000] cfu/ml.A Radiology Results Report for a chest x-ray dated 1/22/26 for R95 revealed in part, .Patchy airspace opacities and subsegmental consolidation in the right lower zone, concerning for pneumonic infiltrate.Review of R95's January 2026 MAR revealed an order for, Doxycycline [antibiotic]. 100 MG. Give 1 tablet by mouth two times a day for pneumonia for 7 Days. The MAR documented the medication was administered 1/23/26-1/29/26.R116A McGeer Criteria Worksheet for R116 documented the following for a UTI without indwelling catheter: .At least 10 [to the fifth power - 100,000] cfu/ml.A UA/C&S lab report with a collection date 1/21/26 revealed in part, .ESCHERICHIA COLI, 15,000 CFU/ML. KLEBSIELLA PNEUMONIAE, 15,000 CFU/ML.Review of R116's January 2026 MAR revealed an order for, Ciprofloxacin. 500 MG. Give 1 tablet by mouth one time a day for UTI for 7 Days. the MAR documented the start date for the antibiotic was 1/28/26.Review of the February 2026 antibiotic surveillance revealed:An Order Listing Report dated 3/9/26 at 9:38 PM.R17A McGeer Criteria Worksheet for R17 documented the following for a UTI without indwelling catheter: At least 10 [to the fifth power - 100,000} cfu/ml.A Urine Culture report dated 2/6/26 revealed, ALPHA-HEMOLYTIC STREP. SPECIES 30,000 CFU/ML.Review of R17's February 2026 MAR revealed an order for, Linezolid [antibiotic]. 600 MG . Give 1 tablet by mouth two times a day for UTI for 7 Days. The MAR documented was administered 2/10/26-2/17/26.R38A McGeer Criteria Worksheet for R38 documented the following for a UTI without indwelling catheter: At least 10 [to the fifth power - 100,000] cfu/ml.A UA/C&S report with a collection date 2/20/26 revealed, .KLEBSIELLA PNEUMONIAE, 60,000 CFU/ML.Review of R38's February 2026 MAR revealed an order for, Levofloxacin [antibiotic]. 500 MG. Give 500 mg by mouth one time a day for UTI for 7 Days. The MAR documented the medication start date was 2/25/26.On 3/10/26 at 4:06 PM, LPN D was interviewed by phone and asked how often she was at the facility to perform her duties as Infection Preventionist. LPN D explained she had not been working at the facility frequently lately due to extenuating circumstances. LPN D was asked about the multiple residents who were marked on the McGeer Criteria Worksheet as having at least 10 [to the fifth power] cfu/ml of a bacteria when the lab results were 15,000, 30,000 or 60,000 cfu/ml. LPN D explained she thought 10,000 was 10 [to the fifth power], and also thought if the report contained a sensitivity result it meant that the resident needed to be on an antibiotic. LPN D was asked if antibiotics were ever stopped if the lab results were negative for infection. LPN D explained she was not able to stop antibiotics.Review of a facility policy titled, Antibiotic Stewardship revised 9/25/24 read in part, .Antibiotic stewardship prescribing protocols are followed: Utilization of McGeer's criteria in determining the presence of symptoms meets the definition of an infection. Diagnostic test results received that do not meet criteria will be reported to the medical practitioner for further evaluation of need.

Based on observation and interview, the facility failed to ensure appropriate cross-connection prevention resulting in the potential for contamination of ice in the ice machine, affecting all residents. Findings include:On 03/10/2026 at 8:25 AM observed the unit 300 nourishment room ice machine drain line terminating below the flood rim and soiled with a black substance. During this observation, when viewed by Staff E, he said he wasn't aware of the concern, and it would be corrected. On 03/10/2026 at 8:35 AM observed the unit 100 nourishment room ice machine drain line terminating below the flood rim. During this observation, when viewed by Staff E he said he wasn't aware of the concern and it would be corrected. On 03/10/2026 at 8:50 AM observed 2nd floor nourishment room ice machine drain line terminating below the flood rim and soiled with black substance. During this observation, when viewed by Staff E he said he wasn't aware of the concern and it would be corrected.

Based on observations, interviews and record reviews the facility failed to ensure two of two nurses reviewed for the medication administration observation followed the protocol for the administration of controlled medications for two (R's 10 & 119) of two residents observed for the medication administration task. Findings include:On 3/10/26 at 8:23 AM, an observation of Licensed Practical Nurse (LPN) A to have prepared the morning medications for R10 was conducted. Included in the morning medications prepared was a controlled medication morphine sulfate 15 mg (milligram) extended-release tablet. LPN A was observed to have unlocked the controlled medication cabinet, obtained the morphine medication and obtained one pill from the packet. LPN A returned the controlled medication packet to the locked box and continued to prepare the rest of R10's medications. At 8:32 AM, LPN A was observed to administer R10's medications and signed off on the morning medications as administered. At 8:36 AM, LPN A started to prepare the medications for the next resident. At this time, LPN A was stopped and asked when they would usually sign out the controlled medication from the controlled medication log. LPN A responded that they usually sign out the medication as they go but they were nervous.On 3/10/26 at 8:49 AM, an observation of Registered Nurse (RN) B to have prepared the morning medication for R119 was conducted. Included in the morning medications prepared was a controlled medication klonopin 0.5 mg tablet. RN B was observed to have unlocked the controlled medication cabinet, obtained the klonopin medication and obtained one pill from the packet. RN B returned the controlled medication packet to the locked box. At 8:56 AM, RN B was observed to administer R119's medications and signed off on the morning medications as administered. At 9:00 AM, RN B started to prepare the medication for the next resident. At this time, RN B was stopped and asked when they would usually sign out the controlled medication from the controlled medication log. RN B responded that they would usually do it when they take the medication from the packet.A review of the facility policy titled Controlled Medication Guidelines revised 3/20/24, documented in part . The licensed nurse will validate the physician's order on the medication administration record matches the controlled medication package and controlled. record. form. When the licensed nurse removes the controlled medication from the package, they will document the quantity removed and the quantity left on the Controlled Drug Receipt/Record/Disposition Form.On 3/10/26 at 12:02 PM, the Director of Nursing (DON) was interviewed, and the observations of LPN A and RN B was discussed. The DON stated they were made aware of the observations, and they have already started education with the nursing staff. The DON stated the nurses should document for the controlled medication after they take it from the packet.

Based on observation, interview and record review the facility failed to ensure proper storage of smoking paraphernalia for one (R71) of two residents reviewed for smoking/accidents. Findings include:The facility policy titled, Smoking Guidelines for Non-Smoking Facility (6/18/24) was reviewed and read, in part: .Policy Overview: The facility is a Smoke-Free facility for residents.Resident Guidelines: No-Smoking signs and/or signs that identify this facility as a Smoke-Free Facility will be prominently displayed minimally at entrances of the building.Residents are prohibited from smoking in all areas of the facility and facility grounds.the facility maintains the right to confiscate smoking items and paraphernalia to ensure resident and staff safety.Family members, visitors, facility staff and volunteers are not to purchase and/or supply residents with smoking materials.On 3/9/26 at approximately 9:10 AM an entrance conference was held with the Administrator. At that time the Administrator reported the facility was non-smoking and did not provide the names of any residents who smoked.On 3/11/26 at approximately 12:03 PM, R71 was observed leaning on a pole near the front entrance of the facility smoking a cigarette. R71 was asked about smoking at the facility and reported that they like to smoke outside. R71 was asked if they were aware the facility was non-smoking. They did not respond to the questions asked and again stated they liked to smoke. Approximately 10 to 20 feet away from R71 was a staff member (herein after Certified Nursing Assistant/CNA F) who reported they were outside with R71. A review of R71's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Cirrhosis of the liver, dysphasia and alcohol abuse. A review of the resident Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderate cognitive impairment).Continued review of R71's clinical record documented, in part, the following:8/1/25: Physician Statement of Capacity for Medication Treatment and Decisions: .This form serves as documentation of the determination of this resident's capacity to participate in medication treatments and decisions.It is my professional opinion that the resident 'lacks the capacity to make reasonable medical decisions and/or provide informed consent to their medical affairs.8/4/25: Smoking Evaluation for Non-Smoking Facility: .able to make decisions regarding tasks of daily life.YES.This is a non-smoking Facility.YES.Resident has been educated and agrees that they will relinquish all smoking materials to the nurse to be locked up between LOAs (leave of absence).(signed by the Director of Nursing (DON).7/17/25: Care Plan: Focus: History of smoking in the community.Interventions: Allow to smoke in designated areas at designated smoking times.educate non-smoking status of the center.On 3/11/26 at approximately 12:38 PM, an interview was conducted with the Administrator. The Administrator confirmed that the facility had a non-smoking policy. The Administrator was asked if residents, including R71 were permitted to smoke on facility property. They reported they were not. They stated those who wished to smoke had been educated not to smoke on the property and must sign out LOA prior to going out. The Administrator was asked about the storage of cigarettes and accompanying paraphernalia. They reported that for R71 cigarettes were being provided by a family member and the facility is not storing them.On 3/11/26 at approximately 12:51 PM, an interview was conducted with Front Desk Staff F. Staff F was asked if they observed R71 smoking near the front entrance. Staff F stated they did see R71 go outside with CNA E. When asked if they often see R71 smoking on facility property, they stated sometimes but noted that they should be smoking on the sidewalk. When asked if they had signed out, Staff F stated they did not need to do so. Staff F was asked if there was a smoking schedule for smokers, including R71, they reported they did not have one.On 3/11/26 at approximately 1:40 PM, R71 was observed in their room. R71 was asked about smoking at the facility and where they stored their cigarettes. R71 opened their drawer and two packs of cigarettes were observed in their drawer.On 3/11/26 at approximately 1:46 PM, an interview was conducted with CNA E. CNA E was asked about R71 and the facility non-smoking policy. CNA E reported that it was the first time they went outside with R71. They stated that they did not believe R71 had a schedule as to timing and how to smoke off facility property. CNA E was not sure as to storage of R71's cigarettes.

This citation pertains to Intake: 2746350.Based on observation, interview and record reviews the facility failed to protect Residents' (R's 64 & 65) right to be free from sexual abuse by another resident (R66) for three of three residents reviewed for abuse, resulting in inappropriate and unwanted sexual contact that would cause the reasonable person severe psychosocial harm (feelings of being violated, embarrassment, humiliation, fear & worthlessness) as a result of the sexual abuse. Findings include:A review of a Facility Reported Incident (FRI) documented that Certified Nursing Assistant (CNA) A observed R66 in the bed of R65 with their hands down the front of the brief of R65. The report went on to note that both residents' were immediately separated and R66 was immediately placed on increased supervision.A review of the medical record revealed R66 was admitted to the facility on [DATE], with diagnoses that included: Parkinson's and dementia. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 (which indicated severely impaired cognition).Further review of the medical record noted R66's daughter to have been appointed full guardianship due to R66 to have been deemed legally incapacitated.On 3/2/26 at 8:12 AM, R66 was observed sleeping in bed. CNA C was observed in a chair next to R66. CNA C confirmed that they were scheduled to be R66's one on one for the duration of their shift. R66 did not wake up with verbal stimuli.A review of the progress notes revealed the following:On 10/3/25 at 8:13 AM, a Nursing note documented Resident does not sleep well. Resident is up throughout the night wandering and calling out for his spouse, enters others resident rooms and space causing them to be upset.On 11/9/25 at 5:25 PM, a Nursing note documented Resident stumbled into another residents room looking for his wife. The other resident grew upset due to the language barrier and threatened the resident to get out of the room. Writer and staff entered the room to separate the residents and interview both regarding what happened. The other resident threatened to Kick his ass with the cane if he didn't get out now. Both residents were assessed for any signs of injury. Both residents redirected. Supervisor notified of the incident.On 11/9/25 at 9:26 PM, a Nursing note documented . Resident was looking for his wife and went into room [ROOM NUMBER] because he believed that was her room. advised him that his wife isn't in there and to ask a nurse next time because the resident that is in that room don't know him. spoke with the other resident as well who stated he was fine.On 11/14/25- a Nursing note documented that R66's wife passed away in the facility.On 11/30/25 at 2:29 AM, a Nursing note documented Resident has been anxious and restless since beginning of shift. Flooded bathroom, hasn't slept, entering roommates space, making him upset.On 1/9/26 at 10:00 PM, a Nursing note documented- Writer heard something pouring in resident room, when writer approached, he had his penis out urinating on the floor. Writer got materials to clean/dry up urine for resident wouldn't fall. Writer administered meds and he spit out meds in hand. Resident wouldn't allow BS (blood sugar) to be drawn. Resident grabbed writer breast about six times while trying to provide care. He continued to laugh and yell something we couldn't understand. This note was documented by LPN B.On 1/11/26 at 9:00 PM, a Nursing note documented Resident received in room picking in trash can. Resident was roaming and entering other resident's rooms and bathrooms. Tried to get in bed with resident next door. Resident hit writer on rear end and laughed. Resident also urinated on floor as if he was standing over the [NAME]. This note was documented by Licensed Practical Nurse (LPN) B. This note was documented by LPN B.On 1/19/26- a Nursing note documented that R66 was transferred to another unit.On 2/3/26 at 8:38 AM, a Nursing note documented Pt (patient) is wandering at night into different residents rooms. He is being redirected all night.On 2/4/26 at 2:41 AM, the Director of Nursing (DON), documented . Writer notified via telephone of inappropriate resident-to-resident contact observed by staff during routine rounds. Writer was not physically present in the facility at the time of the incident. Writer provided direction to staff. Administrator & MD (Doctor) notified. Resident placed with 1:1 supervision. Care plans updated.On 3/2/26 at 10:45 AM, the Administrator was asked to provide all resident to resident incident reports that pertained to R66- from admission to 3/2/26.One incident report was provided by the Administrator.A review of the incident report provided revealed the following, . 2/4/26 at 12:01 AM. Writer was made aware by Cna (Certified Nurse Assistant) that resident was in another residents room. Writer removed pt from hallway and called management. Skin assessment was obtained on both pt, no rare findings. Family was contacted and resident was put on 1 on 1. Resident unable to give description. Resident was brought to the common area and placed on 1-on-1. No injuries observed at time of incident. CNA stated that resident was lying in bed during rounding and she seen another resident which is a male in the bed with the resident. The other resident had his hand in the resident brief.On 3/2/26 at 1:44 PM, LPN B was interviewed and asked about the 1/11/26 incident with R66 trying to get into the bed of another resident. LPN B replied they were in the middle of passing medications and noticed that (R66) was not in their room. LPN B went into R64's room and observed R66 attempting to get into the bed with R64. LPN B stated R66 was holding R64's bed blanket in their right hand, while attempting to get into R64's bed. LPN B stated they observed R64 shaking their blanket and pulling the blanket in attempts to get R66 away. LPN B stated they immediately took R66 back to their room. When asked, LPN B stated R66 used a wheelchair to get around but also walked without the wheelchair which was a concern because R66 was known to wander into other resident rooms. LPN B was then asked about R66's sexually focused behaviors and replied R66 is known to wander into female resident rooms, make sexual remarks to female staff and continues to do so, which is why they felt it was important to document it. LPN B stated the Administration staff had never followed up on their concerns or documentation in R66's record until after the 2/4/26 incident. LPN B expressed their frustration of the lack of support with the Administration staff regarding R66's wandering and sexual behaviors.A review of the medical record revealed R65 was initially admitted to the facility on [DATE], with diagnoses that included: dementia, anxiety and adult failure to thrive. A MDS assessment dated [DATE], noted severely impaired cognitive skills for daily decision making.Further review of the medical record noted R65's son as their guardian.On 3/2/26 at 2:35 PM, R65 was observed laying back in a geri chair in the hallway across from the unit nurse station. An interview was attempted with R65, however unsuccessful. R65 did not make eye contact when spoken to and did not respond to their name or any questions asked.A review of the care plans revealed no implementation of interventions for R66's wandering or sexual behaviors until 2/3/26, that noted staff to sit outside R66's room from 11 PM to 7 AM. This intervention was not effectively conducted by staff as it did not prevent the incident on 2/4/26 that occurred with R65.On 3/2/26 at 10:47 AM, CNA A was interviewed and asked about the incident with R66 and 65 on 2/4/26. CNA A stated they were doing their rounds and turned the light on in (R65's room) and observed R66 in the bed with R65, with R66's hand down the front of R65's brief. CNA A stated they screamed for the nurse and Nurse (LPN D) arrived and helped to remove R66 from the room. CNA A stated they stayed with R65 to observe their skin and change their brief. CNA A stated R65 is non-verbal and did not respond, however R66 was yelling and upset . because I caught him. CNA A stated R66 has a language barrier and they were unable to understand what they were yelling about. CNA A stated they did not remember to have used the language translation system or devices to communicate with R66 after the incident.On 3/2/26 at 11:08 AM, LPN D was interviewed and asked about the incident with R's 66 and 65 on 2/4/26. LPN D explained they were at the nurses station when (CNA A) came to get them and stated (R66) was in the bed with another resident. LPN D stated when they arrived to (R65's) room they observed R66 in the bed with R65, however did not witness R66's hands down the brief of R65. LPN D stated R66 initially refused to get out of the bed and was upset, however they were able to get R66 back into their wheelchair and out of the room. When asked, LPN D stated they usually communicate with the resident through the translate on their personal cellphone but did not remember using it to ask R66 about the incident.On 3/2/26 at 12:12 PM, the facility's camera footage of the 2/4/26 incident was reviewed with the Administrator, Director of Nursing (DON) and survey team in attendance.The camera footage revealed no staff stationed outside of R66's room from 11 PM as noted as an intervention on the care plan. R66 was observed on the camera coming out of their room in a wheelchair at 10:43 PM. R66 looked up and down the hallway before entering the room of R65. CNA A is observed to identify R66 in the room and bed of R65 with their hands down their brief at 11:59 PM (more than an hour after entering the room). CNA A leaves R66 in the bed with R65, exits the room to obtain assistance from another staff member to help remove R66 from the room. Shortly after, CNA A and the second staff member are seen entering the room.On 3/2/26 at 12:25 PM, the Administrator (who serves as the facility's Abuse Coordinator) and the DON was interviewed and both were asked about the numerous documentation in R66's medical record that identified behaviors of wandering into other resident rooms & sexually focused behaviors, which had not been identified to be a concern with interventions implemented to protect other residents prior to 2/3/26. The Administrator explained that after the 1/11/26 incident the IDT (interdisciplinary team) met and thought it was a good idea to move R66 away from R64 and onto another unit. The Administrator and DON was asked to confirm that the facility's IDT team met and felt it was a good idea to move R66 to the unit where the majority of the facility's most vulnerable resident's (Alzheimer's and dementia) resided. The Administrator stated as far as they knew R66's wandering . wasn't a repetitive habit and wasn't a night thing and easily redirectable. The Administrator was asked if they reviewed R66's progress notes that reflected the multiple identified wandering incidents and the Administrator stated they had specifically asked the staff.Review of a facility policy titled Abuse revised 5/24/23, documented in part . Residents have the right to be free from abuse. Prevention consists of facility systems designed to detect, identify, correct, and prevent the occurrence of abuse. Completing ongoing assessments and care planning for appropriate interventions, and monitoring of residents with behaviors, including but not limited to. Sexually aggressive behavior (inappropriate touching, grabbing, saying sexual things etc. Wandering into other's rooms or space. communication disorders or those who speak a different language. and those that are dependent upon staff for care.On 3/2/26 at 3:34 PM, a telephone interview was conducted with the Guardian E of R65 and their spouse (with the approval of the guardian). Guardian E and their spouse was asked about the incident with R65 and R66. Guardian E 's spouse stated they were informed that a man had been found in the bed with their mother. When asked if they were informed of the man to have had their hands down the brief of their mother, Guardian E and the spouse stated they were not informed of that. The spouse stated the facility notified them that a man was found in the bed with their mother and they had since removed the man to another floor and unit to protect their mother. Guardian E and the their spouse stated they were worried about their mother and other resident's well-being with the man resident. When asked how they felt their mother would have reacted to this incident if they were in right mind, they stated in part . No, she would have not (consented to the sexual act) and she would have been very upset. Guardian E and their spouse stated . We didn't put her there for her to be abused. Guardian E and their spouse stated they declined to prosecute when the police contacted them because the facility said that they handled the situation, moved the resident and assured them that it would not happen again.No further explanation was provided by the Administrator or DON before the end of the survey.

This citation pertains to complaint 2689220 Based on interview record review, the facility failed to provide timely on-going assessment and intervention for one resident (R401) of one reviewed for change of condition resulting in a hospitalization to rule out stroke (CVA). Findings include:A complaint was submitted to the State Agency (SA) on 12/8/25 that alleged the facility did not get the resident to scheduled doctor appointments causing a delay in treatment for CVA, neck fracture and wounds that were not reported nor treated. On 12/30/2 at 9:30 AM, a phone interview was conducted with family member (FM A), who reported that in February they had went to visit R401 and the resident reported to them that they were having a stroke. FM A reported that they told the facility, but nothing was being done and the facility delayed giving R401 the proper care and treatment. FM A also reported that the facility made R401 miss their schedule neurology appointment two times and when they finally were able to see the neurologist, they sent them to the hospital to rule out stroke and obtain a cat scan (CT). FM A reported that the day they went to see R401, their left side was very weak and they were no longer able to walk. They also stated that the physical therapy department left a voicemail stating the significant change in condition in the function. A review of the record revealed that R401 was admitted to the facility on [DATE] with the diagnosis of TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS, ENCEPHALOPATHY, UNSPECIFIED and ESSENTIAL (PRIMARY) HYPERTENSION. With a Brief interview for mental status score (BIMs) of 12 which indicates mild cognitive impairment. A review of the record revealed a progress note on 2/27/25 from the nurse taking care of R401 at 10:36 AM which read : Pt (Patient) received in bed a&O (alert and oriented) to baseline, pt stated he felt as if he was having a stroke. pt stated he had tingling to L (left) arm, and can't grab anything with L hand. L hand grasp weak pulse strong. Pt denied dizziness, headache, nausea, blurred vision, numbness to face. Speech is clear, no facial drooping or drooling and no difficulty swallowing. BP (blood pressure) 175/81 HR (heart rate) 64 R (respirations) 18 even and unlabored. NP (Nurse Practitioner) notified. A further review of the record revealed a progress note on 2/27/25 at 11:58 AM from the Nurse Practitioner (NP) which read in part: .Seen at patient request because concerned he is having stroke Called to bedside by staff to evaluate patient as patient states he is concerned he is having a stroke. Patient is unable to elaborate on what the signs are beyond having some new weakness. Patient appears to be at baseline mentation of [NAME] x 2. No changes in mentation or physical presentation noted by nursing staff .Order for one-time vital now placed into [EMR-electronic medical record]. Recommend every 2 to every 4 hours blood pressure monitoring for the time being. Can DC (discontinue) in 24 hours On 12/30/25 at 12:36 PM, an interview with the Director of Nursing (DON) was conducted. The DON was asked what the facility's expectations for someone experiencing stroke like symptoms. The DON reported that the expectation is to assess the resident and if they are having new symptom, send them out immediately because it is time sensitive being that we can not treat strokes in the facility. The DON was asked did the facility have a STROKE protocol or policy, she replied, no. The DON was then asked, why was R401 not sent to the hospital if they had stated they were having a stroke the DON reported, that they should have been sent out for further evaluations since the facility did not have the proper equipment to treat such acute conditions. The DON was also asked where the documentation (the added blood pressure monitoring) that was recommended by the NP found? The DON reported that the facility did not do any follow up on the suspected change in condition. The DON was asked about R40's missed scheduled neurology appointments. The DON reported they would investigate the missed appointments. On 12/30/25 at 1:22 PM, the NP B was called via telephone and interviewed. The NP B was askedif someone complains of having a stroke, what would be done? The NP B reported that they would assess them and see if there were any signs of a stroke. The NP was then asked, for R401, who has a history of strokes and felt as though they were having one, with new onset of left sided weakness, if they should have been further evaled? The NP B explained a new onset of left sided weakness was not considered a stroke symptom and that there needed to be more than one change to be considered a stroke. The NP B was then asked did she reassess or inform the medical provider of R401's new change in condition. The NP B replied I do not know. A Review of the Hospital paper work documented that on 3/27/25 at 6:32 PM a CT of the brain was completed it read in parts Provided History: [AGE] years old Male Neuro deficit, acute, stroke suspectedTechnique: CT imaging of the brain was performed from the skull base to the vertex without contrast.Findings:1. No acute intracranial hemorrhage, mass effect, midline shift, orhydrocephalus.2. Approximately 7 mm (millimeters) chronic appearing lacunar infarct within the posteriorlimb of the right internal capsule is new since 11/22/24. Mild chronicischemic demyelination changes involve both cerebral hemispheres, similar to11/22/2024. Age-appropriate cerebral volume A review of the record revealed that R401 was identified with a change in condition on 2/27/25 with a new onset of left sided weakness. The change in functional ability was identified by the therapy department on 2/28/25. The record also revealed that R401 was not reassessed after the initial change in condition as identified as the NP recommended and the NP did not follow up on the status of R401 newly founded change. It was not until 3/27/25 when R401 was sent to the emergency department by the neurologist (after missing two previously scheduled appointments 3/11/25 and 3/12/25) because there was suspected stroke. There was no additional information provided by the exit of survey.

This citation relates to Intake 2655900. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical and sexual abuse by one Resident, R108, towards two residents, R103 and R104, and by R106, towards two residents, R109 and R110, of six residents reviewed for abuse. Findings include:Review of a Complaint reported to the State Agency, received on 10/29/25, alleged R108 (a male resident) went into R103's (female resident) room naked, got into bed with R103, and touched her breast, and then R103 hit R108 with her shoe. The complaint further alleged R108 attempted to get into R103's roommates' bed, R104 (a second female resident), however did not touch them. The complainant conveyed safety and supervision concerns related to facility residents.Further review of same complaint (dated 10/29/25) alleged a second resident to resident incident occurred on 10/25/25, when R106 (a second male resident) was using other residents' bathrooms, pulled his pants down, and exposed himself to an unnamed female resident who screamed in response.Review of a Facility Reported Incident (FRI), received by the State Agency on 11/01/25, revealed on 11/01/25, R106 (the second male resident) was witnessed by staff allegedly pulling R110's hair, and putting his hands down R109's shirt (a female resident). The report revealed both incidents occurred within the same time frame.Review of a FRI, received by the State Agency on 11/06/25, revealed on 10/28/25, R104 reported R108 (first male resident) came into their room, attempted to get into their bed, and then exposed and fondled himself next to R104 in her room. The report revealed a police report was made. The report showed the Nursing Home Administrator (NHA) stated R104 made no comment to the police. R108:Review of an Accident and Incident Report, dated 10/28/25 at 3:30 p.m., revealed R108 (first male resident) was observed trying to enter other residents' beds (unnamed). The report showed when staff intervened, the resident became combative during redirection and described R104's roommates' bed was unoccupied at the time of the incident. Staff reportedly provided verbal redirection and ensured the safety of all the residents (unnamed) in the area and removed R108 from the environment. The report did not specify the details of the incident, which residents were involved, or any resident outcomes. On 11/05/25 at 11:10 a.m., R103 was observed in their room, dressed and seated in a chair, holding a Styrofoam cup, with a baby doll on her bed. R103 agreed to the interview by nodding. R103 appeared peaceful and content. No bruising or skin concerns were observed.On 11/05/25 at 11:11 a.m., R103 was asked yes/no questions. R103 denied care concerns or abuse concerns, however, Surveyor could not ascertain R103's accuracy due to communication impairment. R103 was oriented to herself only at that time and had no communication board or tool to ascertain her level of communication. R103 responded with a couple words and gestures and by nodding or shaking their head no. Review of R103's MDS (Minimum Data Set) assessment, dated 9/05/25, revealed she was admitted to the facility on [DATE], with diagnoses including hypertensive encephalopathy (brain metabolic disorder), dementia, and aphasia (communication impairment). The assessment showed R103 required assistance with self-care and had cognitive and communication impairment.On 11/05/25 at 11:15 a.m., R104 was observed in the same room in their hospital bed in the same room. On 11/05/25 at 11:15 a.m., R104 reported an incident when R108 attempted to climb into her bed when she was in her bed, about a week ago. R104 said she yelled at R108 to stop, and then R108 stood about four feet away from her next to the bed and fondled himself while exposed. R104 described R108 was only wearing a T-shirt. R104 stated she pushed her call light for assistance and waited 5 to 10 minutes for her call light to be answered by staff, which was too long for her. R104 reported six staff came into the room, including the Nursing Manager (Licensed Practical Nurse (LPN) E), who responded and said the facility needed a memory care unit. R104 explained the incident made her feel scared when it occurred but she was doing fine during the interview. R104 was fully oriented, and able to tell time on her wall clock and on her phone. Review of R104's MDS assessment, dated 10/16/25, showed she was readmitted [DATE], with diagnoses including lung disease and generalized anxiety disorder. The assessment revealed that R104 required maximal assistance for transfers and bed mobility and R104 was cognitively intact.On 11/05/25 at 12:00 p.m., R108 (first male resident) was observed in his bed, sleeping, wearing a sweat outfit and socks.On 11/05/25 at 1:25 p.m., Social Worker (SW) B reported they learned there was an incident when they returned to work recently, when R108 was taking off his clothes, was going into patient's rooms, and was attempting to get into bed with female patients. SW B said R103's Family Member, FM C, learned of it and described to them a male patient was taking off his clothes and was masturbating and said they did not know his name, and said R104 also had concerns (which were unspecified as they said they could not recall the details). SW B said FM C told them this on 10/27/25, prior to the 10/28/25 incident. SW B reported they notified the Director of Nursing (DON) about the incident and were not involved in any investigation beyond reporting. SW B was asked why the incident was not documented in their notes and there was no social services follow-up. SW B acknowledged the incident on 10/28/25 and said there should have been follow-up completed and FM C's call documented. SW B said, Normally there would have been a concern form completed, at a minimum. SW B denied any declines in physical or emotional status for R103 and R104. SW B indicated R104 was a credible reporter and fully oriented. Review of R104's concern forms showed no resident-to-resident incidences, and there were no concerns forms provided for R103. Review of R108's Provider Psychiatry note, dated 10/30/25 at 12:43 p.m., revealed, .(R108) is alert and oriented x 2 (spheres) with intermittent episodes of confusion and able to make his needs known . Behavioral concerns have emerged since the last visit with no identified trigger x 1. (R108) has been displaying sexually inappropriate behaviors towards patients and staff, has been getting into the beds of other residents, and has episodes of combativeness. UA (urinalysis) was collected and resulted negative.Review of R108's SW B's progress note, dated at 10/29/25 at 12:36 p.m., revealed, SW follow up (on) 2/2 reports of (R108) displaying inappropriate sexual behaviors. The note revealed referral to psychiatry, neurology, and preferred activities. No behavioral interventions were noted.Review of R108's Minimum Data Set (MDS) assessment, dated 9/08/25, showed R108 was admitted on [DATE], with diagnoses including Alzheimer's disease, anxiety, and depression. The assessment showed that R108 transferred and walked with supervision and cueing and had cognitive impairment and wandering behaviors.Review of R108's progress note, dated 10/28/25 at 3:26 p.m., showed R108 displayed sexually inappropriate behaviors to patients and staff, getting into other residents' beds and combativeness. Resident were not specified.Review of R108's Care Plan, accessed 11/05/25, showed a behavioral Care Plan dated 10/29/25, which showed R108 wandered into other residents' rooms, made sexual remarks, and had a behavior of being unclothed.On 11/06/25 at 9:32 a.m., the 200 floor Unit manager, Licensed Practical Nurse, LPN E, was asked about R104 reporting they were among the staff who responded when R104 reported R108 fondled himself next to her (R104) when she was in her hospital bed on 10/28/25. LPN E denied any awareness of abuse or exposure by R108 towards R104 or other residents. LPN E said they only heard R104 scream and responded when R108 was in her room and made sure R108 was removed. LPN E said R108 was found in R103's bed fully clothed and was removed from room and said R103 was not present. On 11/06/25 at 11:12 a.m., CNA H was asked about the resident-to-resident incident reported involving R108. CNA H reported they witnessed an incident perpetrated towards R108 towards R103, R104's roommate, on 10/28/25. CNA H described R103 observed R108 in R103's room in R103's bed, sitting there with his pants off, while R103 stood by her bed. R103 then reportedly popped R108 on his head with her house shoe. CNA H said they pulled R103 away from R108, as R103 was upset R108 was in their bed. R103 reported CNA L assisted them removing R108 from the room, and LPN E was in the room as well. CNA H said they were not aware of the incident prior between R108 and R104 or with other facility residents. R106 (second perpetrator):On 11/05/25 at 12:30 p.m., R106 was observed in his room, wearing a sweatshirt and pants, with a hard plastic boot on their leg. Certified Nurse Aide (CNA) A was seated in a chair in R106's room. R106 agreed to be interviewed.On 11/05/25 at 12:32 p.m., R106 said they were doing good and everything was fine. R106 denied any resident-to-resident incidents or abuse towards him or to other residents. R106 was oriented to himself and his surroundings.On 11/05/26 at 12:34 p.m., CNA A reported they were supervising R106 on a 1:1 supervision.On 11/05/25 at 3:09 p.m., SW B was asked about the incidences between R106 and R109 and R110. SW B confirmed the abuse incidents occurred as reported to the State Agency on 11/01/25. SW B stated R110 was only oriented to herself and did not recall the incident. SW B confirmed they had followed up with R109 today (11/05/25) and said they should have followed up sooner. SW B shared R109 was interviewed and had a BIMS (Brief interview for mental status) score of 9/15, which showed cognitive impairment, and said there had been no changes in mood/behavior since the incident for either resident R109 and R110. SW B reported R106 was moved to another floor, had 1:1 supervision, and denied the staff had awareness of any concern with R106 prior to the incident.Review of R106's nursing progress note, by Registered Nurse (RN) K, dated 11/01/25 at 2:58 p.m., revealed the writer overheard commotion at the 200 unit, and staff reported R106 pulled R110's hair, at approximately 2:00 p.m. An unnamed CNA reported R106 had attempted to put their hand down R109's shirt, which had occurred earlier at 11:40 a.m R106 was removed from the victim, R110. The police were notified, a 1:1 supervision was initiated for R106, who stated, I won't do it again.On 11/05/25 at 3:33 p.m., Registered Nurse, RN D, reported R106 was known to enter other resident's rooms and disrobed in their bathrooms to use their toilet prior to the incident. RN D reported they had observed R106 grabbing staff's arms or grabbing them by their pants. RN D described one incident when R106 grabbed R103 on their arm and by their pants and reported they had reported the incidents to LPN E. On 11/06/25 at 9:36 a.m , LPN E was asked about the incident when R106 perpetrated abuse towards R109 and R110 and any concerns with R106's behaviors prior to the incident. LPN E reported they had redirected R106 when they went into other residents' room to use their bathrooms prior to the 11/01/25 incident and acknowledged (unnamed) residents had screamed when R106 was using their bathrooms, so they intervened when this occurred. On 11/06/25 at 11:33 a.m., CNA H reported they were present when R109 was seated at the nurse's station on 11/01/25 and R106 reached over R109's bedside table and touched R109's breast under her shirt. R109 reportedly said, Oh, sh@t. CNA H reported they intervened and immediately moved R109 to her room. CNA H said the police were called and R109 could not specifically recall what occurred. CNA H reported R106 thought it was funny and said they believed R106 understood what occurred, as he had been grabbing staff prior.On 11/06/25 at approximately 11:40 a.m., CNA H described a second incident which was observed after lunch on 11/01/25, between R106 and R110. CNA H described R110 was seated at the nurse's station when R106 pulled R110's hair and would not let go. CNA H explained two staff attempted to assist and R106 would not let go and R110 was crying and cried for 30 minutes after the incident. CNA H reported they removed R106 from the scene and took them downstairs to another floor, and the police were notified and arrived after the incident.Review of CNA I witness statement, undated, showed CNA I was charting at the desk when they witnessed a kitchen aide remove R106's hand from R110's hair. CNA I reported the kitchen aide told R106 to let go, and R106 did not let go right away. Review of LPN J's witness statement, dated 11/01/25, revealed when they returned from break the floor staff let LPN J know an assault had occurred, when R106 assaulted another resident (R110) by pulling her hair with a tight grip.Review of CNA P s witness statement showed R106 grabbed R110 by the hair forcefully and would not let to go, and then R110 started to cry. CNA P intervened however they could not get R106 to let go, and R106 pulled harder, until additional staff intervened. CNA clarified the incident happened on 11/01/25 at 1:00 p.m. by the nurse's station.On 11/06/25 at 1:50 and 1:55 p.m., R108 was observed walking on the 200 hall, where he resided, wearing a sweat outfit, with nursing staff supervising them. R108's mood was calm. On 11/06/25 at 2:05 p.m., R109 was observed dressed in her upright recline wheelchair in her room and agreed to be interviewed.On 11/06/25 at 2:07 p.m., R109 said she did not recall the details, and she believed a man touched her. R109 added, I don't remember. I know the police were here. R109 denied any injury or being upset about the incident during the interview. R109 reported they felt safe. On 11/06/25 at 2:10 p.m. R110 was observed dressed, seated at the nurse's station in a Geri (positional lounge) chair. R110 appeared comfortable and calm. R110 could not answer questions and was unable to be interviewed. R110 was directly supervised by LPN E during the observation.R106 and R108:On 11/06/25 at 2:30 p.m., CNA H was asked if R108 had any resident-to-resident incidents prior to 10/28/25, and they reported there were no concerns or similar behaviors per their awareness.On 11/07/25 at 9:33 a.m., the NHA (Nursing Home Administrator) reported they were unaware of R104's concerns until Surveyor reported them, and had followed up with R104 yesterday, who shared the same incident description. The NHA stated they followed up on the concerns of R103 also and understood four staff members responded to R104 yelling on 10/28/25 in her room and found R108 without his brief on R103's bed, with a CNA (unnamed) already in the room, and said they knew of no further incident. The NHA reported during their investigation they became aware during the survey R108 had a behavior of disrobing in his bed and in the facility prior to the incident, reported to them on 11/06/25 by LPN E and CNA L. The NHA clarified if they had known, they would have followed up. The NHA said they would have expected to have been made aware by facility staff so they could have put a plan in place, and the behavior should have been reported. The NHA clarified R108 was not in bed with R103 or R104 per their interviews and they learned R103 tried to [NAME] R108 out of her bed with a shoe. The NHA clarified the aide, CNA L , who was present, said they did not witness any contact by R108 with either R103 or R104. The NHA confirmed the incident was reported to the State Agency on 11/06/25, and to the police.On 11/07/25 at 9:45 a.m., the NHA was asked about their investigation conclusions regarding the abuse incident reported to the State Agency on 11/01/25 involving R106, R109, and R110. The NHA confirmed they understood the abuse related concerns and R106 was placed on a 1:1 supervision since 11/01/25, and no other incidents had occurred. They denied awareness of R106's inappropriate behaviors prior to the 11/01/25 incident. On 11/07/25 at 11:38 a.m., R103's Family Member, (FM) C, was available by phone, after earlier surveyor attempts. FM C reported they were not directly aware or had not been notified of any incidents between R103 and facility residents. However, they had observed R103 not wanting to go into her bedroom recently and said R103 wanted to stay in the day room and kept the day room door shut. FM C said R103 didn't want to lay in their bed and said this was all a new behavior. FM C said they never determined what happened, and no staff had told them if any incident occurred. FM C shared they reported their concerns to the facility and said facility staff were aware R103 did not want to lay in their bed, which staff had encouraged. On 11/07/25 at 11:40 a.m., FM C further described an incident involving them as a visitor two weeks prior, when they observed R106 wheeling by them in his wheelchair, with his pants down. FM C said R106 grabbed their arm, which upset them. FM C said a nearby staff member said, He (R106) does this all the time,. and intervened. FM C stated whenever R106 wheeled by R103, R103 would become aggressive and start yelling No, but they did not know if an incident occurred or if R103 was afraid of R106, as R103 had communication impairment. When asked if R103 was fearful, FM C said they were initially after admission, however believed R103 had adjusted to the facility now. On 11/07/25 at 12:22 p.m., CNA L was asked during a phone interview about any resident incidents with R108. CNA L reported on 10/25/25 around 2:00 p.m., they had just finished rounds and heard a coworker yell for them to come to R103 and R104's room. CNA L described they observed R108 in their room, standing by the curtain area (middle of room), looking confused, with his pants down and brief removed. CNA L reported R108 then sat on R104's bed, and R103 approached R108, who became combative, and R103 began shewing him away with their house shoe. CNA L said they could not be certain any contact was made to R108 by R103's house shoe. CNA L reported LPN E and CNA H were present when the incident occurred. CNA L reported the residents were separated by these staff and themself. Review of R103's MDS assessment, dated 9/05/25, showed R103 was admitted on [DATE] with diagnoses including dementia and metabolic encephalopathy (brain metabolic disorder). R103 required moderate assistance for toileting and mobility and had severe cognitive impairment.On 11/07/25 at approximately 2:00 p.m., LPN M acknowledged prior to the 10/28/25 resident-to-residents incident they had found R108 in their orientation practice bed, exposed from the brief down. LPN M said they had told LPN E, who said they had care planned prevention prior to 10/28/25. Review of R108's Care Plan, accessed 11/05/25, showed no increased supervision or preventative measures had been added for R108 prior to the 10/28/25 incident, or after the 10/28/25 incident had occurred. On 11/07/25 at 2:11 p.m., Staff N, who asked to remain anonymous, reported they had been touched inappropriately on their bottom by R106 prior to the 11/01/25 incident, which upset them. Staff N said they were aware of other staff who had been touched inappropriately prior to the incident, but denied any residents were involved to their awareness. Staff N reported facility administration were aware these incidents had been occurring and had not intervened to prevent these behaviors towards staff by R106. Staff N stated if the facility had addressed R106's grabbing and touching behaviors prior, perhaps the other incidents would not been as likely to have occurred. Staff N confirmed R106 was on the 1:1 supervision since the 11/01/25 abuse incidents. Review of a police report dated 11/01/25, at 1:57 p.m., revealed an assault occurred at the facility. The reported showed on 11/01/25 at approximately 11:30 a.m., CNA H was at the desk when they observed R106 reach over to R109, sticking his hand down her shirt, and R109 said, Stop. Go away. The report continued R106 was wheeled (in a wheelchair) back to his room. The Officer attempted to interview R109, who was unable to recall the incident. Further review of the same police report revealed Food Service Worker, Staff P, reported on 11/01/25 at approximately 12:30 p.m., they were in the hallway near the nurse's station and observed R106 grabbing R110's hair. The report showed R106 would not let go until staff assisted and said R110 was non-verbal and unable to be interviewed. The report described R106 was moved to another floor to have continuous supervision at that time. The report concluded there were no injuries and a simple assault occurred and was handed off to their Detective. Review of a second police report, dated 11/06/25, revealed on 11/06/25 at 5:08 p.m., a suspicious circumstances incident was determined, when the NHA reported to the police an incident when R108 walked into R104's room, opened his gown, dropped his underwear, and began fondling himself. The report showed the NHA reported this was the first incident for R108 and said he had progressing dementia and corrective measures had been taken. R104 said they were fine and did not want to pursue anything further.Review of the EMR (electronic medical record), including R106's Care Plan, accessed on 11/05/25, revealed no increased supervision had been added for R106 prior to the 11/01/25 incident, when staff and FM C had reported R106's inappropriate touching behaviors to facility management. Further review revealed R106's inappropriate sexual behaviors towards residents after the incident had not been Care Planned until 11/03/25, two days after the two resident-to-resident abuse incidents had occurred. On 11/07/25 at 3:30 p.m., the NHA shared they were reporting additional concerns related to the resident-to-resident incident between R103 and R108 on 10/28/25 discovered in their investigation to the State Agency. The NHA denied any prior awareness of R106's and R108's behaviors, prior to incidents on 11/01/25 and 10/28/25, respectively. Review of the policy, Abuse, updated 4/13/2023, revealed, Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property . The facility will develop and implement written policies and procedures that include: Screening potential employees and prospective residents. Training new and existing staff on prohibiting, preventing, and identifying abuse, neglect, exploitation, mistreatment, and misappropriation of resident property, reporting procedures, dementia and behavior management. Prohibiting, Preventing, and Identifying abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Reporting any allegations of abuse, neglect, mistreatment, exploitation, and misappropriation or resident property including reporting a reasonable suspicion of a crime to the State Survey Agency and other officials in accordance with state law. Investigating allegations of abuse, neglect, misappropriation, mistreatment, and exploitation to include protecting residents during the investigation, and taking necessary actions as a result of the investigation. Establishing coordination with the QAPI (Quality Assurance Performance Improvement) program. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written. Training:The facility will educate its staff upon hire, annually, and as needed, which will include, but not necessarily be limited to, the following topics: Prohibiting and preventing all forms of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Identifying what constitutes abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Residents right to privacy and confidentiality to include the unauthorized taking of pictures or recordings of residents and sharing them in any manner, including social media or the use of technology. Recognizing signs of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Reporting process for suspicions or allegations of abuse, injuries of unknown origin, neglect, exploitation, mistreatment, and misappropriation of resident property without fear of reprisal or retaliation. Reporting reasonable suspicion of a crime by covered individuals without fear of reprisal or retaliation. Content will include but is not limited to: what is reportable as a reasonable suspicion of a crime, each covered individual's obligation to report a reasonable suspicion of a crime against a resident to the administrator immediately as well as the State Survey Agency and Law Enforcement, and the timeframe requirements of reporting. This may include but not limited to: placing a notification in the employee handbook, in-service education, notification letters, notification provision in a service contract. Understanding and ways to deal with behavioral symptoms of residents that may increase the risk of abuse and neglect such as: Aggressive behaviors and/or catastrophic reactions of residents. Wandering or elopement-type behaviors. Resistance to care. Outbursts or yelling out. Difficulty in adjusting to new routines or staff. How to recognize signs of burnout, frustration, and stress that may lead to abuse. Identification: The facility will educate the staff in identifying abuse (mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services), neglect, exploitation, mistreatment, and misappropriation of resident property. Possible indicators of abuse include, but are not limited to: Resident, representative, or staff reports of abuse. Suspicious or unexplained injuries such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Resident, representative, or staff reports of theft or missing property. Verbal abuse of a resident overheard. Physical abuse of a resident observed. Psychological abuse of a resident observed. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature of whether the resident provided consent and regardless of the resident's cognitive status. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. Demonstration of catastrophic reactions. Protection: The facility will attempt to coordinate with State and Local law enforcement annually and as needed to determine which crimes are reportable other than those listed in the definition of Crime. Abuse against residents can be perpetrated by various people within the facility. The facility supports and protects patients, family members, and staff from harm during an investigation of alleged abuse including retribution and retaliation. Protective actions depend upon the people involved. Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Immediately removing the resident from contact with the alleged abuser. Evaluation of the physical and psychosocial condition of the resident and providing emotional support to the patient during and after the investigation as needed. Providing a safe and secure environment for all patients If a staff member is the alleged perpetrator, that staff member should be immediately removed from the facility and the schedule pending the outcome of the investigation. If a non-staff person (visitor, family member, etc.) is the alleged perpetrator, that non-staff person should be immediately removed from the facility, prevented access to the resident pending the outcome of the investigation, and/or referring the matter to the appropriate authorities as indicated. If a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated. Notification to the resident's attending physician and resident representative of the incident or allegation of abuse.Sexual abuse: Non-consensual sexual contact of any type with a resident including but not limited to unwanted touch especially breasts or perineal area, coerced nudity.forced observation of masturbation.

This citation relates to Intake 2655900. Based on interview and record review, the facility failed to report a physical and sexual abuse incident for three residents (R103, R104, and R108) of six residents reviewed for abuse. Findings include:Review of a Complaint reported to the State Agency, received on 10/29/25, alleged R108 (a male resident) went into R103's room naked, got into bed with them, and touched her on her breast, and then R103 hit them with her shoe. The complaint further alleged R108 attempted to get into R103's roommates' bed, R104 (a second female resident), and did not touch them. Review of a FRI (Facility reported incident), received by the State Agency on 11/06/25, revealed on 10/28/25, R104 reported R108 came into their room, attempted to get into their bed, and then exposed and fondled themselves next to her in her room. On 11/05/25 at 11:15 a.m., R104 reported a resident-to-resident incident during an interview, which revealed R108 attempted to climb into her bed about a week prior, when R104 was in her bed. R104 said she yelled at R108 to stop, and then R108 stood about four feet away from their bed and exposed and fondled himself. R104 described R108 wearing only a T-shirt when the incident occurred. R104 stated they pushed their call light for assistance, which took five to ten minutes to be answered. R104 reported six staff came into the room, including Licensed Practical Nurse (LPN) E. R104 said the incident made her feel scared when it occurred. On 11/05/25 at 1:25 p.m., Social Worker (SW) B reported they learned there was an incident when they were off work recently, when R108 was taking his clothes off and was going into patient's rooms and was attempting to get into bed with female patients. SW B said R103's daughter learned of it and described to them a male patient was taking his clothes off and masturbating and said they did not know his name. SW B shared Family Member C told them this on 10/27/25, as well as R104, but said they could not recall what R104 told them exactly. SW B reported they notified the Director of Nursing (DON) about the incident. SW B indicated R104 was a credible reporter. Review of R108's Provider Psychiatry note, dated 10/30/25 at 12:43 p.m., revealed, .(R108) is alert and oriented x 2 (spheres) with intermittent episodes of confusion and able to make his needs known. Behavioral concerns have emerged since the last visit with no identified trigger x 1. (R108) has been displaying sexually inappropriate behaviors towards patients and staff, has been getting into the beds of other residents, and has episodes of combativeness. UA (urinalysis) was collected and negative.Review of R108's SW B's progress note, dated at 10/29/25 at 12:36 p.m, revealed, SW follow up 2/2 (secondary to) reports of (R108) displaying inappropriate sexual behaviors.Review of R108's Care Plan showed a behavioral Care Plan 10/29/25, which showed R108 wandered into other residents' rooms, made sexual remarks and found unclothed. On 11/06/25 at 11:12 a.m., CNA H reported they witnessed an incident perpetrated towards R108 towards R103, R104's roommate, on 10/28/25. CNA H described R103 observed R108 in their room in R103's bed, sitting with his pants off, while R103 stood by their bed. R103 then popped R108 in their head with her house shoe, and they pulled R103 away from R108, as R103 was upset R108 was in their bed. R103 reported CNA L assisted them removing R108 from the room, and LPN E was in the room as well. On 11/07/25 at 9:33 a.m., the Nursing Home Administrator (NHA) acknowledged the concerns related to R108 being found without their brief on R103's bed, with CNA L in their room. The NHA denied staff awareness of the exposure incident of R108 towards R104.The NHA reported during their investigation they discovered CNA L and LPN E were aware R108 had been disrobing in his bed and in the facility prior to the incident. The NHA said they should have been made aware so they could have put appropriate interventions in place. The NHA reported they concluded no contact was made between R108 and R103 and R104, although R103 shewed R108 away with a shoe, but denied any physical contact was made. The NHA reported the incident(s) to the State Agency and the police on 11/06/25, after learning about the incident(s). On 11/07/25 at 12:22 p.m,. CNA L was asked during a phone interview about any resident incidents with R108. CNA L reported on 10/28/25 around 2:00 p.m., they had just finished rounds and heard a coworker yell for them to come to R103 and R104's room. They observed R108 in their room, standing by the curtain area (middle of room), looking confused with their pants down and brief removed. CNA L reported R108 then sat on R104's bed, and R103 approached R108, who became combative, and R10 began shewing him away with their house shoe. CNA L reported LPN E and CNA H were present when the incident occurred. Review of a police report, dated 11/06/25, revealed on 11/06/25 at 5:08 p.m., a suspicious circumstances incident was determined, when the NHA reported an incident on 10/28/25, when R108 walked into R104's room, opened his gown, dropped his underwear, and began fondling himself. Review of the policy, Abuse, updated 5/24/2023, revealed, .Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.The facility will develop and implement written policies and procedures that include: Reporting any allegations of abuse, neglect, mistreatment, exploitation.including reporting a reasonable suspicion of a crime to the State Survey Agency and other officials in accordance with state law.Initial reporting: The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source.and crimes are reported immediately to the Administrator and: Reported to the State Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement when applicable, OR reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials.Assuring the reporters are free from retaliation or reprisal. Conclusion reporting: The facility will ensure the results of the investigation are reported to the Administrator and a final report will be submitted to the State Survey Agency no later than five working days after the discovery of the incident. Any knowledge it has of any actions by a court of law which indicate an employee is unfit for service is reported to the State nurse aide registry or licensing authorities.

This citation is based on complaint: 2655900. Based on observation, interview and record reviews the facility failed to provide adequate supervision for a resident with medical issues and physical limitations which makes client unsafe to leave the facility alone and cognitive function and awareness concerns, for one (R105) of four residents reviewed for supervision/accidents. This resulted in the facility's failure to ensure the necessary supervision for R105 was provided. Findings include:A review of a complaint submitted to the State Agency (SA) documented concerns of R105 to have eloped from the facility. A review of the medical record revealed R105 was admitted to the facility on [DATE] with diagnoses that included: unsteadiness on feet, dysphagia, anxiety disorder, chronic obstructive pulmonary disease, hypertension and alcoholic cirrhosis of liver. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. A review of a Physician Statement of Capacity for Medical Treatment and Decisions documented R105 . lacks the capacity to make reasoned medical decisions and/or provide informed consent for their medical affairs. The specific cause and/or contributing diagnosis to support this decision. signs & symptoms involves cognitive function & awareness . The capacity assessment was signed by the attending Physician on 8/1/25 and signed by a second clinician on 8/3/25. On 11/5/25 at 12:04 PM, R105 was observed sitting in bed watching his cellphone. When asked about him leaving the facility, R105 stated . I got out. I missed my family. I went down the street and all the staff grabbed me and came back.A review of the medical record revealed no documentation of R105 to have eloped from the facility. Review of the Physician orders revealed the following: . Start 8/19/2025. Resident to wear wander alert bracelet. Every shift check placement on resident. Document placement RA=right arm, LA=Left arm, RL= right leg, LL= left leg, OTH=other AND every night shift check function of wander guard. If not functioning please place new wander guard and enter expiration date. End Indefinite. This order was created by the Director of Nursing (DON). A review of R105's care plans revealed an Exit seeking / elopement risk related to: cognitive loss implemented on 8/19/25. A review of a Elopement Risk Evaluation assessment dated [DATE] at 4:01 PM, documented a score of 16. The evaluation noted . If elopement evaluation score is 12 or greater the resident is considered and <sic> elopement risk.A review of the progress notes revealed the following: On 7/30/25 at 3:32 PM, a Social Work (SW) note documented, . Referral made to (behavioral group name) and (third party company name) for competency eval (evaluation) and petition for guardianship. SW (social worker) to follow up and review.On 8/1/25 at 12:00 PM, a Psychology Note documented, . I certify that my clinical findings support that this client. is facility bound due to: medical issues and physical limitations which makes client unsafe to leave the facility alone and illness requiring supportive devices/special transportation/assistance of another person in order to leave their residence. Facility SW requested psychologist to evaluate mental health, cognition, and determine capacity to make reasoned medical decisions and provide informed consent.On 10/11/25 at 11:03 AM, a Nurse Practitioner (NP) note documented, . discharge was cancelled. This is likely due to patient being deemed incompetent making medical decisions. Chart updated to noted that patient will be here long-term.On 10/13/25 at 10:39 AM, a Social Work note documented, . Guardianship court hearing is scheduled for 10/22/25.On 10/17/25 at 11:46 AM, a Social Work note documented, . Resident is currently his own representative. GA (guardianship) hearing scheduled on 10/22/25. He has strong support from his sister.As of the date of survey (11/7/25- exit date), the facility had not updated the medical record regarding the guardianship hearing outcome. On 11/5/25 at 1:11 PM, the DON was interviewed and asked about their note regarding R105 to have a wanderguard placed on 8/19/25 and asked why an elopement assessment was completed on that date for R105. The DON replied the resident kept saying they wanted to leave. The DON was asked why the resident was unable to leave if they were their own responsible party and the DON stated they were told the resident had a guardian. The DON stated they were told R105's sister was the resident's guardian. The DON was then asked specifically if R105 eloped from the facility on 8/19/25 and the DON stated they would have to look into their notes. The DON was asked where their notes were documented, as the medical record contained no documentation of the resident to have left the facility unsupervised and the DON stated they keep notes in their office and requested to look into it and follow back up. At 2:03 PM, the DON returned and stated the resident did leave the facility when they were allowed outside to smoke, so a wanderguard was placed on the resident. The DON stated the resident currently is able to go out to smoke with the supervision of a staff member, since the incident on 8/19/25. The nurse assigned to R105 at the time of the incident was identified as Licensed Practical Nurse (LPN) P. LPN P was interviewed on 11/6/25 at 8:42 AM and asked if they remembered the incident with R105 to have left the facility unsupervised and LPN P stated they did. LPN P stated that residents who smoke get LOA (leave of absence) passes. LPN P stated they believed it was the front receptionist that called them that day to inform them that R105 was walking away from the facility. LPN P stated they went to retrieve the resident with Unit Manager (UM) Q, who was no longer employed at the facility. On 11/6/25 at 10:08 AM, UM Q was interviewed and asked about the incident with R105 to have left the facility unsupervised and stated R105 would go outside to smoke. UM Q stated they received a call telling them that R105 was walking up the street. UM Q stated they got in the car with LPN P and drove around to find R105. UM Q stated they found R105 and got them into the car and brought them back to the facility. UM Q stated R105 could only go out to smoke with the supervision of a staff member after the incident. When asked, UM Q stated they were not informed of R105 to have been deemed incompetent to make medical decisions until they were informed after the incident by the DON.On 11/5/25 at 2:17 PM, the Administrator was interviewed and asked about the incident with R105 and stated the resident signed themselves out LOA to go and smoke (the facility is not a smoking facility). The receptionist saw that R105 was walking and informed the staff. The Administrator stated . he was his own responsible party. The Administrator stated they directed staff to go and get R105. The Administrator was asked why they directed staff to obtain R105 to bring them back to the facility if they were their own responsible party and had signed out on a LOA, and the Administrator stated that R105 was their own responsible party at the time and they should have not brought the resident back to the facility.A review of a facility policy titled Leave of Absence revised 5/17/24, documented in part . Any resident who leaves the facility. will have a Leave of Absence order and be signed out on the Leave of Absence form at their nurses' station. A leave of absence may include but is not limited to: going to a medical appointment, a non-medical leave (such as going shopping, to a family gathering, a home visit etc.) going on a facility activity outing, etc. The resident must have a physician's order to go on a leave of absence. The physician may place parameters on the resident's leave of absence which may include whether the resident can take their medications with them on LOA. If the resident is their own responsible party, they may sign themselves out on the Leave of Absence Form. If they cannot make their own decisions and has a legal representative, the representative signs the resident out on the Leave of Absence Form.A review of R105's record revealed no physician's order ever implemented for a leave of absence.On 11/6/25 at 12:20 PM, the Administrator was recalled for a second interview and asked about R105 to be deemed to lack the capacity for medical treatment and decisions per the capacity document that noted cognitive function and awareness concerns. The Administrator was asked why they considered R105 to be their own responsible party when they were deemed to lack the capacity for medication treatment and decisions as of 8/3/25. At that time the Administrator acknowledged the concern. The Administrator was then asked how the facility allowed R105 to leave on LOA when they did not have a physician's order as noted in their policy and the Administrator acknowledged the concern. At 1:17 PM, the Administrator returned and stated interventions were put in place (staff accompanying resident for smoke breaks) once the incident with R105 and at the time they believed R105 were their own responsible party as a guardian had not been assigned to R105 at the time of the incident. When asked about the current status of R105's guardianship, the Administrator stated they were informed that R105's sisters were appointed guardianship over R105, however they were waiting for the documents to be sent to the facility. No further explanation or documentation was provided.

This citation pertains to Intake 2597366Based on interview and record review, the facility failed to ensure appropriate supervision was provided to a resident for one (R303) of two residents reviewed for transportation resulting in R303 being sent multiple times to medical appointments with no staff supervision. Findings include:A complaint was filed with the State Agency (SA) that alleged in part, .On 8/14/2025. (R303) was sent to the appointment and left in the lobby of the doctor's office without any caretaker from the facility.Review of the clinical record revealed R303 was admitted into the facility on 4/11/25 and readmitted [DATE] with diagnoses that included: dementia, convulsions and blindness right eye. According to the Minimum Data Set (MDS) assessment dated [DATE], R303 had moderately impaired cognition. The clinical record also indicated R303 had a Durable Power of Attorney (DPOA) that was the Responsible Party for financial and medical care.Review of a Physician Statement of Capacity for Medical Treatment and Decisions read in part, lacks the capacity to make reasoned medical decisions and/or provide informed consent for their medical affairs. The specific cause and/or contributing diagnosis to support this decision: impaired insight, impaired reasoning, impaired thinking and memory. It was signed by a Physician/Licensed Psychologist on 3/25/25 and Attending Physician on 3/26/25.Review of R303's physician orders revealed an order with a start date of 8/14/25 that read in part, PATIENT HAS AN APPOINTMENT ON THURSDAY AUGUST 14 @ 2:00 PM.Review of R303's Discharge Care Plan initiated 4/15/25 read in part, DPOA has decided that (R303) is appropriate for long term care placement, discharge plan is to remain long term for 24* care and/or supervision.Review of R303's physician consultation documents revealed a consult dated 7/30/25 that the consulting physician wrote, pt (patient) sent to office twice with no records, no information. She is not able to provide medical history. She does not know why she is here. Someone MUST (underlined) accompany here [sic] to appointments. On 9/4/25 at 12:05 PM, Unit Clerk (UC) F was interviewed and asked who arranged the transportation to appointments at the facility. UC F explained she made the appointments and arranged the transportation. UC F was asked if residents always were sent by themselves or did a staff member accompany them to appointments. UC F explained up until a couple weeks ago, they had been told staff did not accompany residents to appointments, now if the resident is incompetent a staff member goes with them. UC F was asked how it was determined if a resident was incompetent. UC F explained she would go talk to the resident or ask staff if the resident was competent. UC F was asked if R303 went to appointments alone. UC F explained R303 was sent alone.On 9/4/25 at 12:15 PM, Unit Manager (UM) C was interviewed and asked if residents went alone or were accompanied by staff on appointments. UM C explained it depended, if the resident was competent they could go alone. When asked about R303, UM C explained she could not say and would need to talk to the Director of Nursing (DON).On 9/4/25 at 12:17 PM, the DON was interviewed and asked about R303 being sent to appointments alone. The DON explained she had thought R303's family was going to meet her at the appointment. The DON was asked if the facility had its own transportation van with a staff member that drove it. The DON explained they did not, they used different companies that provided wheelchair transportation. The DON was asked if R303 could go on a Leave of Absence (LOA) by herself. The DON said no. When asked why was R303 allowed to be put in a transportation van by herself and leave the facility with no staff accompaniment, the DON acknowledged the concern. On 9/4/25 at 1:13 PM, the Administrator was interviewed and asked about R303 having a care plan for 24-hour care and/or supervision but was sent to multiple appointments via a transportation van by herself with no staff accompaniment. The Administrator acknowledged the concern.

This citation pertains to Complaint #2596436Based on interview and record review the facility failed to ensure timely medical appointments and debridement treatments were implemented to prevent the worsening of a wound for one (R302) out of two residents reviewed for pressure ulcers/wounds resulting in R302 being hospitalized for additional care. Findings include:A complaint was filed with the State Agency (SA) that reported that R302 was scheduled to see their wound surgeon for treatment and the facility sent them to the wrong office. R302 then had to wait another week to see the wound surgeon. On 8/7/25 the wound surgeon examined them at their office, and they immediately sent them to the hospital.Hospital Records were reviewed and documented in part, .(name redacted) Emergency Department 8/7/25.History.R302.presents with evaluation of right foot wound. Patient underwent amputation with Dr. Z 7 weeks ago due to gangrene of his right fifth toe.Patient was seen by Dr. Z today (8/7/25) for wound care. There was concern for further necrosis and infection and patient was sent today for further evaluation. He has been taken to the operating room for debridement and possible 4th toe.amputation.8/8/25.Patient does not speak English.Patient has missed appointments but was seen at the Wound Center yesterday and due to extensive necrosis of the wound it was advised that the patient present to the hospital.the fifth metatarsal was debrided and the right forth toe was amputation <sic> and the head of the right fourth metatarsal was resected, the fifth toe had been amputated on a previous surgery.8/9/25.Patient having pain to right foot relieved with doses of dilaudid. Wound vac in place.Outcome evaluation: Pt AxOx4 (patient alert and oriented to person, place, time and situation), speaks Korean, CyraCom (interpreter) used for explaining discharge.Plan: start vancomycin 1250 mg (milligrams) q (every) 12 hours and Zerbaxa(antibiotic) .culture growing MDR (Multidrug resistant infection) Pseudomonas osteomyelitis (bone infection) and MRSA (Methicillin resistant staphylococcus aureus).A review of R302's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Gangrene, acquired absence of other right toe and orthopedic aftercare following surgical amputation. A review of the residents Minimum Dat Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15.Continued review of R302's clinical record noted the following:6/23/25: Wound Consult: .Patient reports having had infection and drainage in right toes resulting in hospitalization. It <sic> was totally there for 2 weeks and ended up having amputation as well due to osteomyelitis. Patient is currently on IV (intravenous) ABX (antibiotics).wound benefit from continued rehab.6/23/25: Nursing Skin/Wound Note: .R (right) foot surgery 5-digit amputee, 6 sutures.see.assessment for measurements.7/1/25: Administration Note: Wound Care Order Site: Right 5th digit.Cleanse wound with NS (normal saline) .Pat Dry with Gauze.Apply betadine.Cover with ABD (large abdominal dressing).Wrap in kerlix.Tape7/6/25: Wound Consult: .Skin.Right dorsum fifth digit toe amputation site arterial/surgical wound, 3x5 x2.8 x1.1.100% granular.light serosanguineous drainage.no infection.Cleanse area, dry, apply iodine, cover with ABD, wrap with Kerlix, secure with tape daily. Offloading interventions implemented. Wife at bedside updated on wound status/treatment.7/14/25: Order: .Follow-up consult.Patient will need STAT follow-up.initially ordered on 6/24 for 1-2 weeks. *It should be noted that there were no documents that noted R302 was seen by wound consultant within the two-week order.7/17/25: After Visit Summary: R302.7/17/25: 2 PM.Address A.Instructions: Return in about 2 weeks (around 7/31/25).Dressings: Right foot wound.Betadine to gauze, apply to wound cover with 4x4 gauze wrap with kerlix, affix with tape.Sutures removed.Today.Return visit in 2 weeks 7/31/25).7/25/25: Nursing Skin/Wound: Writer contact daughter for wound care concerns regarding pt (R302) waiting for a call back. Authored by Nurse I.7/25/25: Order: Wound care order site - Right foot 5th digit.cleanse wound with NS.Pat Dry with Gauze.Apply Medihoney to wound bed.Created by: Nurse I (7/25/25).Signed by Physician L on 8/6/25.7/30/25: Nursing Skin/Wound: .wound care education was preformed and given with daughter at bedside, writer explain all instructions to family and told them pt. attempts to do is own wound care tx (treatment) and is delaying process of healing, family understood and talk to pt to re direct Him, pt see wound clinic tomorrow 7/31 and writer will follow up.7/31/25: Wound Consult: .Right dorsum fifth digit toe amputation site.3.5x2.8x1.1, 100% granular peri wound, lift serosanguineous drainage.7/14: Continue Vanco (*It should be noted that R302 never received Vanco while at the facility. No order was found in the clinical record).Also indicate that patient will need to see podiatry for wound care and debridement.[electronic medical record] indicates the patient has an appointment with wound clinical today (7/31/25) today at 2:15 (PM). Authored by Nurse Practitioner (NP) M .*It should be noted that R302 never made it to their appointment on 7/31/25 at 2:15 PM.8/3/25: Wound Consult: .Psychiatric: Not agitated, Appropriate affect, mood, judgement and insite (sic).having significant discoloration in remaining toes.Right dorsum fifth digit toe amputation.wound 6.4 x 3.4 x UTD (unable to determine), 90% slough, 10% eschar. 6/24: need for follow-up with (Dr. Name Redacted), podiatry.7/8: Patient has an appointment with infections disease on July 24.7/14: Stable, Continue Vanco dosing per pharmacy.Patient was able to follow-up with Dr. K podiatry/wound on 7/17. Wound care orders provided including dressing changes daily, Betadine to gauze, apply to wounds, cover with 4x4, wrap with Kerlix.Indicate that sutures were removed in clinic. Orders to elevate leg to control swelling.Revisit in 2 weeks, approximately 7/31.8/6/25: Progress Note: .7/14.Continue Vanco, dosing per pharmacy.Patient was able to follow-up with Dr. K podiatry/wound care on 7/17.7/31: patient will need to see podiatry for wound care and debridement.Pt has appointment today at 2:15 PM.8/6: Attached documents reviewed. do not see follow-up notes from podiatry (*It should be noted that R302 was not seen by podiatry on 7/31/25).8/7/25: Nursing Progress Note: Writer notified per Dr. K that resident was sent to ER (emergency room) r/t (due to) wound concerns.Care Plan: Focus: Amputation of right pinky toe r/t gangrene (date initiated 6/21/25).Interventions/Tasks: Administer treatment per physician orders (6/21/25).Report evidence of infection such as purulent drainage, swelling.etc. (6/21/25).Focus: Resident chooses not to agree with plan of care, may be resistive, refuse, or non-complaint with care or treatment as evidenced by pt removed and completed tx by himself causing wound delay (7/11/25).Interventions: Encourage verbalization of needs, fears, concerns, and allow resident to express self.Notify physician if behaviors/non-compliance interferes with resident's basic medical needs.On 9/4/25 at approximately 11:22 AM, an interview was conducted with Wound Nurse (WN) H. WN H reported they started employment as a wound nurse in May 2025. WN H was queried as to R302's treatment and failure to ensure they were followed up by the surgical podiatrist . WN H reported that they work with WN I and noted that they were not that familiar with the resident and was not able to provide additional information. They noted WN I might be more familiar with the resident.On 9/4/25 at approximately 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if they were aware that R302 was taken to the wrong office on 7/31/25. They reported they were aware R302 should have been seen but were not certain why they were sent to the wrong office. The DON was asked who arranged for the transportation to office and they noted that Unit Clerk (UC) G generally schedules transportation. The DON was then asked if they were aware that R302 attempted to do their own wound care and as such it was noted that it was delaying the healing process. The DON reported that R302 had a language barrier and believed attempts were made to educate the resident via their daughter. The DON reported that the facility staff are able utilize MARTTI ( My Accessible Real Time Trusted Translator) however, they did not believe staff utilized the system. The DON was asked if they were aware if R302 was supposed to start the antibiotic Vanco on 7/14/25 as written in NP Ms notes. The DON noted that there were no orders for Vanco and the written statement to remain on Vanco was most likely written in error.An attempt to contact NP M was made on 9/4/25 at approximately 1:26 PM. A message was left, and no return call was received.On 9/4/25 at approximately 1:38 PM, an interview was conducted with UC 'G. UC G was asked about the error in scheduling for R302. UC G reported that they were instructed to send R302 to see the outside Doctor K and noted the order documented to send them to location A. They arranged the transportation and later found out that R302 should have gone to location B. They then reset the appointment for 8/7/25.On 9/4/25 at approximately 3:38 PM, a phone interview was conducted with Wound Nurse (WN) I. WN I was queried as to the wound care provided to R302 and one week delay in him seeing their outside wound surgeon, Dr. K. WN I reported that they worked with WN H, and both had been assigned to R302, and they did not believe they were the person who indicated the wrong address to send the resident. When asked about R302's wound to the right 5th digit, they noted that the residents' wound was declining from the time of entry to the facility until their discharge. WN I noted that treatments were implemented but the resident kept treating themselves as well. When asked if they were aware of what the treatment was, they indicated they were not certain but talked with R302's daughter regarding the self-treatment. WN I was asked if they utilized a translator via MARTTI and they noted they did not. WN I reported that they made a change in the treatment from betadine to Medihoney as noted in the clinical record and reported again that due to the residents decline in healing, they attempted a new treatment.The facility policy titled, Skin and Wound Guidelines (revised 3/30/34) was reviewed and documented, in part: .Policy Overview: To describe the process steps to.identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations.Skin Alterations.Weekly evaluation n of skin alterations.The individualized comprehensive care plan addresses the resident's problem .the goal for prevention and/or treatment and individualized interventions to address the resident's specific risk factors and plan for reduction of risk.The facility policy titled, Change in Condition Policy (10.2022).Policy: It is the policy of this facility that residents will be routinely monitored and evaluated by all staff members to determine the need for additional health services.Observations or Changes of Condition could indicate the need for additional health services or monitoring.seems different than usual.Change in skin color or condition.

R303 Review of the medical record revealed R303 was admitted to the facility on [DATE], with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture, pulmonary hypertension and heart failure. A Minimum Data Set (MDS) assessment dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 15 (which indicated intact cognition). A review of a Nursing note dated 1/8/25 at 9:00 PM, documented in part . Patient observed sleeping in chair when writer attempted wake patient, she had a delayed response which was different from our morning interactions. Writer checked her BP (blood pressure) it was 90/44, writer then checked her blood sugar it was 49 (normal is above 70). Writer assisted CNA (certified nursing assistant) to help patient into bed and elevated her feet. Writer gave the patient orange juice and chocolate candies she had in her room. Her blood sugar went up to 70. Writer attempted to get the patient to eat dinner she ate a small portion and but was still slightly lethargic . Unit manager notified. Monitoring ongoing . There was no documentation of the Physician to have been notified. Review of a Nursing note dated 1/11/25 at 6:53 PM, documented in part . Patients family requested to take pt (patient) out AMA (against medical advice) rt (related to) cardiac issues. After speaking to DON (Director of Nursing) family agreed to have labs ordered and EKG (electrocardiography) in house. Labs drawn, urine sample collected and EKG ordered. Review of the Physician orders revealed an EKG order was not implemented until the next day on 1/12/25 at 7:43 AM, that documented . EKG Symptom(s): CABG (coronary artery bypass grafting) Condition of patient that requires the exam to be performed portably . STAT (immediate) . The order was created by the DON. A review of the record revealed the STAT EKG was not completed and the resident was transferred to the hospital on 1/12/25 at 6:40 PM, for respiratory distress. A review of the record revealed no documentation from the clinical staff regarding the cardiac concerns documented in the 1/11/25 Nursing note. A review of the Pulse Summary noted the following: On 1/10/25 at 10:12 PM- 53 bpm (beats per minute) On 1/9/25 at 1:18 PM- 58 bpm (normal is above 60) A review of the Blood Pressure Summary noted the following: On 1/6/25 at 5:02 PM- 120/48 mmHg (millimeters of mercury) On 1/7/25 at 9:26 AM- 107/55 mmHg On 1/7/25 at 1:37 PM- 92/43 mmHg On 1/7/25 at 5:49 PM & 7:26 PM- 112/60 mmHg On 1/8/25 at 5:27 PM- 90/44 mmHg On 1/9/25 at 12:06 PM- 94/52 mmHg On 1/10/25 at 12:55 PM- 89/55 mmHg On 1/10/25 at 2:27 PM- 90/62 mmHg On 1/10/25 at 7:15 PM- 84/57 mmHg On 1/10/25 at 10:22 PM- 101/50 mmHg These are all noted deviations from R303's baseline. The record revealed no documentation of the Physician to have been notified. Review of a facility policy titled Change in Condition policy dated 10.2022 documented in part . It is the policy of this facility that residents will be routinely monitored and evaluated by all staff members to determine the need for additional heal services monitoring of chronic, unstable, or changes in condition. Results of additional monitoring will be routinely evaluated for appropriateness and effectiveness . Observations or Changes of Condition could indicate the need for additional health services or monitoring . Seems different than usual . Tired, weak, confused, or drowsy . When a change in condition has been identified, the physician team will be called for direction . A Nursing note dated 1/12/25 at 7:39 PM, documented in part . Patient transferred to hospital via ambulance at 18:40 for respiratory distress . A review of the hospital records revealed the following: A Emergency Medicine consult dated 1/12/25 at 8:07 PM, documented in part . presents to the Emergency Center today with a chief complaint of SOB (shortness of breath). Patient has had worsened SOB and fatigue over the last one week, with some confusion over the last week . She does not wear home oxygen and is on 4 L (liters) NC (nasal cannula) here . A General Medicine consult dated 1/13/25 at 4:33 PM, documented in part . She came to the ER due to shortness of breath and hypoxia. Does not wear home oxygen. The patient reports having shortness of breath and fatigue for the past week. There has been some confusion over the past week as well per family . She has significant swelling in her legs and abdomen. There is abdominal discomfort. Patient also stated that she had difficulty making urine for the past week and had little urine output . None of the above signs and symptoms were identified or documented by the facility staff. On 6/25/25 an interview was conducted with the DON. The DON was asked what cardiac issues R303 was experiencing as noted in the Nursing note on 1/11/25. The DON stated they were not sure but would look into it and follow back up. The DON was asked why the STAT EKG was ordered on 1/12/25 and asked if it was completed. The DON stated they would look into it. At 2:20 PM, the DON returned with a radiology requisition dated 1/11/25 for an EKG to be completed due to shortness of breath. The DON was asked again what signs and symptoms R303 was experiencing at that time. The DON was also asked about the indication of having shortness of breath identified by the staff on 1/11/25 considering the resident had to be transferred to the hospital on 1/12/25 due to respiratory distress. The DON stated they were unsure of the signs and symptoms R303 exhibited. The DON did not provide documentation of the EKG to have been completed or the results. No further explanation or documentation was provided by the end of the survey. This citation pertains to intake(s): MI00153566. Based on interview and record reviews, the facility failed to identify a change of condition, notify the Physician, ensure the appropriateness of antibiotics and ensure continuous monitoring, assessment and follow-up for two (R's 302 & 303) of three residents reviewed for a change of condition, resulting in an untreated urinary tract infection (UTI) that developed into septic shock secondary to UTI and Pneumonia and resulted in death (R302) and delayed treatment and transfer to a higher level of care (R303). Findings include: Clinical record review revealed R302 was admitted to the facility on [DATE] for further rehabilitation to improve strength and balance related to an unwitnessed fall at home resulting in lower spinal fractures, rib fractures and rhabdomyolysis (serious condition when lying in a position too long results in skeletal muscle break down and releases toxins into the blood and kidneys). R302 required a Foley catheter (indwelling catheter to drain urine from the bladder) while hospitalized related to their history of aggressive infusion of intravenous fluids related to their dehydration and history of urinary retention. R302 arrived to the facility with a condom catheter (external urine catheters applied like a condom) placed by the hospital. The Brief Interview of Mental Status (BIMS) assessed from 3/28/25 and 5/10/25 scored 15/15 indicating R302 was cognitively intact. On 6/27/25 at 9:39 AM, an interview was conducted with the sibling who filed the allegation (the complainant) and confirmed on Sunday morning 5/25/25 they called the facility concerned they had not heard from R302 in two days which was not normal. Per the sibling complainant, there is a five-hour drive distance between them, but were very close and would text and or converse daily. Unable to contact R302 the day prior, the sibling proceeded to contact the Facility's main number on the morning of 5/25/25 and spoke with a Nurse (unable to recall name) who commented R302 had not eaten in the last two days. While on the phone with the Nurse, it was found R302 had the phone turned off. The Nurse asked what the pass code was, accessed the phone, and instructed to call R302 back and left the room. The sibling said once on the phone with R302, I knew something was not right R302 .sounded weak, had slurred speech, could not understand what they were saying and could hardly speak . I knew R302 was in bad shape and immediately called the facility back and informed the Nurse that R302 sounds very bad, they cannot talk, sounds very weak. The Nurse replied they were in the middle of passing morning medications for 14 Residents and did not have time to send R302 out. The sibling complainant said they would call 911 themselves if the facility would not. The interview proceeded to reveal there was concern when R302 was to follow up with a Urologist back in April and was informed the appointment was not scheduled until May 29, 2025, and recent days prior to the 5/25/25 of having throat pain. A Medical Progress Note dated 4/1/25, authored by Medical Director (MD) F documented R302 was assessed for urinary retention greater than 600 milliliter (ml) and required straight catheter (insertion of tube into the bladder to drain urine, then removed after bladder emptying). Further record review revealed R302 had informed MD F urinary retention happens frequently, especially when after being hospitalized , and MD F ordered to consult with Urology. The Medical Progress note dated 4/2/25 authored by MD F documented R302 was calm, alert and orientated, in no distress but insisted on being evaluated for a Urinary Tract Infection (UTI) related to complaints of .was up peeing all night . and had bladder disease. R302 was adamant going to the hospital to be evaluated for Intravenous (IV) Antibiotics and seen by their Urologist. R302 was sent to the Emergency Department (ED) on 4/2/25 for further evaluation per their request. Record review from the ED discharge from 4/2/25 documented R302 was seen for urinary retention and was to follow up with Urology within three to five days. Record review of the 4/4/25 Progress Note from the Facility Provider documented R302 was to consult with Urology for urinary retention within three-seven days. Further record review revealed not until 4/24/25 was a Urology Consult scheduled and would not be seen until May 29, 2025. On 6/25/25 at 2:23 PM, an interview with Unit Manager LPN C was queried about the process for assuring Resident consultations are scheduled. LPN C replied once a Provider enters the order, Nursing must confirm, print the order, then forward to the unit clerk to schedule. On 6/25/25, the Director of Nursing (DON) was informed the original order from the Facility identified on 4/4/25, R302 was to follow up with Urology within three-five business days, and the first attempt of the follow up was not acknowledged until 4/14/25. Furthermore, the DON was informed that not until 4/24/25 was an appointment confirmed and scheduled for R302 to see a Urologist, which was not until 5/29/25. The DON proceeded to provide an email dated 4/14/2025 at 11:08 AM, the facility was waiting on the doctor's office to call back with a date and time for Urology appointment and had no further comment why this appointment had such a delay in scheduling. Record review of a Nursing Progress note dated 5/6/25 at 2:00 PM documented Nursing observed hematuria (blood in urine) in the resident's brief, and they expressed concerns of pain while urinating and Nurse Practitioner (NP) B was made aware of the situation. Progress notes from 5/8/25 authored by NP B documented .Urinalysis came back positive for infection. Patient started on Keflex . (brand name for Cephalexin an antibiotic). On 5/8/25 a 11:43 AM .Note Text: The system has identified a possible drug allergy for the following order: Cephalexin 500 milligram (mg) give one capsule my mouth three times a day for a UTI for 7 Days . Review of the Medication Administration Record (MAR) documented on 5/8/25 start Cephalexin 500 milligram (mg) give one capsule my mouth three times a day for a UTI. The MAR documented administration of the medication on 5/9/25 at 9:00 AM and 5/9/25 at 1:00 PM. Review of the MAR revealed Macrobid (generic for Nitrofurantoin an antibiotic) 100 mg give one capsule by mouth two times a day for UTI for 5 days. The MAR confirmed full administration of the antibiotic was started on 5/8/25 and completed on 5/13/25. Record review of the Urine Culture and Sensitivity reported on 5/9/25 at 11:05 AM, identified the organism present in R302's urine was Proteus Mirabilis which was resistant to the antibiotic Macrobid (Nitrofurantoin) which indicated this treatment was ineffective in treating R302's UTI. On 6/25/25 at 3:54 PM, an interview by telephone was conducted with NP B and when inquired about overseeing R302's medical care, NP B remarked they were not in front of their computer but recalled R302 had a complicated urinary history and mentioned retention and hematuria. NP B was queried about R302's antibiotic regimen and was unable to recall the specific details. When informed that R302 was started on the antibiotic Macrobid (Nitrofurantoin) on 5/8/25 and the urine culture and sensitivity reported on 5/9/25 confirmed Macrobid (Nitrofurantoin) was resistant to the infection, no comment was made by NP B. When questioned why an ineffective antibiotic for this specific infection remained ordered and administered, NP B had no comment. The DON was interviewed and confirmed laboratory results are posted daily from a dashboard and that themselves, the Infection Control Nurse and Nurse Unit Managers are responsible for reviewing. When inquired how review of R302 culture and sensitivity from 5/9/25 was missed, the DON requested to look into the concern. The DON returned moments later and acknowledged they personally signed off on this. When questioned what signed off meant, they replied this was discussed with NP B and because R302 and was no longer having signs and symptoms of infection, they felt it was appropriate to keep them on the antibiotic Macrobid (Nitrofurantoin). Record Review from Progress note from 5/22/25 at 3:47 PM by Social Worker (SW) G documented during a wellness visit for R302, .He stated he has a sore throat right now. Nurse notified . further record review did not reveal Nursing addressed the sore throat. Record review from an Alert Progress note from 5/23/25 at 9:12 AM by LPN C documented R302 .pt <sic> is so sad. HE <sic> said he wants to home. --NURSING WILL HAVE PSYCH F/U <sic> . On 6/25/25 at 2:23 PM, an interview with Unit Manager LPN C was queried about why there are Progress Notes and additional notes titled Alert Note. LPN C replied any staff member can make an Alert Note if they feel there is something very important and needs to be addressed. When asked why the Alert Note identifies them (LPN C) as the creator of the note, LPN C replied they were not, they just reviewed the Alert Note and the entered the follow up portion . --NURSING WILL HAVE PSYCH F/U <sic> . When asked who originated the Alert note, LPN C said there is no documentation available who was the original creator. When asked if there was an urgency that warranted the staff to create an Alert Note and they are unable to know who found it be an alert, how do you follow up to triage the urgency, LPN C abruptly replied they have 45 residents to oversee on a daily basis and cannot remember specifics on all Residents and Alert Progress Notes don't necessarily stand out. Record review of the CNA (Certified Nurse Assistant) Nutrition Task revealed on 5/23/25 and 5/24/25, R302 was not eating as reported by the sibling complainant on 5/25/25 when they spoke with a Nurse (unable to recall name) who commented R302 had not eaten in the last two days. On 6/25/25 at 3:30 PM, a telephone interview was completed with LPN A who acknowledged they were familiar with R302 since admission to the rehabilitation unit. LPN A recalled the events of that morning of 5/25/25 and confirmed they were the Nurse assigned to R302. When asked why they sent R302 to the hospital, they replied because the sibling was yelling so loud over the phone about sending them, I recruited all the staff to help me transfer. When asked what the sibling was saying they mentioned something about him not eating for two days. When asked if a there was assessment done on R302, they recalled they took the vitals, but no further assessment was completed. LPN A said another nurse called EMS (Emergency Medical Service), a third nurse printed off paperwork, EMS arrived, and they notified the DON and Medical Provider. When asked what the specific change in condition was, LPN A commented nothing was abnormal about R302, they just sent them because the sibling was concerned, they had not eaten in two days and if I didn't send them, they would call 911. LPN A remarked nothing was abnormal with R302. Nursing Progress Note from 5/25/25 at 10:41 AM by Licensed Practical Nurse (LPN) A documented the Resident's family requested R302 be sent out to hospital for change of a condition. The Resident was sent out to hospital at 10:20AM . Hospital Records were reviewed and documented on 5/25/25 at 11:04 AM, R302 arrived with Emergency Medical Service (EMS) and reported R302 had right sided weakness, facial droop, slurred speech, throat pain, and difficulty swallowing. Per EMS, the staff at the Extended Care Facility (ECF) reported last seeing R302 well two days ago .and the ECF staff reportedly seemed unconcerned about patient mental status, but patient is known to ED nurse at bedside who states patient is normally alert and orientated . Per EMS, upon arrival to the facility, R302's Blood Pressure (BP) was 90/40 (below normal), Oxygen level on room air was 82% (normal is 90-100%) and EMS had to apply to Six Liters (6L) of oxygen. Patient is confused. Arousable to voice. Follows basic commands. After evaluation in the Emergency Department, R302 was diagnosed with a UTI and Pneumonia (infection in the lungs) with sepsis (devastating response to an infection leading to organ damage) required admission to the Intensive Care Unit (ICU) for intubation (insertion of an artificial airway). On 5/29/25 at 2:29 AM, R302 was pronounced dead. Record review of the Death Certificate documented the primary cause of death was Septic Shock secondary to UTI and Pneumonia (PNA) with the approximate onset of death within days.

This citation pertains to intake: MI00151683. Based on interviews and record reviews the facility failed to ensure consistency with the timely identification and reporting in changes in condition, ensuring accurate assessments and monitoring for a resident with an identified change of condition, ensure professional nursing standards of practice were consistently followed for medication administration, failed to ensure the implementation of a physician order for oxygen administration and intravenous therapy was administered, failed to ensure accurate and complete documentation of nursing skilled notes and failed to timely transfer to a higher level of care, for one R402 of four residents reviewed for a change of condition and resulting in multiple hospitalization s. Findings include: A review of the medical record revealed R402 was admitted to the facility on [DATE] with diagnoses that included: Fracture of right pubis, repeated falls, severe protein-calorie malnutrition, dysphagia-oropharyngeal phase, and abnormal weight loss. A review of a submitted complaint revealed on [DATE] the complainant was instructed by the facility that they had to sign an Against Medical Advice (AMA) for R402 to be transferred to the hospital due to concerns of the family identifying a change of condition with the resident. Further review of the complaint noted the continuous failure of the facility staff to accurately assess, monitor, report and treat identified changes in condition for R402. Review of the progress notes revealed the following: A Therapy note dated [DATE] at 10:32 AM, documented in part . SLP (Speech Language Pathologist) recently evaluated [DATE] . placed on mechanical soft diet per preference . Pt . requested further downgrade to puree to see if it would be easier for him to eat with fewer feelings of gagging. Pt continues to report lack of appetite and the thought of foods making him gag . Pt reports this happened before and he saw a GI (Gastroenterologist) who placed feeding tube . A Doctor of Osteopathic (DO) note dated [DATE] at 5:20 PM, documented in part . failure to thrive, dysphagia due to previous CVA (stroke) came in after a mechanical fall resulting in a right to pubis fracture . Patient was observed dry heaving . Patient reports poor appetite, unable to tolerate diet as he does not like the food being offered to him. He does report some dry heaving which has been present for the past 2 ,d+[DATE] weeks per his report. Check comprehensive blood work. Add Zofran as needed for 14 days . A Nursing note dated [DATE] at 12:37 PM, documented in part . S/w (spoke with) resident daughter (name) today . had concerns regarding her father because his girlfriend (name), had advised her that he ws aspirating and had an emesis episode. Writer checked on resident and spoke with him. Resident stated that he did not have an emesis episode and that he swallowed his pop too fast and coughed. (daughter name) wanted to know what the protocol was if she requested that her father is sent to urgent care. (daughter name) advised by the writer that is considered AMA. Writer did advise (daughter name) that resident is showing no signs of aspiration, and he currently calm laying in his bed. (Daughter name) was satisfied with the report that was given from writer and stated she was concerned because of the report that was given to her from resident girlfriend . A Nursing note dated [DATE] at 12:28 AM, documented in part . Resident unstable to standing . A Nursing note dated [DATE] at 8:52 PM, documented in part . resident unstable to stand . A Nursing note dated [DATE] at 2:05 PM, documented in part . Writer spoke with daughter (name). She expressed concerns that she and significant other feel resident has had decline neurologically and wishes resident to be sent to hospital . Writer assessed resident who was alert, able to make needs known and VS (vital signs) at baseline. Resident observed to be at baseline with no obvious symptoms of decline noted. Resident denies pain/discomfort at this time. Notified resident that daughter was requesting transfer, resident stated he was okay with whatever. Per MD (Medical Doctor), resident is table for continued care in facility and transfer will be AMA . Daughter uncomfortable with waiting . prefers resident to transfer to (hospital name) for further evaluation . resident sent to hospital via EMS (emergency medical services) . This note was documented by Unit Manager (UM) N. Review of the medical record revealed no nursing assessment/evaluation or vitals obtained for the resident for this period of time, despite UM N documentation of the resident to have been stable. A review of the hospital records revealed the following: A Emergency Medicine consult dated [DATE] at 3:57 PM, documented in part . present to the Emergency Center (EC) today with a chief complaint of AMS (Altered Mental Status) . They (EMS) state when he first arrived his blood pressure was in the 50s. They state he was also hypothermic and tried to warm him up in the ambulance with no improvement. The patient states he doesn't know how he got here or who called the ambulance . Patient is globally weak . Mucous membranes are dry . presents with hypotension and decreased p.o. intake. Patient with dry mucous membranes . with hypotension and unknown cause sepsis initially concern was started on broad-spectrum antibiotics . Patient had AKI (Acute Kidney Injury) continue IV fluids . Admission for continue monitoring . A Infectious Disease consult dated [DATE] at 11:03 AM, documented in part . presented to EC yesterday from his rehab facility AMS. They reported hypothermia. On arrival rectal temp 35.9 (96.6 F), other labs showed create 2.39, BUN 55 . he has been started on vanco and zosyn . Impressions . Hypotension . Hypothermia . Continue IV Zosyn pending further culture data . The review of the above initial presentation and assessment obtained by the EMS personnel and ER revealed an identified change of condition that the facility failed to identify and acknowledge. The facility staff failed to complete an assessment and obtain vitals to inform the Physician of an accurate status for R402. Review of a facility policy titled Changed in Condition policy dated 10.2022, documented in part . It is the policy of this facility that residents will be routinely monitored and evaluated by all staff members to determine the need for additional health services monitoring of . changes in condition . Observations or Changes of Condition could indicate the need for additional health services or monitoring . When a change in condition is identified , the physician team will be called for direction . Review of the medical record revealed R402 was readmitted to the facility on [DATE] with the instructions to stop taking losartan 100 mg (milligrams), stop potassium chloride 20 meq (milliequivalent), to change metoprolol succinate and to start dronabinol. A Physical Medicine and Rehabilitation note dated [DATE] at 8:01 AM, documented in part . in his wheelchair comfortably without complaints except for generalized fatigue and BLE (bilateral lower extremity) weakness. He continues to note the decreased appetite as feeling of gagging while swallowing . A Nursing note dated [DATE] at 11:22 AM, documented in part . spoke with daughter (name) regarding resident and concerns with oral food intake. Resident requesting peg tube placement . Daughter okay with peg tube . A Nursing note dated [DATE] at 5:54 PM, documented in part . Pt (patient) is failing to thrive. He isn't eating any of his food. Writer thought patient hasn't been eating due to increased confusion and attempted to feed pt and he vomited. DON (Director of Nursing) notified . There was no documentation of the DON's recommendation or documentation of the physician to have been notified. Review of the [DATE] Medication Administration Record (MAR)/Treatment Administration Record (TAR) and recorded vitals revealed the following: On [DATE] at 11:23 AM- R402's blood pressure was recorded at ,d+[DATE]. The morning dose of Metoprolol Tartrate 100 mg was held. The blood pressure was not obtained again before the administration of the resident's 9:00 PM administration of Metoprolol Tartrate for high blood pressure. On [DATE] the morning Metoprolol Tartrate was administered without a blood pressure obtained for R402. On [DATE] at 7:31 PM, the recorded blood pressure was ,d+[DATE]. Review of a RT (Respiratory Therapist) note dated [DATE] at 10:00 AM, documented in part . Resident seen this morning due to hypotensive episode, pulse ox on 2L (liters) NC (nasal cannula) 100%. Weaned to RA (room air) without incident. No respiratory distress noted by writer at this time. A review of the medical record reveal no documentation on why or when oxygen was applied to R402 (prior to the documentation of this note) and no physician order for the oxygen to be administered. Review of a facility policy titled Oxygen Administration dated [DATE], documented in part . Oxygen shall be administered using a physician's order unless there is an emergent need. In an emergency situation, the order is to e obtained by the physician after the resident is stable . A Nurse Practitioner (NP) note dated [DATE] at 10:11 AM, documented in part . Chief Complaint; Hypoxemia and tachycardia . Patient reports feeling yucky. Per nursing staff, his appetite has been very poor for the last few days . Oxygen in place . Temperature 96.8 blood pressure ,d+[DATE] heart rate 45 respiratory rate 16 02 saturation 90 on oxygen, 70 on room air . A Speech therapist Summary of Daily Skilled Services dated [DATE] at 3:48 PM, documented in part . Pt with increased confusion and low 02 (oxygen) with inability to get BP (blood pressure) via machine. Nursing notified who then informed unit manager, DON, RT, and NP who came to assess . Pt with increased confusion and difficulty following commands. Nursing notified and addressed . A Nursing note dated [DATE] at 3:57 PM, documented in part . Patient observed with low blood pressure ,d+[DATE] heart rate 115. Writer placed patient on ,d+[DATE]L of 02 (oxygen) via nasal cannula. Patient placed on 1 L 0.9% Normal saline . Patient 02 saturation now at 97% on room air. Patient oxygen began and <sic> desaturated to 89 writer placed patient back on 2L 02 oxygen saturation now at 97%. Orders for stat chest xray and labs <sic> work are in place. Physician present at time of occurrence. Writer will continue to provide care during shift . Review of the medical record revealed no order implemented for the administration of supplemental oxygen. A Nursing note dated [DATE] at 7:35 PM, documented in part . Patient oxygen saturation at 97% on 4L 02 . Heart rate elevated 112. Writer to inform oncoming nurse . Review of the medical record revealed no documentation on why or when R402's oxygen had to be increased from the previous documented 2L to the 4L. Further reviewed revealed no documentation of notification to the Physician regarding the consistent elevated heart rate. Review of the [DATE] MAR/TAR and vitals record revealed the following: On [DATE], the morning Metoprolol Tartrate medication was administered without a blood pressure to have been obtained for R402. A speech therapist Summary of Daily Skilled Services dated [DATE] at 10:30 AM, documented in part . Pt with continued lethargy and refusal for solid foods . Pt with continued increases confusion requiring increase cues and stimulation to participate in tx (treatment) . A Medical Doctor (MD) note dated [DATE] at 1:06 PM, seen today for hypernatremia. Patient having decreased p.o. (by mouth) intake . vitals (blank) . Oxygen in place . Hypernatremia-Likely secondary to intravascular volume depletion. Continue with IV fluids. Repeat BMP tomorrow . Wean 02 as tolerated . Possible PEG tube soon. Occasionally hypotensive. Continue current plan of care with parameters for administration . poor appetite and weight loss . Patient is refusing p.o. intake . A review of a physician order dated [DATE], noted to provide .normal saline x1 liter . A review of the medical record revealed the 1 liter of normal saline ordered on [DATE] was never administered as ordered by the MD. Review of the blood pressure tab noted a blood pressure obtained on [DATE] at 3:27 PM, at ,d+[DATE]. Review of the medical record revealed no documentation of the Physician to have been notified of the abnormal blood pressure level at that time. A Nursing note dated [DATE] at 3:44 PM, documented in part . resident being sent out to hospital via (medical director name) orders. Resident vital signs read ,d+[DATE], 87, 97.6, 93% . resident is able to respond to voice stimulation, the resident is a/ox1 (alert and oriented times one) with confusion and competitiveness . Review of the physician orders noted in part . Complete: Skill Nursing Note Under Assessment Tab every night shift . the nurses failed to complete and/or inaccurate assessments for the following dates: [DATE] (assessment generated but nothing documented) and [DATE] - no respiratory problems noted- the resident required supplemental oxygen, which was not needed previously. A review of the hospital record revealed the following: A Emergency Medicine consult dated [DATE] at 4:44 PM, . presents to the Emergency center today with a chief complain of altered mental status . patient has been experiencing 1 week of decreased responsiveness and decreased PO intake. Today, they checked his blood pressure and found this to be low in the 70's/60's . lethargic . Patient will be admitted to the intensive care unit for close monitoring . A Discharge/Expiration Summary dated [DATE], documented in part . saw patient on [DATE], in ICU .Daughter . aware of poor prognosis and decided for comfort care only . Patient expired on [DATE] and was pronounced . at 4:14 am . On [DATE] at 11:34 AM, the DON (with the Administrator present) was asked about the change of condition identified by the family of R402 on [DATE] that required the resident to be transferred to the hospital, why the facility staff failed to identify and assess the change of condition and inform the family that they would have to sign an AMA for R402 to be transferred to the hospital. The DON was asked about the incomplete and inaccurate skilled nursing notes, why the 1L of Normal Saline was not administered as prescribed by the MD, Why R402 required supplemental oxygen, the date, time, and vitals on the day it was applied. The DON was asked why there was no oxygen order implemented for R402 and the lack of assessment and monitoring of R402 with an identified change of condition. The DON stated they would look into it and follow back up. At 12:04 PM, UM N was interviewed and asked about the day R402 was transferred out to the hospital on [DATE]. UM N was asked about their note indicating that R402 was assessed and vitals to have been at baseline. UM N replied although they documented the note, they did not assess R402. UM N stated they talked to the nurse that was assigned to R402 on [DATE] and relied on their assessment. When asked why they informed R402's loved ones that they would have to sign an AMA for R402 to be sent to the hospital for a change of condition they identified and the facility failed to accurately assess, UM N stated they did not make that decision alone and that they contacted the Physician. UM N asked what Physician was contacted and what details were provided regarding R402's status and UM N stated they could not remember. UM N was asked the nurses name that completed the assessment and vitals on R402 prior to their transfer to the hospital on ,d+[DATE]//25 and UM N stated they could not recall. On [DATE] at 1:57 PM, the DON returned and stated the facility had a standing policy that noted to apply 2L of 02 on any resident under 90%. The DON was reminded that there was no oxygen order ever implemented for R402 and reminded of the documentation of the resident to have required ,d+[DATE]L of oxygen, the DON acknowledged the concern. The DON then stated they reviewed the blood pressures and medication administrations and two of the nurses no longer work at the facility, however one nurse is a current employee who will be re-educated. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: MI00151683. Based on interview and record reviews several failures were identified regarding the facility's nutritional management and oversight that included- a delayed gastroenterology referral/follow up, delayed nutritional assessment/lack of oversight/monitoring, untimely implementation of nutritional interventions and a communication break down with the facility's Interdisciplinary team to ensure a collaborative approach for one R402 of four residents reviewed for Nutrition and Hydration, resulting in a severe weight loss of 13.27% within two months, hospitalization and the contribution to R402's death. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns regarding the facility staff failed to timely follow up with a Gastroenterology appointment for a Percutaneous Endoscopic Gastrostomy tube placement and concerns of the facility staff to timely assess, monitor and evaluate the nutritional status of R402. A review of the medical record revealed R402 was admitted to the facility on [DATE] with diagnoses that included: Fracture of right pubis, repeated falls, severe protein-calorie malnutrition, dysphagia-oropharyngeal phase, and abnormal weight loss. Review of the hospital preadmission documents provided to the facility upon R402's admission documented the following in part, . After Visit Summary . [DATE]-[DATE] . Wt (Weight) 196 lb (pounds) 3.4 oz (ounces) . Most recent update [DATE] at 4:59 PM . Review of a Nursing Admission Evaluation at the facility dated [DATE] at 4:42 PM, documented in part . Most Recent Weight . Weight: 196.0 (Lbs) Date: [DATE] 21:47 (9:47 PM) . Scale: Wheelchair . Review of a Nutrition Admission Assessment note dated [DATE] at 5:00 PM, documented the following . Pt (patient) is unsure of UBW (usual body weight), he reports that he has lost -30# over the past 3 months, question admission weight given same as hospital weight . reporting normal/baseline appetite and intake recently, he denies recent changes to his intake. Pt does note that he has lost -30# over the past 3 months, states he is unsure why. Pt appears well-nourished at bedside . Pt is at risk for inadequate oral intake . Continue current interventions. Weekly weights . This assessment was completed by Registered Dietician (RD) P. Review of R402's weights noted the following: On [DATE] at 11:43 AM- 187.6 lbs This indicated a -4.29 weight loss within one week after admission. A review of the medical record revealed no identification of the weight loss by the facility staff. Further review of the medical record revealed no implementation of interventions to prevent further weight loss, until more than two weeks later. A review of a Nursing note dated [DATE] at 6:46 PM, documented in part . Resident c/o (complaints of) ganging <sic> when he eats. Writer called and notified physician. Oder <sic> to be evaluated by speech was put in at this time . Resident is already on mechanical soft diet no other orders at this time. Writer also logged it in physicians book. Review of a Nurse Practitioner (NP) note dated [DATE] at 9:15 AM, documented in part . Chief Complaint: Diarrhea, weight loss . Patient has poor appetite since admission to facility stating he does not like the food. He does report some recurrent nausea especially in the presence of food . Patient reports poor appetite, unable to tolerate diet as he does not like the food being offered to him. He does report some dry heaving which has been present for the past 2 ,d+[DATE] weeks per his report . Add Zofran as needed . Add low-dose Remeron . With poor appetite and weight loss Add Remeron 7.5 mg at bedtime . Patient is experiencing poor appetite, dry heaving Add Pepcid twice a day, continue for 14 days, monitor response . This is the first documentation of an intervention implemented for R402's weight loss and nutritional concerns. Review of a documented conversation submitted by the complainant with the facility's Nurse Manager (NM) N dated [DATE] at 12:17 PM, documented in part . I spoke with (NM N name) . she stated that (R402) mentioned wanting a PEG tube, and she explained to him that it's not something he can simply have. I asked what needs to happen for him to get one, and she told me he would need a GI referral. I requested that one be added for the doctor to approve, and she agreed to add it to his file . Review of the medical record revealed no documentation of the NM N to have noted in the residents file any follow up of the GI referral for the PEG tube placement and/or notification to the Physician regarding the concern, until the end of [DATE]- almost a month later. A Doctor of Osteopathic Medicine (DO) O note dated [DATE] at 8:41 PM, documented in part . Chief Complaint: Nausea, anorexia . dysphagia (difficulty swallowing) due to previous CVA (cerebrovascular accident- stroke) . Reporting nausea with current food regimen . dry oral mucosa . patient reporting increased nausea with fluid intake. Potentially due to worsening reflux. May require additional management with Tums . A review of a (late entry) Therapy note dated [DATE] at 10:32 AM, documented in part . SLP (Speech Language Pathologist) recently evaluated [DATE] with no s/s (signs/symptoms) of aspiration at the time patient placed on mechanical soft diet per preference. Pt later seen by PRN (as needed) SLP and requested further downgrade to puree to see if it would be easier for him to eat with few feelings of gagging. Pt continues to report lack of appetite and the thought of foods making him gag . Referral for GI (Gastroenterology) may be warranted at this time for further assessment at other possible causes. Pt reports this happened before and he saw a GI who placed feeding tube. A note dated [DATE] at 5:20 PM, by DO O documented in part . Abnormal weight loss . Patient reports poor appetite, unable to tolerate diet as he does not like the food being offered to him. He does report some dry heaving which has been present for the past 2 ,d+[DATE] weeks per his report. Check comprehensive blood work. Add Zofran as needed for 14 days, maintain on low-dose Remeron nighttime . The medical record revealed R402 was transferred to the hospital on [DATE] due to the family's concern of a change in condition. Review of the hospital records revealed the following: An Emergency Medicine consult dated [DATE] at 3:57 PM, documented in part . Patient is globally weak . Mucous membranes are dry . presents with hypotension and decreased p.o. (by mouth) intake. Patient with dry mucous membranes decreased p.o. intake. Has a history of severe anxiety significant other requiring G tube . Patient had AKI (acute kidney injury) continue IV (intravenous) fluids . Question whether symptoms are just secondary to decreased intake and deconditioning since his pelvic fractures last year. Admission for continued monitoring . A Gastroenterology and Hepatology Consultation dated [DATE] at 10:52 AM, documented in part . has had difficulty swallowing. Patient reports that he has been able to tolerate some liquid green, otherwise gags with all other consistencies. He reports some intermittent nausea without vomiting . AKI noted . Patient was given fluid boluses and started on antibiotics . Laboratory Data ([DATE]) BUN- 55 . Bicarbonate- 17 . Could consider Corpak (feeding tube) for nutrition . Will consider PEG placement further work up of dysphagia . A Discharge Summary filed [DATE], documented the following . Principle Problem: AKI . dysphagia . Protein-calorie malnutrition, severe . Dysphagia, history of PEG tube placement in the past due to poor p.o. intake. Seen in consultation by speech pathology, case discussed . Patient was gagging during evaluation by speech pathology without having anything in his mouth, however consume thin liquids and purees with ease . Outpatient follow-up recommended . will need to be readmitted to subacute rehab . Review of the facility's medical record revealed the following progress notes: On [DATE] at 2:31 PM, a Nursing note documented in part . Patient discharged from (hospital name) . diet order in place placed on pureed diet until evaluated by speech therapy . Review of the hospital documents provided to the facility upon admission documented the following: . dronabinol 2.5 mg (milligram) capsule, Take 1 capsule by mouth daily for 3 days . You are started on appetite stimulant. Please address with PCP (primary care provider) within a week whether it's successful, and if your nutrition is adequate. Might need to be evaluated for PEG again . Review of a Nursing readmission assessment dated [DATE] at 1:58 PM, documented in part . Most Recent Weight . 187.2 (lbs) Date: [DATE] . The facility staff failed to obtain a new weight for R402 upon re-admission. The next weight recorded in the medical record was dated [DATE] at 187.2 lbs. A Nurse Practitioner (NP) note dated [DATE] at 4:21 PM, documented in part . Dietitian following . results of CMP (comprehensive metabolic panel) from [DATE] reviewed: Total protein 4.9 albumin 2.7 Continue supplementations, low-dose Remeron and dronabinol. Monitor diet intake and weight per facility protocol . Review of the medical record revealed no dietary re-evaluation since readmission on [DATE]. Further review of the record revealed no dietary supplementations ordered for R402. A Nursing note dated [DATE] at 11:22 AM, documented in part Writer spoke with daughter (name) regarding resident and concerns with oral food intake. Resident requesting peg tube placement . Daughter okay with peg tube if MD (medical doctor)/dietician feel it is warranted. Concern logged for MD. Dietician aware of decreased consumption . A Late Entry Dietary note dated [DATE] at 11:40 PM, documented in part . suffering from dysphagia and nausea also for the last couple of days, worsening ability to tolerate po intake . Current diet is regular, minced moist, nectar thick. PO intake per FAR (food intake documentation) is poor to variable ,d+[DATE]%. Pt reports poor appetite & PO intake . RD recommends health shakes TID . CBW (current body weight) ,d+[DATE]- 180 . reports unintentional wt. loss since x,d+[DATE] months r/t (related to) poor PO intake & appetite. Weekly wt. in place for monitoring changes . 13% wt. loss per pt/clinical records . Continue current interventions . This late entry had a created date of [DATE] by PRN (as needed) Registered Dietician (PRN-RD) Q. Note the above late entry note back dated to [DATE], noted a weight from [DATE] of 180 that had not been obtained at the time of the supposed [DATE] entry date. Further review of the record revealed two supplement orders with a created date of [DATE] and back dated to [DATE] as the start dates. The House Supplement was ordered for three times a day and the House Med Pass Supplement was ordered for twice a day. Review of the [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed neither the house supplement nor house med pass supplement documented as administered to R402. This reflected the created date of [DATE] for both orders to be confirmed as the actual date both orders were implemented. A review of the DO O note dated [DATE] at 11:12 AM, documented in part . Chief Complaint: Generalized weakness, exertional fatigue . Tolerating full p.o. intake (not accurate). Still reporting some generalized weakness . Patient is not progressing significantly, still reporting significant fatigue . Dietitian following . Continue supplementations, low-dose Remeron and dronabinol. Monitor diet intake and weight per facility protocol. Patient is not having adequate improvement currently . Poor appetite and weight loss . A Nursing note dated [DATE] at 5:54 PM, documented in part . Pt is failing to thrive. He isn't eating any of his food. Writer thought patient hasn't been eating due to increased confusion and attempted to feed pt and he vomited. DON (Director of Nursing) notified . A NP note dated [DATE] at 10:11 AM, documented in part .Patient had been having trouble with dysphagia and nausea also for the last couple of days. Was having worsening ability to tolerate p.o. intake . appears very fatigued . reports feeling yucky. Per nursing staff, his appetite has been very poor for the last few days . Patient's daughter (name) was contacted . During last hospitalization , she was told that father had requested to have a PEG tube placed due to poor appetite but was declined and staff recommended follow-up with GI outpatient. Nurse manager at this facility has been trying to obtain a follow-up appointment with GI specialist outpatient for the past week . Start patient IV hydration . Obtain stat blood work, Continue to monitor closely . Continue supplementations, low-dose Remeron and dronabinol. Monitor diet intake and weight per facility protocol. Patient is still experiencing significant anorexia. Nurse management still working on securing a GI consult. Patient has requested placement of a PEG tube in the past . Check BMP (basic metabolic panel) today . Review of a care plan titled . inadequate PO intake r/t (related to) dysphagia . unintentional 13% weight loss . included the following interventions . Alert dietician if consumption is poor for more than 48 hours . Give resident supplements as ordered . A review of the meal intake documentation for [DATE] revealed multiple documentation of R402's poor meal consumption. The facility staff failed to continuously comply with the resident's plan of care. A Nursing note dated [DATE] at 3:44 PM, noted the resident was transferred to the hospital for a change in condition. Note the late entry dietary evaluation and the late implemented supplements (house supplement and house med pass supplement) dated [DATE], was implemented and documented after R402 was transferred to the hospital on [DATE] and was no longer in the facility. A review of the hospital record revealed the following: A Emergency Medicine consult dated [DATE] at 4:44 PM, . presents to the Emergency center today with a chief complain of altered mental status . patient has been experiencing 1 week of decreased responsiveness and decreased PO intake. Today, they checked his blood pressure and found this to be low in the 70's/60's . lethargic . Patient will be admitted to the intensive care unit for close monitoring . A Nutritional assessment dated [DATE], documented in part . Pt meets criteria for Unspecified severe protein calorie malnutrition and is at refeeding risk with electrolyte fluctuations . Once corpak placement verified and able to start TF (tube feeding) . Pt familiar to service from previous admission earlier this month . Swallowing difficulty. Pt now with continued wt loss 13% since [DATE]. Pt with dysphagia and gagging with po intake. Plan at this time is for corpak placement . Significant wt loss noted . [DATE] 86 kg (kilograms, converted to lbs. is 189.6 lbs) [DATE] 77.2 kg (170.2 lbs) . Patient meets criteria for unspecified severe protein-calorie malnutrition chronic disease . A Discharge/Expiration Summary dated [DATE], documented in part . saw patient on [DATE], in ICU .Daughter . aware of poor prognosis and decided for comfort care only . Patient expired on [DATE] and was pronounced . at 4:14 am . Review of a Certificate of Death included Severe Calorie Malnutrition with a noted approximate interval between onset and death of Weeks as a cause of death. The last recorded weight in R402's medical record at the facility was dated [DATE] (the day the resident was transferred to the hospital) and recorded at 180 lbs. This is a 7.2 lbs weight loss from the [DATE] recorded weight. The weight noted at the hospital on [DATE] was recorded at 170. 2 lbs, this confirmed a total weight loss of 10.05 % within three weeks and a total of 13.27 % loss from the admission weight obtained two months prior. On [DATE] at 9:45 AM, Registered Dietician (RD) P was interviewed and asked what interventions were implemented for R402 regarding the initial weight loss on [DATE] after only a few days of being at the facility. RD P stated normally the nurses would notify them of any weight loss or the facility's electronic system would flag it for their review. RD P reviewed the medical record of R402 via their laptop and stated they remembered the resident and believed the facility's initial weight was inaccurate and believed the facility staff duplicated the hospital's recorded weight. RD P was asked if they had addressed that with the Administration, DON and Nursing staff and RD P stated they believed they did. RD P was asked to provide documentation of them to have noted R402's initial weight to be inaccurate and was addressed with the facility staff and RD P stated they didn't believe they had maintained documentation of the concern. RD P was asked again what interventions were implemented to prevent further weight loss for R402 and RD P stated they would look into it and follow back up. RD P was asked why none of their documentation identified or addressed R402's nutritional concerns and possible PEG tube placement and RD P replied they were unaware of the resident to have requested a PEG tube and unaware of any discussion with the facility's Interdisciplinary team of a PEG tube placement. RD P was asked how the facility closely monitored high risk nutritional residents and if there was additional documentation to provide regarding the overview of R402's nutritional concerns and status. RD P stated they check on the resident's monthly but there was no additional meetings or discussions for residents that are high risk for nutritional concerns and/or decline. No further explanation or documentation was provided by RD P by the end of the survey. On [DATE] at 10:42 AM, the PRN (as needed) Registered Dietician (PRN-RD) Q was interviewed (with RD P present) and asked about the late entry evaluation that was dated for [DATE], however noted as the created date of [DATE] when the resident was no longer in the facility. PRN-RD Q stated they had consulted with R402 on [DATE], however did not lock their assessment until [DATE]. PRN-RD Q was asked if that was the case, why was the supplements for House Supplement ordered for three times a day and the House Med Pass Supplement ordered for twice a day both have the created dates of [DATE] and was observed with no documented administrations on the [DATE] MAR and TAR by the nurses and PRN-RD Q did not have a response. PRN-RD Q stated they would usually put the orders in right away. PRN-RD Q was asked their involvement in monitoring the nutritional status and the possibility of a PEG tube placement for R402 and PRN-RD Q stated no one had talked to them regarding PEG tube placement for R402. PRN-RD Q and RD P both were asked who was monitoring the effectiveness of the Remeron and Dronabinol therapy with R402 and neither provided an answer. The hospitalization discharge ([DATE]) paperwork was read to PRN-RD Q and RD P regarding if the Dronabinol was ineffective to follow up with GI outpatient for PEG tube placement and both denied being aware of the hospital discharge note. PRN-RD Q and RD P were both requested to provide all documentation regarding the nutritional care for R402 that would help to possibly fill in the concern areas regarding the lack of dietary and/or nutritional oversight for R402. No further explanation or documentation was provided by the end of the survey. On [DATE] at 11:34 AM, the Administrator and DON was interviewed together and the nutritional concerns noted above was reviewed. The Administrator and DON stated they were unaware of the Registered Dietician concerns of the staff not obtaining accurate weights and documenting hospital weights. The DON stated the RD had never brought that concern to their attention. The DON stated the Administration team meets every morning to discuss any issues or concerns with the residents. When asked if R402 was discussed at any of the morning meetings and if they could provide documentation of the concerns for R402, both stated they were not aware of any discussion for R402. The Administrator and DON stated they were unaware of the reviewed nutritional concerns for R402. The Administrator and DON stated they had already started immediate education with the facility staff. On [DATE] at 12:04 PM, Unit Manager (UM) N was asked about the discussion with R402's family member on [DATE], regarding the PEG tube - GI consultation and why it was never followed up on timely. UM N stated they had a hard time trying to find a GI doctor that would take the resident. UM N was asked if they informed the attending physician/Medical Director of the facility to help facilitate an appointment for R402 and UM N stated they had not. UM N stated eventually they found a GI doctor that would see R402, however they were unable to provide documentation of a scheduled appointment and could not provide the GI's doctor name or phone number. Review of a facility policy titled Monitoring Adequate Nutrition and Hydration Status dated [DATE], documented in part . The RD or nutritional professional will screen each resident upon admission, readmission and begin the comprehensive assessment to evaluate nutritional needs of each resident . The RD or nutritional professional will determine residents at risk and communicate to the IDT any information that impacts care. A systematic approach can help staff's efforts to optimize a resident's nutritional status. This process includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary .

This citation pertains to intake # MI00150676. Based on interview, and record review, the facility failed the appropriate level of assistance per plan of care to prevent serious injury (acute appearing distal tibia fracture) for one (R406) of four residents reviewed for quality of care. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency on 2/19/24 documented R406 sustained an injury of unknown origin which was a fracture of the tibia and fibula while receiving care from an agency CNA (Certified Nursing Assistant) on 2/14/25. On 4/9/25 at 10:40 AM, R406 was observed lying in bed with a trapeze bar positioned above the head of the bed and there was a pillow placed along the resident's right lower extremity. R406 was alert and remembered this surveyor from a previous survey. The resident reported since their initial back injury that brought them to the facility in August 2024, their right leg tended to wander to the right and when it did, they didn't have any control over the leg and the leg can just slide down. They reported they usually have a pillow or wedge to the right side to keep the leg up. They were informed of the investigation into the reported incident from 2/14/25 and was asked to recall the events as best they could. R406 reported the aides have a habit of lifting the pad underneath them to turn or move them. The nighttime aide (not sure of their name) did it so fast my right leg came off the mattress. She picked it (leg) up and it happened again so quickly and my foot hit the floor. I know it hit the floor because I felt that cold tile floor. Right after that I tried to call her back to ask the nurse for a pain med but I was afraid so I didn't. I talked to that aide after that and she said she didn't do anything. I talked to the nurse the next day (not able to recall any specific nurse's name). I was afraid to have the aide come back after that. Review of the clinical record revealed R406 was initially admitted into the facility on [DATE] with diagnoses that included: acute appearing distal tibia fracture (2/19/25), wedge compression fracture of third lumbar vertebra (8/29/24), and encounter for other orthopedic aftercare (8/29/24). According to the Minimum Data Set (MDS) assessment dated [DATE], R406 scored 15/15 on the Brief Interview for Mental Status exam (BIMS) which indicated intact cognition, was frequently incontinent of urine and always incontinent of bowel, had occasional pain and received as needed pain medication, and had no falls since the previous MDS assessment on 12/3/24. According to the Kardex (specific instructions on the resident's care needs) R406 required two-person assistance with bed mobility, including toileting and the use of a mechanical lift (Hoyer) for transfers (which was the same status prior to this incident and remained unchanged since this incident). Review of the progress notes included a Physical Medicine and Rehabilitation entry on 2/20/25 at 3:34 PM which read, .Based on the view of the films .recommend NWB (Non-Weight Bearing) right LE (Lower Extremity) and ER (emergency room ) Ortho evaluation of new acute appearing distal tibia fracture .[Physician 'H'] is aware that patient may need casting or splinting but needs to be determined by Ortho .The patient was not examined at this time but stated that she noted new pain on Friday when being changed when her right leg hit the floor . Review of the documentation submitted to the State Agency on 2/19/25 revealed the same documentation provided by the facility for review on 4/9/25. This documentation revealed there was only one witness statement obtained which was from an Agency Certified Nursing Assistant (CNA 'G') on 2/18/25 by phone with the Director of Nursing (DON) that read, Name and title of person conducting interview: [name redacted] DON Date of incident: 2/14/25 Date/Time/Place of interview: 2/18/25 STATEMENT: Went in around 1am to answer call light. Resident needed her brief changed. Resident already complaining of pain to right leg. Pulled the bed pad towards me to roll resident over, resident leg did not hit the floor at all. Assisted the resident with 1 PA (Physical Assistance) .VIA PHONE 2/18/25. There were no other interviews from other staff, or residents included in the documentation provided during this survey, or submitted to the State Agency as part of this investigation. There was no documentation of any education that the facility implemented following this incident to ensure all staff were informed of the need to provide care per plan of care. Review of the facility's investigation documented, in part: .It was brought to the attention of the Administrator on 2/19/25 that the resident [R406] had a fracture of the Tibia and Fibula, the incident actually occurred on 2/14/25 which the CNA (Certified Nursing Assistant) that was caring for the resident was from the agency .Investigation initiated immediately to see what occurred on the day in question .Investigation: Injury of unknown origin 2/19/25 .Writer was notified on 2/19/25 that resident [R406] had complaint on 2/14/25, she did not notify the nurse due to incident that occurred with the CNA (although R406 reported she had notified the nurse the next morning), resident stated that she did not feel safe to tell the nurse due to CNA reactions. Nurse Manager (the Nurse Manager/NM 'A' was not informed until 2/18/25) ensured safety and the resident stated that she feels safe living in the facility. On 2/17/25 resident complained of mild pain to right leg, resident asked for pain medication. Medication was administered for pain to the right leg, and it was effective. The next day the resident called the Nurse Manager to her room and stated that she was having increased pain to her right leg, nurse manager informed the Nurse Practitioner and ordered a STAT Xray. Facility received the Xray results back which stated distal tibia fracture. A new order was placed for the [R406] to see PM&R (Physical Medicine & Rehab) and no weight bearing to affected leg. Physician went into access [R406] the resident refused to be transferred to the hospital she stated that she prefers to see the Ortho; Nurse manager made [R406] appointment to see Orthopedic. The CNA involved in this investigation is an agency staff that we interviewed, she stated that she went into the residents room around 1:00AM to answer her call light, resident needed a brief change. She stated the resident was already complaining of right leg pain. CNA stated she pulled the resident towards her to roll resident over to change her, residents leg never hit the floor at all. Nurses that worked with the resident was asked if the resident complained of any pain or were they aware of any incidents with the resident they stated no (there was no documentation included in the investigation documents of this). 2/19/25 The social worker (SW) did wellness visit completed with resident and her daughter via phone. Resident reports that she does not feel safe in the facility currently .Resident is requesting to transfer facilities and will notify SW when she found a facility to transfer to. Social Services dept will continue to follow up as needed . On 4/9/25 at 2:06 PM, an interview was conducted with the Administrator. When asked to review the facility's investigation and timeline of events for R406's injuries, the Administrator reported that person involved is an agency staff. The Administrator further reported the resident was complaining of pain on 2/14 and at first it was an injury of unknown origin but then confirmed the aide did not follow the plan of care and should've had two people during care. When asked if this was their complete investigation, they reported Yes. On 4/9/25 at 2:12 PM, the Director of Nursing (DON) joined the interview. The DON confirmed the events as documented on the facility's investigation. When asked if staff had been offered any education in regard to staff not providing care per their assessed needs, the DON reported they did not. The DON and Administrator were informed of the concerns that care had not been provided per plan of care. When asked if the resident's plan of care which required two-person assist with bed mobility, incontinence care, and transfers had changed following this incident, or if they required that level prior, both the DON and Administrator reported nothing had changed, R406 required that level at the time of the incident. The Administrator further reported for safety, she's always been a two person assist. On 4/9/25 at 5:21 PM, a phone interview was conducted with Agency Certified Nursing Assistant (CNA 'G'). When asked to recall the events from the time they provided care to R406 on 2/14/25, CNA 'G' reported: I had her and when I was trying to turn her, she's a very healthy lady and don't mean to be disrespectful, but I pulled her and I proceeded to change her brief three to four times because she had the runs. Recall the resident saying my leg was about to fall off the bed but it didn't fall and I was able to get it back on. When asked to clarify what they meant by they were able to get the leg back on if it didn't fall down, CNA 'G' reported she didn't fall or anything. When asked if they were aware the resident's plan of care required the resident required two people to assist with incontinence care, CNA 'G' reported that was their first time working at the facility and wasn't told that in report. According to the facility's policy titled, Repositioning dated 8/9/2023: .Residents who are immobile and/or dependent upon staff for repositioning should be repositioned at least every two hours .If ineffective, the turning and repositioning frequency will be modified to resident tolerance .Moving up in bed .Roll the resident toward you to place the slide sheet or draw sheet against the resident's back .Roll the resident onto the sheet and spread the sheet out flat under the resident. If needed, have the 2nd staff member roll the resident toward them to spread the sheet out flat under the resident .

This citation pertains to Intake #MI00137799 Based on interview and record review the facility failed to thoroughly assess and ensure professional standards of care were followed for a resident expressing concerns of pain and change in condition for one (R904) of three residents reviewed for pain, resulting in R904 calling 911 on their own to ensure hospitalization , arriving at the emergency department tachycardic (rapid heart rate) and hypotensive (blood pressure 77/62) and continued hospitalization following a surgical procedure for a left groin hematoma. Findings Include: A complaint was filed with the State Agency (SA) that alleged R904 made concerns to nursing staff that noted they were not doing well and had terrible leg pain. Nursing staff did not take them seriously and they had to call 911 on their own to ensure they were taken to the Hospital. A review of R904's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: peripheral vascular disease, acute embolism and thrombosis and chronic obstructive pulmonary disease. A review of R904's Minimum Data Set (MDS) revealed the resident has a BIMS (Brief Interview for Mental Status) score of 15/15 (cognitive intact cognition. Continued review of the R904's clinical record documented, in part, the following: 6/12/23 (4:28 PM): .Patient was seen and examined today .Was called to evaluate patient today because nursing concern of continued erythema (reddening of the skin) by bilateral . incisions . He does report continued pain . 6/13/23 (2:59 AM) : Resident has c/o (complains of) pain at a level of 10/10 to his left leg. He stated that he feels he has another blood clot in his upper left thigh and requested to have a doppler. Writer contacted Physician G and was advised just administer pain medication and he will come to see the resident in the morning. Physician G also stated that since the resident is currently on treatment for DVT, there are no other treatments that can be ordered . *It should be noted that there was no indication in the resident's clinical record that Physician G returned to see the resident in the morning as noted above. 6/13/23 (9:15 AM) .Writer went and observed surgical incisions to bilateral groin. Staples are to remain in place . Staples are still in place .noticed some hardness near site . Floor nurse, UM (Unit Manager) and NP (Nurse Practitioner) aware . 6/13/23 (1:56 PM): Resident requested to see writer requesting another doppler be completed. Writer spoke to NP who stated that this was not indicated. NP will follow up with resident tomorrow . 6/13/23 (4:44 PM): Resident alert and verbal c/o severe pain to left leg pt.(patient) request to transfer to hospital, (name redacted) Nurse Practitioner (NP) F notified with orders that if pt leave it will be against medical advice, pt made aware and insist that his vascular MD (Medical Doctor) wants him to go to the hospital, pt called 911 from his cell phone, nursing manager made aware, writer called EMS (Emergency Medical Services) for transpiration per nursing manager, pt did sign AMA (against medical advice) and verbalizes understanding. (Authored by Nurse H). Hospital records were reviewed and revealed, in part, the following: .6/14/23 ED (emergency department) discharge to (name redacted) .Patient presented to ED (emergency department) for shortness of breath. Also notes abdominal and LLE (lower left extremity) pain. In ED found to be tachycardic (rapid heartbeat) and Hypotensive .Reason for SICU (surgical intensive care unit) .patient reports to (name redacted) Hospital ED for SAR (shortness of breath) and left lower extremity pain . hypotensive to the 70's and in A-fib with RVR (rapid ventricular response) to the 150s on presentation to (name redacted) .CTA (Computed tomography angiography) was done and demonstrated 10.5x5.7x18 cm (centimeter) hematoma in the left anterior lateral thigh .Admitting Diagnosis and Chief Complaint: Pt currently has the chief complaint of pain and further describes it as follows: Location: Left leg .Severity 8/10 . ED Patient ill-appearing and vital signs notable for sinus tachycardia .Plan for hematoma evacuation on 6/15 unless clinically indicated sooner .Discharge (6/27/23) . Following review of the Hospital records as noted above and attempt to determine what vital signs were obtained for R904 prior to hospitalization . Continued review of R904's clinical record noted that last vital signs, including blood pressure, pulse (bpm), respirations and 02 sats were taken were on 6/13/23 at 12:44 AM. R904's Medication Administration Record (MAR) was reviewed and documented R904 received Calan (a drug used to treat high blood pressure) SR 120 MG on 6/13/23 at 9:00 AM. It should be noted that there was no evidence in R904's clinical record that they indicated the resident's blood pressure was taken prior to and/or following the administration of the medication. A review of R904's clinical assessments noted the last assessment completed for the resident was on 6/6/23 for a total body skin assessment. No further pain and/or change in condition was noted in the clinical record. On 9/28/23 at approximately 12:43 PM, a phone interview was conducted with Nurse H. Nurse H reported that they no longer provide nursing services to the facility. Nurse H was asked about R904, and the hospitalization request written on 6/13/23 at 4:44 PM. Nurse H recalled that the resident was complaining of pain and wanted to go to the hospital. They contacted their unit manager and called the NP who told them that there was no reason for the resident to go to the hospital. Nurse H remembered that the resident called 911 and believes they filled out an AMA form. With respect to the lack of vitals noted in the resident's record, Nurse H stated that they did not recall whether vitals were completed and again expressed that they had reported the resident's concern to their unit manager and NP. On 9/28/23 at approximately 12:54 PM, a phone interview was conducted with NP F. NP F was queried as to R904 as to their pain, request for a doppler and hospitalization . NP F reported that they recalled the resident and noted that a doppler had been completed on or about 6/6/23 that indicated another clot. The resident was then placed on anticoagulants. When asked as to why they indicated to Nurse H that if the resident decided to go to the Hospital, it would be AMA, NP F stated that the resident had just had a doppler done and they felt there was no need for the resident to go right away. The Surveyor reported to NP F that the resident called 911 on their own and when they arrived at the hospital, they were tachycardic, hypotensive, possible pneumonia and had a large hematoma on the anterior left thigh. When asked if nursing staff should have, at a minimum, taken vitals for a resident reporting distress and need to go to a hospital, NP F reported that at vitals should be taken at least once per shift and increased when a resident is not feeling well. On 9/28/23 at approximately 3:47 PM, an interview was conducted with the DON. The DON was asked to provide the AMA document as noted in the Progress Note authored by Nurse H and/or any additional discharge documentation. The DON noted that an AMA form was not completed, and the wording used by Nurse H was used incorrectly. No additional discharge information was provided as the DON noted that a list of medication is generally provided. With respect to obtaining vitals for R904, the DON reported that vitals are usually taken at the beginning and end of the shift. The DON was asked as to why the last vital (including blood pressure) for R904 was taken on 6/13/23 at 12:44 AM and not taken again either at the beginning of the day shift at 7 AM and/or again prior to administering R904's blood pressure medication (Calan). The DON reported that the resident left the facility at or around 4:30 PM and Nursing staff had till the end of the shift at 7 PM to take the resident's vitals. When asked whether R904's blood pressure should be taken prior to the administration of blood pressure medication, the DON noted that that is only done per physician orders for obtaining parameters prior to administration. On 9/28/23 at approximately 5:01 PM, a phone interview was conducted with Physician G. Physician G was asked as to whether Nursing staff should obtain vitals/blood pressure prior to administering blood pressure medication and/or during a resident concern with change in condition. Physician G noted that it is expected that Nurses check the residents blood pressure. When asked if Nurses are only to check a resident's parameters if there is an existing order, again Physician G noted that there does not need to be an order for checking parameters, Nurses can obtain vitals without an order.

Based on observation, interview and record review, the facility failed to ensure consistent and comprehensive skin assessments and implement interventions for one (R912) resident reviewed for pressure ulcers (PU), resulting in R912 developing an unstageable PU(Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). Findings include: On 9/27/23 at 11:01, R912 was observed lying in bed propped up on his left side with head elevated. R912 was interviewed about his wounds. R912 stated he came to the facility with one stage four wound (left thigh) that was infected and received intravenous antibiotics. R912 stated that he had two small wounds on his gluteus area and uses a wound vac (a mechanical pump that removes nonviable tissue) for the stage four wound. Record review revealed that R912 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] revealed that R912 had a brief interview for mental status(BIMs) of a 13 (intact cognition) and had present on admission one stage 4 pressure wound on left thigh. Record review of R912's care plan revealed that stage three pressure injury to the right gluteal was identified on 9/18/23 however, interventions were not implemented until 9/27/23. Record review of clinical assessments for 9/18/23 identified a new skin area to the right gluteus with the measurements of area 28.5cm (centimeters) length 8.8cm and width 4.9 cm. The wound was noted as an unstageable wound with eschar and granulated tissue. The clinical records revealed that this was the only assessment completed for the right gluteus (completed on 9/18/23 and 9/25/23) no other assessments to assess the skin were completed prior to these dates. On 9/27/23 at 11:44 am, an observation was done of the wound care treatment. Wound Care Nurse A and Director of Nursing (DON) completed the treatment as ordered. The wound vac was applied to the left thigh, a hydrocolloid dressing to the left gluteus and a hydrocolloid dressing to the right gluteus. The wound bed was beefy red with a darkened quarter sized thick hard non- viable area (eschar) near the parameter of the wound. There was a scant amount of serous-sanguinous drainage with no odor noted. On 9/27/23 an interview was conducted with Nurse A and the DON. They were asked how often were skin assessments done for all residents, where in the resident record could they be found and who typically does the assessments. Nurse A replied the assessments are done weekly by the nurses, one for skin and wound that is done weekly by wound care nurse and one progress note weekly from the medical doctor or nurse practitioner. Record review of the clinical records revealed that assessments completed dated for 8/14/23 ,8/17/23,8/21/23,8/28/23, 9/5/23, 9/11/23, 9/18/23, 9/25/23 for residents' stage four to the left hip. On 9/27/23 at 1:36 PM, the DON, Administrator and Nurse A interviewed on how they are notified of changes in the skin, where are the weekly skin assessments documented. The DON, Administrator and Nurse A were asked to provide shower sheets for R912 to show initial date of skin impairment. There were no weekly skin assessments completed for this resident from 8/14/23 - 9/27/2023 and one shower sheet dated 8/17/23. New skin impairment to the right gluteus was identified 9/18/2023. On 9/28/23 at 11:40AM DON interviewed stated that weekly skin assessments should have been completed in the skin total body evaluation. Record review of clinical record revealed that the treatment ordered on 9/19/23 for the right gluteus to be Cleansed with normal saline, and pat dry. Apply hydrocolloid dressing to area. Record review revealed that additional skin assessments were completed and locked on 9/27/23 but back dated to 8/30/23. On 9/27/23 at 1:30PM, the DON was interviewed to see if there were any additional information for skin assessment she would like to provide. The DON replied the one shower sheet was all that they had for R912. On 9/28/23 at 1:20PM, the DON provided body sheets that were completed by Nurse A. The body sheets brought for review did not identify the skin impairment of the right gluteus. On 9/28/23 at 1:53PM, the DON was interviewed about the body sheets provided and was asked what the area was circled on the picture considered. The DON replied, The Coccyx. The area that was in question was the right gluteus. Review of the facility policy revealed that A full body, or head to toe, skin and oral cavity assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . There was no additional information provided by the exit of the survey.

This citation pertains to intake: MI00134813. Based on interview and record review the facility failed to consistently identify the root cause analysis of multiple falls, consistently implement adequate and effective interventions to prevent further falls for one (R905) of three residents reviewed for falls, resulting in the resident to have been transferred to the hospital and required surgical intervention (hemiarthroplasty right femoral neck) for a right femoral neck fracture. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . Residents third fall happened approximately 1/23/23 . they (facility) took an x-ray and (R905) was all fine . resident was in excruciating pain . facility conducted another x-ray as resident was in so much pain, the second x-ray discovered (R905) had a bone fracture (right hip) and was sent out to (hospital name) . Resident needed surgery, once surgery was completed . complainant was notified by surgeon that (R905) would not be able to stand or walk again. Resident was put in hospice care . Review of the medical record revealed R905 was admitted to the facility on [DATE] with diagnoses that included: dementia, history of falling and muscle wasting and atrophy. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing note dated 8/30/22 at 8:30 AM, documented in part . Cena (aide) observed pt on the floor while making rounds around 4:40 am. Pt (patient) stated he was trying to get to the bathroom. Pt did not have nonskid socks on. Pt be <sic> was in the lowest position. No c/o (complaints of) pain from the fall but back pain that has been paining <sic> ongoing. Assessed pt from head to toe. Small skin tear noted on right forearm . Care plan and fall assessment completed. Review of a care plan titled At high risk for falls, and at risk for additional falls related to resident will forget that he needs help to transfer and will attempt to transfer self-due to cognitive impairment r/t (related to) Vascular Dementia . date initiated 7/25/22, documented the following initial interventions . Bed in low position . Encourage to transfer and change positions slowly . Provide assist to transfer and ambulate as needed . Refer to the Therapy Plan of Treatment in the medical record for more detail . Therapy evaluation and treatment per orders . The initial fall interventions implemented on R905's care plan was inadequate for a resident diagnosed with dementia, classified as a high fall risk and with a history of falls. Review of a facility Incident Report dated 8/30/22 at 6:40 AM, documented in part, . Cena observed pt on the floor near bedside while rounding on all patients. Pt did not have nonskid socks on. Bed was in lowest position . continue with low bed, non-slip footwear, assistance with toileting on schedule, not to left <sic> unattended in bathroom, utilization of fall precaution signs, and provide education to the patient and family . Review of the medical record revealed no documentation of the Interdisciplinary team (IDT) to have met to identify and discuss the root cause analysis of R905's fall. Further review of R905's fall care plan revealed on 8/30/22 non-skid footwear and the utilization of fall precaution signs were added to the care plan. Review of a Nursing note dated 9/4/22 at 3:45 AM, documented in part, . While doing rounds @ (at) 0330 (3 AM) writer observed patient laying on the floor of his room on his right side at the foot of his bed in front of the bathroom. Patient was dry but had removed all his clothing, bed dry . has redness to right shoulder, right hip, and right knee. Patient c/o back pain . Review of a Nursing note dated 9/4/22 at 4:29 AM, documented in part . Because Patient has history of falls put in order for patient to have scoop mattress for added safety . Further review of R905's fall care plan revealed on 9/4/22 an intervention for a Scoop/perimeter mattress was added. Review of a facility Incident Report dated 9/4/22 at 4:00 AM, documented in part, . observed patient laying on the floor of his room on his right side at the foot of his bed in front of the bathroom . Patient has redness to right shoulder, right hip, and right knee. Patient c/o back pain . Patient educated on safety and using call light and waiting for help, bed placed in lowest position . Review of the medical record revealed no documentation of the Interdisciplinary team to have met to identify and discuss the root cause analysis of R905's fall. Review of a Nursing note dated 11/6/22 at 6:15 AM, documented in part . Observed resident sitting upright on floor. Assessed for injuries . Resident unable to recall how fall occurred. Safely transferred to bed . Bed in lowest position, and call light within reach. Further review of R905's fall care plan revealed on 11/7/22 documented an intervention to Provide activities/items of interest. This is an ineffective intervention that was implemented to prevent fall for a resident with dementia, a history of falls and noting that the falls have occurred in the early morning hours. Review of the facility Incident Report dated 11/6/22 and review of the medical record revealed no documentation of the Interdisciplinary team to have met to identify and discuss the root cause analysis of R905's fall. Review of a Nursing note dated 12/9/22 at 5:06 PM, documented in part . Resident found on floor by CNA (aide). States hit head . Abrasion rt (right) elbow, cleansed and band aid applied. Redness rt top of shoulder . Review of a facility Incident Report dated 12/9/22 at 4:19 PM, documented in part . found on bathroom floor by CNA. Resident states hit top of head . Abrasion to right elbow . The patient was attempting to go to the restroom alone with no assistance . Patient was educated ask for help before going to use the restroom. Patient was educated on how to use call light and informed when to use call light . This education was not effective as the resident is diagnosed with dementia. Review of the fall care plan revealed no modifications or new intervention implemented. Review of the medical record revealed no documentation of the Interdisciplinary team to have met to identify and discuss the root cause analysis of R905's fall. Review of a Nursing note dated 12/22/22 at 6:51 AM, documented in part . CNA notified Nurse that pt was on the floor. Pt states he was trying to take the cover off of him and placed himself on the floor . Nurse observed pt lying on right shoulder on the floor on the right side of the bed . Review of the facility Incident Report dated 12/22/22 at 1:50 AM, documented in part . CNA notified Nurse that pt was on the floor. Nurse observed pt lying on right shoulder on the floor on the right side of the bed . Review of the fall care plan documented a new intervention implemented on 12/22/22, ensure proper body alignment while in bed. Review of the medical record revealed no documentation of the Interdisciplinary team to have met to identify and discuss the root cause analysis of R905's fall. Review of a Nursing note dated 1/19/23 at 7:30 AM, documented in part . Writer heard a loud noise and went to investigate, and observed patient laying on the floor next to his bed in front of closet, on his right side. Upon walking into patient room, patient stats <sic> I fell out of bed getting my shirt. Writer observed patient had on his socks and shoes, which he did not have on while in bed. Writer exam <sic> pt, he has a bruise to lateral side of right knee and right elbow . Patient is back in bed awaiting <sic> x-ray, with call light in reach . Review of a Nursing note dated 1/21/23 at 7:25 PM, documented in part . c/o pain 7/10 (seven out of ten) to left leg and knee, writer assessed and note bruising to lateral leg and swelling to anterior knee . Review of a Nursing note dated 1/25/23 at 4:27 PM, documented in part . Son in building, noted irate and attempts to start yelling on writer about stat- x-rays not yet done, writer encouraged son to talk in an appropriate voice tone . Writer called (radiology service) for ETA (estimated time of arrival) . will follow up with driver to give ETA and get back to facility . Review of a Nursing note dated 1/25/23 at 6:08 PM, documented a STAT (immediate) bilateral X-ray of hip and femur and knee for pain. Review of a Nursing note dated 1/26/23 at 11:42 AM, documented in part . Patient sent out to hospital at this time to (hospital name) for eval (evaluation) and tx (treatment) . right hip shows fracture and sending patient out . Review of the hospital records dated 1/26/23, documented in part . Patient presents to the Emergency Center today s/p (status post) fall that occurred 5 days ago at ECF (Extended Care Facility). Xrays show a right subcapital hip fracture . + (positive) hip pain . Trauma team contacted. Plan to admit . Review of a Surgeon note dated 1/27/23, documented in part . Procedure(s): Hemiarthroplasty Right Femoral Neck . Incision Closure: Deep and Superficial Layers . Post-Op Condition of Patient: Stable . On 2/24/23 at 10:57 AM, the Interim Director of Nursing (IDON) A was interviewed and asked if they could provide any investigations for all of R905 falls, provide any documentation of IDT meetings to identify and discuss the root cause analysis of the resident falls. The interventions were reviewed with IDON A, and they were questioned about the initial adequacy of the interventions and the effectiveness of the interventions implemented thereafter. IDON A stated they were newly employed with the facility but would look into it and follow back up. Shortly after the DON returned and stated there was no IDT documentation to provide. The IDON A provided one investigation completed for R905's 1/19/23 fall. The IDON A stated they reviewed the fall interventions for the resident and questioned the effectiveness of the documented interventions themselves. The IDON A stated since they have been employed with the facility, they have completed a lot of education pertaining to falls with the facility staff. No further information or documentation was provided by the end of survey.

This citation pertains to intake: MI00131520 and MI00132012. Based on observation, interview and record reviews the facility failed to consistently complete accurate Braden assessments, timely implement preventive interventions to prevent pressure ulcers, implement and monitor the effectiveness of physician ordered treatments and timely identify skin changes and/or worsening of pressure ulcers for two (R's 175 and 20) of four residents reviewed for pressure ulcers, resulting in R175 to have been transferred to the hospital, admitted to the Intensive Care Unit (ICU) for sepsis, required Intravenous (IV) empiric antibiotics and ultimately documented on the death certificate as Sepsis due to infected sacral wound as the first cause of death and resulting in R20 to have developed a sacral Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) pressure ulcer that required surgical debridement and IV antibiotics. Findings Include: R175 A complaint submitted to the SA documented concerns of the facility to have failed to provide care to prevent and treat a pressure ulcer. Review of the hospital record with an admitted [DATE] documented the following, . ADMITTING DIAGNOSIS Severe sepsis . 2:15 PM . Patient presents to the Emergency Center today with abnormal labs. Patient was sent in by his assisted living facility for an elevated WBC (white blood cell) count of 18.7. Patient also is complaining of a recent fever and ulcers on his buttocks . Positive for fever . Tachypnea present . decreased breath sound present . Slightly diminished breath sounds to the right lung . Patient has a lactic acid of 3.0. Empiric antibiotics have been started and he will be treated with IV fluids . Severe sepsis with organ dysfunction, suspect 2/2 (secondary to) decubitus ulcer vs. aspiration PNA . Temp (temperature) 103, HR (heart rate) low 100s, WBC 18.9 with left shift . BP 80s/40s . met sepsis fluid resuscitation criteria . IV Vancomycin and IV Zosyn started in the ER (emergency room ) . unstageable sacral decub with pus and surrounding erythema . Plan for beside debridement . Penile wounds . noted also to have penile ulcers that he did not know of . Discharge Summary Note . was admitted to the hospital for confusion and abnormal labs. Patient was found to be hypotensive, with severe sepsis secondary to infected sacral decubitus ulcer. He was admitted to IICU and started on broad spectrum IV ABX (antibiotics) . Patient underwent debridement of his sacral wound by General sx (surgery) . Clinically, patient continued to be lethargic, with persistent hypotension- despite Midodrine (medication to help raise blood pressure) . and severely debilitated . Review of Certificate Of Death documented in part, . Pronounced dead on- August 26, 2022, . 03:45 AM . Place Of Death- Hospital . Inpatient . IMMEDIATE CAUSE- Sepsis due to infected sacral wound . Review of the medical record revealed R175 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction due to embolism, end stage renal disease, hypertension and systolic congestive heart failure. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 which indicated intact cognition and required a Two persons physical assist for bed mobility, transfer, dressing, toilet use and required staff assistance for all other Activities of Daily Living (ADLs). Review of an Admission/Re-Admission Evaluation dated 6/6/22 at 7:37 PM, documented in part, . Skin integrity issue(s) present- No . no skin concerns were documented on the body chart on the admission assessment, which indicated the resident was admitted to the facility without any skin concerns or pressure ulcers. Review of an admission Braden Scale for Predicting Pressure Sore Risk dated 6/6/22 at 7:37 PM, documented a score of 19.0 which indicated the facility categorized the resident to be At Risk and check off No for the need to proceed to preventative care planning for this resident. The Braden Scale assessment consist of six areas- 1) Sensory Perception, 2) Moisture, 3)Activity, 4)Mobility, 5) Nutrition and 6)Friction & Shear. The facility staff documented the following upon admission: Moisture- Rarely Moist: Skin is usually dry . Activity- Walks Occasionally Mobility- Makes frequent though slight changes in body or extremity position independently. Friction & Shear- Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Review of the initial Occupational Therapy evaluation completed on 6/7/22, documented the resident was dependent for toilet transfer, sit to lying, lying to sitting, sit to stand and chair/bed to chair transfer and required substantial/maximal assistance to roll left and right. Review of the initial Physical Therapy evaluation completed on 6/7/22, documented the resident was substantial/maximal assistance to roll left and right and dependent for chair/bed to chair transfer, sit to lying, sit to stand, toilet transfer, walk 10 feet gait and wheelchair mobility. The patient goal documented was Legs stronger and walk. Review of both the Occupational and Physical therapy evaluations in comparison to the admission Braden assessment, indicated the resident was unable to walk occasionally, make independent body changes and positioning and required maximum assistance with friction and shear. Review of a care plans documented the following: Functional Mobility initiated 6/7/22, documented the following interventions . Hoyer lift for transfers . Wheelchair training . ADL self-care deficit as evidence by increased assist related to deficits in strength, balance and activity tolerance initiated 6/7/22, documented the following interventions . mechanical lift for transfers . Requires assistance/ potential to restore function for TRANSFERRING from one position to another initiated 6/7/22, documented the following intervention . TRANSFERS: 2 person assist with mechanical lift . Urinary/bowel incontinence related to Impaired Mobility initiated 6/20/22, documented the following interventions . Provide incontinent care as needed, report changes in skin integrity found during daily care . Pain risk related to immobility, aging process initiated 6/20/22, documented the following interventions . Encourage/Assist to reposition frequently to position of comfort . In comparison with the admission Braden assessment this indicated the resident moisture, activity, mobility and friction and shear sections were not completed accurately. Further review of additional Braden assessments completed documented a score of 19 on 6/13/22, 6/20/22 and 6/27/22 all inaccurate scores. Review of the medical record revealed no interventions initially implemented to prevent pressure ulcers until 6/20/22 (two weeks after admission) which documented in part, . At risk for alteration in skin integrity related to: impaired mobility, incontinence, ESRD (end stage renal disease), aging process . Goal- Decrease/minimize skin breakdown risks . Interventions- Barrier cream to peri area/buttocks as needed . Observe skin condition with ADL care daily; report abnormalities . Wrap/pad oxygen cannula . these were the only interventions implemented on the care plan. Further review of the medical record revealed a barrier cream to peri area/buttocks as needed was never implemented for the resident, as evidenced by no physician order. Review of the physician orders documented the following order apply remedy zguard to excoriation buttocks every day and night shift this had a start date of 7/5/22, almost a month after admission. This order was implemented by the Wound Care Nurse (WCN) I. Review of the medical record revealed no documentation of the wound care nurse, physician, practitioner or nursing staff to have documented the assessment, monitoring of the buttocks while receiving the ordered zguard treatment to the excoriated buttocks to ensure the treatment was effective. Review of a Nursing note dated 8/7/22 at 12:02 PM, documented in part . Resident noted with redness and discoloration to Left sacral/coccyx area. Resident encouraged to T/R (turn and reposition) WIB (while in bed). MD (medical doctor) contacted and made aware of clinical situation. Logged for wound care to f/u (follow up). Tx (Treatment) initiated. There were no measurements documented of the skin concern. Review of the August 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented a new treatment that was first applied on 8/9/22 (two days after notifying the physician of skin changes). The treatment ordered was ThereHoney every day shift for Area of concern Cleanse sacral/coccyx region with wound cleanser, pat dry and apply small amount to area, cover with 4x4 and ABD (abdominal) pad . Review of a Nursing note dated 8/9/22 at 11:54 AM, documented in part . pt (patient) seen today for Sacro coccyx wound-site is reddened with yellow slough (slough- is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Peri wound is red, lit amt (amount) serous drainage . There were no measurements documented on the Sacro coccyx wound. Review of a wound physician noted dated 8/10/22 at 2:27 PM, documented in part . evaluated for an unstageable sacral coccyx pressure ulcer . Reports his pain level varies . at times it is severe, repositioning and offloading help to alleviate some of this as well as medications. Currently treated with topical prescriptive honey for autolytic debridement . sacral unstageable pressure ulcer (Unstageable pressure ulcer- Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) with slough necrotic tissue yellow and brown adherent to wound bed . Plan- Clean and apply therahoney, cover with four on foam and change x week and prn . pressure reduction mattress . pressure reduction check cushion . limit time up in chair . assist with frequent turning and repositioning, encourage patient to also participate in frequent turn and reposition . offloading with pillows in bed . Review of a Skin & Wound Evaluation dated 8/10/22 at 12:25 PM, documented the following in part . Pressure . Unstageable . Slough and/or eschar . Location- Sacrum . Acquired: In-House Acquired . How long has the wound been present- New . Area 7.4 cm2 (centimeters squared) . Length 5.8 cm . Width 1.8 cm . 10 % of wound filled Slough . 90% wound filled Eschar . Exudate- Light, Serous . Review of an order implemented on 6/7/22, documented a daily body audit. Despite the resident to have had a daily body audit order (which was not consistently signed off as completed by staff), R175 was admitted without any wounds, developed excoriation to the buttocks on 7/5/22, redness and discoloration to the sacra/coccyx area, two days later documented observed yellow slough and then on the next day it was assessed by the physician and diagnosed as an unstageable pressure ulcer. The facility staff failed to timely identify, monitor and report the worsening of this wound. Review of the August 2022 MAR and TAR revealed the treatment to the sacral/coccyx area was not signed off as administered on the 8th, 12th or 16th. Review of a Nursing note dated 8/16/22 at 1:21 PM, documented in part . CENA (aide) called writer and wound nurse in room for wound change before breakfast. Writer observed unstageable sacral coccyx pressure ulcer color yellow tannish green necrotic tissue with a pungentstrong <sic> foul musty odor smell. Wound was cleaned <sic> Normal saline medi honey applied and new dressing applied to buttocks. Patient was observed having mental status <sic> and hallucinating. Patient seeing things that was not there on the wall and in the room. Doctor was notified new order to do lab work . new order given to send patient out to hospital for sepsis hallucinations mental status . 1300 (1:00 PM) EMS (Emergency Medical Services) was called patient is going to (hospital name) . On 11/15/22 at approximately 1:00 PM, WCN I was interviewed and asked when they were first made aware of any sacral/coccyx concerns for R175. WCN I was also asked why they implemented an order for excoriation on 7/5/22 and never followed back up with the resident to assess the area and assess if the treatment was effective. WCN I was asked how the resident admitted with no skin concerns, developed excoriation to the buttocks on 7/5/22 and then developed an unstageable on 8/10/22, without staff identifying the worsening of the wound, despite having a daily body audit ordered? WCN I was also asked why the treatment ordered for the buttocks on 8/7/22 didn't start until 8/9/22. WCN I stated they would review the chart and look into all of the questions asked and follow back up. On 11/15/22 at 1:44 PM, the Director of Nursing (DON) was interviewed and asked the same questions noted above (with WCN I) and stated they would look into the record and follow back up to discuss. The DON did not follow back up regarding R175 before the end of survey. On 11/16/22 at 3:51 PM, WCN I stated they must had gotten busy and that is the reason they did not follow back up with R175 once they ordered the treatment on 7/5/22. 39592 R20 On 11/14/22 at 12:40 PM, R20 was observed lying in bed. A peripherally inserted central catheter (PICC - used for intravenous infusions) line was observed in R20 right upper arm. R20 did not respond to any questions asked. Review of the clinical record revealed R20 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: dementia, stroke and sepsis. According to the MDS assessment dated [DATE], R20 had severely impaired cognition and required the extensive to total assistance of staff for all ADL's. The MDS assessment also indicated R20 had a facility acquired Stage 4 pressure ulcer. Review of R20's admission MDS assessment dated [DATE] indicated R20 had no pressure ulcers when admitted into the facility. Review of R20's Skin & Wound Evaluations revealed the first documentation of a pressure ulcer on 8/31/22 which read in part, .Stage: Unstageable . Sacrum . In-House Acquired . New . Length 3.8 cm . Width: 1.3 cm . Slough: 20% of wound filled . Review of a MP (Medical Practitioner) Wound Progress Note for R20 dated 8/31/22 at 10:28 AM revealed in part, .initial wound care . seen today for an unstageable pressure ulcer with onset about a week ago Review of R20's August 2022 Treatment Administration Record (TAR) revealed a treatment that read, cleanse coccyx site with ns (normal saline) and pat dry. apply therahoney and cover with foam drsg (dressing) daily and prn (as needed) every day shift for wound care. TAR was marked as completed on 8/19/22, then was left blank, indicating treatment was not done, on 8/20/22, 8/21/22, 8/22/22, 8/23/22 and 8/26/22. Further review of R20's clinical record revealed no documentation of a skin assessment or progress note that described what type, size or characteristics of any wound on R20's sacrococcyx area until 8/31/22, 12 days after a treatment was put into place for an unspecified wound. Review of R20's MP Wound Progress Notes revealed: On 9/7/22 at 10:14 AM , .evaluated for a poor healing sacral unstageable pressure ulcer . Area was debrided and noted base with mostly slough and areas of tendon exposure, reclassified as stage 4 . On 9/23/22 at 12:43 PM, .While hospitalized , her wounds were debrided again . Her wounds have worsened to a Stage IV sacral pressure wound . On 10/19/22 at 2:11 PM, .patient is evaluated for a stage IV sacral pressure ulcer with current infection and is treated with IV antibiotics for osteomyelitis . On 11/9/22 at 9:29 AM .This patient is evaluated for stage IV sacral pressure ulcer . Patient has had complications of wound infection, surgical debridement, IV antibiotics continue for treatment for osteomyelitis . On 11/15/221 at 12:58 PM, WCN I was interviewed and asked if there was any documentation of R20's sacrum pressure ulcer before 8/31/22. WCN I explained she had seen the wound on 8/19/22, and entered a treatment order. When asked why there was no assessment or progress note, WCN I explained she had gone home early on 8/19/22 and was out sick for 10 days and had not documented on the wound prior to leaving that day. WCN I was asked if she was the only nurse that could assess, document on a wound, or complete the daily treatments. WCN I explained she did not do the daily treatments, the floor nurses did those, and any nurse could assess and document on wounds. WCN I was asked what the wound looked like on 8/19/22, and if the treatments had been completed per orders would it have progressed to an Unstageable/Stage IV pressure ulcer on 8/31/22. WCN I explained it was a small wound that she had expected to heal. On 11/15/22 at 1:50 PM, the DON was interviewed and asked about the lack of documentation of R20's pressure ulcer prior to 8/31/22 and the missing treatments on the August TAR. The DON explained she did not know about the missing treatments, and would look into them. On 11/16/22 at 2:41 PM, the DON was asked again about the missing treatments, and if audits were done to ensure treatments were completed per orders. The DON explained there were audits of the treatments done, but had no explanation of why R20's treatments were not completed. Review of a facility policy titled, Skin Management Guidelines dated 3/2022 read in part, .Skin alterations and pressure injuries are evaluated and documented by the licensed nurse . Body audits are completed: By the licensed nurse daily for patients with pressure injuries and documented on the eTAR; new findings are documented in a progress note . By the licensed nurse weekly for patients without pressure injuries and documented on the eTAR; new findings are documented in a progress note . The Braden Scale is the clinically validated tool used to identify potential levels of risk for pressure injury development . The Braden Scale is competed at the time of admission and is also available as an independent assessment . The Immediate Jeopardy (IJ) started on 8/16/22. The IJ was identified on 11/15/22 at 3:02 PM. The Administrator was notified of the IJ on 11/15/22 at 4:03 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 11/16/22 at 3:01 PM, based on the facility's implementation of an acceptable plan of removal as verified onsite by the State Agency (SA). Although the immediacy was removed, the facility's deficient practice was not corrected and remained as an isolated incident that is not immediate jeopardy.

Based on observation, interview and record review, the facility failed to ensure consistent meal assistance was provided, interventions for weight loss were timely updated and implemented, consistently monitor food and supplement intake and ensure physicians were notified of the significant weight loss for two (R226 and R10) out of six reviewed for weight loss resulting in significant weight loss and the potential for continued decline in nutritional status. Findings include: On 10/16/22 at approximately 10:59 AM, R226 was observed lying flat in her bed. On the bedside table on the side of R226's bed was a Styrofoam container with a full serving on scrambled eggs and one piece of toast, a bowl of un-eaten oatmeal, six un-open containers of ensure and a full Styrofoam cup of water. All the food and beverages were out of reach of the resident. When asked about the breakfast meal, R226 reported that their stomach was bothering them, and they were not hungry. A review of R226's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: quadriplegia, urinary tract infection (UTI), Bi-Polar Disease and Chronic Kidney Disease. An admission weight of 157 pounds (lbs.) was noted in the record. A review of the residents Minimum Data Set (MDS) noted the resident was cognitively intact. Further review of the MDS noted the resident required extensive one person assist for feeding. Continued review of R226's clinical record, documented, in part: R 226's weights: 9/28/22: 157 lbs,10/1/22: 160 lbs,10/15/22: 162 lbs,10/26/22:134.8 lbs11/1/22: 135 lbs. and11/12/22: 130 lbs. *It should be noted R226 had a Severe Weight Loss of 27-pounds in approximately seven weeks. Nutritional assessment dated (9/30/22): Most recent weight: 157 lbs.UBW (usual body weight) 150's .Diet: Regular .Functional Problems Affecting Ability to Eat: Inability to perform ADLs without significant physical assistance .Nutritional Problem .increased nutrient/protein needs .Nutritional Interventions: Supplements .Nutritional Statement/Summary . per son 150's .hospital weight 149# and 155# .family reported no concerns related to chew/swallow .requested total meal assistance patient not able to feed self-related to limited hand use . The Plan of Care on the Kardex documented, Food/Fluids .Total meal assistance. Care Plan: Focus: Nutritional status as evidenced by actual/potential weight loss/gain related to 1. Major depression . (hospital RUE/LUE (right/left upper extremity), RLE/LLE (right/left lower extremity) edema .3. Total meal assist with decline of meal intake prior to admission .4. Sig wt. change might r/t fluid - Revised by Dietary Staff P .Interventions: Encourage and assist as needed to consume foods and/or supplements and fluids offered (date initiated 9/29/22) .honor food preferences (9/29/22) .Provide diet as ordered: regular (9/30/22) .Report signs or symptoms of diet and/or texture intolerance (9/29/22) .Review weights and notify physician and responsible party of significant weight change (9/29/22) .total meal assistance (9/30/22) . (It should be noted that no further interventions were implemented into the Care Plan after 9/30/22 - all interventions were implemented by Registered Dietician (RD) O. Nutrition/Weight Note 11/11/22: .131.6 # .11/1 135# weight has been declining since 10/15 .admit weight 157# on 9/28. Factors with potential to impact weight are: variable appetites and PO intake, current dx UTI .loss of fluids, reduced edema currently per nursing .dx quadriplegia, MRSA, bipolar .meal refusal .per FAR is 50-70%, eats independently with set up help. Ensure is in place TID, RD recommends cueing and tray set up with meals . A 30 day look back on the electronic Task record for self-performance documented, in part, the following: Independent: 10/26/22 (6:29 PM), 10/28/22 (1:31 PM), 11/1/22 (9:38 AM), 11/7/22 (10:42 AM, 11/12/22 (10:04 AM) .Supervision (oversight only) 10/28/22 Limited Assistance (Resident highly involved in activity, staff provide guided maneuvering .) 10/24/22: 11:21 AM/ 1:01 PM) .10/25/22 9:49AM, 2:07 PM 6:19 PM), 10/26/22 9:55 AM, 1:42 PM, .10/27/22 (10:02 AM, 1:42 AM), 10/28/22 10:32 AM, 10/29/22 9:35 AM 1:46 PM, 10/30/22 8:35 AM, 1:01 PM, 11/1/22 1:49 PM, 7:42 PM .11/2/22 2:03 PM, 7:20 PM, 11/3/22 10:00 AM, 1:32 PM, 11/4/22 9:48 AM, 1:53 PM, 11/7/22 1:33 PM, 6:28 PM ,11/8/22 10:44 AM, 7:47 PM, 11/9/22 1:45 PM, 7:55 PM, 11/12/22 1:48 PM, 11/13/22 1:23 PM, 11/15/22 10:02 AM, 2:01 PM, 11/16/22 1:31 PM . A 30 day look back on the electronic Task record regarding Ensure noted that facility staff noted that R226 accepted Ensure 10/16/22 - 11/14/22 three times per day with the exception of refusal dates on 10/21/22 at 9:19AM and 6:35 PM, 11/9/22 at 10:28 AM, 11/10/22 at 10:03 AM, 11/13/2022 at 9:57 AM. On 11/17/22 at approximately 11:16 AM an interview was conducted with RD O regarding R226 significant weight loss. When asked what the underlying cause for the weight loss, RD O replied that it was possible it was due to edema. RD O was asked to provide documentation that indicated the weight loss was due to edema. When asked if they were aware that the resident required one to one assistance with eating, RD O responded Yes. When asked why there were several days documented in R226's Kardex that noted she was eating either independently, with supervision or with limited assistance, RD O reported that she was not aware. When asked who in the facility provided oversite to ensure the resident was receiving assistance with eating, RD O reported that she believed it would be the nurses. RD O noted that it might be best to speak with RD P. On 11/17/22 at approximately 11:55 AM, an interview was conducted with RD P. When asked as to the resident's weight loss, RD P noted that she spoke with the resident yesterday (11/16/22) after lunch and noted that she had not eaten much and stated that her eating is variable. When asked if any interventions were put in to place when they started to see a decline in the resident's weight, RD P reported that they spoke with the resident's son who told me to add some desserts like pudding and jello. When asked if the physician was notified about the weight loss and would have considered placing an appetite stimulant, RD P stated she was not certain. When asked if the resident ever received any medication that that caused a reduction in the resident's possible edema, RD P did not provide an answer. *It should be noted that there was not documentation in the resident's record that noted any diuretics were ordered. When asked why staff were indicating the resident was eating either independently or with limited assistance, RD P was not certain. On 11/17/22 at approximately 4:00 PM, the Director of Nursing (DON) provide a paper copy of a 14 day look back titled Eating Self Performance. The document was highlighted for the section Limited Assistance and indicated that they had interviewed a CNA who stated they recorded Limited Assistance because the resident could hold her cup with their elbow. The DON reported that they in-serviced the CNA on correct recording. The DON was asked as to why staff also reported that the resident was independent and consumed over 75% of their food on their own. The DON did not have an answer. 41415 R10 On 11/14/22 at 10:41 AM, R10 was observed in their room sitting in their wheelchair. Observed on the bed side table was an unopened ensure container. An interview was conducted with the resident at that time. On 11/15/21 at 8:54 AM, R10 was observed eating breakfast by themselves, an estimated 25-30% of breakfast was consumed by the resident. Review of the medical record revealed R10 was admitted to the facility on [DATE], with a readmitted [DATE] and diagnoses that included: traumatic subarachnoid hemorrhage, Parkinson's disease and hypertension. A MDS assessment dated [DATE], documented a BIMS score of 6 which indicated severely impaired cognition and required staff assistance for all ADLs. Review of R10's Weight Summary revealed on 10/1/22 the resident weighed 127.0 lbs. (pounds) and on 11/14/22 the resident weighed 106.6 lbs., which is a severe weight loss of 20.6 lb. loss and a -16.06 % loss in only six weeks. Review of a Nutrition assessment dated [DATE] at 3:17 PM, documented in part . Patient's weight status . Loss . Enter % of weight loss or gain . 11.2 . 10% in 6 months . If significant weight loss, is patient on planned weight loss regimen (not answered) . Review of a Dietary note (documented by Registered Dietician- RD O) dated 10/13/22 at 9:15 AM, documented in part . Full nutrition assessment completed, documented day to day weight change identified and pending re-weight, re-weight obtained . daily weight with difference: 10/10: 101.2 . from 10/9: 126.8 . re-weight 10/12: 101.4 . factors with potential to impact weight: Parkinson's . meal records on average 50/75% intake with an occasional meal refusal . increased nutrient needs r/t (related to) current medical condition . Parkinson's . Intervention- Ensure plus qd (every day) . recommend changing ensure plus to ensure clear. Patient displeasure for chocolate flavor facility stock only includes ensure plus-chocolate . recommend ensure clear tid (three times a day) with all meals . weekly weight for trends . Review of a Dietary note (documented by Dietician P) dated 10/21/22 at 3:36 PM, documented in part . pt (patient) has weight loss since admission 9/30: 127 . 18% weight loss noted. Factors with potential to impact weight: dx (diagnosis) Parkinson's, depression, current COVID 19 infection . eats independently with set up help. Ensure clear TID with all meals is in place. RD (Registered Dietician) attempted taking <sic> to patient & son. Recommend considering mirtazapine for appetite stimulant. RD will continue to monitor & f/u (follow up). Review of a Dietary note (documented by RD O) dated 11/2/22 at 2:07 PM, documented in part . follow up: patient moved to long-term status from rehab: 10/24/22 . significant weight loss . labs: n/a (not applicable) . increased nutrient needs r/t current medical condition aeb (as evidence by): Parkinson's. Interventions- Ensure Clear tid . oral diet as prescribed . encourage and assist as needed for adequate meal and fluid intake . nutrition supplement as prescribed. RD O did not acknowledge or followed up on the recommendation of the mirtazapine to possibly be added for an appetite stimulant as documented in the 10/21/22 dietary note. Further review of the medical record revealed no documentation of the notification to the physician regarding the resident weight loss. On 11/17/22 at 11:04 AM, RD O was interviewed and when asked what interventions was implemented besides the ensure supplements to prevent further weight loss, RD O started looking in the resident's medical record but was unable to find any other interventions implemented for R10. When asked if they communicate with the other Dietician (Dietician P) regarding the any recommendations or plan of care made to implement an effective nutritional plan and interventions for the residents in the facility, RD O stated they do communicate with Dietician P. When asked why they didn't acknowledge or follow up on the recommendation of mirtazapine for an appetite stimulant made on 10/21/22 when they completed the follow up nutrition assessment on 11/2/22, RD O stated R10's weight was stable. When asked how they considered a body weight loss of 16.06% in six weeks stable, RD O stated the resident was maintaining their weight. RD O was asked if the physician was notified of the resident weight loss and stated, I'm sure the doctor was notified, RD O was asked to provide documentation of the physician to have been notified. On 11/17/22 at approximately 11:30 AM, Dietary P was interviewed and when asked stated they did make the recommendation of the mirtazapine being added to stimulate the resident's appetite. When asked Dietary P stated, that both RD O and themselves usually will review the previous note to see what recommendations were made previously to ensure effectiveness. Review of the electronic and paper chart revealed no documentation of the physician to have been notified of R10's weight loss. On 11/17/22 at 2:47 PM, the DON was interviewed and asked if the physician should have been made aware of the resident's weight loss and stated the physician should have been contacted. The DON stated they would call the physician to inquire about R10's weight loss. At 3:28 PM, the DON stated they contacted R10's Physician who stated they were unaware of R10's weight loss but will follow up on it with their next consultation with R10. Review of a facility policy titled Medical Nutrition Therapy And Documentation dated 11/2020 documented in part, . Subsequent nutritional assessments as part of quarterly reviews, evaluation of weight loss or other nutrition related evaluations . Ongoing monitoring is important to determine the patient's progress in meeting goals . If nutritional goals are not achieved, and interventions are determined to be ineffective, different or additional pertinent approaches are considered and implemented as indicated . communication with physician . Frequent monitoring and documentation is suggested for patients who are . experiencing significant weight changes or trends .

This citation pertains to MI00132012 Based on interview and record review, the facility failed to educate and offer the COVID 19 vaccination to three (R's 329, 26 and 46) of 5 residents reviewed for immunizations, resulting in R329 cotracting COVID-19 and requiring hospitalization . Findings include: R329 Review of the medical record revealed R329 was admitted to the facility on [DATE] with diagnoses that included: adult failure to thrive, sarcopenia, need for assistance with personal care and chronic obstructive pulmonary disease. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 8 which indicated moderately impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the Immunization tab revealed no documentation of a COVID 19 vaccine. Review of the medical record contained no documentation that R329 had been educated and provided the opportunity to consent and/or decline the COVID 19 vaccine. Further review of the medical record revealed the following: On 10/19/22 R329 tested positive for COVID 19. On 10/24/22 at 11:41, a Nursing note documented in part . Pt (Patient) continues to have symptoms of cough and large loose stool today. Pt is receiving Guaifenesin tabs for productive cough q (every) 12 hr (hours). Asked nurse to give pt PRN (as needed) Immodium <sic> per physician order. On 10/25/22 at 2:00 PM, a Nursing note documented in part . resident condition continuously going down and seen by (practitioner name) today and resident lab works <sic> was reviewed and chest X-ray result was done and result is available seen by (practitioner name). repeat blood work up ordered for tomorrow. Physical therapy was done and resident could not participate due to his weakness unable to stand even jus <sic> a minute and his blood pressure goes down and becomes tachycardic and dessatting <sic> informed (practitioner name) and was send <sic> to hospital via 911 to (hospital name) wife informed and went to hospital with resident. Review of the resident vitals revealed the following: On 10/25/22 at 11:55 AM, Blood Pressure (BP) 98/70, Pulse 118 and O2 sat (oxygen saturation) - 90% on Room Air (RA). At 2:08 PM, BP- 96/67, Pulse 251 (was crossed out and noted Disputed value at 2:09 PM) and O2 sat- 85% on RA. On 11/17/22 at approximately 11:00 AM, the facility's Director of Nursing (DON) and Administrator was asked to provide R329's consent for COVID 19 vaccination, and the Administrator stated they would also provide the MCIR (State immunization database of documented immunizations). Shortly after the Administrator replied the facility had no records of the facility to have educated and/or offered R329 the COVID 19 vaccine. There was no MCIR report provided. On 11/17/22 at 11:57 AM, the Infection Control Nurse (ICN) A was interviewed and asked to provide the COVID 19 vaccine consent form for R329. ICN A stated they would look into it and follow back up. At 2:10 PM, ICN A returned and stated the facility did not offer R329 the COVID 19 vaccine and somehow the resident was missed by the facility staff. At 2:54 PM, ICN A returned and stated the Administration staff made them aware that R329's wife worked at the facility and stated their husband doesn't take vaccines, but the wife feels they gave their husband the vaccine before. ICN A was asked to clarify, R329's wife stated the resident doesn't take vaccines but the wife also stated they may have administered the COVID 19 vaccine to the resident in the past? ICN A confirmed what was repeated and the ICN A nurse was informed that the facility's failure to offer R329 the COVID 19 vaccine was still a concern. 39592 R26 Review of R26's medical record revealed they were admitted into the facility on [DATE] and readmitted [DATE]. Review of the medical record revealed no documentation of R26 ever receiving the COVID-19 vaccine. No documentation of education or a consent for the COVID-19 vaccination had been provided. R42 Review of R42's medical record revealed they were admitted into the facility on [DATE]. Review of the medical record revealed no documentation of R42 ever receiving the COVID-19 vaccine. No documentation of education or a consent for the COVID-19 vaccination had been provided. On 11/16/22 at 12:07 PM, RN A, who was the Infection Preventionist, was interviewed and asked about R26 and R42 COVID-19 vaccinations. RN A explained both residents were unvaccinated for COVID-19 and she could not find a declination for the vaccine for either resident. When asked if the residents and/or their representatives had been provided education on the vaccine, RN A had no answer. Review of a facility policy titled, Screening and Vaccinations dated 5/2022 read in part, .COVID-19 - offer upon admission either the single dose COVID-19 vaccine or one of the two (2) dose vaccines with the second dose administered per manufacturer's recommendations to eligible patients/residents who have never received or who had previously refused the COVID-19 vaccine . Every vaccine offered required, distribution of the Vaccine Information Statement (VIS) which explain the risks and benefits of the vaccine, screening for eligibility and contraindications, completion of the Vaccination Information Acknowledgement or signed consent/declination (if required by the state) and a physician's order to administer the vaccine .

This citation pertains to intake: MI 908. Based on interview, and record review, the facility failed to assess for a removal of a catheter and provide necessary treatment and services to six residents (R701, 708, 709, 710, 711 & 712) of six residents reviewed who required care for indwelling catheters, resulting in an immediate jeopardy when R701 developed a Urinary Tract Infection ([CONDITION(S)]) which caused septic shock, admission into the Intensive Care Unit (ICU) and expired two days after being hospitalized . This deficient practice resulted in R701's death and the potential for serious injury, infection, harm, and/or death to all facility residents with urinary catheters. The Immediate Jeopardy (IJ) started on [DATE]. The IJ was identified on [DATE] at 11:16 AM. The Administrator was notified of the IJ on [DATE] at 3:45 PM and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] at 2:28 PM, based on the facility's implementation of an acceptable plan of removal as verified onsite by the State Agency (SA). Although the immediacy was removed, the facility's deficient practice was not corrected and remained at a pattern incident that is not immediate jeopardy. Review of R701's Certificate of Death (date signed [DATE]) documented in part, . Cause Of Death . a) Septic Shock due to Urinary Tract Infection . Review of the medical record revealed R701 was admitted to the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission evaluation dated [DATE] at 6:11 PM, documented in part . Clinical Evaluation Renal/Urinary . indwelling catheter . Yes . Review of a hospital Discharge Summary dated [DATE] at 12:00 PM, documented in part . Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Septic shock . Acute [CONDITION(S)] with [CONDITION(S)] . Urinary tract infection associated with indwelling urethral catheter . diagnosed with septic shock with multiorgan dysfunction, acute resp (respiratory) failure . intubated and admitted to intensive care unit. His overall condition was very poor and after discussions with family, they requested comfort care and extubation. The patient expired while under comfort care . Further review of the medical record revealed there was no comprehensive interdisciplinary review and assessment of the use of the indwelling catheter or the assessment for the removal of the urinary catheter completed. A facility policy titled Focus on F Tag 690 (no date) documented in part, . A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catherization is necessary . Review of a facility policy titled Catheter Care: Indwelling Catheter dated ,d+[DATE], documented in part . Purpose: To recommend the steps of catheter care hygiene for residents with indwelling catheters . Do not disconnect the catheter and drainage tube unless the catheter must be irrigated . Verify physician's order . Examine genitalia for signs of inflammation, skin breakdown or discharge . Secure catheter tubing to resident's leg using a securement device . Prevents traction on the urethral . Check that tubing is not looped, kinked, clamped or positioned above the level of the bladder and off the floor . document date, time and care provided . Unusual observations, color and amount of urinary output, any leaking of urine around the catheter or blood in the urine and/or complaints and subsequent interventions including communications with physicians . Review of the physician orders revealed no orders for catheter care, securement of the catheter or checking of the catheter tubing daily. Review of the medical record revealed the following: A Dietary note dated [DATE] at 3:50 PM, documented in part . meal refusal ,d+[DATE], ,d+[DATE] x two meals, ,d+[DATE] x two meals . Review of the medical records revealed this was the start of the change in condition for the resident. A Temperature Summary documented a [DATE] at 8:02 PM, documented a 99.1 temperature. Further review of the medical record revealed no notification to the physician regarding the low-grade temperature. In addition to the loss of appetite the resident developed a low-grade temperature. A Nursing note dated [DATE] at 5:38 AM, documented in part . Pt (patient) reports of malaise (feeling of discomfort, illness or fatigue), skin is hot to touch. VS (vital signs) assessed and noted to have fever of 101.4. Nursing assistant state pt. has been feeling malaise past few day <sic> . Urine output is dark . Pt stated he is not drinking enough and encourage nectar thick liquids. Pt will drink when staff encourages . MD notified, new orders for STAT (immediate) UA (urinalysis) C+S (Culture and Sensitivity), CBC (Complete Blood Count) w/diff, CMP (Comprehensive Metabolic Profile) and Tylenol 500 mg 2 tabs prn Q6 for fever. A Nursing note dated [DATE] at 11:36 AM, documented in part . foley is draining dk (dark), tea colored urine . new orders for [MEDICATION(S)] for 5 days. Will monitor . A Nursing note dated [DATE] at 5:30 PM, documented in part . urine remains dk (dark) tea colored . A Nursing note dated [DATE] at 11:15 AM, documented in part . lethargic but responsive . pt. has poor appetite. Urine is very dark and pt. needs much encouragement to drink fluids. Has small nosebleed this am-stoppled within couple minutes . Further review of the medical failed to reveal documentation that R701's physician was notified of this decline and becoming lethargic; the resident remained in the facility. A Nursing note dated [DATE] at 11:50 AM, documented in part . patient had small nosebleed again-easily stopped. Urine sludgy . new orders for iv (intravenous) fluids . and labs . A Nursing note dated [DATE] at 1:12 PM, documented in part . patient sleepy-ate no lunch . A Nursing note dated [DATE] at 6:16 PM, documented in part . pt. is sleeping . urine is clearing- remains tea colored but is clearer than earlier . pt. did not eat dinner but did take few sips <sic> water . A Nursing note dated [DATE] at 8:06 AM, documented in part . Writer rec'd report from off-going shift nurse that patient has change in orientation. Writer obtained patient vitals . temperature 101.7 temporal, sp02 91% RA (Room Air) at rest and unresponsive. Writer phoned (Emergency Medical Services name redacted) for transfer . Writer phoned (name of hospital) intake to give report to ED (Emergency Department). A Nursing note dated [DATE] at 8:17 AM, documented in part . Writer observed pt. lethargic and unresponsive. Pt also did not take scheduled morning meds (medications). Pt does have [CONDITION(S)] and is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . is receiving IV fluids . MD (Medical Doctor) stated to send pt. out to (hospital name redacted) . Review of the hospital medical records revealed the following ED Physician note dated [DATE] at 8:19 AM, documented in part . Presents to the EC <sic> after a nurse at (nursing facility name redacted) discovered him with decreased responsiveness. They state he had a temperature of 105 and was tachycardiac. They also reported blood in his foley catheter which was not there yesterday . Patient is unresponsive and cannot provide history . He is ill-appearing . Mucous membranes are dry . No gag reflex. Patient was intubated for [CONDITION(S)] and airway protection . [CONDITION(S)] present. Rhythm irregular . Foley catheter in place with blood in bag . Skin is pale . Tactile fever . unresponsive . Decision Making: 9:30 AM Blood cultures and urine were sent. Appears septic with fever . was started on [MEDICATION(S)] and [MEDICATION(S)] (antibiotics) . He is still tachycardiac. Patient was given [CONDITION(S)] fluid bolus . CT (Cat Scan) will be performed on the way to the ICU . Final Impression . [CONDITION(S)] . Unresponsive . [CONDITION(S)] . Hematuria . Dehydration . On [DATE] at 8:37 AM, the DON (Director of Nursing) was interviewed and asked why a comprehensive interdisciplinary review and assessment of the resident's urinary catheter was not completed, why the resident was not assessed for the removal of the catheter and why the resident did not have physician orders for catheter care. The DON stated that usually for a resident that is admitted with a urinary catheter, the facility would address the purpose of the catheter and we like to see if we can get it out, usually within the first ,d+[DATE] hours . The DON stated it would be documented in the nursing notes. The DON then stated that physician orders were not needed for catheter care, despite the facility policy documenting to verify physician orders. When the DON was asked how the facility ensures that catheter care is being completed correctly and ensure that it is being done daily, the DON did not have a response. The DON stated they were not employed with the facility at the time the resident was in the facility but would look into it. Shortly after the Administrator provided the Certified Nursing Assistants (CNA) tasks documentation. Review of the CNA tasks documented a catheter care task, however, was not completed for the following dates: February 2021- dayshift- ,d+[DATE], Evening shift- ,d+[DATE] & ,d+[DATE] and Night shift- ,d+[DATE]. [DATE]- Night shift- ,d+[DATE] and ,d+[DATE]. A Nursing Assistant Skills Review Checklist provided by the facility's Human Resource (HR) department documented the following for the training of CNAs regarding a urinary catheter, . Catheter: external/internal-care, positioning, covering of bag, emptying, cleaning, storage of bag, leg bag usage . On [DATE] at 9:16 AM, CNA M was interviewed and asked what catheter care they provide for residents with urinary catheters and CNA M replied in part, . We use wipes for the inner and outer care. We empty catheter tip of urinary bag and empty the catheter and wipe again. External is the privacy bag and internal is when we clean every time we change the patient, and we clean the catheter with the wipes from the inner to outer side . CNA M did not address the responsibility of ensuring the securement of the urinary catheter device or the checking of the urinary catheter tubing. On [DATE] at 1:24 PM, CNA Q was interviewed and asked what catheter care they provide for residents with urinary catheters and CNA Q replied in part, . we use wipes to clean urethra top to bottom, wipe and check bag, empty bag and clean the nozzle of the catheter bag . When asked what type of wipes the CNA's were using to provide catheter care, CNA Q provided a Fit Right Aloe Wipe in a green package. CNA Q did not state the responsibility of ensuring the securement of the urinary catheter device or the checking of the urinary catheter tubing, as documented in the facility policy. No additional explanation or documentation was provided by the end of survey. R708 Review of the clinical record revealed R708 was last admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE] R708 had mild cognitive impairment. Per nursing admission assessment dated [DATE], of R708 revealed that this resident was alert to situation, person, place, and time. The Nursing Admission assessment also revealed that R708 had an impairment to the left upper and lower extremity in range of motion. R708 had an indwelling urinary catheter. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R708's orders revealed no physician orders for catheter care. R709 Review of the clinical record revealed R709 was last admitted to this facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R709 was assessed as being cognitively intact in the MDS assessment. Review of the Nursing Admission assessment dated [DATE] revealed that R709 had an indwelling urinary catheter in place. Review of R709's orders revealed no physician orders for catheter care. During an interview on [DATE] at 11:31 a.m. when asked how often catheter care was completed where he was washed around where the catheter goes into the penis, R709 replied That has not been done yet. R709 also added that he had the catheter for three weeks. R712 Review of the clinical record revealed R712 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing admission assessment revealed that R712 was alert to situation, person, place, and time. Also, the assessment stated that it was unable to determine on range of motion of extremities. Review of the medical record revealed R712 had an order to maintain the foley catheter, however there were no orders for catheter care. During an interview on [DATE] at 11:45 a.m. when asked how often is the foley catheter care done Nurse Q replied It is supposed to be done every shift. The Certified Nurse Assistants do the cleaning, and they can document in their charting. The nurses can document in the TAR (Treatment Administration Record). When asked how do they document the care if there is no order in the system? Nurse Q replied, If there is no order in the computer, no one is doing it. R710 Review of the clinical record revealed R710 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R710 had intact cognition, required the extensive assistance of staff for all ADL's, and had an indwelling catheter. Review of R710's orders revealed no physician orders for catheter care. R711 Review of the clinical record revealed R711 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R711 had severely impaired cognition, required the extensive assistance of staff for all ADL's, and had an indwelling catheter. Review of R711's orders revealed no physician orders for catheter care. On [DATE] at 1:20 PM, CNA I was interviewed and asked about catheter care. CNA I explained they used wipes to clean the resident and the catheter from the insertion site down the tube a little bit and wipe down the catheter bag and clean the tip of the catheter before and after emptying the bag. When asked how often catheter care was done, CNA I explained when the resident got up in the morning and every time their brief was changed. On [DATE] at 1:24 PM, CNA J was interviewed and asked about catheter care. CNA J explained she cleaned from the insertion site out in all directions, cleaned the tube down and away and emptied the bag. When asked how often catheter care was don, CNA J explained when the resident was changed and with baths.

This citation pertains to Intake #MI 346 Based on observation, interview, and record review the facility failed to perform a thorough assessment on an unresponsive resident with an active Do Not Resuscitate order before initiating chest compressions for one resident (R# 904) of one resident reviewed, resulting in the initiation of chest compressions and verbalized feelings of frustration and complaints of pain and fear. Findings include: A review of a complaint reported to the State Agency on [DATE] alleged the facility failed to ensure nursing staff performed a thorough assessment of an unresponsive resident before initiating cardiopulmonary resuscitation (CPR). Review of the clinical record revealed R904 had been admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:47 PM there was a DNR order entered into the medical record for R904 by their primary physician. Also, on [DATE] there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note dated [DATE] at 1:30AM, and authored by Licensed Practical Nurse, (LPN), Nurse C, said, Patient was observed unresponsive by CNA (Certified Nursing Aide) who informed the nurse. Writer at the time didn't know patient was hospice and DNR, did 15 chest compressions and patient started breathing. 911 was called prior to knowing of status. Hospice nurse called and came out to examine. Patient is doing well, hospice nurse currently in room with patient. Husband was called by hospice nurse, no answer, hospice nurse left message for husband with contact number, writer will follow up with husband. MD called and Tigger [sic] text to inquire of x-rays or new orders, awaiting respond. An interview on [DATE] at 2:25 PM with Unit Manager, Nurse B, took place regarding understanding of management's knowledge of Nurse C performing CPR on [DATE] for R904 who had an active order for DNR. Unit Manager, Nurse B, indicated they were aware of the resuscitation performed by Nurse C for R904, who was both Hospice and DNR. The Unit Manager, Nurse B said they spoke with Nurse C who shared R904 was unresponsive and a sternal rub with 15 chest compressions were performed on R904. Nurse B continued to explain Nurse C admitted they had not validated R904's code status and did not know R904 was a DNR. During the interview, Nurse B was asked what method Nurse C used to determine R904 was unresponsive but was not able to validate what assessment method was used by Nurse C. On [DATE] at approximately 3:00 PM, Nurse B provided a typed phone interview with Nurse C for review. The statement revealed that Nurse C did not check for a pulse prior to starting CPR on R904. On [DATE] at 3:20 PM R904 was observed in their room in bed. At that time, R904's family member was present in the room visiting with R904 and performing range of motion exercises with them. R904 was awake, alert, and engaging in the exercises and conversation with their family member. An interview was conducted with R904's family member and they said they were aware of an individual who filed a complaint with the State Agency with their permission, on their behalf. R904's family member agreed to speak with the surveyor regarding the concerns alleged by the complainant to the State Agency. The family member began by describing R904's disease process and time spent caring for their loved one as R904 had suffered from progressive supranuclear ophthalmoplegia for many years. The family member explained R904 had severely debilitating physical symptoms from the disease, but still had intact cognition. R904's family member was then asked about the concerns filed with the State Agency and expressed a concern regarding an incident where a staff member found R904 unresponsive and began chest compressions on them as part of the cardiopulmonary resuscitation (CPR) process. R904's family member said the facility made them aware of the incident, but they were upset at the assessment used by the staff member who initiated chest compressions as part of the CPR process. R904's family member said, Shouldn't the nurse have checked her pulse? They further indicated they were unclear of what was meant when the facility told them R904 was unresponsive. R904's family member further expressed their frustration over the incident citing they were R904's activated durable power of attorney and R904 had an active order for Do Not Resuscitate (DNR). R904's family member indicated no part of the CPR process should have been initiated because they were a DNR. R904 was asked about their recollection of the incident. R904 said they were on the floor, and they woke up to, Someone beating on my chest, it knocked the wind out of me. R904 was asked if they remembered anything prior to the waking up and said they did not. R904 explained they thought they were in a deep sleep, and somehow ended up on the floor. R904 was asked if they knew how they ended up on the floor and said they did not. R904 said they remember hearing someone calling their name, but they were not able to respond. R904 was asked again to describe what they remembered from the incident and if they could provide any more details. R904 said they remembered a female, with long hair and an orange shirt who jumped on me and started banging on my chest. R904 was asked if they experienced any pain from the incident and stated, Lots of pain, and I remember I started coughing and was scared. A follow-up review of R904's clinical record was conducted and did not reveal an assessment for pain after the incident. An Interview with LPN C was done on [DATE] at 6:45 PM. LPN C shared they did not check the code status in the electronic medical record or the paper chart at the nurses' station that contained a red paper that indicated R904 was a DNR before they started CPR. During the interview, Nurse C was asked to explain what happened the night of [DATE]. Nurse C shared they ran into R904's room because CNA wanted them to check on R904. Nurse C said they found R904 unresponsive, called R904's name, touched R904's shoulder, did a sternal rub and said R904 was still unresponsive. Nurse C further shared that they gave 10 to 15 chest compressions and R904 just woke up, started talking and seemed fine. Nurse C clarified that they should have checked R904's pulse before starting chest compressions but they had not performed a pulse check. Review of facility policy titled, Cardiopulmonary Resuscitation: Adult, The American Heart Association has established evidence-based decision making guidelines for initiating CPR when [CONDITION(S)] occurs. CPR is initiated unless one of the three following conditions is present: 1) a valid DNR order is in place. Also, the BLS Healthcare Provider Adult [CONDITION(S)] Algorithm -2015 Update that is included in the facility policy states, .Look for no breathing or only gasping and check pulse (simultaneously), is pulse definitely felt within 10 seconds? No normal breathing, pulse felt Provide rescue breathing .check pulse every 2 minutes .

This citation pertains to intake(s): MI 839 & MI 846. Based on observation, interview and record review the facility failed to prevent resident to resident abuse for three (R's 708, 709 and 710) of six residents reviewed for abuse, when R709 caused a left hand . Laceration . Skin tear, open, visible . tendon and required emergency room (ER) services for glue repair for (R708) and when R709 grabbed R710's left arm and caused redness. Findings include: R's 708 & 709 A report submitted by the facility to the State Agency (SA) documented in part, . Resident #1 (R709) allegedly scratched Resident #2's (R708) hand, resulting in a skin tear. Residents were immediately separated and first aid was provided to Resident #2 (R708). Resident #2 was sent out to the hospital for treatment . Resident #2 was sent to the emergency room to be evaluated due to increased bleeding per MD (Medical Doctor) order . Both residents have dementia and were unable to recollect anything about the incident the next day . On 12/1/21 at 10:11 AM, R708 was observed laying in their bed. When interviewed regarding the incident the resident could not recall having to go to the hospital or recall another resident causing an opening to their arm or hand. Review of the medical record revealed R708 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R708's progress note dated 9/24/21, documented in part . At approximately 9 Res (resident) was sent out to hosp (hospital) r/t (related to) skintear <sic> to left hand family and physician notified. Review of R708's hospital After Visit Summary dated 9/23/2021 documented in part, . Laceration Repair With Glue Discharge Instructions . Review of R708's ED (Emergency Department) note dated 9/23/21 at 11:08 PM, documented in part . Pt sent . for evaluation following assault at ECF (Extended Care Facility) . Pt (patient) has wound to top of left hand, with tendon exposed, currently bleeding is controlled . Review of the medical record revealed R709 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R709's progress notes dated 9/23/21 at 6:40 PM, documented in part . around 6:20 PM she started swinging at the residents and the staff, pt seems a little upset, unable to determine why, during the dinner meal the family was here to stay with the patient and she was happy, after family left she was ok sitting at the nurses station, until writer saw pt trying to swing at another resident, the pt was moved immediate for safety of all residents and was brought to the nurses station, she was still trying to hit every staff member who tried to talk <sic> By. Writer keep <sic> trying got calm patient down she is throwing things at the staff . Further review of the progress notes revealed no documentation of R709 causing harm to R708. On 12/1/21 at 10:17AM, the Administrator was asked to provide the Facility Reported Incident (FRI) and investigation report regarding R's 708 and 709. At 11:36 AM, a second request was made to the Administrator regarding the FRI and investigation report and the Administrator stated they were unable to find the report and they were still looking for the file. On 12/2/21 at 7:45 AM, the Administrator stated the facility was unable to find the investigation file regarding R's 708 and 709. The facility stated when asked, the facility did not have an incident and accident report for the incident with R's 708 and 709. On 12/1/21 at 3:32 PM, Certified Nursing Assistant (CNA) H (the aide assigned to R708 on 9/23/21) was interviewed and asked about the incident with R708 and R709 and CNA H stated in part . I didn't witness it, an agency nurse told me, she seen it . (Agency Licensed Practical Nurse- LPN B name redacted) was wrapping her (R708) hand. We couldn't stop the bleeding, so she went out to the hospital . On 12/1/21 at 3:49 PM, a telephone interview was attempted with LPN B, and a message was left to return the call. On 12/2/21 at 9:48 AM the Director of Nursing (DON) was asked to call LPN B and have them return the call for an interview regarding the incident and no return phone call was made prior to the end of survey. Review of R709's preadmission hospital Discharge Summary contained a Plan of Care assessment by the hospital Occupational Therapist dated 8/4/21 at 8:45 AM, documented in part . Pt (patient) with poor command following despite verbal, manual, and hand-over-hand assist . Pt getting agitated and attempting to kick and swing fist at writer while assisting with bed mobility . Pt will require 24hr (hour) care at D/C (discharge) . Review of a Mood/Behavior physician note dated 8/10/21 at 5:25 PM, documented in part . She is prescribed [MEDICATION(S)] for delusions . Review of a Nursing note dated 8/27/21 at 9:02 PM, documented in part . Pt combative when this RN (Registered Nurse) was trying to give injection . Review of a Nursing note dated 8/27/21 at 9:03 PM, documented in part . Pt combative when this RN tried to check her BS (blood sugar). Review of a Nursing note dated 9/7/21 at 4:46 PM, documented in part . Pt refused medication in the morning and gave hard time nurse <sic> to check BS, she was very aggressive and wanted punch <sic> nurse . Review of a Nursing note dated 9/12/21 at 4:25 PM, documented in part . Pt gave hard time nurse <sic> to check BS and give insulin, nurse called 2 times for help, pt hit nurse during check her BS <sic> . Review of a Nursing note dated 9/13/21 at 6:32 AM, documented in part . Patient refused all evening and morning meds (medications). Writer tried multiple times and then stopped when patient became very combative. Patient was anxious and irritable . Review of a Nursing note dated 9/18/21, documented in part . At 1915 (7:15 PM), Writer notified by cena (certified nursing assistant), patient displaying agitation and aggressiveness toward staff and residents. Writer attempted to check patient vitals, patient attempt to hit writer. Writer called patient son, and ask if able to come to facility to calm resident . Son arrived to facility, at 2000 (8:00 PM), to calm patient . Review of Nursing note dated 9/19/21 at 1:24 PM, documented in part . pt being combative today trying to give medications . Review of a Nursing note dated 9/19/21 at 5:36 PM, documented in part . pt is being very aggressive and physically abusive towards the staff and trying to towards patients as well. New medication order received by the MD. Med give to the patient, while trying to give the medication pt was trying to stab the writer and the other nurse and the aid with her fork from dinner, the silverware was safely moved from patients hand. Pt is at the nurse <sic>station at this time, refusing to be changed and to eat . Review of a Nursing note dated 9/19/21 at 5:47 PM, documented in part . Pt is at the nurses station at this time, she threw coffee at the staff member, pt was trying to hit another resident as well, a <sic> resident is afraid of the patient, pt is under supervision at all times . Review of a late entry Nursing note dated 9/22/21 at 4:15 PM, documented in part . Resident assisted to be in the hallway by the nursing station w (with)/ social distancing amongst her resident peers as she is attempting to hit/kick anyone in her vicinity. She is making physical contact with staff . She was pull BM (bowel movement) from her brief, placing it on the hand rail and attempting to flick it out off her fingers to anyone passing by . This went on for . an hour prior to the son arriving . Review of a Nursing noted dated 9/22/21 at 4:26 PM, documented in part . pt is upset at this time, after checking BS she started getting upset, she also needs changing and refusing for the aids <sic> to change her, pt is getting agitated at this time, she is hitting the staff who is offering help . Review of R709's care plans revealed no behavioral care plan implemented for verbal, physical harm, agitation or aggression until 9/24/21. Prior to the 9/23/21 incident with R709 assaulting R708, the facility failed to implement interventions for the resident behaviors. This failed to provide guidance to staff on interventions to utilize for the resident behaviors and to prevent harm to the resident and others. On 12/2/21 at 7:40 AM, the Administrator (who also serves as the facility's Abuse Coordinator) was interviewed and asked how they concluded that resident to resident abuse did not occur with R's 708 and 709 and the Administrator stated because of the resident dementia, she did not feel it was willful. R's 709 & 710 R710 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing note dated 10/21/21 at 9:40 AM, documented in part . Pt (R710) was propelling herself in hallway in her wheelchair when another resident (R709) approached her and grabbed her left upper arm. Residents were immediately separated, redness noted on pts arm no complaints of pain . Review of a facility Incident Report dated 10/21/21 at 9:40 AM, documented in part . Resident grabbed another residents left upper arm in hallway, residents were immediately separated. Resident threw cup of water at staff member and continued swinging at staff and pinched a staff member . SW (Social Worker) petitioned pt to go to (hospital name redacted) . On 12/1/21 at 2:16 PM, CNA I was interviewed and asked about the incident on 10/21/21 involving R's 709 and 710 and stated in part, . (R709) was towards the wall. (R710) was coming around (R709) and (R709) grabbed (R710) arm. (R710) didn't know what was going on. I got (R709) off (R710) arm. I had to separate them. I never knew if (R709) was mad, (R709) never showed signs of being angry . On 12/1/21 at 2:30 PM, the Abuse Coordinator was interviewed and asked how they concluded the resident-to-resident abuse did not occur in the incident involving R's 709 and 710's when R709 had multiple previous behaviors of physical behaviors with others. The Administrator stated because of the cognition level, they didn't feel that R709 had will intent to harm R710. The Administrator was then asked why R709 was petitioned to the hospital if they were not a danger to other residents and the Administrator stated because (R709) threw a cup of water at staff and was swinging at staff, per the nursing note on 10/21/21. Review of a facility policy titled Patient Protection- Abuse, Neglect, Mistreatment and Misappropriation Prevention dated 10/2021, documented in part . The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive . behavior . It is essential that center practices help prevent abuse, possible reoccurrence and respond actively to detect and prevent abuse . Physical Abuse includes hitting, slapping pinching, and kicking . The center screens potential and new admissions to determine whether the patient has a personal history of or is at risk for developing abusive actions or aggressive behaviors toward others. If the patient has such a history or presents such a risk, the center reviews the patient's status to determine if the patient is appropriate for admission and if the center can meet the patient's needs .

This citation pertains to intake(s): MI 172 and MI 219. Based on interview and record review the facility failed to consistently complete accurate skin assessments, inform the practitioner of the worsening of a sacrum/coccyx wound (R#706) and prevent a coccyx/buttock wound development on a resident who entered the facility with no wounds (R#705) two of three residents reviewed for pressure ulcers, resulting in R#706 being transferred to the hospital for a higher level of care for their sacrum/coccyx wound and R#705 being discharged from the facility with a coccyx/buttock wound. Findings include: R#706 A complaint submitted to the State Agency documented in part, . the facility allowed the residents bed sores to get progressively worst . A review of the clinical record revealed the following: R#706 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented short- and long-term memory problems and severely impaired cognition for daily decision making. R#706 required staff assistance for all Activities of Daily Living (ADLs). A hospital transfer form dated 12/14/20 (provided to the facility from the hospital upon the resident's discharge) documented a bilateral Coccyx Stage II pressure ulcer. An Admission/Re-Admission Evaluation dated 12/14/20 at 3:23 PM, documented sacrum/bil. (bilateral) buttocks pressure wounds. A MP (Medical Practitioner) Wound progress note dated 12/15/20 at 10:00 AM, documented in part . seen for evaluation of pressure ulcer wound on sacro-coccyx measuring 8.6 cm (centimeters) x 16.4 cm . projected tx (treatment) include [MEDICATION(S)] gel on ABD (abdominal) pad direct applied to wound base . Diagnosis . Unstageable pressure ulcer, sacral-coccyx . Plan - Cleanse wounds with NS (Normal Saline), pat dry, and apply [MEDICATION(S)] gel on ABD pad direct, secure with Tape q (every) day/prn (as needed) . The December 2020 Treatment Administration Record (TAR) revealed the following: Cleanse sacrum with NS, apply triad paste and cover with comfort foam q (every) shift- pressure wound. Every shift (7AM-7 and 7PM-7). Staff documented for 12/14/20- 7PM-7 shift however failed to complete the treatment for 12/15/20- 7AM-7 shift, the documentation was left blank. Coccyx wound: Cleanse with NS, pat dry, apply [MEDICATION(S)] gel on ABD pad, secure with tape Q day/PRN, every shift (7AM-7) was left blank for 12/16/20 all day. The resident received no treatment to the coccyx wound on 12/16/20. A MP Wound progress note dated 12/22/20 at 9:00 AM, documented in part . He is seen for evaluation of unstageable pressure ulcer wound on sacro-coccyx . measures 6.7cm x 7.1cm, necrotic yellow base with moderate serous drainage . A Skin & Wound Evaluation dated 12/30/20 at 5:11 PM, documented in part . Pressure, Unstageable, Slough and/or eschar, Sacrum . Area 50.8 cm2 (centimeters squared), Length 9.8 cm, Width 8.3 cm, Depth- [MEDICATION(S)], Undermining- [MEDICATION(S)], Tunneling- [MEDICATION(S)] . The remainder of the evaluation contained multiple blank areas. A MP Wound progress note dated 1/5/21 at 9:57 AM, documented in part . seen for evaluation of progress of unstageable pressure ulcer wound with unknown onset to sacro-coccyx. Wound noted with black eschar and yellow base to mid-core with some sero-purulent drainage seeping from underneath black eschar, mild foul drainage noted . Length in cm - 9.8. Width in cm - 8.4 . Plan - D/c [MEDICATION(S)] gel. Recommend transfer to hospital for deep wound debridement and further evaluation due to increased WBC (white blood cell) count (17.4) Review of the clinical record revealed staff failed to identify and inform any practitioner of the worsening of the wound, until identified by the Wound NP more than two weeks after the last Wound NP consultation. The December 2020 & January 2021 TAR record documented the following order: Body audit- daily, every day shift for Skin observation (7AM-7) start date 12/15/20 and signed as completed everyday until transferred to the hospital on 1/5/2021. The order failed to leave a space for staff to document any abnormal findings and further review of the clinical record revealed no abnormal findings documented by the nursing staff from the daily skin observations. A care plan titled Sacrum-coccyx extending to bilateral buttocks: unstageable pressure wound . documented the following interventions- Administer treatment per physician orders, Report evidence of infections such a purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn (as needed). The staff failed to follow the resident's care plan. A Temperature Summary was reviewed and revealed the following abnormal temperatures: 1/5/21 at 2:20 PM- 96.8, 1/4/21 at 4:27 PM- 96.3 and 12/31/20 at 1:14 PM- 99.0 A review of the resident labs revealed the following: A 12/20/20 at 3:47 (reported date/time) Complete Blood Count w (with) Differential (CBC w Diff) revealed the following: WBC- 12.4 (normal 3.5-10.1), Neutrophils- 9.8 (normal 1.5-7.2) and Immature Granulocytes- 0.12 (normal 0.00-0.04). A 12/28/20 at 1:05 PM a NP progress note documented in part, . CBC Date 12/24/2020 CBC Results- WBC 13.8 . A 12/31/20 at 6:12 PM (reported date/time) CBC w Diff revealed the following: WBC- 17.4 (normal- 3.5-10.1) , Neutrophils- 15.0 (normal- 1.6-7.2), Monocytes 1.1 (normal- 0.0-0.9) and Immature Granulocytes 0.10 (normal- 0.00-0.04). Further review of the clinical record revealed no notification to the physician or NP regarding the abnormal labs/temperatures and no intervention and/or treatment implemented by the physician and/or NP for the abnormal labs/temperatures. A Nursing note dated 1/5/21 at 2:13 PM, documented in part, Wound care NP (Nurse Practitioner) seen pt. and talked to NP (name redacted) and ordered to send pt. to (hospital name redacted) for sacral wound debridement . (medical transportation name redacted) contacted to transport pt. More than four hours from the Wound NP recommendation to transfer to the hospital. A Certificate of Death documented in part . date of death - January 06, 2021 . Actual or Presumed Time of Death- 12:04 AM . Time Pronounced Dead- 12:04 AM . Place of Death Hospital . emergency room . Due to- [CONDITION(S)] . Approximate Interval Between Onset and Death- Days . On 4/28/21 at 3:58 PM, the Director of Nursing (DON) was queried regarding the lack of accurate and/or incomplete skin assessments, staff not identifying and reporting worsening of wound and abnormal labs and stated they were hired by the facility within the last year and they immediately identified this as being a problem within the facility and they have been trying to fix it. The DON stated they would check to if they could gather any additional information and/or documentation regarding R#706. No further explanation and/or documentation was provided by the end of survey. The DON was asked to provide the resident's Skin worksheets, and nothing was provided by the end of survey. On 4/29/21 at 3:41 PM, the Medical Director (MD) I was queried (via telephone) on R#706's care. When asked about the lack of intervention and/or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD I then instructed NP J to finish the interview as NP J was the practitioner that followed R#706's care the most throughout the resident's stay at the facility. On 4/29/21 at 4:16 PM, NP J was queried regarding the lack of intervention and/or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP J could not recall why the labs were never addressed however stated they would look into the resident's chart to see what happened. No further information and/or documentation was provided by the end of survey. R#705 A complaint submitted to the State Agency documented concerns regarding the resident developing a bedsore (pressure ulcer) at the facility. R#705 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 (indicating severely impaired cognition) and requiring staff assistance for all ADLs. A review of the clinical record revealed the following: An Admission/Re-Admission Evaluation dated 6/16/20 documented in part, . Clinical Evaluation Integumentary (Skin) . Skin integrity issue(s) present- No . An admission Braden Scale for Predicting Pressure Sore Risk dated 6/16/21 documented a score of 10.0, High Risk. A Nursing noted dated 6/16/20 at 4:23 pm, documented in part . Skin assessment done, bilat lower arm bruising, otherwise no issues . A WP Wound Progress Note dated 8/25/20 at 12:07 pm documented in part, . Patient is at increased risk for skin break down d/t (due to) limited mobility, poor appetite . and multiple comorbidities . Patient requires staff assistance to turn and reposition, and factors that may complicate current status include c/o (complaints of) pain with repositioning and incontinence . Moisture barrier cream q (every) shift/prn (as needed) protectively, Assist with frequent repositioning per facility protocol, pressure guard mattress . An At risk for alteration in skin integrity . care plan was reviewed and failed to list an intervention for staff to assist in repositioning the resident. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Body audit every day shift every Tue (Tuesday) for skin observation This order was implemented three months after the resident was admitted into the facility. On 10/7/20 a Bed Mobility task was added to the Certified Nursing Assistants (CNAs) shift to shift documentation. A Nursing note dated 10/9/20 at 3:23 pm documented in part, . Left message for (daughter name redacted) regarding the small open area on the right and left buttock and requested that she call the second-floor nursing station. Despite the weekly body audits being signed off as completed every Tuesday and not identifying any concerns with the resident's skin, On Friday 10/9/20 a small open area on both buttocks was identified. On 10/9/20 the intervention for . frequent checks and changes of brief, frequent turns . was added to the At risk for alteration in skin integrity care plan. A care plan titled Right buttock open area . implemented the following interventions on 10/12/20, . Encourage and assist as needed to turn and reposition; use assistive devices as needed . Use pillows and/or positioning devices as needed . Despite this intervention being implemented on 8/25/20 as directed by the Wound practitioner, the facility implemented this intervention after the development of the resident's buttock pressure ulcers. A 10/9/20 Skin & Wound Evaluation documented in part, . Right buttock . Area- 16.9 cm2 (centimeters squared), Length- 6.5 cm, Width- 4.4 cm . Patient and family notified of wound status and treatment . The last documented Skin & Wound Evaluation dated 12/18/20 at 10:30 am, documented in part . Area- 11.1 cm2, Length- 3.8 cm, Width- 3.9 cm . of the resident's coccyx/buttock wound. The resident was discharged from the facility on 12/23/20, with the coccyx/buttock wound still present. On 4/28/21 at 1:53 pm, the Director of Nursing was queried on the late implementation of the intervention to turn and reposition the resident as ordered by the wound practitioner. The DON who was not employed by the facility at the time the resident was admitted into the facility stated they would look into it further and follow up. The skin worksheets, skin alteration records and pressure ulcer observation tool was requested for this resident at that time. No further information and/or documentation was provided by the end of survey. A facility policy titled Skin Practice Guide dated 1/2013 documented in part, . The Skin Worksheet is completed by the nursing assistant at least two time per week with the patient's bath (shower, tub, bed). Results are submitted to the licensed nurse for review and follow-up as needed . Patients with pressure ulcers have a head-to-toe skin evaluation completed daily by the licensed nurse to identify additional skin changes. Documentation of the evaluation is located in the Treatment Administration Record or progress note . If a change in patient condition occurs, such as a deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible part and documents findings in the clinical record . Communications with the physician, patient and family are documented in the clinical record .

This citation pertains to Intakes #MI 038 and MI 885. Based on interview and record review the facility failed to adequately monitor and ensure timely action was taken for abnormal labs and complete a physician ordered urinalysis and culture and sensitivity test for 2 of 3 residents (Resident #701 and Resident #706) reviewed for lab results resulting in R#701 not being hospitalized for [CONDITION(S)] (excessive sodium levels in the blood) and R#706 having a lack of interventions implemented for a possible infection and was hospitalized . Findings include: A Complaint was filed with the State Agency (SA) that alleged R#701 was not being properly treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#701's Hospital records documented, in part, the following: emergency room notes (dated 11/16/20) .admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .ED (emergency department) Nurse note: Pt brought to EC by daughter. Pt currently resides at (name redacted) facility where he is there for rehab .dtr .reports health has been declining over the last week .She reports decrease in mentation decrease in food/fluid intake, .pneumonia, eyes are rolling back in his head, recently treated with enemas for constipation .Pt is currently AxOX3 however appears confused and is only able to follow simple commands Medical Decision Making . The patient is a . male who presents to the emergency center with his daughter for evaluation of altered mental status. On arrival he has a low-grade temp of 99.7 .does become hypoxic on RA (room air) .Fluids were initially provided .Labs show .Pt is hypernatremic at 161. Creatinine is 2.75, BUN 95 which is similar to labs 3 days ago .Will start pt on D5 H20 (a form of H20 used to replace lost fluids) . A review of R#701's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) indicated the resident was cognitively intact and required extensive one- and two-person assistance for most Activities of Daily Living (ADL). Further review of the MDS indicated the resident was always incontinent of bowel and bladder. Continued review of the resident's record revealed, in part, the following: 11/7/2020: General Progress Note: Patient had no BM (bowel movement) for 5 days gave an enema in 2 hrs. patient had a xLG (xtra large) BM today .encourage to drink more fluids . 11/13/2020: Test: X ray of abdomen results show ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) .NP (nurse practitioner) notified new order to start IV .9 normal saline at 75cc (cubic centimeter) for 24 hours. PT (patient to be NPO (nothing by mouth) for 24 hours . 11/13/2020 (NP 'nurse practitioner' Note) Chief complaint - Ileus . seen and examined today following review of abdominal x-ray results .+ for ileus without obstruction. Pt had reported emesis overnight . Acute ileus .Give fleet enema . Repeat abd Xray tomorrow and draw Stat CBC .Will monitor closely . 11/16/2020 (General Progress Note): Patient is awake, responsive and able to communicate .assisted to w/c (wheelchair) for transport to ct scan appt. talked with dtr at 8:40 who stated that she wanted dad to have his hearing aids and amplifier .pt. was given all those things .had full oxygen tank .connected to when he left the facility .in stable condition. A review of R#701's Care Plan revealed, in part: Focus: ADL Self-care deficit .Interventions: Assist with .eating as needed Focus: Bowel Elimination Alteration; Constipation related to: Altered hydration, Lack of Exercise, Medications, Nutrition (date initiated 11/6/2020) .Interventions: .Encourage and assist as needed to consume fluids offered at and between meals .Enemas per physician order .Record BM and report abnormalities .Report S&S (signs and symptoms) such as abdominal cramping, diarrhea, .no BM for 3 days . R#701's Comprehensive Metabolic Panel Lab Results revealed the following: Panel Lab Result (11/5/2020): Sodium: Result 142 .Blood Urea [MEDICATION(S)] (BUN) level .28 . Panel Lab Results: (11/13/2020): Sodium: Result: 146 .Flag H (high) . (BUN) level .91 .H (high) . Review of the medical record failed to reveal that these labs were reported to the physician, and appropriate action was not taken. A review of the resident's Point of Care (POC) electronic record for the month on November 2020 did not provide any information as to the amount of R#701's fluid intake and only provided information that fluids were offered. On 4/28/21 at approximately 1:47 PM, an interview and record review were conducted with the Director of Nursing (DON) regarding R#701. The DON reported that she was not employed at the time the resident resided at the facility. When queried as to the resident's constipation, the DON indicated that the record indicated that some methods were taken to ensure the resident had a bowel movement, including an increase in fluid intake, however fluid intake amounts should have recorded. When queried as to the lab reports on 11/13/20, that indicated an increase in sodium levels and BUN, the DON again indicated that no further assessments were made after 11/13/20. A review of the facility policy titled Hydration Practice Guide (2012) documented, in part, the following: Overview: Maintaining adequate fluid intake is an essential component of heath .Hydration management is the promotion of adequate fluid balance the prevents complications .At risk for volume depletion .Sodium Dehydration >150 .Interventions for Consideration .Increasing fluid intake through implementation of fluid intake strategies .may include. Hydration prompting .Fluid increases: Some patients may have medical conditions warranting an increase in fluid intake during periods of .vomiting . R#706 A review of the clinical record revealed the following: R#706 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented short- and long-term memory problems and severely impaired cognition for daily decision making. R#706 required staff assistance for all Activities of Daily Living (ADLs). A hospital transfer form dated 12/14/20 documented in part, . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . A Temperature Summary was reviewed and revealed the following abnormal temperatures: 1/5/21 at 2:20 PM- 96.8, 1/4/21 at 4:27 PM- 96.3 and 12/31/20 at 1:14 PM- 99.0. A review of the resident labs revealed the following: A 12/20/20 at 3:47 (reported date/time) Complete Blood Count w (with) Differential (CBC w Diff) revealed the following: WBC- 12.4 (normal 3.5-10.1), Neutrophils- 9.8 (normal 1.5-7.2) and Immature Granulocytes- 0.12 (normal 0.00-0.04). A 12/28/20 at 1:05 PM a NP progress note documented in part, . CBC Date 12/24/2020 CBC Results- WBC 13.8 . A 12/31/20 at 6:12 PM (reported date/time) CBC w Diff revealed the following: WBC- 17.4 (normal- 3.5-10.1) , Neutrophils- 15.0 (normal- 1.6-7.2), Monocytes 1.1 (normal- 0.0-0.9) and Immature Granulocytes 0.10 (normal- 0.00-0.04). Further review of the clinical record revealed no notification to the physician or NP regarding the abnormal labs/temperatures and no intervention and/or treatment implemented by the physician and/or NP for the abnormal labs/temperatures. A UA (urinalysis) C/S (culture and sensitivity) DX: Leukocytosis was ordered on 1/1/21, however further review of the clinical record revealed no results of a UA or C/S. On 4/28/21 at 8:47 AM, the Director of Nursing (DON) was queried regarding the lack of interventions and/or treatment and follow up of the resident's abnormal labs and vitals and asked to provide all UA and C/S results for this resident. The DON stated they would follow up. At 9:42 AM, the DON returned stating they could not find any UA or C/S results for the resident. At 10:32 the DON returned and stated they called the laboratory to request the results and the laboratory stated they did not have a UA or C/S in their system for that resident. The facility staff failed to complete the ordered UA and C/S. A care plan titled Renal insufficiencies related to: infection . dated 12/15/20 documented the following intervention in part, . Obtain labs as ordered and notify physician of results . A NP progress note dated 1/5/21 at 12:17 PM, documented in part . Routine labs reveal acute leukocytosis of 17.4 . No fevers, cough, or rigors reported. Wound NP reports new onset purulent drainage with recommendation for ER (emergency room ) transfer for wound debridement . A Certificate of Death documented in part . date of death - January 06, 2021 . Actual or Presumed Time of Death- 12:04 AM . Time Pronounced Dead- 12:04 AM . Place of Death Hospital . emergency room . Due to- [CONDITION(S)] . Approximate Interval Between Onset and Death- Days . On 4/29/21 at 3:41 PM, the Medical Director (MD) I was queried (via telephone) on R#706's care. When asked about the lack of intervention and/or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD I then instructed NP J to finish the interview as NP J was the practitioner that followed R#706's care the most throughout the resident's stay at the facility. On 4/29/21 at 4:16 PM, NP J was queried regarding the lack of intervention and/or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP J could not recall why the labs were never addressed however stated they would look into the resident's chart to see what happened. No further information and/or documentation was provided by the end of survey. A facility policy titled Change in Condition (dated 11/2016) documented in part, . Purpose: To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications .

This citation pertains to Intake Number(s): MI 353 Based on interview and record review, the facility failed to accurately and consistently assess skin, notify the physician of changes in a pressure ulcer, and administer treatment according to the wound care practitioner's recommendation for one (R#801) of three residents reviewed for pressure ulcers, resulting in a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) worsening to an infected Stage 4 (full thickness skin loss) pressure ulcer that required intravenous antibiotics and a hospital admission. Findings include: A complaint was received by the State Agency that alleged, On 6/23/20 (Resident #801) had a partial hip replacement left femur fracture. Had in hospital wound care on both heels, inside ankles, and his sacrum area (all were minor at this time). On 6/29/20 he was transferred to (facility name redacted) for rehab. He was discharged for home on 8/5/20. During this time the wound on his sacrum developed into a stage 4 ulcer. (Facility name redacted) did notify me of the treatment given to this wound, however I didn't realize it was so bad. On 8/6/20 I took him to the ER because the wound was black and had a very bad odor. This is when it was diagnosed as a stage 4 ulcer. He was discharged home on[DATE] . On 9/15/20 and 9/17/20, the complainant was interviewed. The complainant reported they were aware R#801 had a wound on their buttock, but did not have any idea it was as bad as it was. The complainant stated, They told me it was a bruise that was opening up. The complainant reported on 8/6/20, the day after R#801 was discharged from the facility, a home health care nurse came to the home and removed the dressing from the wound on R#801's coccyx. The complainant further reported the wound was large, black, and had bad odor and that the home health care nurse was concerned about the condition of the wound. The complainant sent R#801 to the emergency room where the resident was treated for [REDACTED]. R#801's clinical record was reviewed and revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had intact cognition, required extensive two person assistance for bed mobility and transfers, and did not have any pressure ulcers. A Significant Change MDS dated [DATE] documented R#801 had two unstageable deep tissue injuries (DTIs). A Nursing Admission assessment dated [DATE] documented R#801 had [MEDICAL CONDITION] to front of their bilateral legs and a surgical wound. There were no pressure ulcers documented on admission. physician's orders [REDACTED]. Notify MD of any change in skin audit every day and night shift for skin care beginning 6/30/20 and discontinued on 7/7/20. Body audit - daily one time a day for Skin observation beginning on 7/17/120. Cleanse coccyx wound, pat dry and apply opti-foam gentle Ex as needed AND every day shift every 2 day beginning on 7/14/20. A review of R#801's July 2020 Treatment Administration Record (TAR) revealed no body audits were completed for R#801 between 7/8/20 and 7/18/20. A NP (Nurse Practitioner) Wound Progress Note dated 7/14/20 and entered late on 7/17/20 documented, .seen per primary NP request for coccyx wound. Wound is less than one week old and manually measured at 5.5 cm (centimeters) x 5.0 cm purple discoloration with minimal serosanguineous (mixture of blood and serum) drainage, periwound [DIAGNOSES REDACTED] .Location - Coccyx. Type - Pressure .Pressure Severity - Deep Tissue Injury .After cleansing with NS (normal saline), pat dry, and apply [MEDICATION NAME] gentle Ex q2d (every two days)/prn (as needed) .Assist to frequently reposition from side to side Low air loss mattress .W/c (wheelchair) with cushion if up in the chair Nutrition support: assist with 1:1 feeding;currently on ProSource ZAC liquid nutrition supplement Manage incontinence in a timely manner . A photo of the wound dated 7/14/20 showed a black open area inside of the purple discoloration. A Skin & Wound Evaluation dated 7/14/20 and locked (completed/signed off on) one month later on 8/14/20 documented Pressure as the type of wound that was staged as a DTI and was located on R#801's left buttock. It was documented the DTI was present on admission. However, the admission skin assessment did not document any skin impairment to R#801's coccyx/sacral /buttock area. It was documented it was unknown how long the wound was present and it measured 8.2 cm x 3.9 cm. Subsequent NP Wound progress notes and Skin & Wound Evaluations revealed the following: A NP wound progress note dated 7/24/20 documented the DTI to R#801's left buttock changed to an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough - non-viable tissue that is typically yellow, tan, or grey in color or eschar - dead or devitalized tissue that is usually black, brown, or tan in color) that measured 6.0 cm in length by 3.5 cm in width with a small amount of serosanguineous drainage. It was documented the wound base consisted of necrotic yellow slough. The treatment was changed to Cleanse wound with NS, pat dry and apply [MEDICATION NAME] gel on 4x4 gauze, cover with border gauze qd/prn for autolytic debridement and moist wound healing . A Skin & Wound Evaluation dated 7/24/20 documented R#801's left buttock changed to an unstageable pressure ulcer. It was documented, DTI, stable currently likely to open. A photo attached to the assessment from the same date showed the wound had an open yellow area that was dark underneath the yellow. A NP Wound Progress Note dated 7/31/20 documented, .patient seen for evaluation of unstageable wound on coccyx/left buttock measuring 8.2 cm x 5.2 cm, necrotic and fluctuating wound base with minimals <sic> serous drainage, irregular edges, periwound [DIAGNOSES REDACTED]. Current treatment is .[MEDICATION NAME] gel to coccyx, and ischium .The assessment documented the wound was 8.2 cm x 5.2 cm with moderate serous drainage with a necrotic, fluctuating wound base. It was documented the wound had strong malodor (foul odor). The treatment plan documented, Cleanse wound with dakin's 1/4 strength, pat dry and apply Santyl (a topical [MEDICATION NAME] agent) on moist 4x4 gauze, cover with border gauze qd/prn for enzymatic debridement and moist wound healing . physician's orders [REDACTED].#801 and revealed the treatment change documented by the Wound NP on 7/31/20 was never initiated from 7/31/20 until their discharge from the facility on 8/5/20. On 9/16/20 at 10:20 AM, the Director of Nursing (DON) was interviewed. The DON reported the wound NP (NP D) came to the facility twice a week, one day specifically for pressure ulcers. When queried about the facilities protocol for skin management, the DON reported upon admission residents' received a weekly skin assessment done by the nurse and if they were admitted with a pressure ulcer, they received daily skin assessments. The DON explained the nurses did not stage wounds and that was done by NP D. According to the DON, any changes in skin were reported to the NP D and the attending physician and they would order a treatment based on the nurse's description. The DON was queried about when R#801 developed the DTI/Unstageable pressure ulcer to their left buttock and what was put in place to treat it. At that time, the DON reviewed R#801's clinical record and reported it did not look like they had the pressure ulcer to the left buttock upon admission based on the admission nursing assessment. The DON further reported it was first documented on a Skin and Wound Evaluation form on 7/14/20 that R#801 had a wound to their left buttock. When queried about who completed daily pressure ulcer treatments, the DON reported the floor nurses did. When queried about expectations for notification and documentation when a wound worsened, such as a foul odor, the DON reported the nurses should document in the progress notes if there was change identified during daily body audits. The nurse would report the change to the unit manager who would then look into what was going on and contact the physician and NP D. On 9/16/20 at 1:00 PM, the DON provided additional information. The DON reported they reviewed R#801's clinical record further and the hospital records indicated the pressure ulcer to R#801's left buttock was present when they were discharged from the hospital and therefore was present on admission. When queried about what interventions and treatment was put in place if the wound was present on admission, the DON stated, The interventions did not get implemented like they should have. The DON reported the impaired skin integrity to R#801's buttock should have been identified on admission and interventions and treatment would have been put in place. A Discharge Summary completed by NP C on 8/5/20 (the day R#801 was discharged from the facility) documented, .The patient's poor nutritional status and development of wounds also concerning for poor outcome. We did discuss at length the ongoing complex care needed for the patient and the wife has opted to take the patient home on discharge and plans for additional help at home .Unstageable sacral pressure wound .All skin and wound care decisions per wound care NP and skin management team at (facility name redacted). The patient remains at high risk for unavoidable wound and skin worsening .HHC (home health care) services for wound care and teaching for the wife for wound dressings . There was no documentation of the worsening condition of the sacral wound as documented in NP D's note on 7/31/20. On 9/17/20 at 9:05 AM, Physician B was interviewed. Physician B reported the wound care NP (NP D) as well as the nurse managers were responsible for coordinating care of residents with pressure ulcers. Physician B further reported that if there was a change in condition of a pressure ulcer and they had a planned discharge he would expect to be notified. When queried about whether they knew R#801's pressure ulcer developed a strong odor and increased drainage, Physician B reported they were not aware and they should have been notified. Physician B reported that information would have impacted the decision to discharge the resident as planned and may have determined additional treatment was needed. On 9/17/20 at 9:12 AM, wound NP D was interviewed via the telephone. NP D reported they saw residents with wounds in the facility two times a week, one of those days were dedicated to pressure ulcer wounds. NP D reviewed their notes for R#801 from 7/31/20 and reported the wound did develop a strong malodor, moderate drainage, and measured 8.2 cm by 5.2 cm. NP D reported at that time she changed the treatment to (sodium hypochloride/[MEDICATION NAME]) with the goal of removing the necrotic tissue and decreasing the odor. NP D reported a facility manager rounded with her and was present during the assessment and treatment was discussed. When queried about their knowledge of R#801's planned discharge, NP D reported they were not involved in discharge planning and that the facility Director of Nursing (DON) and/or unit managers rounded with her for all pressure ulcers. NP D was unaware the new treatment order did not get implemented. On 9/17/20 at 9:56 AM, NP C was interviewed via the telephone. When queried about the facility's process when a resident with a pressure ulcer had a change in condition of the wound, NP C reported the attending physician would typically be notified and stated the wound NP (NP D) in collaboration with the facility's wound management team primarily managed all aspects of wound care. NP C reported they were unaware that the unstageable pressure ulcer on R#801's coccyx had developed a foul odor and increased drainage. On 9/17/20 at 9:35 AM, the DON was interviewed. The DON reported herself and the unit managers rounded with NP D when she came to the facility to see residents with pressure ulcers. The DON reported they were not aware of the treatment change or the change in condition of R#801's pressure ulcer on their coccyx as documented on 7/31/20. The DON further reported the expectation would be that the unit manager notified the physician or nurse practitioner about the change in the wound to determine if additional treatment was needed. The DON was unaware the treatment change documented by NP D on 7/31/20 was not implemented. Hospital records for R#801 were reviewed and revealed R#801 went to the emergency roiagnom on [DATE] (the day after they were discharged from the facility) with a chief complaint of wound check. ED Provider Notes documented, .presenting from home with concerns for sacral wounds .decubitus ulcer, malodorous, surrounding [DIAGNOSES REDACTED] Elevated WBC (White Blood Count) .Vanco and [MEDICATION NAME] (IV antibiotics) ordered .consult to wound care. A Pre-Op note dated 8/8/20 documented R#801 had surgical debridement of the wound. Prior to the debridement, the unstageable pressure ulcer measured 9.0 cm x 5.5 cm with eschar obscuring the base. It was documented that the wound had dark green serous exudate (drainage) .Foul odor . A Discharge Summary for the hospital admission from 8/6/20 through 8/13/20 documented R#801's [DIAGNOSES REDACTED]. A facility document explained by the DON to be the Skin Management policy was reviewed and documented the following: .Initial Evaluation .Review the hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development .Nursing staff complete the Patient Admission/Readmission Screen .Admission Skin Evaluation .A comprehensive skin evaluation is completed upon admission .Complete the Patient Admission/Readmission Screen .Including a head-to-toe full body audit to identify the presence of pressure ulcers .Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation of skin evaluations is completed on the Treatment Administration Record .Upon completing an evaluation, the interdisciplinary team develops a patient specific care plan to include prevention and management interventions with measurable goals .Nursing assistants perform daily skin observations with routine care .Results are submitted to the licensed nurse for review and follow-up as needed .Wound Management .wound management also includes: implementation of a center based wound team .wound documentation .dressing selection .Wound Management Team .The members of the wound team collaborate with the patient's attending physician to assist in determining wound etiology; individualized treatment strategies and evaluating the effectiveness of the current plan of care .The wound management team re-evaluates pressure ulcers .weekly .If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the patient's overall clinical condition needs to be re-evaluated .

This citation pertains to MI 5942: Based on interview and record review the facility failed to ensure effective interventions were implemented to prevent the development of a pressure ulcer for a resident identified as having a history of pressure ulcer and failed to consistently assess the resident post development of a pressure ulcer for one (R#901) of two residents reviewed for pressure ulcers, resulting in the development of an unstageable (full thickness skin and tissue loss with obscured wound bed) pressure ulcer. Findings include: A complaint was received by the State Agency which expressed concerns with the development of a pressure ulcer under the coccyx for R#901, and expressed that this had negatively impacted the resident's quality of life. The clinical record for R#901 was reviewed and revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission minimum data set (MDS) assessment dated [DATE] it was documented that the resident was rarely to never understood, had severely impaired cognition, and required the extensive assistance of two persons for bed mobility. Per the MDS assessment it was documented R#901 did not have a pressure ulcer, scar over a bony prominence, or non-removable dressing, and had been identified as being at risk for the development of pressure ulcers/injuries. Review of R#901's skin assessment as part of the resident's admission/readmission screen dated 6/14/19 identified the following pertaining to the resident's sacrum: blanchable [DIAGNOSES REDACTED] that has scar from prior pressure ulcer, orders for (brand name barrier cream) placed. Review of R#901's admission braden scale (tool used to predict pressure ulcer risk) dated 6/14/19 revealed the resident was at moderate risk for pressure ulcer development with a score of 14. Per this assessment it was documented the resident had slightly limited sensory perception, was occasionally moist, was chairfast pertaining to activity level, had very limited mobility, had nutrition that was probably inadequate, and identified friction and shear as a potential problem. It was noted that scoring guidelines for the braden tool were as follows: 15-18=at risk, 13-14=moderate risk, 10-12=high risk, 9 or less=very high risk. Also per this assessment the following guideline was included: If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60), advance to next level. It was noted that R#901 was of advanced age. Review of a Pressure Ulcer assessment for R#901 dated 6/17/19 revealed R#901 did not have an existing pressure ulcer. This assessment did note the presence of a left hip surgical incision and blanchable redness present to the resident's coccyx. Per review of the Extrinsic Risk Factors section of the assessment, the following factors had been selected for R#901: Requires staff assistance to move, confined to a bed/chair all or most of time, persistently wet from incontinence/wound drainage/perspiration, and cognitive loss. Review of a braden assessment for R#901 dated 6/21/19 with a locked date of 6/26/19 identified R#901 as being at risk for pressure ulcer development (the lowest risk category on the scale), with a score of 18 on the assessment. This assessment documented R#901 had no impairment in sensory perception, was occasionally moist, was chairfast related to activity, had no limitation in mobility, had adequate nutrition, and had a potential problem with friction and shear. It was noted the assessment for risk of pressure ulcer development had been completed on the same date as the resident's assessment reference date for the admission MDS assessment (6/21/19), which documented R#901 was severely cognitively impaired and required the extensive assistance of two persons for bed mobility. Review of a skin note dated 6/25/19 at 12:02PM authored by Nurse Manager 'A' documented the following: pt (patient) noted to have open area to coccyx, current measurements are as follows 3x2cm (centimeter), 100% granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal). small amount of bloody drainage noted. area cleansed and tx (treatment) applied. wound care consult placed. PA (physician assistant) notified of new area. per family there is hx (history) of breakdown in same area . Review of a general progress note dated 6/25/19 at 4:45PM documented the following: Patient alert oriented x1, able to make his needs known. VS (vital signs) stable. Medicated with pain med per pt request. Left hip staples intact. Patient incontinent of b/b (bowel/bladder). Patient has anew <sic> pressure sore in coccyx area Extensive 2 person assist for transfer . Review of a MP Wound Progress Note dated 6/27/19 at 12:20PM for an initial visit revealed, in part, the following per the Comprehensive History section: Pt is a (age redacted) year old (race and gender redacted), with hx (history) of dementia, recently admitted to hospital with left hip pain s/p (status [REDACTED]. Factors that may hinder wound healing include pain with movement, and also lying on his back for long periods of time. Pt exhibited sever <sic> pain when being repositioned to examine wound. Review of the wound exam documentation for the resident's coccyx wound revealed the area was an unstageable pressure wound which measured 3cm in length by 3cm in width. The wound was noted to have a moderate amount of serosanguineous (blood and fluid) drainage. The wound base was documented as Granulation Other. The granulation and percentage description documented 10% PINK. The following description was also provided: NECROTIC, DENUDED, FLUCTUATING BASE. The edge of the wound was noted to be irregular, and the periwound was described as [DIAGNOSES REDACTED]tic. Also per this note was the following: UNSTAGEABLE PRESSURE ULCER, C[NAME]CYX .CLEANSE WOUND WITH NS (normal saline), PAT DRY, AND APPLY (Brand name [MEDICATION NAME] debridement ointment) ON 4X4 GAUZE, COVER WITH BORDER GAUZE QD/PRN (daily/as needed) FREQUENTLY REPOSITION WITH WEDGE/PILLOWS W/C (wheelchair) WITH CUSHION LOW AIR LOSS PRESSURE MATTRESS . Review of a braden assessment for R#901 dated 6/28/19 (after the development of the pressure ulcer) revealed R#901 was at moderate risk for pressure ulcers, with a score of 13 on the assessment. Per this assessment R#901 had slightly limited sensory perception, was very moist, was chairfast pertaining to activity, had very limited mobility, had adequate nutrition, and friction and shear had been identified as a problem. Review of a MP Wound Progress Note dated 7/2/19 at 9:47PM revealed, in part, the following: .seen per nursing request for evaluation on wound on coccyx. Wound is a stage 3 pressure ulcer which presents with a 100% necrotic yellow base. Current treatment for [REDACTED].) Wound healing is complicated by pain to left hip s/p (status [REDACTED].Also per this note was the following: .Pressure ulcer stage 3 coccyx .CLEANSE WOUND WITH NS (normal saline), PAT DRY, AND APPLY ON 4X4 GAUZE, COVER WITH BORDER GAUZE QD/PRN. THIS WILL HELP BY ENZYMATIC DEBRIDEMENT, AND REMOVING DEAD SKIN AND TISSUE FREQUENTLY REPOSITION WITH WEDGE/PILLOWS W/C WITH CUSHION LOW AIR LOSS PRESSURE MATTRESS . Review of physician orders [REDACTED].#901 revealed, in part, the following: Order date 6/14/19 discontinued on 7/26/19: (Brand name barrier cream) to buttocks and coccyx BID (twice a day) and PRN (as needed) every day and night shift for Skin Care AND every 1 hours as needed for skin care. Review of R#901's TAR for the time period of the resident's admission to identification of the wound (6/14/19-6/25/19) revealed the above order for brand name barrier cream had been documented as administered on the night shift of 6/14/19, day and night shift of 6/15/19-6/22/19, night shift only for the date of 6/23/19, and both day and night shift of 6/24/19-6/25/19. Also per review of the TAR for (MONTH) 2019 it was revealed there was no documentation for the month to indicate the barrier cream had been applied on as as needed basis. Order date 6/17/19: Call MD for any changes in skin integrity every day and night shift. Per a physician order [REDACTED].#901 had been ordered a wound care consult related to an open area on the coccyx. Per review of a physician order [REDACTED].#901 had been ordered daily body audits. The TAR daily body audits were completed for R#901 on 6/29/19 and 6/30/19 (following the identification of a new wound on 6/25/19). Review of care plans for R#901 revealed, in part, the following: Per a plan of care dated 6/14/19 it was documented, At risk for alteration in skin integrity related to impaired mobility. generalized weakness, recent surgery s/p (status [REDACTED]. Interventions per the plan of care included the following: Initiated 6/14/19-Encourage to reposition as needed; use assistive devices as needed, Observe skin condition with ADL (activities of daily living) care daily; report abnormalities, Initiated 6/17/19-Elevate heels as able and use pillows/positioning devices as needed. Review of a plan of care dated 6/15/19 documented, Blanchable, redness scar from Ulcer. Interventions per the plan of care, all initiated on 6/15/19, documented the following: Administer treatment per physician orders, Encourage and assist as needed to turn and reposition; use assistive devices as needed, and Follow up care with physician as ordered. Per a plan of care dated 6/25/19 it was documented, pressure ulcer at coccyx related to: decreased mobility, incontinence, multiple comorbidities. Interventions per the plan of care included the following: Date initiated 6/25/19-Administer treatment per physician orders, Diet and supplements per physician orders, Encourage and assist as needed to turn and reposition; use assistive devices as needed, and follow up care with physician as ordered. Interventions implemented on 6/28/19 (following the discovery of the new wound on 6/25/19) included the following: Daily body audit, pressure reducing surface on bed and wheelchair, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn (as needed),and use pillows/positioning devices as needed. Per a plan of care initiated 6/14/19 it was documented, ADL (activities of daily living) Self care deficit related to impaired mobility, generalized weakness, recent surgery s/p (status [REDACTED]. Per an intervention dated 7/7/19 it was documented, Limit time in wheel chair to 2 hours at most. Pt to be in bed, and re-positioned frequently for healing. On 9/5/19 at 3:04PM the facility's Director of Nursing (DON) was queried in regard to skin assessments at the facility. The DON explained that a resident without pressure ulcers would receive weekly skin assessments, and residents with pressure ulcers would receive daily skin assessments. The DON was queried as to the process a nurse was to follow if a new area was noticed on a resident's skin, and the DON explained that staff would let the unit manager know, and an assessment would be completed. The nurse and the manager would input notes. The DON explained that nurses did not stage wounds at the facility. When queried as to why R#901 had not received daily body audits following the identification of the wound, the DON explained that it may have been an omission by the unit manager. Per the DON staff would have been looking at the resident's skin daily with activities of daily living. Review of a facility policy titled SKIN PRACTICE GUIDE dated 1/13 revealed, in part, the following per the ADMISSION SKIN EVALUATION section: If the patient does not have a skin alteration, but has risk factors that put the patient at risk for skin breakdown, an initial plan of care is initiated. The initial plan of care includes identifying patient specific risk factors for the development of pressure ulcers and identifying and evaluating risk factors that can be removed or modified upon admission .A weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown that do not have a pressure ulcer. Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation of skin evaluations is completed on the Treatment Administration Record. The policy also included the following definitions of granulation tissue and necrotic tissue (eschar): GRANULATION TISSUE Red tissue with cobblestone or bumpy appearance, bleeds easily when injured and NECROTIC TISSUE (ESCHAR) Dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color; my appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides or edges of the wound. Per the RESIDENT ASSESSMENT INSTRUMENT (RAI) section of the policy it was documented, The MDS is an information gathering tool that assists in identifying patient strengths and limitations. The MDS establishes the following triggers for the presence of or risk for pressure ulcer development: -impaired bed mobility

This citation pertains to intake number MI 949 and MI 031. Based on interview and record review, the facility failed to identify upon admission, assess, and implement treatment for [REDACTED].#902) of two residents reviewed for surgical wounds, resulting in a foul smelling, bleeding incision being discovered after the removal of a cervical collar during cardiopulmonary resuscitation (CPR) three days after the resident's admission into the facility. Findings include: A complaint was submitted to the State Agency that documented, .(R#902) recently had neck surgery. The nurse in charge was unaware (R#902) had neck surgery. The neck pad needed to be changed. The pad was stained with old blood which appeared to be a couple days old. The bandage had a foul odor due to not being changed. When (R#902's) bandaging was pulled back, there appeared to be an onset of an infection where the surgical incision was located. There was swelling around (R#902's) neck which causes belief there was leakage in the area. Although (R#902) had been in the facility for 2 days, no nursing staff were aware he had neck surgery. When attempts were made to review (R#902's) medical records, it was discovered nursing staff did not have anything documented so it took a while to learn any information about (R#902). The specific cause of death is unknown. It is unknown if the negligence of the wound care lead to the death . A second complaint was submitted to the facility that documented, .officers were dispatched to the facility for the report that (R#902) was getting CPR from staff. (R#902) was deceased . According to paramedics at the scene there were concerns of medical care and possible neglect to wounds . An unannounced onsite investigation was conducted on [DATE]. A Case Report from the local police department dated [DATE] documented the following: .On [DATE] at 0553 hours (5:53 [NAME]M.), (Police Officer I) and I (Police Officer J) were dispatched to (facility address and name redacted) for an ambulance run. Dispatched <sic> advised the staff had started performing CPR on the patient in (R#902's room number redacted) .Officers arrived on scene at the same time as (name of company redacted) Paramedics. Upon entry into the patients room, I observed multiple staff personnel performing CPR on (R#902) .Paramedic immediately noticed Livor Mortis (settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin after death) on (R#902's) body indicating (R#902) had been deceased for at least an hour or two. CPR was stopped, (paramedic) ran a heart monitor strip, and contacted (local hospital name redacted) for a time of death at 0620 hours (6:20 [NAME]M.) . .Observations of (R#902's) body .(R#902) was lying in bed on his back. The livor mortis could be seen on his sides leading to his backside. (R#902) was wearing a 'Aspen (cervical - neck) collar' around his neck with a small bandage underneath .(Paramedic K) asked staff why (R#902) was wearing a (cervical) collar with a bandage. None of the staff knew the answer including his assigned nurse (Nurse G). Upon further investigation Officers observed the interior of the neck brace was stained with blood. The bandage was peeled back and officers observed a large incision across (R#902's) neck was becoming infected and was emitting a foul odor. (R#902) had large bruising around his upper chest. (Paramedic K) also noted a large swollen area on (R#902's) left collar bone. According to (Paramedic K) the swollen area had indications it was a trapped pocket of air which is highly unusual . .Disposition .(facility name redacted) staff knew nothing of (R#902's) condition and appeared to provide inadequate care for (R#902) . R#902's clinical record was reviewed on [DATE] and it revealed the following: R#902 was admitted into the facility on [DATE] and was discharged on [DATE] after he expired in the facility. R#902's [DIAGNOSES REDACTED]. A progress note written by Nurse F on [DATE] at 4:48 P.M. documented, Patient arrived from (hospital name redacted .No complaints at this time .Patient has cervical collar in place and dry dressing noted to front of neck. Skin assessment to be done . A progress note written by Nurse L on [DATE] at 5:40 [NAME]M. documented, .received in the bed with the cervical collar on . On [DATE] at 4:50 P.M. a progress note documented, .Cervical collar maintained . A progress note written by Nurse G on [DATE] at 1:40 [NAME]M. documented, .Received in the bed with the cervical collar on . A progress note written by Nurse G on [DATE] at 3:08 [NAME]M. documented, @3am during Rounds observe patient in bed 45 degree no sign of distress, appears to be sleepy with o2 3L NC (nasal cannula) on. C (cervical)-collar in place . A progress note written by Nurse G on [DATE] at 8:32 [NAME]M. documented, @6:50am (another progress note corrected the time to 5:50am) patient unresponsive no pulse hand was cold. called code blue. 0554 (5:54 [NAME]M.) start CPR .0604 police arrived 0605 (paramedic) came .NO pulse or respiration . A second progress note written by Nurse G on [DATE] at 8:40 [NAME]M. documented, @ 5.50 am found patient unresponsive, called Nursing staff for help. Staff called Code Blue. writer started CPR immediately. 5.52 am AED (automated external defibrillator) pad placed activated AED, no shock advised continued with compression .2 person CPR with Ambu bag (a hand held manual resuscitator to deliver breaths during CPR). removed C-collar adjust jaw for open Air way . C- collar with old dry blood. neck dressing intact .paramedic decided stop CPR . Progress notes, physician's orders, care plans, admission assessment, and skin assessments were all reviewed for R#902. There was no documentation that R#902 was admitted into the facility after surgery and had an incision to the front of his neck. There was no documentation that R#902's skin underneath the cervical collar or bandage had been assessed upon admission or after admission. There were no physician orders to address treatment or assessment required for the surgical incision. An Admission/Readmission Screen dated [DATE] did not document an incision to R#902's neck on the skin assessment. Hospital discharge instructions present in R#902's clinical record at the facility documented Surgeries/Procedures performed in the last 30 days XXX[DATE] .Anterior (front) cervical diskectomy C4-C6 with fusion corpectomy allograft with instrumentation spinal cord monitoring .Patient Instruction .Follow-Up Care .Check your neck incision twice a day in front of a mirror .Call your doctor if you have: Increased or [MEDICATION NAME] redness, swelling, drainage or warmth at or around your incision .trouble swallowing or breathing (call your doctor immediately) . On [DATE] at 11:45 [NAME]M., Nurse G was interviewed via the telephone. When queried about R#902 on the midnight shift of [DATE] to [DATE] (7:00 P.M. to 7:00 [NAME]M.), Nurse G reported that around 11:00 P.M. on [DATE], R#902 had some secretions, she listened to his lungs, told the resident to deep breathe and cough and he coughed for me. Nurse G reported she entered R#902's room at approximately 3:00 [NAME]M., but didn't touch him and he looked like he was sleeping. Nurse G further stated, At 5:55 ([NAME]M.), (R#902) is in the same position and didn't move. I'm shaking him so I'm starting CPR. When queried about the surgical incision to R#902's neck, Nurse G stated, I started CPR and moved the collar. That's when I saw it. On [DATE] at 1:22 P.M., Nurse F was interviewed. Nurse F reported she was the admitting nurse for R#902 on [DATE]. When queried about whether or not she assessed R#902's skin underneath the cervical collar and dry dressing noted in her progress note, Nurse F stated, I did not look. I knew he had an incision because I wrote it on the 'skin sheet'. The skin sheet Nurse F referred to documented R#902 had a dressing in place on the front of the neck, but did not document an assessment of what was underneath the dressing. Nurse F reported that the admitting nurse would address any orders for new admissions and stated, I don't recall when asked if R#902 had any treatment orders for the surgical incision. On [DATE] at 1:40 P.M., the Director of Nursing (DON) was interviewed. The DON reported that upon admission, the nurse would review orders from the hospital, notify the physician, and discuss orders. When queried about whether or not the nurse should remove any dressings observed to assess the skin underneath, the DON stated, Yes, unless there was an order that says not to remove (the dressing). When queried about why R#902 did not have any assessment or acknowledgement of a surgical incision, the DON stated, I just started the investigation today. I spoke with the wife. I tried to get a hold of police. On [DATE] at 5:35 P.M., Nurse C was interviewed via the telephone. Nurse C reported he worked 7:00 P.M. to 7:00 [NAME]M. on [DATE] going into [DATE] on the 100 hallway. Nurse C reported he was not assigned to R#902, but worked on the same hallway. Nurse C stated, Around 6 [NAME]M., (Nurse G) ran down the hall and summonsed me to come and see (R#902). He was unresponsive so we initiated CPR and called 911. Nurse C reported R#902 appeared cyanotic, blue around the lips and fingertips, did not have a pulse, and was not rousable. When queried about any knowledge of a surgical incision to R#902's neck, Nurse C stated, Just when the police came in. Nurse C reported he saw a bandage to R#902's neck but couldn't see what was underneath it. On [DATE] at 5:45 P.M., an attempt to contact Nurse D via the telephone was made. Nurse D (one of the nurses present during R#902 receiving CPR) was not available for interview prior to the end of the survey. On [DATE] at 5:50 P.M., multiple attempts were made to contact Certified Nursing Assistant (CNA) [NAME] (R#902's assigned CNA) via the telephone. However, the phone call would not go through and therefore, CNA [NAME] was not available for interview prior to the end of the survey. A facility policy regarding surgical wounds/incisions was requested. A policy titled, Skin Practice Guide was provided. Review of the section of the policy titled ALTERATION IN SKIN INTEGRITY revealed, If non-pressure related ulcers or other skin alteration, e.g., skin tears, surgical incisions, etc. are identified; a Skin Alteration Record is initiated. The policy also documented, .A comprehensive skin evaluation is completed upon admission .complete the Patient Admission/Readmission Screen .including a full head to toe body audit to identify the presence of .skin alterations .

This citation pertains to intake #MI 0 and # 7. Based on observation, interview, and record review, the facility failed to ensure resident safety for one resident, (R#702) of three residents reviewed for safety, resulting in a decline in function for eating and a transfer to the emergency room with a broken humerus. Findings include: On 7/16/19 at 9:40 AM, a review of R#702's closed clinical record was conducted and revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. R#702's most recently completed Minimum Data Set (MDS) assessment dated [DATE] indicated R#702 had moderate cognitive impairment, did not exhibit and behaviors, was non-ambulatory, required extensive 2 person assist for transfer and bed mobility, and required limited assistance of one staff member with eating. A review of R#702's nursing progress notes was conducted and revealed the following: A progress note on 7/13/19 at 6:28 PM by Licensed Practical Nurse (LPN) 'A' that read, Note Text: Per report, pt (patient) did not eat well yesterday. Noted this shift that pt not feeding self with right hand as she normally does. Keeping right hand and wrist guarded and whincing <sic> at times. No brusing <sic>, swelling of <sic> warmth noted to wrist. When questioned if wrist hurts pt nods her head and says yes . A late entry progress note written on 7/15/19 at 11:40 PM, with an effective date of 7/13/19 at 10:27 PM, from LPN 'B' that read, Late Entry: Note Text: Pt alert and responsive. During shift pt continued to keep her right hand and wrist guarded. Small bruise noted . A progress note written on 7/14/19 at 4:30 PM by LPN 'A' that read, Note Text: Called per nurse at 4 PM after transferring back to bed when noted right upper arm with discoloration <sic> and [MEDICAL CONDITION]. Resident continues to guard extremity .orders obtained for upper arm X-ray <sic> <sic> and upper extremity venous Doppler . Follow up progress notes from LPN 'A' that indicated the doppler could not be done in the facility and R#702 had been transferred out to the emergency room . It was noted that LPN 'B' did not document a progress note for their shift on 7/12/19 when it was first reported to LPN 'A' that R#702 had not been feeding herself. On 7/16/19 at approximately 11:30 AM, an interview with the Director of Nursing (DON) was conducted regarding R#702's injury to their arm. The DON stated, We just found out that it was fractured yesterday and we started our investigation. (Dr. 'M') followed up at the hospital and came in and told me about it. A review of R#702's right humerus (upper arm bone) x-ray results from the hospital dated 7/14/19 at 9:36 AM was conducted and read, .There is a displaced oblique [MEDICAL CONDITION] humeral diaphysis (a break in the lower end of the upper arm bone). Remote trauma suspected in the right mid humeral diaphysis . On 7/16/19 at 1:55 PM, an interview with LPN 'A' was conducted regarding her care of R#702 prior to the transfer to the emergency roiagnom on [DATE]. LPN 'A' explained that R#702 was able to feed herself with her right hand and it was reported to her on the start of her day shift on 7/13/19 by LPN 'B' that R#702 didn't feed herself on 7/12/19. LPN 'A' stated, She was guarding her right arm and wrist so I ordered an x-ray. She wasn't able to feed herself during the day either, an aide had to feed her. The x-rays for her wrist and hand came back negative so we just monitored her. LPN 'A' continued to explain that she gave report to the night shift nurse, LPN 'B' on 7/13/19 and took report back from LPN 'B' on the day shift on 7/14/19. LPN 'A' explained that LPN 'L' who was performing duties as a nursing aide called her to come look at R#702's arm when she was getting her ready for bed. LPN 'A' stated, It was red and swollen and it looked like [MEDICAL CONDITION] so I called the doctor and he ordered an x-ray and a doppler. They couldn't do the the doppler here so she went out to the hospital. On 7/16/19 at 2:10 PM an interview with Certified Nurse Aide (CNA) 'K', who provided care for R#702 on 7/13/19 from 11 PM, to 7/14/19 7 AM, was conducted. CNA 'K' indicated she received report from CNA 'J' who worked with R#702 on 7/13/19 from 3 PM until 11 PM. CNA 'K' stated, When I came in (CNA 'J') reported there was something wrong with her arm. He mentioned something about the hoyer lift coming down on her arm. I asked him if it was on his shift and then he said, 'No, I think it was on the day shift and I think that's what happened.' I asked him how he knew or heard about that and he told me he didn't know for sure, but that was just what he thought. On 7/16/19 at 2:25 PM, an interview with CNA 'J' was conducted. CNA 'J' was asked if the day shift CNA (CNA 'I') reported anything to him regarding R#701's arm. CNA 'J' stated, No, CNA's don't do report at (facility name redacted). CNA 'J' was then asked about him reporting to CNA 'K' about R#702's arm being hit by the hoyer lift. CNA 'J' stated, I just told her that's what I thought happened. When queried why he thought R#702 had been hit with the hoyer lift, CNA 'J' stated, I saw where the bruise on her arm was and it matched up with where the hinges are on the hoyer lift. On 7/16/19 at 2:51 PM, an interview was conducted with Dr. 'M'. Dr. 'M' was queried about the nature of the fracture and stated, Typically we wouldn't expect a distal humerus fracture to be spontaneous or pathological. On 7/16/19 from 4:00 until 4:20 PM, phone calls were placed to the following staff members who had been assigned to R#702's care from 7/12/19-7/13/19: CNA 'I', CNA 'H', LPN 'O', CNA 'P', CNA 'Q' and LPN 'B'. Voicemails were left and none of the calls were returned by the end of the survey. On 7/17/19 at 11:41 PM, an interview was conducted with the facility's Administrator and Director of Nursing regarding their investigation into R#702's fracture. The Administrator stated, We are still working on our investigation, we know something had to have caused it, but we still don't know yet. On 7/16/19 at 3:45 PM, the DON reported the facility did not have a policy for a safe environment. Further, on 7/16/19 at approximately 4:00 PM, and 7/17/19 at approximately 9:30 AM, a request for a policy regarding resident's rights for services to attain or maintain the highest practicable physical, mental, and psychosocial well-being was requested, however; it was not received by the end of the survey. The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation pertains to intake #MI 3. Based on interview and record review, the facility failed to ensure timely diagnostics and transfer to the emergency department after a fall, for one resident (R#701) on [MEDICATION NAME] (a blood thinning medication) of three residents reviewed for quality of care, resulting in a transfer to the emergency department with a subdural hemorrhage (a type of bleeding that often occurs outside of the brain as a result of a severe head injury.) Findings include: On [DATE] at 4:50 PM, an interview with the complainant was conducted and it was explained that on [DATE] in the early morning R#701 had a fall. The complainant stated that they got to the building at approximately 10:45 AM, and R#701 was participating in therapy. The complainant stated, I was mad when I found out about the fall and when I got there I looked at him (R#701) and I knew something wasn't right. His posture wasn't right, his neck was bent down and his chin was tucked into his chest. I told the therapist this wasn't normal for him. The complainant continued to explain that the nursing staff was made aware of of his neck posture and they ordered an x-ray of his neck. The complainant then said that R#701 received his lunch around 12 PM and was complaining of a headache. During lunch the complainant stated, While he was eating he dropped his fork and his body slumped. He became more unresponsive and they finally called to have him sent to the hospital. The complainant then stated, When we got to the hospital he had a very large brain bleed (subdural hemorrhage). The doctor in the emergency room told me it was new, maybe only six to eight hours ago it happened. I chose not to have surgery for [REDACTED]. I put him in hospice and he died yesterday. On [DATE] at 10:45 AM, a review of R#701's closed clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#701 did not have a completed Minimum Data Set assessment, however; multiple nursing progress notes documented that R#701 was alert and oriented to person and sometimes place, was able to make needs known, was independently ambulatory, but unsteady, and had exhibited some agitation during the night time hours. A review of R#701's progress notes was conducted and revealed the following: A progress note written by Licensed Practical Nurse (LPN) 'F' dated [DATE] at 6:41 AM, that read, Note Text: Patient is alert and orientedx1 (alert to person), he is mildly confused but can follow re directions <sic>, he had a fall at 5;30am <sic>, he was found on the floor in the bathroom, he stated that he wanted to urinate, some of the urine spilled on the floor and he slipped and fell , he hit his head against the wall,patient denies pain at this time and he got his scheduled pain medications. DR (doctor) notified, and family member notified too. There are no new orders at this time, fluid and call light are within reach for safety. A progress note written by LPN 'D' on [DATE] at 11:00 AM, that read, Note Text: Pt is A/O X1 (alert and oriented to self only) .body guarding noted .Upon return to room, new complaints of pain to neck noted, neck appeared stiff . A progress note written by LPN 'D' on [DATE] at 11:30 AM that read, Note Text: Upon entering room, Pt was assessed to have L (left)-sided arm and facial drooping, and was sitting in chair . Pt was not verbally responsive, and eyes are slightly open. Pt appeared lethargic, and was unable to follow commands .new orders to admit pt out to ER (emergency room ) .(Ambulance service name redacted) was called and arrived . On [DATE] at 12:32 PM, a review of a facility provided incident report for R#701's fall was conducted and read, Description of Incident: Patient went to the bathroom without supervision .he slipped on his way out of the bathroom falling on his buttocks, he stated that he hit his head against the wall . A review of a statement by LPN 'F' contained in the incident report read, I was in another pt room when (CNA 'R') came and got me that the pt had fallen .The patient said he slipped and hit his head. I notified (Dr. 'N') and told him he had fallen and hit his head. I did not mention that the patient was on [MEDICATION NAME] . On [DATE] at 12:38 PM, a phone call was placed to LPN 'F' and a voicemail was left. LPN 'F' did not return the phone call by the end of the survey. On [DATE] at 12:44 PM, a phone call was placed to LPN 'D' and a voicemail was left. LPN 'D' did not return the phone call by the end of the survey. On [DATE] at 3:36 PM, an interview with Dr. 'N' and Nurse Practitioner 'S' was conducted via telephone. At that time, Dr. 'N' indicated that he did receive notification that R#701 had fallen and hit his head on [DATE] via a text. When queried if he had been made aware that R#701 was on [MEDICATION NAME], Dr. 'N' indicated that the nurse did not inform him of that. When asked if the nurse should have informed him of R#701 being on [MEDICATION NAME], Dr. 'N' stated, It would have been nice, it might not have changed what was done, but at the very least I would have had more questions before making a decision. On [DATE] at 11:22 AM, an interview with Certified Occupational Therapy Assistant (COTA) 'T' was conducted. COTA 'T' indicated she worked with R#701 on [DATE] before lunch. When queried if she noticed anything unusual about R#701's posture, COTA 'T' stated, I didn't notice anything, but his wife mentioned something about his posture not being as straight. On [DATE] at approximately 10:00 AM, a review of R#701's CT (computed tomography) imaging scan dated [DATE] at 2:17 PM from the hospital was reviewed and read, Study Result EXAM: CT HEAD W/O (without) IV (intravenous) CONTRAST [DATE] 2:17 PM. COMPARISON: Head CT, [DATE] Findings: There is a new large left hemispheric acute subdural hemorrhage measuring approximately 1.8 cm (centimeters) in greatest thickness. There is mass effect with approximately 12 mm (millimeters) rightward shift of the septum pellucidum (a thin, triangular, vertical double membrane separating the anterior horns of the left and right lateral ventricles of the brain). There is a smaller anterior right frontal subdural hemorrhage measuring approximately 4 mm in thickness .Impression 1. Large acute left hemispheric subdural hemorrhage, 1.8 cm in thickness. Rightward midline shift of approximately 12 mm. 2. small anterior right frontal subdural hemorrhage approximate 4 mm in thickness . On [DATE] at 11:41 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding R#701's fall. The DON explained that the nurse should have informed Dr. 'N' that R#701 was on [MEDICATION NAME] and stated, We started neuro checks on him and sent him out once he had a change in condition. On [DATE] at approximately 4:00 PM, and [DATE] at approximately 9:30 AM, a request for a policy regarding resident's rights for services to attain or maintain the highest practicable physical, mental, and psychosocial well-being was requested, however; it was not received by the end of the survey. The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation has 2 deficient practices This deficient practice pertains to intake Deficient Practice #1 Based on interview and record review, the facility failed to implement safety interventions consistent with the plan of care based on assessment needs to prevent falls for one resident (#522) of 13 residents reviewed for falls, from a total of 24 sampled residents, resulting in resident falling multiple times with injuries in which the resident sustained [REDACTED]. Findings Include: On 6/7/16 at 2: 40 p.m., a review of the facility's clinical record revealed Resident #522 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Resident 522's progress notes and facility's Incident Reports, Resident #522 fell four separate times between 4/16/16 and 5/7/16, while attempting to ambulate unassisted. The most recent fall occurred on 5/7/16, which resulted in a left dislocated shoulder. Resident #522's five (5) day Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 6 (cognitively severely impaired), required extensive assistance with two person assistance for transfer, bed mobility and toilet use. The MDS assessment indicated Resident #522 was not steady and only able to stabilize with staff assistance. The MDS assessment also indicated that Resident #522 had a fall prior to admission, one fall with no injury, and one fall except major injury. Further review of the 30 day MDS assessment dated [DATE] revealed Resident #522 had one fall with no injury and one fall except major injury. A review of Resident 522's admission Fall assessments revealed the following: 4/13/2016 - 17:05 (5:05 p.m.): History of falling: Blank Physical performance limitations: Need to rock body or push off on arms of chair when standing up from chair, Impaired balance during transitions, Gait problem, Musculoskeletal problem. Medications: None of the above. Disease & Conditions: Decline in functional status, Chronic or acute condition resulting in instability, Muscle weakness, Cognitive impairment, Alzheimer's disease, Low levels of physical activity, Fatigue, weakness. Laboratory Tests: None of the above. Environmental Factors: None of the above. Care plan initiated/revised: Yes. Additional observations/comments not captured in the previous sections: Pt. (patient) [AGE] year old male admitted on [DATE] with primary [DIAGNOSES REDACTED]. Pt presented with unsteady gait, generalized weakness and history of falls. Pt needs moderate assist with transfers and ADL's. Skilled PT (physical therapy)/OT (occupational therapy) to increase mobility and activity tolerance. Bed placed in lowest position and call light within reach. 04/18/2016 - 11:42 a.m.: History of falling: Blank Physical performance limitations: Need to rock body or push off on arms of chair when standing up from chair, Difficulty maintaining standing position, Impaired balance during transitions, Musculoskeletal problem. Medications: None of the above. Disease & Conditions: Decline in functional status, Incontinence, Muscle weakness, Impulsivity or poor safety awareness, Cognitive impairment, Alzheimer's disease, Low levels of physical activity, Fatigue, weakness. Laboratory Tests: None of the above. Environmental Factors: None of the above. Care plan initiated/revised: Yes . 04/18/2016 - 11:46 a.m.: History of falling: 04/17/2016 - 21:28 (9:28 p.m.) Physical performance limitations: Need to rock body or push off on arms of chair when standing up from chair, Difficulty maintaining standing position, Impaired balance during transitions, Musculoskeletal problem. Medications: None of the above. Disease & Conditions: Decline in functional status, Incontinence, Muscle weakness, Impulsivity or poor safety awareness, Cognitive impairment, Alzheimer's disease, Low levels of physical activity, Fatigue, weakness. Laboratory Tests: None of the above. Environmental Factors: None of the above. Care plan initiated/revised: Yes . 05/01/2016 - 23:17 (11:17 p.m.): History of falling: 05/01/2016 - 23:17 (11:17 p.m.) Physical performance limitations: Need to rock body or push off on arms of chair when standing up from chair, Difficulty maintaining standing position, Impaired balance during transitions, Musculoskeletal problem. Medications: None of the above. Disease & Conditions: Decline in functional status, Incontinence, Chronic or acute condition resulting in instability, Muscle weakness, Impulsivity or poor safety awareness, Cognitive impairment, Low levels of physical activity. Laboratory Tests: None of the above. Environmental Factors: None of the above. Care plan initiated/revised: Yes. Additional observations/comments not captured in the previous sections: Pt confused as per baseline, very impulsive with poor safety awareness . 05/08/2016 - 11:48 a.m.: History of falling: 05/07/2016 - 13:00 (1:00 p.m.) Physical performance limitations: Need to rock body or push off on arms of chair when standing up from chair, Difficulty maintaining standing position, Impaired balance during transitions. Medications: None of the above. Disease & Conditions: Decline in functional status, Incontinence, Muscle weakness, Impulsivity or poor safety awareness, Cognitive impairment, Low levels of physical activity, Fatigue, weakness. Laboratory Tests: None of the above. Environmental Factors: None of the above. Care plan initiated/revised: Yes. Additional observations/comments not captured in the previous sections: Pt remains very confused, is very impulsive and has poor safety awareness . A review of the facility's incident reports revealed the following: 1. On 4/16/16 at 7:22 p.m. - Attempting self-ambulation in room, holding onto tray table. Table slid, and patient fell to floor on his right side. No injuries, and no new orders. Corrective Action Taken Following Incident: Patient to lie down to rest after therapy to prevent patient trying to get into bed unassisted. According to the PT (Physical Therapy) Service Log Matrix, on 4/16/16, Resident #522's PT start time was at 14:50 (2:50 p.m.) and stop time was at (15:51 (3:51 p.m.), which was approximately four hours prior to the fall at 7:22 p.m. A review of the General Progress Notes documented the following: 4/15/16 - 02:07 (2:07 a.m.): Patient rec'd sitting at nurses' desk in w/c (wheelchair). He is very impulsive and was observed attempting to exit chair several times during report. Patient requires continuous monitoring and has to be redirected due to confusion. He is A/O (alert/oriented) X 1-2 with a pleasant demeanor. He is a new admit to the facility day #2 and has an hx (history) of numerous falls . 4/16/16 - 21:31 (9:31 p.m.): documented Resident #522 noted ambulating from w/c to bed using over-bed table, before this nurse could get to patient, the over-bed table slid, and pt. fell to floor and landed on his R (right) side. Pt. did not hit his head. Pt. assisted back to bed via assist of three staff and Hoyer lift. Head to toe assessment reveals no red, bruised, or open areas. Pt. denies c/o (complaint of) pain. Continues to receive skilled PT/OT services. All due meds administered. Call light in reach. No c/o voiced. A review of Resident #522's care plan revealed the following: Date Initiated/Created: 4/13/16: At risk for falls/unavoidable falls due to delirium, debility, incontinence, history of falls. Cognitive loss as evidenced by BIMS score Date Initiated/Created: 4/13/16: Hourly Rounding Date Initiated/Created: 4/15/16: Bed in low position Date Initiated/Created: 4/18/16: 1:1 sitter, Assist to lie down in bed and rest after therapies. A review of the facility's incident reports revealed the following: 2. On 4/17/16 at 9:28 p.m. - Attempted to get up out of wheelchair to follow family member when they left to go home. No major injuries, but abrasions to left upper thigh and left calf. Corrective Action Taken Following Incident: Spoke with family members and asked that they bring patient in wheelchair to nursing station for one-to-one (1:1) monitoring when they leave to go home. Patient is on Q (every) hour monitoring when in room. Place in visual area when awake for monitoring. A review of the General Progress Note documented the following: 4/17/16 - 19:16 (7:16 p.m.): Pt. was in rm. (room) visiting with son. Son left pt. at bedside in w/c, when leaving to go home. CNA (Certified Nurse Assistant) went to rm. to retrieve pt. to bring him back to the nurses station for 1:1 monitoring, and pt. was noted lying in floor at head of bed. Pt. assisted to bed with assist of Hoyer lift and 2 staff. Physical exam reveals abrasion to L (left) upper thigh, area cleansed with NS (normal saline) and left OTA (open to air). Pt. denies c/o pain .also explained to family the importance of bring father to nursing station for 1:1 monitoring. Incisions to (R) side of head, and abd (abdomen) intact . A review of Resident #522's care plan revealed the following: Date Initiated/Created: 4/17/16: Family to bring pt. up to nursing station for 1:1 monitoring when they leave facility after visit . so staff can place pt. in visual area for monitoring A review of the facility's incident reports revealed the following: 3. On 5/1/16 at 11:17 p.m. - Pt. found lying on back in floor, parallel to bed. No injuries. Corrective Action Taken Following Incident: Family to return pt. to nursing station for 1:1 assist for monitoring when leaving from their visit. Reinforce to family to notify staff when leaving so staff can seat pt. in visual area for monitoring. A review of the General Progress Note documented the following: .Visitor in rm. saw pt. fall to floor while ambulating and holding onto over-bed table. Pt. observed lying in floor on his back parallel to bed. Head to toe assessment reveals no red, bruised, or open areas noted. Pt. denies c/o pain. Neuro-Checks WNL's (within normal limits). Pt. lying in bed with bed in low position .Q (every) 1 hr. (hour) rounding. S/P (status [REDACTED]. A review of the facility's incident reports revealed the following: 4. On 5/7/16 at 1:00 p.m. - Observed on bedside floor flat on his back with (L) left arm straight out to his side. Patient stating left should pain. Injury: Resulted in dislocation of (L) shoulder. Physician notified. Describe care and medications . Vitals taken, patient unable to move left arm at shoulder but can bend at elbow. Was patient taken to a hospital: Yes. Date: 07-May-2016 - 1:30 p.m. By whom: Ambulance. Person notified: Daughter. Corrective action taken following incident: Patient assessed by RN (Registered Nurse), MD (Medical Doctor) contacted. Patient transferred to .hospital for evaluation. If returns - 24 hour 1:1 sitter 5/8/16. A review of the General Progress Note documented the following: . Called to room by CNA . Pt. states has severe left shoulder pain. Pt. vitals taken, BP (blood pressure) 159/79, HR (heart rate) 80, RR (respiratory rate) 20 . Further review of the facility's Hourly Rounding Log Sheets dated 4/13/16 documented the following: 4/13/16 - 6:00 p.m. - 10:00 p.m., 12:00 a.m. - 6:00 a.m. There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 4/14/16 - 7:00 a.m. to 10:00 p.m., 12:00 a.m. - 6:00 a.m. There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 4/15/16 - There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 4/16/16 - There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 4/17/16 - There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 4/18/16 - There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 5/1/16 - 4/14/16 - 7:00 a.m. to 1:00 p.m., LOA (leave of absence). 2:00 p.m. to 7:00 p.m. Hourly Rounding resumed at 8:00 p.m. to 10:00 p.m. There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 5/2/16 - There was no hourly rounding documented from 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. 5/7/16 - 7:00 a.m. to 1:00 p.m. At 1:30 p.m., Resident #522 was discharged to the hospital for pain that resulted in a left dislocated shoulder. On 6/8/16 at 3:10 p.m., during an interview, when queried what additional safety interventions were implemented after Resident #522's fall on 4/16/16, Licensed Practical Nurse (LPN) H stated, Resident #522 had therapy in the morning and the afternoon. We put the patient in bed to lie down to rest after therapy . When queried about the therapy schedule for Resident #522, LPN H stated, I'll have to check. At that time, Resident #522's Service Log Matrix (PT) was requested, and revealed on 4/16/16, Resident #522's physical therapy ended at 3:51 p.m., (approximately 4 hours before the fall at 7:22 p.m.). LPN H further stated, We maintain a log. They are turned in at the end of every 24 hours and to the unit manager. There was no explanation concerning the one gap between 10:00 p.m. to 11:00 p.m., and 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. on the hourly rounding log sheets. On 6/8/16 at 3:30 p.m., during an interview, Registered Nurse (RN) I stated, We do frequent monitoring. At least every hour. When I returned to work, Resident #522 was on 1:1 sitter. On 6/8/16 at 3:45 p.m., during an interview, when queried how residents are placed on hourly rounding and 1:1 sitter, the Director of Nursing (DON) stated, When residents are admitted and assessed, things like low bed position, call light in place, and things within reach are standard. Residents are assessed on an individual basis. One-to-one (1:1) is determined when patient has had multiple falls. When asked what other measures are implemented before residents are placed on 1:1 sitter, the DON stated, Usually, we do hourly checks, 30 minute checks, 15 minute checks, then 1:1. The DON further stated, With the population/severity, we cannot always do a 1:1 for all of the patients. At that same time, the DON was asked what safety measures were put in place during the one hour gap between 10:00 p.m. to 11:00 p.m., 12:00 a.m. to 2:00 a.m., 4:00 a.m., and 6:00 a.m. on the hourly rounding log sheets, and if there was a facility's policy regarding the implementation of monitoring checks and hourly rounding, the DON stated, We have a checks in balance we put in place. They are using an old form. When sheet was revised, no one paid attention. ( ) Deficient Practice #2: Based on observation, interview, and record review the facility failed to ensure that an oxygen tank was properly stored and secured for one (#508) of two residents reviewed for specialty care from a total of 24, resulting in the potential for injury and accidents. Findings include: On 6/6/16 at approximately 1:00pm, an observation was made of Resident #508's bedroom. The resident was not present in the room at this time. An oxygen tank was observed to be standing upright on the floor of the resident's bedroom across from Resident #508's bed. An observation of the gauge of the tank revealed that the oxygen tank was about half full. The tank was freestanding, as it was not observed to be contained inside a transport/securement device. At this time, Nurse 'A' was queried in regards to the oxygen tank in Resident #508's bedroom. After observing the oxygen tank, Nurse 'A' responded, It shouldn't be there .this isn't appropriate and removed it from the resident's bedroom. On 6/6/16 at 2:00pm, the clinical record for Resident #508 was reviewed and revealed the resident was originally admitted into the facility on [DATE] and was readmitted on [DATE] and 6/5/16 with [DIAGNOSES REDACTED]. Per a review of active physician orders [REDACTED].#508 was ordered oxygen at 2 Liters to maintain an oxygen saturation of greater than 92%. On 6/7/16 at 9:45am the Director of Nursing (DON) was queried in regards to the method of storing oxygen tanks at the facility. The DON responded that oxygen tanks were not to be freestanding, and stated that if oxygen tanks were not in the oxygen storage room, then oxygen tanks should be in a holder on the wheelchair or on a stand. On 6/8/16 at 4:00pm, a review of facility policy titled Storage Requirements for Non-Flammable Gases less than 3000 cubic ft. (Oxygen Cylinder Storage) dated 5/31/2007 was conducted and revealed the following: Per Section H of the policy, all oxygen cylinders are to be secured in a manner as to prevent them from being damaged in any way, i.e. knocked over, vessel integrity violated and/or the valves/controls damaged. ( )

This citation pertains to intake number(s) MI 586 Based on interview and record review, the facility failed to implement safety interventions based on the Resident's assessment needs to prevent falls and minimize injury from falls for one (#701) of three sampled residents reviewed for falls from a total of three Residents, resulting in Resident #701 falling multiple times with injury, culminating in a fall in which the resident sustained [REDACTED]. Findings include: A review of the clinical record was conducted on 10/13/15 at 10:00 a.m. revealed that Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Initially progress notes indicated that the resident was severely cognitively impaired. According to the Resident's progress notes and Facility Incident and Accident reports, Resident #701 fell four separate times between 7/28/15 and 8/7/15, while attempting to ambulate unassisted. The most recent occurred on 8/7/15, resulted in a right femoral neck fracture. A review of the Resident's Fall assessment dated [DATE], was reviewed and revealed, in part, the following: History of falling: blank Physical performance limitations: need to rock body or push off on arms of chair when standing up from chair, difficulty maintaining standing position, impaired balance during transitions. Medications: antipsychotics, narcotic analgesics Disease & Conditions: decline in functional status, incontinence, Parkinson's disease, hip fracture, impulsivity or poor safety awareness, other dementia, low levels of physical activity, and pain. Additional observations/comments not captured: Pt is [AGE] year old female admitted on [DATE] with primary [DIAGNOSES REDACTED]. Pt (patient) presented with unsteady gait, generalized weakness and history of fall. Pt needs moderate assist with transfers and ADL' s (Activities of Daily Living). Skilled PT/OT to increase mobility and activity tolerance. Based on multiple factors, pt is at risk of falls. Proceed to care plan for intervention. No further fall assessments documents were found in the Resident's clinical record. On 8/13/15 at 10:00 a.m., a review of the Facility Accident and Incident report dated revealed the following: Date of Incident: 7/28/15/10:30 p.m. (Fall with minor injury). Description of Incident: res observed on floor adjacent to bed in sitting position with back up against night stand. Noted right elbow skin tear. Corrective Action: re-orientate res when anxious. General Progress Note dated 7/29/15: Client up in w/c at 11 pm in hallway for safety monitoring. Attempted x2 to get out of chair. Poor safety awareness .Client went to bed at 4:15 am. Attempt x1 to get OOB (out of bed). Frequent visual checks done for safety monitoring. A review of the Resident's initial care plan (Date initiated 7/29/15) revealed the following: Focus: At risk for falls due to history of falls, impaired balance/poor coordination, unsteady gait, confusion, hallucination Goal Minimize risk for injury r/t falls. Interventions: · Bed in low position (7/29/2015) · Encourage to transfer and change positions slowly (7/29/2015) · Have commonly used articles within easy reach (7/29/2015) · Provide assist to transfer and ambulate as needed (7/29/15) · Reinforce w/c (wheelchair) safety as needed such as locking brakes (7/29/15) A Facility Incident and Accident Report dated 7/30/15 revealed, in part, the following: Date of Accident 7/30/15 8:06 p.m Description of Accident: res observed on floor lying on left side of bed noted skin tear to right wrist stated he was trying to get out of bed. Corrective Action: Resident placed in common area for visual rounds until resident is ready to go to sleep. The corrective action was updated to the Resident 's Care Plan 7/30/15. A Facility Incident and Accident Report dated 8/3/15 revealed the following. Date of Accident: 8/3/15 9:00 p.m., res observed on floor in front of w/c in hallway fall observed by nurse who noted that he did not hit his head. Resident observed lying on left side with no c/o pain/discomfort .res transferred into w/c by two nurses will continue in common area for increase visual rounds. Corrective Action: Monitor hourly for supervision. A progress note dated 8/7/2015 at 12:38 p.m., revealed the following: Note: Resident still in bed when rounds made. Vital signs taken and resident am care done by CENA (certified nursing assistant) and up for breakfast and eat very slow. Resident medication given without difficulty. resident voiced tired cena took resident to br (bathroom) then to bed in low position. resident witnessed by cena standing and fell on floor prior reaching him. observed resident on the floor on his right side. resident stated was going to the window when asked. assessment done and observed skin tear on his rt elbow and rt outer knee. treatment done. resident limited assessment done on upper and lower extremities due to rigidity and spasm. put back in wheelchair sat across from nurses station, resident went to physical therapy and back therapist stated resident voiced pain went and checked and resident pointed to rt hip. pain medication given asked NP (nurse practitioner) to checked on resident and ordered STAT x-ray called company. on continuous hourly rounds Licensed Practical Nurse (LPN) A. A progress note dated 8/7/15 at 21:30 stated the following, pt is alert and confused. R hip Xray came in with acute R femerol neck fx. MD informed and order to send pt. to hospital Resident #701 did not return to the Facility. On 10/13/15 at 2:30 p.m., an interview was conducted with LPN A regarding the Resident's fall with injury on 8/7/15. LPN A stated,she remembered that a CNA had put the Resident in his bed at around 9:15 a.m. and he fell asleep. The CNA walked past the Resident's room and saw the Resident starting to fall. She was not able to catch him. She remembered doing an assessment, but could not do a full assessment due to his rigidity. He was placed in a wheelchair in front of the nurses station and remained there until he was taken to rehabilitation later that afternoon and started to complain of pain. The NP then ordered the x-ray and we found out that he had a fracture to his right hip. When asked why the Resident was not returned to his bed as per his request, LPN A was not sure. When further queried as to what interventions are done by the Facility for Resident's with severe fall risk like Resident #701, LPN A stated, we have done things like 1:1 care with Resident's, we also have special mattresses called a scoop mattress. It is used to protect a patient from rolling or climbing out. It is very helpful. On 10/13/15 at 9:02 a.m. and 2:50 p.m., interview(s) were conducted via the telephone with the Complainant. The Complainant stated that she was very disappointed with the way the Facility handled Resident #701 with respect to his fall history. When specifically asked about her concerns, the Complainant stated, after Resident #701 fell for the third time, we had a meeting with the staff who assured us that they would keep him safe. We even agreed to pay for an aide to come in and sit with him during the night time. They knew he had fallen a number of times and the reason he was at the Facility was due to a fall and a fractured hip, we never expected this to happen again. I just think they were not keeping a constant eye on him. He fell four time in 10 days. He was not able to walk on his own. The reason he was there was for rehabilitation. When he would go to the bathroom, they would take him to the toilet, but just leave him there. We talked to the facility about that. He is very confused person. The only thing they wanted to do was keep him in front of the nurse's station in his wheelchair. He really didn't like that much, neither did we. Even on the day he broke his hip, they put him in his wheelchair in front of the nurses station. He is now in another Facility. They have mats on the floor to protect him, a special scoop bed, a special wheelchair to protect him from sliding and someone watching him all the time. He has not had any other falls or injuries. On 10/13/15 at 3:40 p.m., an interview and record review was conducted with Social Worker (SW) B regarding the meeting with the Resident's family pertaining to Resident 701's care. A review of the Resident's progress note dated 8/4/15/ late entry revealed, in part, the following: made family aware that the goal will focus on decreasing fall risk and keeping patient safe. Will have family meeting tomorrow. SW B stated, I do remember the family meeting on 8/5/15. The resident was present. He was very confused and fidgety. We talked about fall interventions. We recommended that if he were to go home he would need 24 hour care. Family had some concerns about call lights and wanted him to have a private aide with him at night. They were provided with some company names, but decided to use their own person. I think the aide was only here one time and then he went out with the fracture. On 10/13/15 at 3:00 p.m. an interview was conducted with the Director of Nursing (DON). When queried about Resident #701's fall(s) that occurred on 7/28/15, 7/30/15, 8/3/15 and 8/7/15, the DON reported, This was one of our most challenging patients regarding falls. According to his family and hospital records he had a history of [REDACTED]. Honestly, I probably would not have accepted him on admission, but we did. I believe we did what we could to prevent them, but it was inevitable that he would keep falling giving his fall history. When further queried as to what other interventions could have been in place to prevent the Resident from falling, the DON stated, at the Facility we do not use a fall alarm system, fall mats or restraints. We do not find those types of systems helpful. In terms of Resident #701 we could have provided a scoop mattress. That was in our plan following the accident on 8/7/15, but the Resident never returned. In terms of 1:1 assistance, we did not provide that for him, it requires a lot of staffing. We decided to progress with one thing at a time so that we would not exhaust all our options at one time. A review of the facility's Policy titled Falls Practice Guide issued 12/2011, was reviewed on 10/13/15 at 3:20 p.m., and revealed, in part, the following: Purpose: The purpose of the fall Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patients quality of life . Initial Evaluation: Upon admission, review hospital discharge records, transfer sheets or other data regarding the patient ' s history of, or risk factors for, experiencing a fall. Interview the patient and family or responsible party about the patient ' s history of falls . . Medications Review: Medication side effects may pre-dispose a patient for falls or fall risks. Such medication or medication classifications may include, but are not limited to: · Anti-parkinsonian agents · Psychotropics Initial Plan of Care: . if patient is found to be at risk for falls, the physician is contacted for orders . fall reduction an injury prevention strategies that can be implemented upon admission may include, but are not limited to the following: · Orientation to surroundings and use of call light · Placement of call light within reach · Low -bed · Cushioned floor mats next to bed · Removal of trip hazards · Use of appropriate footwear · Use of hip protectors as clinically indicated · Review medication for possible side-effects · FYI: provide nursing staff 24 hour access to supplies and equipment that may be needed for fall management interventions .low beds, bedside mats, hip-protector products, positioning devices. ( )