Every finding on record at Optalis Health & Rehabilitation at Kent-Crossing

Based on observation and interview the facility failed to properly secure medications in 3 of 12 medication carts and 3 of 6 treatment carts resulting in the potential for compromise of medications and/or misappropriation of medications, and accidental ingestion. Findings include: During an observation on 8/11/26 at 11:31 AM, The door on room [ROOM NUMBER] had a caddy on it with personal protective equipment supplies in the caddy. Noted prescription cream medication on the door caddy in reach of anyone that walked by the door. Noted that there was not a nurse near in view of the door. During an observation on 8/11/26 at 11:51 AM, a bottle of nasal spray and prescription antibiotic cream were sitting on the dresser in Resident #113's room. Review of Resident #113's electronic health record (EHR) noted that Resident #113 did not have orders to self-administer medications. Noted that there was not a nurse in view of the medications.During an observation on 8/12/26 at 12:40 PM, a medication cart was noted to be unlocked near room [ROOM NUMBER]. There was not a nurse in view of the cart. During an observation on 8/13/26 at 9:07 AM, an unlocked treatment cart was noted near room [ROOM NUMBER]. There was not a nurse in view of the cart. During an observation on 8/13/26 at 9:09 AM, a treatment cart neat room [ROOM NUMBER] was noted to be unlocked and a medication cart near room [ROOM NUMBER] was also noted to be in locked. There was not a nurse in view of either of the carts that were unlocked. During an observation on 8/13/26 at 12:08 PM, a treatment cart near room [ROOM NUMBER] was noted to be unlocked. There was not a nurse in view of the cart. During an interview on 8/13/26 at 1:55 PM, Nursing Home Administrator (NHA) A reported that nurses were expected to lock the treatment and medication carts when they were not near them. NHA A reported that he was going to work on educating staff right away on proper medication storage. During a follow up interview on 8/18/26 at 8:55 AM, NHA A reported that the facility had completed education with all nursing staff on proper medication storage and the importance of ensuring medications and treatment supplies are locked when not in use. During an observation on 8/18/26 at 8:56 AM, a medication cart near room [ROOM NUMBER] was noted to be unlocked without a nurse in view of the cart. Licensed Practical Nurse Manager (LPN-M) J observed this writer near the cart and walked by cart and locked it. When this writer queried LPN-M J about the unlocked cart, LPN-M J reported that it was not her cart and continued to walk away. Review of the facility's Medication and treatment storage policy dated 2/3/26 revealed, Policy overview: It is the policy of this facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage of all medications and treatments. General Guidelines: All medications and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, freezers, refrigerators, medication rooms) . During medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart

This citation pertains to intake 3025394. Based on observation, interview and record review, the facility failed to provide pressure ulcer preventative care and pressure ulcer treatment for 1 (Resident #111) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the development of an avoidable pressure ulcer. Findings include: Resident #111Review of an admission Record revealed Resident #111 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and functional quadriplegia (state of complete immobility of all four limbs due to severe physical disability or frailty from another medical condition.)Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 10/27/25, Revealed, . Section: M: Skin Conditions: Does this resident have one or more unhealed pressure ulcers/injuries? No.Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 4/22/26, Revealed, . Section: M: Skin Conditions: Does this resident have one or more unhealed pressure ulcers/injuries? Yes . C. Stage 3: (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). Review of Resident #111's Care Plan revealed, Focus: At risk for skin integrity . Date initiated: 10/27/25. Interventions: .Provide preventative skin care routinely and prn (as needed). Start date: 10/29/25 .Review of Resident #111's Progress Note dated 3/15/26 revealed, New open area noted to L (left) posterior thigh. Resident is unaware that wound was present, or how wound was acquired Review of Resident #111's Progress Note dated 5/1/26 revealed, Wound NP (Nurse Practitioner) and nurse assessed wounds on 4/27. Removed dressing dated 4/24. Observed noted decline in wound . Orders updated to reflect appropriate treatment . Nurses were re-educated .Review of Resident #111's Orders revealed, Wound care site: Left rear thigh. 1. Cleanse with NS (Normal Saline) or wound cleanser . Noted missing documentation to indicate if the wound care had been completed or not on the following dates: 6/10/26 and 6/21/26.During an interview on 8/18/26 at 10:11 AM, Nurse Practitioner (NP) FF reported that she was aware that Resident #111 had developed a pressure ulcer in the facility, but she was not sure if the facility had determined how the wound had developed. NP FF reported that she was aware that Resident #111 had a broken wheelchair for some time and at the facility had to use a different chair in the interim as they awaited a new chair, and Resident #111 also had experienced issues with a leaky catheter (medical devices that drain urine from your bladder) that could have affected the integrity of her skin during that time. During a wound care observation and interview on 8/18/26 at 9:09 AM, Licensed Practical Nurse (LPN) V removed Resident #111's brief and rolled Resident #111 onto her side to view Resident #111's wound. It was noted that Resident #111's open wound did not have a dressing on the wound. LPN V confirmed that Resident #111 should always have a dressing on the wound to protect the integrity of the skin. LPN V confirmed that she had not been informed by staff that Resident #111 did not have a dressing on the wound. LPN V confirmed that Resident #111 developed the stage 3 pressure ulcer at the facility. During an interview on 8/18/25 at 11:41 AM, Director of Nursing (DON) B reported that she expected staff to inform nursing if a dressing was missing so that nursing staff could reapply a new dressing to the wound to protect the integrity of the skin. When this writer queried DON B about missing documentation to indicate if Resident #111 had gotten wound care treatment as ordered, or if she had refused, DON B reported that she was unaware that Resident #111's wound care orders had missing documentation. DON B reported that she was aware that there were concerns with the wound care program at the facility.

This citation pertains to intake 3052012 and 3051250. Based on interview and record review, the facility failed to ensure resident safety in 1 (Resident #106) of 5 residents reviewed for accidents and hazards resulting in Resident #106 leaving the facility with an unauthorized person, traveling to a different state, and 2-day hospitalization. Findings include: Resident #106 Review of an admission Record revealed Resident #106 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels.)Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 5/15/26 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #106 was moderately cognitively impaired. Review of Resident #106's Care Plan revealed, Focus: Exit-seeking elopement risk related to dementia and desire to seek family in New Jersey. Family has history of stating that they are coming to pick her up but have no plan seeking safe discharge and following with this plan at this time. If family members show to facility- guardian should be contacted. Guardian requested that police be called if this happens as well . Date initiated: 12/28/25 . Interventions: Report to nurse if resident is actively exit seeking, packing their belongings, voicing desire or need to leave facility. Date initiated: 12/28/25.Review of Resident #106's Progress Note dated 6/13/26 revealed, Increased confusion and agitation noted .Observed packing belongings in room and stating she is waiting for her Husband to pick her up .Review of Resident #106's Hospital Discharge summary dated [DATE] revealed, Hospital Course: (Resident #106) with a past medical history of dementia, T2DM (type 2 diabetes mellitus) on insulin . initially presented with (police department) after eloping from Michigan long term care facility with friend . She was set up with transport back to facility in Michigan .Review of Resident #106's Progress Note dated 6/24/26 revealed, . (Resident #106) is seen today related to recent, unapproved visit to New Jersey . (Resident #106) made an unapproved visit to New Jersey last week facilitated by her spouse who paid for transportation .During an interview on 8/11/26 at 3:17 PM, Guardian H reported that they were Resident #106's court appointed guardian (someone legally named by a judge to make decisions on behalf of another person when that person is unable to make or communicate responsible decisions about their personal care, health, or finances). Guardian H reported that Resident #106 was not from Michigan, and that she had voiced the desire to return to New Jersey, but Resident #106 did not have any support for a safe discharge to New Jersey at the time, which is why she was in Michigan. Guardian H reported that she had hired a companion staff to take Resident #106 on outings to help Resident #106 with her desire to leave the facility. Guardian H reported that the companion staff member that took Resident #106 out weekly was the only person she had authorized the facility to allow Resident #106 to leave with. Guardian H reported that due to an extensive history of Resident #106's that she was aware of, she did not feel that it was safe for Resident #106 to leave the facility with anyone else. Guardian H reported that on 6/15/26 between 9:00 PM and 10:00 PM, she was contacted by the facility and informed that the facility staff had just discovered that Resident #106 had been authorized to leave the facility 12 hours prior with a visitor. Guardian H reported the facility proceeded to tell her that they were able to find the contact information of the visitor from the visitor sign in sheet, so they contacted the visitor who informed the staff that he was a family friend that had picked Resident #106 up to take her back to New Jersey. Guardian H reported that by the time the facility had discovered Resident #106 had left with the visitor and made contact with the visitor, Resident #106 and the visitor were in New Jersey. Guardian H reported the facility had contacted the police, who made contact with the visitor and asked him to take Resident #106 to the nearest hospital. Guardian H reported that Resident #106 was in the hospital for two days until the facility was able to arrange for transportation for her to return home. Guardian H reported that Resident #106 was dependent on insulin, and that she had not received insulin for the duration of the 12-hour trip to New Jersey. During an interview on 8/11/26 at 4:20 PM, Agency Nurse (AN) F reported that she was the nurse caring for Resident #106 the day that she left the facility with an unauthorized visitor. AN F reported that Resident #106 had approached her with the visitor and asked AN F for an LOA (leave of absence) pass. AN F reported that it was her understanding that nurses wrote an LOA pass to indicate to the front desk reception staff that the nurse was aware that the resident was off the unit. AN F reported that she did not check Resident #106's orders or care plan to see if Resident #106 was allowed to leave the facility with the visitor. AN F reported that she later found out from the facility's scheduler, that Resident #106 left the facility with an unapproved visitor. During an interview on 8/11/26 at 3:33 PM, Nursing Home Administrator (NHA) A reported he had been made aware around 9:00 or 10:00 PM on 6/14/26 that Resident #106 had not returned from an LOA with a visitor. NHA A reported that the facility front desk Receptionist had sent a team message to the interdisciplinary team (IDT) chat informing staff of the residents that had not returned from the facility yet as the Receptionist was leaving for the night. NHA A reported that as soon as he saw that Resident #106 was on the list, he began looking into the leave because he was aware that Resident #106 had only one approved visitor to leave with, and she was not typically out that late. NHA A reported he discovered when AN F wrote Resident #106 an LOA pass, Resident #106 took the pass to the facility Receptionist who identified that the visitor with Resident #106 was not an approved visitor. The Receptionist then called the facility on call Manager, who told the Receptionist that Resident #106 could leave with the visitor. NHA A reported that Manager KK had misread Resident #106's chart orders, and this ultimately led to Resident #106 leaving the facility with an unapproved visitor. Manager KK was not present during survey to interview. Review of Manager KK written statement dated 6/15/26 revealed, On 6/14/26, I got a phone call around 9:30 AM. I was in the middle of doing a couple other things when the front desk had call (sic) me asking about (Resident #106) and if she could go out on LOA because the nurse had given her an LOA pass. I told her (Receptionist) please hold on and let me double check the chart. I had quickly skimmed over her chart to find the LOA order. I thought I had seen the order for her to go out. The front desk had called me back and I told them it should be fine. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the LOA policy was reviewed and deemed appropriate, LOA orders were added to the banner of each resident chart for easier and quicker access, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to intakes 3155515 and 3071084. Based on interview and record review, the facility failed to prevent significant medication errors in 2 (Resident #104 and Resident #106) of 3 residents reviewed for medication errors, resulting in Resident #104 missing multiple insulin doses requiring hospitalization for hyperglycemia (high blood sugar) and Resident #116 receiving new doses of a transdermal (application of a medicine through the skin, typically by using an adhesive patch) opioid medication without previous patches being removed. Findings include: Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which include type 1 diabetes mellitus with hyperglycemia (condition where pancreas does not make enough insulin to keep blood sugar under control leading to elevated blood glucose levels). Review of Resident #104's Emergency Medical Services (EMS) report dated 6/21/26 at 11:30 AM revealed, Chief Complaint: Hyperglycemia . Blood Sugar: 582 . Events leading to illness/injury: Pt (Resident #104) reports being admitted to (facility) yesterday and has not received his insulin orders since being admitted . Pt began to experience increased thirst with frequent urination and generally feeling unwell. Pt reports that he informed the nursing staff that he needed his insulin to which staff told him to they do not have any insulin orders for him and to go back to his room. Pt reports that after going back to his room he began to feel even worse and contacted 911 on his own behalf .Review of Resident #104's Hospital Records dated 6/21/26 revealed, . ED Course: Patient (Resident #104) arrived via EMS with a chief complaint of elevated blood sugar . has been admitted in the past for DKA/HHS (Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. These are two serious, life threatening conditions that can happen in people with diabetes) . he has not received insulin in about 24 hours . Blood sugar for them (EMS) was 582. He was given 700 mL (milliliters) of fluid through IV (Intravenous) with EMS. On arrival here blood sugar is 500 .Review of Resident #104's Progress Note dated 6/20/26 revealed, Resident arrived at facility via EMT at 3:30pm . On-call verified medications and stated to use the standard sliding scale (pre written chart that matches blood glucose (BG) levels to a specific insulin dose, usually rapid or short acting insulin, to correct high glucose or cover meals) for insulin .Review of Resident #104's Medication Administration Record (MAR) revealed, Order: glargine insulin pen (long-acting insulin typically taken once daily to help control blood sugar levels) . Inject 22 units one time a day. Start date: 6/21/26 at 7:00 AM. Noted that there was no documentation to indicate that Resident #104 received this medication as ordered on 6/21/26 at 7:00 AM. Review of Resident #104's MAR revealed, Order: Insulin aspart (fast-acting form of insulin typically given with meals to control blood sugar) Inject 5 units with meals . start date 6/20/26 at 5:00 PM. Noted documentation that Resident #104 received this medication as ordered on 6/20/26 at 5:00 PM. Noted that there was no documentation to indicate that Resident #104 had received this medication as ordered on 6/21/26 at 7:00 AM or 11:00 AM. Review of Resident #104's MAR revealed, Order: Insulin Aspart. Inject as per sliding scale (151-200: 2 units, 201-250-4 units, 251-300 6 units, 301-350-8 units, 351-400 10 units and contact physician) before meals for hyperglycemia. Start date 6/20/26. Noted documentation that Resident #104 received this medication as ordered on 6/20/26 at 5:00 PM. Noted that there was no documentation to indicate that Resident #104 had received this medication as ordered on 6/21/26 at 7:00 AM or 11:00 AM. Review of Resident #104's Vital signs noted one documented blood glucose of 209 at 6/20/26 at 5:00 PM. Noted no documented blood glucose levels on 6/21/26. Review of Resident #104's Progress Note dared 6/21/2026 at 1:36 PM revealed, .Nurse was alerted at about 1120am, by staff that resident called 911 on himself. Nurse went to resident room where EMT were assessing him and checking his blood sugar. The reading was HI on glucose machine. Nurse went and printed a face sheet and contacted the administrator on call, who told writer that resident needs to be sent out .During an interview on 8/18/26 at 10:11 AM, Nurse Practitioner (NP) FF reported when a new resident is admitted to the facility, the admission orders are reviewed by the provider and then entered into the resident's electronic health record (EHR) by the admitting nurse and confirmed by a second nurse. NP FF reported that she was not aware that Resident #104 had missed receiving multiple doses of insulin and was sent to the hospital for hyperglycemia. NP FF reported that she did not know why Resident #104 had not been given insulin, or why the provider (herself or the Medical Director) had not been notified. During an interview on 8/18/26 at 11:41 AM, Director of Nursing (DON) B reported that she was aware that Resident #104 had not received his insulin as ordered and was sent to the hospital due to hyperglycemia. DON B reported she had investigated the incident and discovered that there was an error with the facility's EHR system which caused a delay in a pending order becoming active. DON B reported that this error occurred because nurses in the facility were not aware that they needed to check the pending orders in EHR to confirm the order so that it would go active and alert the nurse that a medication needed to be administered. When queried if the nurse caring for Resident #104 on 6/21/26 had been made aware by Resident #104 that he had not received insulin that day, DON B reported that she did not investigate to determine if the nurse knew, because she had been told Resident #104 called EMS himself. Resident #116 Review of an admission Record revealed Resident #116 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit (trouble communicating effectively because their thinking skills are impaired) and long-term use of opioid analgesic (type of medicine that helps relieve severe pain). Review of Resident #116's Care Plan revealed, Focus: (Resident #116) is on pain medications therapy (opioid pain medication patch) r/t disease process . Goal: (Resident #116) will be free of any discomfort or adverse side effects from pain medication through review date. Interventions: Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness Date initiated: 12/27/25. Review of Resident #116's Incident Report dated 5/30/26 and documented by Licensed Practical Nurse (LPN) I revealed, Incident Description: During routine skin assessment and shower care, resident was noted to have three (opioid pain medication) patches in place . Upon assessment, patches were found to be dated 5/15/26, 5/25/26, and 5/27/26. Resident Description: When asked if he was aware that he had on three patches, resident stated I didn't know. Immediate action taken: Patches were removed per facility protocol. Unit Nurse, Director of Nursing (DON), and on call (provider) notified of findings . Review of Resident #116's Medication Administration Record (MAR) revealed, Order: (Opioid Transdermal Patch . Apply 1 patch transdermally (sic) every 72 hours for chronic pain and remove per schedule. Start date: 4/17/26. Noted documentation that the patch was removed on the following dates: 5/15/26, 5/24/26, and 5/25/26 by Registered Nurse (RN) DD and Agency Licensed Practical Nurse (LPN) LL. Review of Resident #116's MAR revealed, Order: Second nurse MUST sign witness to (opioid pain medication patch) disposal . both nurses must dispose of patch per facility protocol and sign the narcotic sheet as verification of waste. Start date: 5/9/26. Noted that Registered Nurse (RN) DD had documented see progress notes under this order on 5/24/26. Noted that there was not a progress note in Resident #116's electronic health record (EHR) on 5/24/26 to indicate if the order was completed or not. On 5/25/26, RN DD documented that Resident #116 was out on LOA without medications on 5/27/26. Review of Resident #116's EHR did not indicate that Resident #116 was not in the facility on 5/27/26. During an interview on 8/18/26 at 10:11 AM, Nurse Practitioner (NP) FF reported that she had been notified on 5/30/26 that Resident #116 was found with multiple patches on him. NP FF reported that she had concerns for oversedation (level of sedation is greater than intended or safe for the procedure or condition) from continued opioid effects of the medication and risk of overdose from the opioid pain patches not being removed prior to additional patches applied. On 8/13/26 at 1:01 PM and 8/18/26 at 11:06 AM, this writer attempted to contact RN DD via telephone. RN DD did not return this writer's calls by survey exit. During an interview on 8/18/26 at 11:08 AM, LPN I reported that on 5/30/26, she was the nurse caring for Resident #116 when facility staff assisted Resident #116 with a shower. LPN I reported that one of the aides had notified her that they had found two patches on Resident #116, so she went in and removed the older patch from him. Then, the aides came back to her a few minutes later and told her that they had found another patch on Resident #116, so she completed a full skin assessment and removed all of the patches, alerted management, and the provider. LPN I reported that Resident #116 was a more sleepy than normal. During an interview on 8/18/26 at 11:41 AM, Director of Nursing (DON) B reported that she had been aware from LPN I on 5/30/26 that Resident #116 was found with multiple opioid pain medications on him during a skin assessment. DON B confirmed that RN DD and LPN LL had documented that they had removed the patches from Resident #116, but that was not accurate, and that they had not removed the patches. DON B was unable to report what kind of education nursing staff had received after this incident to ensure that they were not documenting orders as completed when they had not completed them, medication administration, or proper storage and disposal of narcotic medications. DON B was unable to report if any current staff were auditing nursing documentation and narcotic waste to ensure that nurses were documenting accurately and wasting narcotics accurately.

This citation pertains to intake 3155515. Based on interview and record review, the facility failed to maintain accurate medical records for 3 (Resident #111, Resident #112, and Resident #116) of 16 residents reviewed for complete and accurate medical record documentation, resulting in missing treatment documentation for Resident #111, inaccurate documentation of a code run for Resident #112 and inaccurate documentation of removal of medication patches for Resident #116. Findings include: Resident #111Review of an admission Record revealed Resident #111 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and functional quadriplegia (state of complete immobility of all four limbs due to severe physical disability or frailty from another medical condition.)Review of Resident #111's Treatment Administration Record (TAR) revealed, Wound care site: Left rear thigh . Noted missing documentation to indicate if the wound care had been completed or missed on the following dates: [DATE] and [DATE].Review of Resident #111's TAR revealed, Vital signs every shift or 3 days and then every day shift for monitoring. Start date: [DATE]. Noted missing documentation to indicate if the treatment had been completed on [DATE] and [DATE]. Review of Resident #111's TAR revealed, Maintain foley catheter (tube inserted into the urethra to drain the bladder of urine) and provide care every shift . Start date: [DATE]. Noted missing documentation to indicate if the treatment had been completed on [DATE]. Review of Resident #111's TAR revealed, Monitor right outer thigh . start date [DATE]. Noted missing documentation to indicate if the treatment had been completed on [DATE]. Review of Resident #111's TAR revealed, Skin care order every shift for skin care Start date: [DATE]. Noted missing documentation to indicate if the treatment had been completed on [DATE] and [DATE]. Review of Resident #111's TAR revealed, Suprapubic (catheter) output amount every shift. Start date: [DATE]. Noted missing documentation to indicate if the treatment had been completed or not on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 11:41 AM, Director of Nursing (DON) B reported that she was aware that the facility had concerns with the wound care program, but she was unaware of Resident #111's missing documentation of treatments in the Medication Administration Record (MAR) and TAR. DON B confirmed that nurses were supposed to document completion of all treatments, or document why a treatment was missed if it was missed. DON B confirmed that the facility was not monitoring nursing documentation for accuracy of records. Resident #112 Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of [DATE] revealed that Resident #112 was admitted to the facility on [DATE] with pertinent diagnoses that included debility (weakness) and atrial fibrillation (irregular heartbeat.) Review of Resident #112's Incident Report dated [DATE] revealed, writer entered resident's room at approx (approximately) 06:10 to do a blood sugar check. upon entering the room writer noticed resident laying in center of the bed. Writer grabbed residents' hand to prepare for a finger stick and noticed her fingers were stiff and cold, and resident (Resident #112) was unresponsive. Writer turned the light on and noticed resident wasn't breathing. CPR was immediatelyinitiated. Night supervisor was notified of the code. 911 was initiated by staff .During an interview on [DATE] at 2:50 PM, Licensed Practical Nurse (LPN) P reported that he was the nurse caring for Resident #112 on [DATE]. LPN P reported that he had entered Resident #112's room to check her blood sugar with Certified Nursing Assistant (CNA) L around 6:00 AM. LPN P reported that when he grabbed Resident #112's finger, he noted that she was very cold, so he turned the light on and checked Resident #112's pulse and noted that she did not have a pulse. LPN P reported that he ran out of the room to check Resident #112's Code status (medical instructions about whether you want life support treatments if your heart or breathing stops) and when he confirmed that Resident #112 was a full code (indicating that Resident #112 wanted life sustaining treatments) he instructed CNA L to begin Cardiopulmonary Resuscitation (CPR), while he went to call a code and grab a crash cart. LPN P reported that he also texted the night shift supervisor, LPN Z to come assist. LPN P reported that LPN Z did come to Resident #112's room to assist, but that she just stood there like she was frozen as he and CNA L switched between compressions and ventilation (rescue breaths) until the paramedics arrived and took over. LPN P confirmed that staff at the facility did not place an Automated External Defibrillator (AED-portable medical device that can help someone who has a sudden, life threatening stop of the heart's normal rhythm) on Resident #112. During an interview on [DATE] at 11:28 AM, LPN Z reported that she was the supervisor on duty when Resident #112 was found without a pulse and the facility initiated CPR on Resident #112. LPN Z reported that she was notified by staff and she went to Resident #112's room around 6:10 AM and observed CNA L doing compressions on Resident #112. LPN Z reported that another nurse came to Resident #112's room and began to assist CNA L with compressions and ventilation while they waited for the emergency medical services (EMS) to arrive. LPN Z reported that she started shouting orders to staff and telling them what to do until the EMS arrives. LPN Z confirmed that the facility did not place an AED on Resident #112, and that an AED was placed by the paramedics. During an interview on [DATE] at 11:54 AM, CNA L reported that she was in Resident #112's room with LPN P when Resident #112 was found without a pulse. CNA L reported that as soon as LPN P recognized that Resident #112 did not have a pulse he ran to his cart outside of Resident #112's room to check Resident #112's code status and told CNA L to Start CPR because Resident #112 was a full code. CNA L reported that she hopped right on the bed and began compressions until another nurse came in and assisted with compressions. CNA L confirmed that the facility staff did not use an AED on Resident #112. Review of Resident #112's Cardiac-Respiratory Arrest Documentation sheet dated [DATE] and completed by LPN Z revealed, Time of arrest: 6:12 AM. Time code paged: [DATE]. Time compressions initiated: 6:12 AM . AED used: yes. Time AED pads placed: 6:20 AM. Shock advised: No . Observations/interventions: 6:12 AM: Code. 6:14 ventilation. 6:15 AM: No pulse. 6:20 AM: AED placed. 6:23 AM: EMS arrived Noted that the documentation did not reflect what LPN P, LPN Z and CNA L reported to this writer about an AED not being used. After review of Resident #112's Cardiac-Respiratory Arrest Documentation this writer attempted to contact LPN Z for further interview. LPN Z did not return this writer's call by survey exit. Review of Resident #112's EMS Run Sheet dated [DATE] revealed, Call received: 6:18 AM . Cardiac Arrest Information: who first initiated CPR: Healthcare Provider (facility staff). Type of bystander CPR: compressions and ventilation . Was an AED applied prior to EMS arrival: No .Resident #116 Review of an admission Record revealed Resident #116 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit (trouble communicating effectively because their thinking skills are impaired) and long-term use of opioid analgesic (type of medicine that helps relieve severe pain). Review of Resident #116's Incident Report dated [DATE] and documented by Licensed Practical Nurse (LPN) I revealed, Incident Description: During routine skin assessment and shower care, resident was noted to have three (opioid pain medication) patches in place . Upon assessment, patches were found to be dated [DATE], [DATE], and [DATE]. Resident Description: When asked if he was aware that he had on three patches, resident stated I didn't know. Immediate action taken: Patches were removed per facility protocol. Unit Nurse, Director of Nursing (DON), and on call (provider) notified of findings . Review of Resident #116's Medication Administration Record (MAR) revealed, Order: (Opioid Transdermal Patch . Apply 1 patch transdermally (sic) every 72 hours for chronic pain and remove per schedule. Start date: [DATE]. Noted documentation that the patch was removed on the following dates: [DATE], [DATE], and [DATE] by Registered Nurse (RN) DD and Agency Licensed Practical Nurse (LPN) LL. Review of Resident #116's MAR revealed, Order: Second nurse MUST sign witness to (opioid pain medication patch) disposal . both nurses must dispose of patch per facility protocol and sign the narcotic sheet as verification of waste. Start date: [DATE]. Noted that Registered Nurse (RN) DD had documented see progress notes under this order on [DATE]. Noted that there was not a progress note in Resident #116's electronic health record (EHR) on [DATE] to indicate if the order was completed or not. On [DATE], RN DD documented that Resident #116 was out on LOA without medications on [DATE]. Review of Resident #116's EHR did not indicate that Resident #116 was not in the facility on [DATE]. On [DATE] at 1:01 PM and [DATE] at 11:06 AM, this writer attempted to contact RN DD via telephone. RN DD did not return this writer's calls by survey exit. During an interview on [DATE] at 11:08 AM, LPN I reported that on [DATE], she was the nurse caring for Resident #116 when facility staff assisted Resident #116 with a shower. LPN I reported that one of the aides had notified her that they had found two patches on Resident #116, so she went in and removed the older patch from him. Then, the aides came back to her a few minutes later and told her that they had found another patch on Resident #116, so she completed a full skin assessment and removed all of the patches, alerted management, and the provider. LPN I reported that Resident #116 was a more sleepy than normal. During an interview on [DATE] at 11:41 AM, Director of Nursing (DON) B reported that she had been aware from LPN I on [DATE] that Resident #116 was found with multiple opioid pain medications on him during a skin assessment. DON B confirmed that RN DD and LPN LL had documented that they had removed the patches from Resident #116, but that was not accurate, and that they had not removed the patches. DON B was unable to report what kind of education nursing staff had received after this incident to ensure that they were not documenting orders as completed when they had not completed them, medication administration, or proper storage and disposal of narcotic medications. DON B was unable to report if any current staff were auditing nursing documentation and narcotic waste to ensure that nurses were documenting accurately and wasting narcotics accurately.

This citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401.Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 8 of 9 Residents (#39, #76, #86, #139, #27, #140, #37, #22) reviewed for medication errors when a.) Medication orders were transcribed and administered incorrectly and B.) medications were not administered as ordered resulting in Resident #39 receiving excessive doses of an antipsychotic medication and Resident's #76, #4, #86, #139, #27, #140, #37, #22's medications were omitted resulting in the decompensation (functional deterioration of a physical or mental system) for Resident #76, and the potential for health complications. Findings include: Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia (chronic and serious mental health condition that can significantly affect how a person thinks, feels, and behaves) and cognitive communication deficit. Review of Resident #39's Care Plan revealed, Focus: (At risk for changes in behavior & mood r/t (related to) paranoid schizophrenia .Interventions: Administer medications per physician orders. Date Initiated: 01/29/2026 . Review of the facility's Medication Error Investigation revealed, Resident #39 was admitted on [DATE] . On 1/28/26, Licensed Practical Nurse (LPN) P entered an order for Haloperidol (Haldol) Deaconate (antipsychotic medication) intramuscular solution 100 mg/mL (milligrams per milliliter) give 2.5 ml IM (intramuscular) to be given one time a day on the 16th-21st. In the additional directions it was noted to give every 21 days. The correct order was to give Haloperidol Deaconate intramuscular solution 100 mg/mL give 2.5 ml IM to be given one time a day once every 21 days. The error in order transcription resulted in the resident receiving doses of IM Haldol on 2/17/26, 2/18/26, and 2/21/26 . Noted that the investigation report indicated the incorrect dates that Resident #39 received the Haldol injections. Review of Resident #39's Medication Administration Record (MAR) revealed, Haloperidol Decanoate Intramuscular Solution 100 MG/ML (Haloperidol Decanoate) Inject 2.5 ml intramuscularly one time a day starting on the 16th and ending on the 21st every month for schizophrenia every 21-day IM inject. Start date: 2/17/26. The medication was documented as administered by LPN LLL on 2/17/26 and on 2/20/26 and 2/21/26 by LPN EE. During an interview on 3/17/2026 at 12:52 PM, Family Member (FM) MMM reported that Resident #39 had been admitted to the facility on [DATE] after a hospitalization. FM MMM reported that Resident #39 was followed by a (Local Mental Health Authority-company that provides public services for mental health, substance use, and developmental disabilities) and that the Mental Health Authority would review her medications each month and provide her monthly haldol injection. FM MMM reported that on 3/6/26, she was informed by the Mental Health Authority that Resident #39 had received three doses of her monthly haldol injection at the facility in error. FM MMM reported that she was informed by the Mental Health Authority's Nurse (MHAN) BB that she had talked to LPN EE at the facility on 2/27/26 when she called to discuss Resident #39's medication orders, and it was discovered that the facility had transcribed the order wrong and administered multiple does. FM MMM reported that she had not been contacted by the facility until 3/9/26. FM MMM reported that she had noticed a decline in her mother's condition since February when Resident #39 had received the multiple doses of Haldol injections which included a decline in participating in therapy, increased tremors and confusion. During an interview on 3/18/2026 at 4:28 PM MHAN BB reported that when Resident #39 came in for her medication review appointment on 2/19/26, she had planned to administer Resident #39's monthly Haldol injection, but she was told by Resident #39 that she had just gotten the injection at the facility, so she did not administer the injection and requested Resident #39's medication records from the facility to review. MHANBB reported that she called the facility on 2/27/26 to review Resident #39's medications because she had not yet received Resident #39's medication records from the facility. MHAN BB reported that she spoke to LPN EE on 2/27/26 and reviewed Resident #39's orders with him. MHAN BB reported that when LPN EE read Resident #39's Haldol order to her, she informed LPN EE that the order was incorrect, and Resident #39 should have only received 1 Haldol injection every 21 days. MHAN BB reported that LPN EE told her that he thought the order looked incorrect, and he asked a supervisor about it, but that he was told to administer the medication anyway. Review of Resident #39's Nursing Narrative note dated 2/27/26 from the Mental Health Authority revealed This RN called (Facility) nursing line to inquire about medication records regarding this patient's Haldol 250mg Q3wks (every 3 weeks). This RN spoke to a (LPN EE) who stated that the last time this patient received this medication was on 02/21. (LPN EE) also stated that the order was written as, Haldol 250mg from 02/16-02/21, therefore, this patient received multiple doses within a week. (LPN EE) did state that the patient refused the medication a few times, but states that he knows she got it at least twice from him. (LPN EE) states, I thought the order looked weird. He states that he asked his supervisor at (Facility) for clarification and was told to give the medication as the order stated . Review of Resident #39's Progress Note dated 3/7/26 (8 days after the telephone call with MHAN BB on 2/27/26) and documented by LPN EE revealed, Spoke with nurse at (Local Mental Health Authority) and was asked to do a complete medication review of this resident's medications. During the review, it was brought to the attention of this nurse that there was a discrepancy regarding resident's Haloperidol Deaconate Intramuscular solution 100 mg/ml. The order in (electronic medical record) reads Inject 2.5 ml intramuscularly one time a day starting on the 16th and ending on the 21st of every month for schizophrenia every 21 days which was incorrect. Two doses were administered by this nurse. The nurse was asked about the resident's condition and asked to obtain a set of vitals. The resident was fairly new to this unit, so nurse didn't have knowledge of their baseline . the resident's mental state to the nurse seemed to be AOx 2-3 (alert and oriented) and her vitals were exceptionally great (did not indicate what vital signs were) . During an interview on 3/18/2026 at 11:50 AM, LPN P reported that she had entered Resident #39's Haldol order when she was admitted to the facility. LPN P reported that she knew that the order was supposed to be scheduled for every 21 days, and she was not sure she made the error in transcribing the order. During an interview on 3/18/2026 at 3:55 PM, LPN EE reported that he had administered two doses of Resident #39's Haldol injection on 2/20/26, and 2/21/26. LPN EE reported that he recalled questioning the order, and so he had asked his Unit Manager about the order and was instructed to administer the injections anyway. When this writer queried as to which Unit Manager instructed him to administer the injections, LPN EE reported that he could not recall. LPN EE reported that he had been made aware of the medication errors when he completed a medication review with MHAN BB. LPN EE reported that he could not recall the date that he spoke to MHAB BB or when he reported the incident to the facility. LPN EE could not recall if he had contacted the physician to inform him of the medication error. During an interview on 3/18/2026 at 1:51 PM, Nurse Practitioner (NP) OOO reported that she was notified on 3/9/26 regarding the medication errors that occurred in February 2026. NP OOO reported that by the time she had been notified of the medication errors, Resident #39 was planning to discharge from the facility, so she encouraged her to go to the hospital for an evaluation which she was agreeable to. During an interview on 3/19/2026 at 9:55 AM, Facility Pharmacist (FP) CCC reported that haldol injections that are given monthly are dose dependent and specific for each person that receives the medication. FP CCC reported that the typical effective dosage was between 50-200 mg per month (noted that Resident #39 received 300 mg in one month), and that any dose greater than 450 mg per month had limited clinical experience to determine potential complications. FP CCC reported some of the risks of receiving haldol and a dose greater than ordered included hyponatremia (condition where sodium levels in the blood are too low), Agranulocytosis (severe, life-threatening condition defined by a dangerously low white blood cell count making the body unable to fight infections), parkinsonian symptoms (tremor, shaking at rest, bradykinesia (slowness of movement), limb rigidity, and postural instability (poor balance). FP CCC reported that it would be important to monitor the resident's complete blood count (CBC- is a standard lab panel measuring components of blood—white cells, red cells, and platelets—to evaluate overall health and detect conditions) after this medication error. During an interview on 3/19/2026 at 11:30 AM, Director of Therapy (DOT) UU reported that she was familiar with Resident #39 as she was seen regularly by Physical and Occupational therapy at the facility. DOT UU reported that therapy staff had noted concerns with Resident #39 and how she was presenting in therapy during the last two weeks of February. DOT UU reviewed Resident #39's therapy notes and reported that it was noted that they had to downgrade tasks for Resident #39 on 2/18/26 due her having difficulty grabbing small items on 2/18/26, which DOT UU reported was abnormal for Resident #39. On 2/19/26, therapy staff noted that she required moderate verbal cues throughout therapy session due to poor sequencing, which she felt was a decline from Resident #39's baseline. DOT UU reported that she did also recall that Resident #39 seemed more confused, and lethargic during the last two weeks of February. Resident #76 Review of an admission Record revealed Resident #76 was originally admitted to the facility on [DATE] with pertinent diagnoses which included schizoaffective disorder, depressive type (chronic mental health condition combining schizophrenia symptoms including hallucinations, delusions, disorganized thinking with major depressive episodes, specifically without mania). Review of Resident #76's Care Plan revealed, (Resident #76) has/is at risk for a behavior problem /change in mood r/t (related to) dx (diagnosis) of schizoaffective disorder. Date initiated: 1/7/26. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 01/07/2026 . Review of Resident #76's MAR revealed, Haloperidol Decanoate Intramuscular Solution 100 MG/ML (Haloperidol Decanoate) Inject 2 ml intramuscularly one time a day every 28 day (s) for Schizophrenia Please inform SW (Social Worker), DON (Director of Nursing), provider if she refuses. The order was documented as refused on 2/16/26 by LPN JJJ. Noted that LPN JJJ did not document if she had notified the SW, DON, or provider that Resident #76 refused her injection. During an interview on 3/18/2026 at 11:50 AM, LPN P reported that she frequently cared for Resident #76, and for the last month she had fallen, and had an increase in her behaviors which she felt was due to Resident #76 missing her monthly injection. LPN P reported that it was common for residents to miss medications, because there were several nurses at the facility that were not good at following up on missed or refused medications. LPN P reported that Resident #76's behaviors and confusion were usually manageable and that she was usually able to be redirected when she was upset, but over the last month she noted Resident #76 was screaming out more, attempting to self-transfer more often, and overall seemed more irritable. During an interview on 3/19/2026 at 11:46 AM, Certified Nursing Assistant (CNA) I reported that she cared for Resident #76 often and was very familiar with her. CNA I reported that she had definitely noticed an increase in behaviors over the last month (February). CNA I reported that Resident #76 had been attempting to self transfer more often, and that she did have a fall on 2/27/26 and 3/3/26. CNA I reported that Resident #76 would refuse cares and could become verbally aggressive, which she also felt had increased over the last few weeks. Review of Resident #76's Progress Note dated 3/7/26 revealed, Attempt to assist with res (resident) am (morning) care this am. res denied for assigned CNA to assist with cares, res yelling out I hurt, I hurt. Writer able to med (medicate) res with scheduled am oxy/Ativan (oxycodone- pain medication, Ativan-anti-anxiety medication). res refused am meal, lunch meal taken with consuming approximately 50% meal tray, res refused to allow assigned CNA or writer to assist with ADL (activities of daily living) care, multiple attempts offered . Review of Resident #76's Progress Note dated 3/10/26 revealed, Res ref (refused) to allow assigned staff until time noted (3:11 PM) to change res, dress, and get up . Review of Resident #76's Progress Note dated 3/12/16 revealed, Staff assigned CNA offered for res to get up into w/c (wheelchair) with refusal, approximately 5 minutes later res had self-transferred into w/c and propelling self in 100 hall, observation of res sitting in half in and half off w/c seat base with yellow anti tippers pushed off to the corner, addressed res safety needs with returning res back to room, donning (putting on) pants . Review of Resident #76's Progress Notes dated 3/12/26 revealed, Res sitting in the hallway spontaneously verbalizing so this is the time the men's penis' get cut off . res also verbalized about how she had become sterile and she is not even sexually active. Review of Resident #76's IDT (Interdisciplinary Team) note dated 3/13/26 revealed, Discussed recent fall with IDT. Resident had medication changed due to graduating hospice. She was observed on the ground lying on right side . resident has been making delusional statements to staff . Discussed resident with (local psych service provider) after she assessed resident's recent behaviors. Recommendation to increase monthly Haldol from every 28 days to every 21 . Noted that this note did not address that Resident #76 had missed her February 2026 Haldol injection. Review of Resident #76's Progress Note dated 3/13/26 and documented by NP QQQ revealed, . resident is seen for psychiatry follow up . staff report that patient (Resident #76) had an increase in delusions and behaviors significantly and has not been at baseline .It was determined that patient did not receive her scheduled haloperidol injection that was due last month on 2/16. This is likely contributing to her current decompensation . She states that she is very depressed . She has delusional expressions throughout visit . During an interview on 3/18/2026 at 4:00 PM, Unit Manager (UM) T reported that if a resident refused a medication, nursing staff were expected to contact the Unit Manager and the facility's provider so that the facility could follow up and ensure that the medication was offered again. UM T confirmed that once a nurse documents a medication as refused, they must complete a follow up notification to create a new order for the medication to be offered again. UM T' reported that she was not made aware that Resident #76 had not received her monthly Haldol injection in February 2026. UM T reviewed Resident #76's record and confirmed that LPN JJJ had documented the medication as refused, but she did not notify the Unit Manager, Social Worker, or Provider to ensure that the injection was offered again. During an interview on 3/19/2026 at 12:28 PM, Director of Nursing (DON) B reported that nurses were supposed to ensure that if they were not able to administer a medication that they contacted the Physician and Unit Manager. DON B confirmed that she was not aware that Resident #76 had missed her monthly Haldol injection on 2/16/26. During an interview on 3/18/2026 at 1:51 PM, NP OOO reported that she had not been notified that Resident #76 had refused her Haldol injection on 2/16/26. NP OOO reported that if she had been made aware that Resident #76 had refused her injection, she would have placed an order to ensure that the injection was offered again. NP OOO reported that she expected nurses to let her know when residents' medications were omitted, so she could manage their care and orders adequately. Review of the facility's Medication Administration policy dated 8/7/23 revealed, Policy Overview: To safely and accurately prepare and administer medica on according to physician order, professional standards of practice, and resident needs General Instructions: . Administer medication in accordance with frequency prescribed by physician and standards of practice . If a pharmacy supplied medication is not available, refer to the pharmacy policy and procedures related to emergency pharmacy delivery and emergency supply kit usage . Resident refusal of medications: Document refusal on MAR, Notify physician of refusal as clinically indicated . Residents #86, 139, 27, 140, 37, and 22: Review of the facility's Investigation Summary .Allegation: Potential Neglect - Medication Administration Delay, that occurred on 12/2/25, stated, .it was identified that an agency nurse (Licensed Practical Nurse (LPN) NNN) assigned to the afternoon shift left the facility mid-shift without providing notice to the leadership team or completing assigned medication administration duties.for a portion of the assigned residents. (This included Residents #86, 139, 27, 140, 37, and 22) Review of the facility's Summary of Medication Errors on 12/2 (2025), dated 12/2 (2025), indicated Residents #86, 139, 27, 140, 37, and 22 were all noted to have scheduled medications not offered or given for the night shift due to .recent medication error where agency nurse (Licensed Practical Nurse (LPN) NNN) failed to pass HS (at bed time) medications or .nurse (LPN NNN) failed to pass HS medication. In reviewing the missed medications for each resident from the night of 12/2/25, the medication errors that were considered to be significant medication errors based on the possibility of jeopardizing a resident's health and safety were:Residents #86 was not offered and did not receive doses of Seroquel (an antipsychotic medication used to treat the mental health conditions of schizophrenia and/or bipolar disease and it carries a Federal and Drug Administration (FDA) black box warning (serious warning issued for medications that carry significant risks) 150 milligrams, Keppra (anti-seizure medication) 100 milligrams per milliliter-7.5 milliliters, and topamax (anti-seizure medication) 50 milligrams.Resident #139 was not offered and did not receive a dose of oxycodone (a potent opioid medication for treating moderate to severe pain that carries a FDA black box warning) 10 mg.Resident #27 was not offered and did not receive doses of her metoprolol (tartrate) (beta-blocker medication to treat high blood pressure) 25 mg and norco (a potent pain medication which combines an opioid (hydrocodone) and acetaminophen to treat moderate to severe pain) 10-325 mg.Resident #140 was not offered and did not receive a dose of lasix (a potent diuretic/water pill; helps treat fluid retention) 20 mg.Resident #37 was not offered and did not receive a dose of risperidone (an antipsychotic medication that carries a FDA black box warning) 1.5 mg.Resident #22 was not offered and did not receive a dose of olanzapine (an antipsychotic medication that carries a FDA black box warning) 10 mg. Attempts were made to reach LPN NNN to discuss the incident but no response was received before the end of the survey.

This citation pertains to intakes 2696710.Based on interview and record review the facility failed to report allegations of abuse and neglect to the State survey agency and/or other officials when applicable for 13 (Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and140) of 13 residents reviewed for reporting of alleged violations resulting in the State survey agency and/or nurse licensing department not being notified or notified timely, a delay in officials being aware of abuse/neglect allegations, and the potential for abuse and/or neglect to occur and/or reoccur. Findings include:Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and 140:Review of the facility's Investigation Summary .Allegation: Potential Neglect - Medication Administration Delay, that occurred on 12/2/25, stated, .it was identified that an agency nurse (Licensed Practical Nurse (LPN) NNN) assigned to the afternoon shift left the facility mid-shift without providing notice to the leadership team or completing assigned medication administration duties.for a portion of the assigned residents (Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and 140) .Reporting Determination .Based on the findings of the investigation.this event was determined not to meet criteria for reportable neglect .As the individual involved was an agency employee, any employment-related actions or reporting to the State Board of Nursing are the responsibility of the agency . Review of the facility's Summary of Medication Errors on 12/2 (2025), dated 12/2 (2025), indicated Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and 140 all were noted to have scheduled medications not offered or given for the night shift due to .recent medication error where agency nurse (LPN NNN) failed to pass HS (at bed time) medications or .nurse (LPN NNN) failed to pass HS medication.During an interview on 03/19/2026 at 3:17 PM, Nursing Home Administrator (NHA) A confirmed LPN NNN worked approximately the first 2 hours of her night shift (Scheduled 7 PM - 7 AM) on 12/2/25, proceeded to end her shift without telling anyone, and left the building without returning. NHA A confirmed the facility had not reported LPN NNN to the State Survey Agency or to the State's Nurse Licensing Department (The facility proceeded to submit a late complaint to the State's Nurse Licensing Department on 3/19/26).Attempts were made to reach LPN NNN to discuss the incident but no response was received before the end of the survey. Resident #75:Review of Resident #75's .Medication Error report, dated 12/2/25, stated, Nursing leadership was notified just before midnight 12/3 (night of 12/2/25 going into the morning of 12/3/25) that the assigned agency nurse (LPN NNN) for 200 hall had left the job assignment around 9pm, locking her med (medication) cart keys in the med room without.giving report to another nurse, Agency provided a replacement nurse (Registered Nurse (RN) PPP) around 4 am.As DON (Former DON YY) was reviewing 24 hour summary, it was noted that resident didn't receive their bedtime medications.Statements.Certified Nurse Aide S.Statement.this nurse acted like she was overwhelmed.she went on break around 9 (PM) but we didn't see her again so we started looking around and saw her med (sic) keys in the med (sic) room. We called the on call nurse as soon as we notice (sic) her keys (LPN NNN's medication keys) and that was around midnight. We got a replacement nurse around 330 am (3:30 AM). The Statement from RN PPP on this report stated, (RN PPP) had been the nurse that took over on the assignment for the nurse that had walked out without notifying anyone. She reports she clocked in around 0330 (3:30 AM) and her agency reports the same. She verified that when she arrived to the facility, none of the HS medications for rooms 207-216 had been administered. RN PPP's statement on the report also stated, .I looked at the MAR (medication administration record) and saw noting (sic) was given. It was after 4am by that time and too late to give any of the meds.Review of the facility's nurse license complaint submission to the State of Michigan's Licensing and Regulatory Affairs' Professional Licensing department, undated (Facility reported it was submitted 3/19/26), stated, Nurse (LPN NNN) was working thru (through) agency at [Facility Name] on 12/2/2025, when she walked off the job not alerting anyone that she had left. She abandoned her position resulting in 13 patients not receiving their HS meds (medications). The facility assumed that the agency [The Nurse Agency's Company Name] would report the license, but do not believe they have.Review of the facility's abuse policy, updated 5/24/2023, stated, Initial Reporting: The facility will ensure that all allegations involving abuse, neglect, . are reported immediately to the Administrator and: .Reported to the State Survey 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 .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.

This citation pertains to intake 2696710 Based on observation, int erview, and record review, the facility failed to ensure that residents received care in accordance with professional standards in 17 (#130, #4, #5,#13,#22,#27,#35,#37,#41,#75,#77,#86,#97,#122,#139,#140,and #2) out of 17 residents reviewed for quality of care resulting in missed medications, inaccurate documentation of medications and treatments administered, medications given without order parameters, and missing neurological (neuro) assessments after unwitnessed falls. Findings include:Inaccurate documentation of medications and treatments administered Resident #130 Review of an admission Record revealed Resident #130 was originally admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease and chronic pain syndrome. Review of a Minimum Data Set (MDS) assessment for Resident #130, with a reference date of 2/3/26 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #130 was cognitively intact. Review of Resident #130's Care Plan revealed, Focus: The resident needs hemodialysis (life-sustaining treatment for kidney failure that filters waste, toxins, and excess fluids from the blood when kidneys can no longer function effectively) r/t (related to) renal failure. Date initiated: 2/10/26. Interventions: Administer medications per physician orders. Date Initiated: 12/31/2025 . During a Medication Administration observation on 3/18/2026 at 8:02 AM, Licensed Practical Nurse (LPN) JJJ prepared the following medications to administer to Resident #130: Senna Plus (stimulant laxative and stool softener), Omeprazole (medication used to treat heartburn), Eliquis (anticoagulant medication), Methocarbamol (muscle relaxant), Midodrine (medication used to treat low blood pressure), Sevelamer (medication used to treat high phosphorus levels in adults with chronic kidney disease), and Tylenol. LPN JJJ placed all of the medications into a cup and entered Resident #130's room. Resident #130 took all of the medications noted except the three Sevelamer tablets, which she had asked LPN JJJ to bring back after she had breakfast as she was supposed to take that medication with food. LPN JJJ left Resident #130's room with the three pills that Resident #130 did not take in the medication cup that she labeled and placed in her medication cart. Review of Resident #130's Medication Administration Record (MAR) revealed that LPN JJJ had documented the following medications and treatments as completed at the same time that she had documented the following medications as administered to Resident #130 at the same time that this writer had observed the medication administration: Lidocaine External Patch 4 %, (topical pain medication patch), Lokelma Oral Packet 10 GM (medication used to treat adults with high potassium levels), Sevelmaer, Colace (stool softener). It was noted that the above listed medications had not been administered during the observation. Also noted that LPN JJJ had also documented the treatment order weight daily before breakfast one time a day for heart failure weight gain of 2 to 3 pounds call provider. at the same time that she had documented the medications as administered. Review of Resident #130's Weights revealed that Resident #130 had not had a daily weight documented since 3/10/26. In a follow up interview on 3/18/2026 at 9:37 AM, LPN JJJ reported that she did not give Resident #130 her lidocaine patch. When this writer queried as to why it was documented that she had administered the patch, LPN JJJ reported that she would just strike out the documentation and was not able to provide a reason why she had documented the medication as administered. This writer then queried as to if she had given Resident #130 her Lokelma oral packet, LPN JJJ reported that she did not know what that was. LPN JJJ then walked to her medication cart with this writer and looked through her cart to find Resident #130's lokelma packet. She then reported that she would get one to her. LPN JJJ was not able to report why she had documented the medications (lokelma, sevelamer, and colace) as administered when they had not been. In an additional follow up interview on 3/18/2026 at 12:50 PM, LPN JJJ reported that she never gave Resident #130 her sevelamer medication with her breakfast as she had requested. Noted that LPN JJJ did not change her documentation in Resident #130's record to indicate that Resident #130 had missed her morning dose of sevelamer. In an interview on 3/18/2026 at 12:58 PM, Resident #130 confirmed that she had not received her lidocaine patch that morning, and she never received her morning dose of sevelamer that she had requested to take with her breakfast. Resident #130 also reported that she had not had her weight obtained that morning. In a follow-up interview on 3/19/2026 at 12:01 PM, LPN JJJ confirmed that she did not obtain Resident #130's daily weight on 3/18/26. In an interview on 3/18/2026 at 4:00 PM, Unit Manager (UM) T reported that nurses were expected to document medications and treatments as administered only after the medication and treatment was completed. In an interview on 3/19/2026 at 12:28 PM, Director of Nursing (DON) B reported that nurses were expected to document medications and treatments as administered only after the medication and treatment was completed. DON B confirmed that documenting a medication or treatment as administered without completing it was not an accurate reflection of the resident's medical record. DON B reported that nurses were expected to report all missed medications and treatments to the Unit Manager and Provider if indicated. In an interview on 3/18/2026 at 1:51 PM, Nurse Practitioner (NP) OOO reported that it was her expectation that nurses were communicating and notifying her when medications were missed and not given so she could monitor the plan of care. NP OOO confirmed that she had not been notified regarding missed medications for Resident #130. Medications given without order parameters Resident #130 Review of Resident #130's Orders revealed, Midodrine HCI oral tablet 5 MG. Give 1 tablet by mouth two times a day for hypotension and 3 tablets by mouth as needed for hypotension (low blood pressure), may give with scheduled dose. Start date: 3/10/26. This order was transcribed by LPN FFF and signed off on by NP OOO. During a Medication Administration observation on 3/18/2026 at 8:02 AM, Licensed Practical Nurse (LPN) JJJ prepared midodrine and placed the medication in a cup. LPN JJJ placed the medication into a cup and entered Resident #130's room. It was noted that LPN JJJ did not assess Resident #130's vitals (blood pressure, heart rate, temperature and oxygen saturation) prior to administering medications. LPN JJJ gave Resident #130 her medications, including the midodrine, which she took. Review of Resident #130's Vital Signs in her electronic medical record on 3/18/26 at 10:00 AM noted that she did not have a vital sign assessment documented for 3/18/26. In an interview on 3/19/2026 at 12:01 PM, LPN JJJ reported that she thought that she took Resident #130's vital signs prior to administering her medications and that she had documented the vital sign assessment in Resident #130's record. When this writer queried LPN JJJ about where she had documented Resident #130's vital signs, LPN JJJ reviewed Resident #130's record reported that she must have forgot to document them, but they were fine. LPN JJJ reported that midodrine was a medication that required a blood pressure assessment prior to administering. LPN JJJ was unable to report what the parameters to hold Resident #130's midodrine order, because there were not parameters indicated on the order. During an interview on 3/18/2026 at 2:22 PM, LPN FFF reported that she had entered the order for Resident #130's midodrine. LPN FFF reported that the order should have had parameters for blood pressures noted, and she was not sure how this was missed. During an interview on 3/18/2026 at 4:00 PM, Unit Manager (UM) T reported that nurses should assess vital signs prior to administering midodrine. UM T reviewed Resident #130's midodrine order with this writer and confirmed that the order was missing blood pressure parameters. In an interview on 3/18/2026 at 1:51 PM, Nurse Practitioner (NP) OOO reported that all midodrine orders should have a blood pressure parameter indicated so that the nurse knows when they need to hold the medication. NP OOO reviewed Resident #130's midodrine order with this writer and confirmed that the order was missing parameters, and therefore nursing staff were administering the medication without clarification on when they would need to hold the medication. Missed Medications Resident #4 Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes with diabetic neuropathy (chronic condition where the body resists the effects of insulin or fails to produce enough to maintain normal blood sugar levels) and obstructive sleep apnea (serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much, causing the airway to collapse). Review of Resident #4's MAR revealed, Ozempic (once-weekly injection that improves blood sugar control in adults with type 2 diabetes) Subcutaneous (fatty tissue layer between the skin and muscle) solution pen. Inject 0.25 mg one time a day every Friday for DMII (Diabetes Mellitus Type 2). Start date 3/6/26. This order was documented as not given 3/13/26 by LPN FFF. Noted that there was not documentation to indicate that LPN FFF had contacted the provider to inform that Resident #4 did not receive his medication. During an interview on 3/18/2026 at 2:22 PM, LPN FFF reported that she did not administer Resident #4's Ozempic on 3/13/26 because she could not find it. LPN FFF reported that she thought that she had contacted the provider and she had re-ordered the medication from the pharmacy, but she could not recall if she had documented that she did. During an interview on 3/19/26 at 9:50 AM, Pharmacy Tech (PT) RRR reported that the last time that the pharmacy had sent Resident #4's Ozempic medication to the facility was on 3/3/26. PT RRR reported that the facility was responsible for re-ordering the medication, and that the pharmacy had not received a refill request for Resident #4's Ozempic for the month of March. During an interview on 3/18/2026 at 1:51 PM, NP OOO reported that she had not been made aware that Resident #4 missed his Ozempic injection on 3/13/26. Review of the facility's Medication Administration policy dated 8/7/23 revealed, Policy Overview: To safely and accurately prepare and administer medica on according to physician order, professional standards of practice, and resident needs General Instructions: . Administer medication in accordance with frequency prescribed by physician and standards of practice . If a pharmacy supplied medication is not available, refer to the pharmacy policy and procedures related to emergency pharmacy delivery and emergency supply kit usage . Resident refusal of medications: Document refusal on MAR, Notify physician of refusal as clinically indicated . Missing neurological (neuro) assessments after unwitnessed falls Resident #4 Review of Resident #4's Incident Report dated 10/18/25 revealed, Unwitnessed fall. Incident Description: Nursing Description: At 1030, Nursing staff observed resident was on the floor. Resident was laying on his back. resident stated he needed to go to the bathroom .Immediate action taken: Head to toe assessment performed. no alterations to skin integrity noted. neuro check initiated . Review of Resident #130's Neurological Assessment form for the 10/18/25 fall revealed, Directions: Complete neurological evaluation with vital signs initially, then every 30 minutes x2, then everyhour x4, then every 4 hours x6, then every shift x 3 days . Noted that there was a missing documentation of a neurological assessment completed on 10/22/25 for the 7AM-7PM shift. Review of Resident #4's Incident Report dated 1/6/26 revealed, Unwitnessed fall. Nursing Description: At 1330 (1:30 PM), resident was noted laying on the floor between his wheelchair and the bed .Resident stated he hit his head . Immediate action taken: head to toe assessment was performed. No alterations to skin integrity noted. no redness or bruising to head. resident denied pain. resident was transferred from floor to bed via mechanical hoyer lift. vital signs obtained and neuro check initiated . Review of Resident #130's Neurological Assessment form for the 1/6/26 fall revealed, Directions: Complete neurological evaluation with vital signs initially, then every 30 minutes x2, then every hour x4, then every 4 hours x6, then every shift x 3 days. It was noted that there was missing documentation of neurological assessments completed on 1/7/26 at 02:30 AM, and 6:30 AM, on 1/9/26 from 7AM-7PM and on 1/10/26 from 7AM-7PM. During an interview on 3/19/2026 at 11:27 AM, LPN GGG reported that nurses were Absolutely required to complete neurological assessments on any resident after an un-witnessed fall. LPN GGG reported that the nurses were supposed to document their assessment on the Neurological Assessment sheet and continue the assessments until the last date as indicated on the sheet. During an interview on 3/19/2026 at 11:39 AM, LPN GG reported that nurses were required to initiate and complete neurological assessments for all residents after an unwitnessed fall. During an interview on 3/19/2026 at 12:28 PM, Director of Nursing (DON) B reported that nurses were required to complete neurological assessments on all residents after an unwitnessed fall. DON B reviewed Resident #4's Neurological Assessments with this writer and confirmed that the facility was missing documentation to verify that Resident #4 had not missed any neurological assessments. Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: bipolar disorder (a chronic mental illness characterized by dramatic shifts in mood, energy, and activity levels). Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 1/9/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Review of a Care Plan for Resident # 5 with a reference date of 1/2/26 revealed the following focus/goals/interventions: Focus: The resident needs dialysis (life-saving medical procedure that acts as an artificial kidney to remove waste and toxics from the blood) r/t (related to) end stage renal (kidney) disease, Dialysis 7:05-11:30am, pick up at 6:15am every Monday, Wednesday, Friday. Goal: The resident will have no signs.of complications.Administer medications per physician orders. During an observation on 3/18/26 at 10:38am it was noted that Resident #5 was not in her room. Review of a Treatment Administration Record for Resident #5 at 10:39am on 3/18/26 revealed RN JJJ had already documented the following for this date, despite the fact that Resident #5 was absent from the building since 6:25am(prior to the start of RN JJJs shift): 1. For the entire shift Resident #5 had no episodes in which she voiced feeling sad and/or lonely. The order read Complete based on individual observation of patient. 2. RN JJJ documented she had observed the resident's dialysis site to monitor for skin integrity management. The order read my initials indicate skin intact without concerns, 3. Enhanced barrier precautions were maintained throughout the shift, and 4. RN JJJ monitored Resident #5's dialysis port for s/s (signs and symptoms) for infection and bleeding. In an interview on 3/18/26 at 10:48am, Registered Nurse (RN) JJJ reported she was Resident #5's nurse for the day. RN JJJ reported her shift began at 7:00am. In an interview on 3/18/26 at 11:02am Receptionist V reported per the appointment schedule calendar, Resident #5 left the building at 6:25am on this date and had not returned to the facility as of this time. In an interview on 3/18/26 at 11:05am, Certified Nursing Assistant (CNA) OO reported she was working on Resident #5's unit today and the resident had already left for dialysis before CNA OO began her shift at 7:00am. During an observation on 3/18/26 at 12:03pm, Resident #5 exited a transportation van in the circle driveway of the building and entered through the main door. In an interview on 3/18/26 at 12:04pm, Resident #5 reported she left the building while the overnight shift was still on duty, at approximately 6:25am, and had not seen RN JJJ prior to leaving. Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and 140:Review of the facility's Investigation Summary .Allegation: Potential Neglect - Medication Administration Delay, that occurred on 12/2/25, stated, .it was identified that an agency nurse (Licensed Practical Nurse (LPN) NNN) assigned to the afternoon shift left the facility mid-shift without providing notice to the leadership team or completing assigned medication administration duties.for a portion of the assigned residents (Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and 140) . Review of the facility's Summary of Medication Errors on 12/2 (2025), dated 12/2 (2025), indicated Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and 140 all were noted to have scheduled medications not offered or given for the night shift due to .recent medication error where agency nurse (LPN NNN) failed to pass HS (at bed time) medications or .nurse (LPN NNN) failed to pass HS medication. This summary revealed the following residents and the number of missed scheduled night time medications from 12/2/25:Residents #13 (4 missed medications), #22 (5 missed medications), #27 (4 missed medications), #35 (4 missed medications), #37 (9 medications), #41 (1 missed medication), #75 (2 missed medications), #77 (1 missed medication), #86 (8 missed medications), #97 (2 missed medications), #122 (3 missed medications), #139 (8 missed medications), and #140 (4 missed medications). During an interview on 3/18/2026 at 3:50 PM, Former Director of Nursing (FDON) YY reported she was the Director of Nursing on 12/2/25, confirmed LPN NNN left her shift early before passing out all scheduled night time medications, and confirmed this resulted in the residents listed in the 12/2/25 missed medication investigation/summary (noted above) not receiving their night time medications. Attempts were made to reach LPN NNN to discuss the incident but no response was received before the end of the survey. Resident #75:Review of Resident #75's .Medication Error report, dated 12/2/25, stated, Nursing leadership was notified just before midnight 12/3 (night of 12/2/25 going into the morning of 12/3/25) that the assigned agency nurse (LPN NNN) for 200 hall had left the job assignment around 9pm, locking her med (medication) cart keys in the med room without.giving report to another nurse, Agency provided a replacement nurse (Registered Nurse (RN) PPP) around 4 am.As DON (Former DON YY) was reviewing 24 hour summary, it was noted that resident didn't receive their bedtime medications.Statements.Certified Nurse Aide S.Statement.this nurse acted like she was overwhelmed.she went on break around 9 (PM) but we didn't see her again so we started looking around and saw her med (sic) keys in the med (sic) room. We called the on call nurse as soon as we notice (sic) her keys (LPN NNN's medication keys) and that was around midnight. We got a replacement nurse around 330 am (3:30 AM). The Statement from RN PPP on this report stated, (RN PPP) had been the nurse that took over on the assignment for the nurse that had walked out without notifying anyone. She reports she clocked in around 0330 (3:30 AM) and her agency reports the same. She verified that when she arrived to the facility, none of the HS medications for rooms 207-216 had been administered.I looked at the MAR (medication administration record) and saw noting (sic) was given. It was after 4am by that time and too late to give any of the meds. During an interview on 03/19/2026 at 10:22 AM, NHA A reported the abbreviation MP PM as seen on Resident #75's electronic medication administration record indicated Medication Pass PM (at night) and the window of time to pass medications scheduled to be given for the Hours of MP PM were 7PM-10PM. Review of Resident #75's electronic medication administration record, dated 12/1/25-12/31/25, revealed that on 12/2/25 two medications, mirtazapine (antidepressant) tablet 7.5 milligrams by mouth at bedtime and melatonin (helps regulate sleep) 6 mg by mouth, were not given and had been scheduled to be given during the Hours of MP PM (7PM-10PM window per the facility).Review of Resident #75's progress notes, dated 12/3/2025 at 5:17 AM, indicated the melatonin and mirtazapine were Not given, out of range (out of the range of time they could be given). This citation is linked to intake 2689014. R2 According to the Minimum Data Set (MDS) dated [DATE], R2 was cognitively intact per his BIMS (Brief Interview Mental Status) of 14/15. R2 diagnoses included unspecified conjunctivitis in bilateral (both) eyes. Review of R2's Order Summary did not contain a current order for antibiotics to treat conjunctivitis. During an observation and interview on 3/17/2026 at 12:00 PM R2's eyes had light green drainage coating upper and lower lashes. Both eye's sclera looked red and irritated looking. Resident said he did not know what was going on with his eyes. R2 then used his right hand to rub both eyes. During an observation and interview on 3/18/2026 at 10:49 AM, R2 was awake in bed reading. Both eyes had light green drainage coating upper and lower lashes. Both eye's sclera looked red and irritated looking. R2 stated he has something in his eyes, and he should wipe them out with warm water. He said he would wait until nursing would tell him what to do with his eyes. During an interview and record review on 3/19/26 at 11:19 AM, Unit Manager (UM) LL stated, (R2) does not allow staff to keep his hands clean and he rubs his eyes. (R2) does not allow staff to administer eye drops. (R2) has a Care Plan for refusing care. (R2) also has refusal on MAR/TAR. I do not see where (R2) has a diagnosis of conjunctivitis. The order for antibiotic eye drops was for 7 days back in November 2025 for conjunctivitis. While looking in R2's medical chart, UM LL stated, (R2) does have conjunctivitis right now. Currently he does not have anything ordered for the infection. It should be documented in progress notes and MAR/TAR when (R2) refuses warm compresses and treatments. Gentamycin was started 3/10/26 and finished 3/15/26. UM LL reviewed R2's medical chart to see if R2 allowed administration in his MAR, stating, The refusal should be progress notes with his care plan updated. (R2) missed one dose of Gentamycin on 3/13/26. The refusal was not charted. At noon on 3/12/26 06 as documented. UM LL stated, The 06 should be documented on that date in his progress notes. UM LL looked in R2's progress notes and stated, (R2) has 02 documented at 6 PM on 3/11/ and 3/13/26. He was at dialysis those days and missed the dose. Residents that are at dialysis or an appointment should be getting their antibiotics when they come back. The physician should be contacted of missed doses and obtain a new order, then document in the resident's progress notes. On 3/12/26 07 was documented in (R2's) MAR and progress notes and it was not. I'm looking in (R2's) MAR for March (2026) to see if an order was obtained to give his antibiotic eye drops after he came back from dialysis, and there is no order for late administration of the medication. There is a progress note dated 3/12/26 at 1:16 PM that states NA. Obviously after looking at R2's progress notes are not being done as expected. The progress notes are not being followed up on and they should be so the facility knows what is going on with the resident. According to (R2's) Physician Orders he was to receive antibiotic eye drops 4 times a day starting 3/10/2026 and ending 3/15/26. (R2) continues to have conjunctivitis because he did not get his full dose of antibiotics. Nurses are to notify the physician with every missed dose of antibiotic. I'm looking at correspondence between nursing and the provider and there are no messages to the provider that (R2) still has the infection. I am ultimately responsible for letting the provider know the infection continues. During an interview and record review on 3/19/2026 at 1:05 PM, Regional Infection Control Preventionist (ICP) AA, reported she was at the facility 2 days a week to fill in until the facility has a full-time ICP. While reviewing R2's medical chart with Director of Nursing (DON) B, ICP AA stated, (R2) has conjunctivitis. His first treatment was 2/23-28/26 with Gentamycin. To my knowledge, the antibiotic was completed. On 3/10-3/15/26 Gentamycin was again ordered and documented it was completed. Unit Managers expected to follow the infections on their halls and fill out an Infection Control Work Sheet and return it back to me. While reviewing R2's Infection Control Work Sheet, ICP AA stated, (UM LL) assigned to (R2) did not fill out the sheet that stated the antibiotic was completed. It was another Unit Manager (UM T). (UM T) got her information from the medical director's note and he in turn would get his information from medical records and reassessment of the resident. ICP AA reviewed R2's medical records discovering the medical director had not placed a note stating (R2) was reassessed. During an interview on 3/19/26 at 4:00 PM, Nurse Practitioner (NP) II stated, I was not notified (R2) missed doses of his antibiotic, did not complete the entire series of antibiotic, or that he still had conjunctivitis until today, after you spoke with (ICP AA). I just assessed (R2) before talking to you and yes, he still has conjunctivitis in both eyes. Review of facility policy Antibiotic Stewardship reviewed date 2/4/25, revealed, .Recommendations and interventions of an effective antibiotic stewardship program are designed to ensure that residents who meet criteria for infection receive the right antibiotic for the right duration.Facility staff and medical practitioners have a responsibility to assure that antibiotics are requested and provided .only for the length of time needed to adequately treat the infection.

Based on observation, interview, and record review the facility failed to ensure oxygen was consistently provided per physician's orders for 2 (Residents #25 and 130) of 2 residents reviewed for respiratory care resulting in oxygen flow rates being provided above and below orders with the potential for difficulty breathing. Findings include:Resident #25: Review of Resident #25's minimum data set (MDS; resident information), dated 3/16/26, had a brief interview for mental status score of 0 which reflected she had severe cognitive impairment. Resident #25's MDS indicated she had a diagnosis of respiratory failure.Review of Resident #25's physician order for oxygen, start date 1/13/2026, indicated she was to receive oxygen via NC (nasal cannula; oxygen tubing) at a continuous flow rate of 3L (3 liters per minute). During an observation on 03/17/2026 at 10:30 AM, Resident #25 was lying in her bed with her oxygen concentrator on, her oxygen tubing was on, and the flow rate was set to 1.5 liters per minute. During an observation on 03/17/2026 at 11:40 AM, Resident #25 was lying in her bed with her oxygen concentrator on, her oxygen tubing was on, and the flow rate was set to 1.5 liters per minute. The portable oxygen tank on the back of her wheelchair near the privacy curtain was empty. During an observation and interview on 03/17/2026 at 2:49 PM, Resident #25 was awake in bed and was observed putting her oxygen tubing back on her face/nose. The oxygen concentrator was running and was set at a flow rate of 1.5 liters per minute. Resident #25 was confused and reported she didn't know what her oxygen was supposed to be set at. During an observation on 03/18/2026 at 8:00 AM, Resident #25 was lying in her bed with her oxygen concentrator on, her oxygen tubing was on, and the flow rate was set to 1.5 liters per minute. During an observation on 03/18/2026 at 8:15 AM, Certified Nurse Aide (CNA) KKK pushed Resident #25 in her wheelchair out of her room and towards the front dining room. Resident #25 had no oxygen tubing on and the portable oxygen tank on the back of the wheelchair was empty. During an observation on 03/18/2026 at 8:27 AM, Resident #25 was seated upright in her wheelchair in her room, her oxygen tubing was on, and the oxygen concentrator was running at a flow rate of 1.5 liters per minute. The portable oxygen tank on the back of the wheelchair was empty. During an observation on 03/18/2026 at 9:01 AM, Resident #25 was seated upright in her wheelchair in her room, her oxygen tubing was on, and the oxygen concentrator was running at a flow rate of 1.5 liters per minute. During an observation and record review on 03/18/2026 at 9:49 AM, Resident #25 was in her wheelchair near the bird cage/enclosure at the end of the 200s hall with no oxygen on, no oxygen tubing was present, and the oxygen tank on the back of her wheelchair was empty. At 10:00 AM, Registered Nurse (RN) JJ checked up on Resident #25. Various staff passed by Resident #25 and no new oxygen tank or oxygen tubing were brought to the resident. The oxygen flow rate order was reviewed at that time, and Resident #25's oxygen order remained 3 liters per minute continuous oxygen via nasal cannula. Resident #25 was out of her room, away from her oxygen concentrator, and was not being provided continuous oxygen.During an interview on 03/18/2026 at 11:02 AM, Interim Director of Nursing (IDON) B confirmed Resident #25's physician order for oxygen indicated the flow rate was continuous and the flow rate of 3 liters per minute. When asked if Resident #25 had been weaned off supplemental oxygen IDON B stated, Not that I recall. IDON B confirmed if Resident #25 was out of her room, and away from her oxygen concentrator, she should still be receiving oxygen. During an observation on 03/18/2026 at 11:35 AM, Resident #25 was in her wheelchair near the bird cage/enclosure at the end of the 200s hall with no oxygen on, no oxygen tubing was present, and the oxygen tank on the back of her wheelchair was empty.During an observation on 03/18/2026 at 12:03 PM, Resident #25 was seated in a wheelchair at a dining table with a staff member. Resident #25 had no oxygen on, no oxygen tubing was present, and the oxygen tank on the back of her wheelchair was empty. Review of Resident #25's physician order for oxygen on 03/18/2026 at 2:24 PM, indicated the order had been revised. The oxygen order now indicated Start Date.3/18/2026 19:00 (7:00 PM), 3 liter (per minute) flow rate, and the duration was changed to PRN (as needed). During an observation on 03/18/2026 at 2:39 PM, Resident #25 was lying in her bed with her oxygen concentrator on, her oxygen tubing was on, and the flow rate was set to 1.5 liters per minute. During an observation, interview, and record review on 03/18/2026 at 2:41 PM, RN JJ reported Resident #25's oxygen concentrator was running at 2 liters per minute. The surveyor observed the flow rate indicator to be at 1.5 liters per minute when looking at the flow rate gauge at eye level. Resident #25 was wearing her oxygen tubing and the concentrator was running. Resident #25's physician order was reviewed with RN JJ. RN JJ confirmed the oxygen order was for 3 liters per minute as needed. RN JJ reported the oxygen order had been changed on 3/18/26 and she wasn't made aware of the change. Review of the facility's Oxygen Administration policy, reviewed date 2/4/26, stated, Oxygen shall only be administered by physician order.Attach oxygen delivery device ordered by the physician to the oxygen unit.Turn the unit on to the desired flow rate. Resident #130 Review of a Face Sheet revealed Resident #130 was a female, with pertinent diagnoses which included end stage renal (kidney) disease, heart failure, pulmonary hypertension (a chronic condition characterized by high blood pressure in the arteries of the lungs), anemia (a deficiency of healthy red blood cells or hemoglobin), high blood pressure, diabetes, obstructive lung disease, and chronic respiratory failure. Review of an Order Summary Report for Resident #130 revealed the active physician order .Oxygen Delivery via .NC (nasal cannula) .Liter flow: 2L (2 Liters) .Duration .continuous .every shift for Difficulty breathing/hypoxia (a condition where tissues receive inadequate oxygen) . with a start date of 3/10/26. Review of a current Care Plan for Resident #130 revealed the focus .The resident has or is at risk for altered respiratory status related to Anxiety, CHF (Congestive Heart Failure), COPD (Chronic Obstructive Lung Disease) . with interventions which included .O2 (oxygen) at 2 liters via (nasal cannula, mask) .Resident will sometimes refuse to wear oxygen . initiated 12/31/25. In an observation on 3/18/26 at 1:37 PM, Resident #130 was observed in bed in her room with the head of her bed elevated, wearing oxygen via nasal cannula. Noted Resident #130's oxygen concentrator was set at 4 Liters per Minute (LPM). In an observation on 3/18/26 at 1:52 PM, Resident #130 was observed in bed in her room with the head of her bed elevated, wearing oxygen via nasal cannula. Noted Resident #130's oxygen concentrator was set at 4 LPM. In an observation and interview on 3/18/26 at 2:11 PM, Resident #130 was observed in bed in her room with the head of her bed elevated, wearing oxygen via nasal cannula. Noted Resident #130's oxygen concentrator was set at 4 LPM. Agency Registered Nurse (RN) JJJ responded to Resident #130's room to verify her oxygen concentrator settings, and noted the concentrator was set to 4 LPM. Agency RN JJJ reported Resident #130's oxygen concentrator should be set at 2 LPM per the physician orders.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living.Findings Include:On 3/18/26 at 9:12 AM, observation of the underside of the three-compartment sink found a volleyball sized hole in the wall.On 3/18/26, starting at 9:42 AM, observation of station one and station three pantries found the underside cabinetry under a sink and the ice machine shows increased accumulation of debris, black spots, and water damage.On 3/18/26 at 10:35 AM, observation of the 500-hall soiled utility room found a strong odor emanating from the room. A review of the room found a mop sink positioned behind the door. The mop sink looked dry at the bottom and as this surveyor placed his hand over the floor drain of the mop sink, hot air was felt pushing up the drain, indicating the p-trap had evaporated and sewer gas was being let into the room. Further review of the mop sink found that it was connected to a chemical pre-dispense unit, and the faucets handles were left on (so staff can get chemicals more easily). This set up creates undue back pressure on the faucets internal vacuum breaker ruining the integrity of the unit.On 3/18/26 at 10:38 AM, observation of the 500-hall spa room found large tuffs of matted hair in each of the shower chairs wheels.On 3/18/26 at 10:48 AM, observation of the 100-hall soiled utility room found the underside cabinetry to the sink was dilapidated with old stains and water damage. Further review on the underside of the cabinet found the back wall juncture was observed to be deteriorating with holes for pests to utilize.On 3/18/26 at 11:05 AM, observation of the 600-hall spa tub room found soaking wet washcloths, towels, and pieces of toilet paper lying in the tub of the unit. Further review of the room found a shower chair with brown and yellow staining and streaking down the legs of the chair.On 3/18/26 at 12:53 PM, observation of the garden activity room found bubbling and chipping paint and drywall in the greenhouse area off the back of the room. Routine roof leaks have caused the wall juncture under the roof to deteriorate. An interview with Maintenance Director (MD) G, found that this area is looking to get renovated with the transition of the dialysis onsite, and this is one of the locations being reviewed.On 3/18/26 at 1:13 PM, observation of the 600-hall clean linen room, across from resident room [ROOM NUMBER], found multiple water fixtures that were leaking or had possible stagnant lines. The room was converted from a shower room and contained working wall fixtures for a commode, a hand sink, a shower, and a tub. At this time, the [NAME] valve (a built-in backflow protection device) coming out of the wall to service the commode was found with a slow leak leaving a puddle of water on the ground.On 3/18/26 at 1:24 PM, observation of the 600 high Soiled Utility room found the hopper was leaking from the wall. MD G stated that he was addressing the issue.On 3/18/26 at 1:35 PM, observation of the 700-hall lounge found a cushioned chair with increased accumulation of debris and trash under the seat cushion. Further review found increased trash and debris on top of the vending machine as well as black spots and accumulation in and on the heating and cooling unit located on the wall above the vending machines.On 3/18/26 at 2:16 PM, observation of the 300-hall shower room found a shower bed with black staining underneath the mat of the shower bed.

This citation pertains to intake 2749417 Based on observation, interview, and record review the facility failed to provide an environment that promoted and enhanced resident dignity in 1 Resident (#130) of 3 residents reviewed for dignity resulting in feelings of humiliation, frustration, embarrassment, and negative psychosocial outcomes impacting the residents' quality of life. Findings include:Resident #130Review of an admission Record revealed Resident #130 was originally admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease and chronic pain syndrome. Review of a Minimum Data Set (MDS) assessment for Resident #130, with a reference date of 2/3/26 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #130 was cognitively intact. During a medication administration observation on 3/18/2026 at 8:02 AM, Licensed Practical Nurse (LPN) JJJ was preparing medications at her medication cart outside of Resident #130's room. Resident #130's door was open, and she was lying in bed crying out Please come help me. It was noted that her call light was on. LPN JJJ yelled out to Resident #130 that she was going to have to wait . LPN JJJ then turned to this writer and said She's going to just yell out nonstop; she always does. It's because she is a drug addict. Noted that LPN JJJ was right in front of Resident #130's room and at a distance that Resident #130 could hear LPN JJJ when she called her a drug addict. LPN JJJ continued to dispense medications as Resident #130 continued to scream out for help. LPN JJJ loudly sighed every time that Resident #130 yelled and continued to state, you just have to wait. After LPN JJJ had all of Resident #130's medications prepared, she walked into Resident #130's room without knocking or identifying herself and asked Resident #130 What is wrong with you? Resident #130 was on her personal cell phone with 911, and she told LPN JJJ that she was calling 911 for help because nobody helped her while she yelled out. Resident #130 was noted to be tearful. LPN JJJ yelled out to the 911 operator that Resident #130 was fine and did not need assistance, and the dispatcher ended the call. Resident #130 then reported that she was in pain and LPN JJJ said Well I have Tylenol for you. She then gave Resident #130 her medications and walked out of her room. Resident #130 stated I still need help as LPN JJJ was exiting her room, and LPN JJJ ignored Resident #130 and continued to exit her room. It was noted that LPN JJJ did not assess Resident #130's pain or offer any other non-pharmacological interventions. After LPN JJJ walked out of Resident #130's room, she stated to this writer She (Resident #130) is drug seeking, she is probably withdrawing right now. It was noted that Resident #130 continued to yell out for help and LPN JJJ continued to ignore her. During an interview on 3/18/2026 at 12:58 PM, Resident #130 reported that she was very frustrated with how staff at the facility treated her. Resident #130 reported that she felt like she had to yell out to get help because the staff just ignored her. Resident #130 reported that she had overheard LPN JJJ call her a drug addict earlier that morning and that she often heard staff complaining about her and that she felt like they treated her like ghetto trash. Resident #130 was noted to be tearful during the interview. Review of the facility's Dignity policy dated 9/21/23 revealed, Policy Overview: It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feelings of self-worth, and self-esteem. General guidelines: Residents will be treated with dignity and respect at all times .

This citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401Based on interview and record review, the facility failed to inform the resident representative, in advance, of care to be provided for 2 (Resident #15 and Resident #39) of 6 residents reviewed for resident rights, resulting in: 1. Resident #15 receiving psychotropic medication without consent from his resident representative. 2. Resident #39 attended an offsite medical appointment without representation from her Durable Power of Attorney (DPOA).Findings include: Findings include: Resident #15 Review of an admission Record revealed Resident #15 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: schizoaffective disorder, bipolar type (chronic mental health condition combining hallucinations, delusions, disorganized speech with severe mood swing, specifically mania and often depression). Review of a Minimum Data Set (MDS) assessment for Resident #15 with a reference date of 2/10/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 14/15, which indicated the resident was cognitively intact. Section N of the MDS revealed Resident #15 was taking an antipsychotic and an antianxiety medication. Section Q of the MDS revealed the resident had a legal guardian. Review of a State of Michigan Probate Court Report of Physician for Resident #15, with a reference date of 6/3/25, revealed .3. Based on the examination.the individual suffers from.schizoaffective disorder, moderate cognitive impairment.4. These infirmities interfere in the following ways with the individual's ability to receive or evaluate information in making decisions: process and understand medical information.6. I believe the individual.is not able to make informed decisions in the following areas.authorizing or refusing medical treatment. Review of a Determination of Inability to Participate in Complex Decision Making form for Resident #15, with a reference date of 6/20/25, revealed I have evaluated (Resident #15) and based on my observations, evaluation and professional opinion, he IS NOT able to make medical treatment decisions and IS NOT able to participate in making medical treatment decisions. The document was signed by 2 physicians. Review of a Psychotropic Medication Use policy with a reference date of 2/3/26 revealed: Policy Overview.The facility will.obtain consent from the resident or authorized representative for each psychotropic medication ordered.Upon admission, the facility will identify when a resident is prescribed a psychotropic medication.the resident or authorized representative will be educated on the risks versus benefits of the psychotropic medication and informed consent obtained. In an electronic communication on 3/19/26 at 10:50am, Nursing Home Administrator (NHA) A agreed to provide all Psychotropic Medication Consent forms for Resident #15. Review of a Physician's Order for Resident #15 with a reference date of 5/28/25 revealed Perphenazine (antipsychotic medication) Oral Tablet 4 MG (milligrams) 2 tablets by mouth two times a day Review of a Psychotropic Medication Consent form with a reference date of 8/8/25 for Perphenazine for Resident #15, revealed I. Medication Class antipsychotic, Perphenazine Oral Tablet 4MG, 2 tablets by mouth two times a day.Education was provided to and consent received from (Resident #15). Of note, this consent form for Perphenazine was chronologically closest to the start date of this medication which was 5/28/25. Review of a Physician's Order for Resident #15 with reference date of 8/8/25 revealed Alprazolam (anti-anxiety medication) oral tablet .25mg, give 1 tablet by mouth every 8 hours as needed until 8/22/25. Review of a Psychotropic Medication Consent form with a reference date of 8/11/25 for Alprazolam for Resident #15, revealed Medication class.Antianxiety.Education was provided to and consent received from (Resident #15). In an interview on 3/19/26 at 12:28pm Social Services Coordinator (SSC) X reported residents/their representatives must give informed consent prior to the use of psychotropic medications because the medications are mood altering, can present risks to the resident's health, and may cause undesirable side effects. In an interview on 3/19/26 at 12:42pm Social Services Coordinator (SSC) E reported if a resident has been deemed unable to make medical decisions, such as with Resident #15, informed consent for the use of psychotropic medications must either be received from the legal guardian or the authorized resident representative. SSC E confirmed Resident #15 could not make medical decisions for himself, did not have a legal guardian when he was initially prescribed Alprazolam or Perphenazine, and his authorized resident representative did not provide consent for the use of the medications Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia (chronic and serious mental health condition that can significantly affect how a person thinks, feels, and behaves) and cognitive communication deficit. Review of Resident #39's Letters of Co-Guardianship dated 9/30/25 revealed that Resident #39 had been appointed two-co guardians. During an interview on 3/17/2026 at 12:52 PM, Family Member (FM) MMM reported Resident #39 had been admitted to the facility on [DATE] after a hospitalization. FM MMM reported her and her sister were Resident #39's co-guardians, and that they had made all of Resident #39's medical treatment decisions. FM MMM reported Resident #39 was followed by a (Local Mental Health Authority-company that provided public services for mental health, substance use, and developmental disabilities) and that the Mental Health Authority would review her medications each month and provide her monthly Haldol (antipsychotic medication) injection. FM MMM reported that on 2/2/26, the facility sent Resident #39 to an outside medical appointment with a staff member from the facility without notifying her or Resident #39's other co-guardian. FM MMM reported that Resident #39 was not able to participate in the appointment, so the office cancelled the appointment. FM MMM reported that on 2/19/26 the facility sent Resident #39 to an appointment at the Local Mental Health Authority without a staff member to assist her. FM MMM reported that she and Resident #39's other guardian had not been notified about Resident #39's appointment, and that she was very upset when she found out that Resident #39 had attended the appointment by herself. FM MMM reported that she had always attended Resident #39's appointments with her because she was not capable of making her own decisions. FM MMM reported that the facility was aware that she wanted to be notified of all appointments with Resident #39 so that she could attend with her. FM MMM reported that she learned that Resident #39 had attended another appointment without her knowledge when Resident #39 informed her. FM MMM reported she was never notified of any appointments that the facility had scheduled for Resident #39, and if she had been made aware, she would have attended the appointments with her. During an interview on 3/18/2026 at 4:28 PM, Mental Health Authority Nurse ([NAME]) BB reported she was one of the nurses that assisted Resident #39 when she came to her appointment on 2/19/26 without her guardian or a staff member from the facility. [NAME] BB reported she thought it was unusual for Resident #39 to attend her appointment without FM MMM because she always went to Resident #39's appointments with her. [NAME] BB reported Resident #39 was able to participate in her appointment, but that she was notably more confused. [NAME] BB reported that FM MMM had always been a great resource and advocate for Resident #39, so she did feel that it was beneficial for her to participate in Resident #39's medical appointments. During an interview on 3/19/2026 at 11:11 AM, Unit Clerk (UC) U reported she was responsible for scheduling outside medical appointments for residents at the facility. UC U reported she could not recall if she had scheduled Resident #39's appointment with an outside medical provider on 2/2/26, but that she thought that the appointment had been cancelled, and she did not know any further details related to that appointment. UC U reported she had scheduled Resident #39's appointment on 2/19/26. UC U reported that if a resident had a guardian, she would write down the appointment information on a slip to give to the guardian. UC U reported she had completed a slip for Resident #39's appointment to give to her guardian, and that when she went to give it to her (FM MMM) when she was at the facility, FM MMM was in the middle of a conversation with another staff member at the facility in the dining area. UC U reported she waited for over 20 minutes for FM MMM but that she did not want to interrupt the conversation, so she placed the slip that included the appointment information Resident #39's meal tray in her room. UC U first reported that she did not know if FM MMM had received the slip she left for her on Resident #39's meal tray. UC U then reported that she had spoken with FM MMM on the phone after she had left the slip, and that FM MMM confirmed that she was aware of the appointment. When this writer further queried, UC U reported that she could not recall the date or information that she had shared with FM MMM regarding her appointment on 2/19/26. When asked by this writer for documentation to verify that UC U had spoken with and informed FM MMM of Resident #39's medical appointment on 2/19/26, UC U was not able to provide any documentation. UC U reported that anytime a resident at the facility had a guardian, she was supposed to ensure that the guardian was aware of their outside appointments, and if they could not attend with the resident, the facility would send a staff member to attend with them. UC U was unable to report if Resident #39 required a staff member to assist her at an appointment if her guardian was not able to attend, but did report that typically, a resident with a guardian would need staff assistance if the guardian could not attend.

Based on interview and record review, the facility failed to ensure all residents maintained their right to self-determination for 1of 4 residents (Resident #5), reviewed for choices, resulting in Resident #5 experiencing feelings of frustration and anxiety, and interference with maintaining her highest practicable level of independence.Findings include:Resident #5Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: bipolar disorder (a chronic mental illness characterized by dramatic shifts in mood, energy, and activity levels).Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 1/9/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact.Review of a Care Plan for Resident # 5 with a reference date of 1/2/26 revealed the following focuses/goals/interventions: 1. Focus: The resident has a physician's order for unsupervised self-administration of.all prescribed medications.Goal: The resident will take medications safely and as prescribed.Interventions: assess resident's ability to safely self-administer medications specified on admission, quarterly.2. Focus: The resident has a psychosocial well-being problem.r/t (related to) risk for loss of independence.Goal: The resident will have no indications of psychosocial well-being problem. Provide opportunities for the resident.to participate in care.Review of a Physician's Order for Resident #5 with a reference date of 12/26/25 revealed OK to self-administer medication, status: Active.In an interview on 3/17/26 at 11:27am, Resident #5 reported she felt very frustrated because the agency employed nurses refused to honor her preference of self-administering her medications. Resident #5 reported she had been approved to self-administer her medications, but the agency nurses did not seem to know that and frequently refused to allow her to do so. Resident #5 stated I hate it when they stand over and watch me take my pills, it makes me nervous.In an interview on 3/18/26 at 10:48am, Agency Registered Nurse (RN) JJJ reported she was caring for all the residents on Resident #5's unit on this date, and she had routinely done so. RN JJJ reported she relied on a verbal report from the off going shift to learn about the care preferences of each resident. When further queried, RN JJJ reported none of the residents on Resident #5's unit were able to self-administer their medications.In an interview on 3/19/26 at 11:22am, Resident #5 reported it was important to her that she be allowed to exercise her highest level of independence. Resident #5 reported she had lost a lot in her life and gained a sense of empowerment when she was able to care for herself independently. Resident #5 stated The agency staff don't listen to me; I shouldn't have to keep telling them I can give myself my own medications. I get very frustrated by that.In an interview on 3/19/26 at 11:27am, Certified Nursing Assistant (CNA) KK reported she usually worked on Resident #5's unit. When queried about Resident #5 not being allowed to take her own medications, CNA KK stated every time an agency nurse works, they don't allow Resident #5 to take her own medications. CNA KK confirmed Resident #5 became frustrated every time a nurse refused to allow her to take her own medications. CNA KK reported being as independent as possible was very important to Resident #5, and she always wanted to do whatever she could for herself.In an interview on 3/19/26 at 11:32am, Licensed Practical Nurse (LPN) GG reported he was aware of ongoing difficulties regarding agency nurses not abiding by resident preferences for their cares. LPN GG reported agency nurses were expected to use the assignment sheet/work sheet which outlined each resident's care preferences.Review of an Assignment/Worksheet for the 500 hall (where Resident #5 resided) revealed her preference to self-administer medications was not documented.

Based on interview and record review, the facility failed to maintain accurate and consistent code status documentation and advanced directive information for 1 resident (Resident #84) of 2 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.Findings include:Review of an admission Record revealed Resident #84 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: depression and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #84, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #84 was cognitively intact.In an interview on [DATE] at 8:53 AM, Resident #84 reported that she told the facility what her wishes for emergency medical treatment were when she admitted and stated, If my heart stops, I don't want anyone pounding on my chest .I don't want to live if I am going to be in pain.Review of Resident #84's admission Evaluation dated [DATE] revealed, .Advanced Directive/Advanced Care Planning:. Do not resuscitate (DNR).Review of Resident #84's Nursing-Progress Note dated [DATE] revealed, .Pertinent alert charting: additional supportive documents signed with res (resident) tonight, advance directives, res states her spouse is her DPOA (durable power of attorney). Res request DNR document, forward to clinical secretary.Review of Resident #84's Advance Directives dated [DATE] revealed, I wish the following personal choices for my care to be honored by all who read this. I fully understand the impact and potential consequences of these choices and wish to emphasize my desire to have the procedure performed or withheld, as indicated below. Cardiopulmonary Resuscitation - No. The document was signed by the resident, witnesses and the physician. Review of Resident #84's DNR order signed on [DATE] revealed, .I have discussed my health status with my physician.I request that in the event that my heart and breathing should stop, no person shall attempt to resuscitate me. The document was signed by the resident, physician and witnesses.Review of the facility binder Code Status located at the nurse's station revealed, Resident #84's admission record with the print date of [DATE] and a copy of Resident #84's DNR order dated [DATE]. The documents were in a red sleeve to indicate DNR. This binder contained Advanced Directives and corresponding DNR's for all residents. The residents who indicated that they would like CPR and wanted to be Full Code, were in clear sleeves.Review of Resident #84's Current Physician Orders revealed, Adv Directive: Full Cardiopulmonary Resuscitation (CPR).Active [DATE]. There were also discontinued orders for Full Code - CPR with a start date of [DATE] and discontinued on [DATE]. This order does not match the resident's advance directive and/or the resident's interview above.Review of Resident #84's Physician Note dated [DATE] revealed, .Code Status: DNR per discussion with patient.Review of Resident #84's Psychiatry Note dated [DATE] revealed, .Code Status: Adv Directive: Full Cardiopulmonary Resuscitation.Review of Resident #84's Physician Note dated [DATE] revealed, .Code Status: DNR per discussion with patient.review of Resident #84's Physician Note dated [DATE] did not mention code status. Review of Resident #84's Social Work Note dated [DATE] revealed, .Code status education reviewed. Resident wishes to remain full code at this time but expresses desire to talk with husband regarding this. This was the last documentation related to code status.In an interview on [DATE] at 8:55 AM, Social Worker (SW) X reported that Resident #84 was her own decision maker and her current advanced directive orders were listed as Full Code. SW X reported that Resident #84's code status had been discussed at care conferences in [DATE] and again on [DATE] and the resident was undecided about her code status, and as a result would continue a code status of Full Code. SW X was not aware that Resident #84 had DNR documentation in her records; SW X wanted to conduct an interview with Resident #84 to confirm her preferences for DNR and/or Full code. In a subsequent interview on [DATE] at 11:55 AM, SW X reported that she had interviewed Resident #84 after this surveyor identified code status inconsistencies in the record, and at first the resident reported that she did not want CPR but when Resident #84 was given the paperwork to sign for DNR, the resident requested to talk with her husband and sister about it before she signed the document. Therefore, Resident #84 would remain full code until they were able to further verify her wishes. SW X reported that she would try to clear up Resident #84's coded status with physicians and update the code status book to reflect FULL CODE for the time being.

This citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401. Based on interview and record review, the facility failed to ensure proper notifications were made after the identification of a significant medication error for 1 (Resident #39) of 2 residents reviewed for notifications, resulting in the lack of assessments, monitoring, and potential for worsening medical conditions. Findings include:Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia (chronic and serious mental health condition that can significantly affect how a person thinks, feels, and behaves) and cognitive communication deficit. Review of Resident #39's Care Plan revealed, Focus: (At risk for changes in behavior & mood r/t (related to) paranoid schizophrenia .Interventions: Administer medications per physician orders. Date Initiated: 01/29/2026 .Review of the facility's Medication Error Investigation revealed, Resident #39 was admitted on [DATE] . On 1/28/26, Licensed Practical Nurse (LPN) P entered an order for Haloperidol (Haldol) Deaconate (antipsychotic medication) intramuscular solution 100 mg/mL (milligrams per milliliter) give 2.5 ml IM (intramuscular) to be given one time a day on the 16th-21st. In the additional directions it was noted to give every 21 days. The correct order was to give Haloperidol Deaconate intramuscular solution 100 mg/mL give 2.5 ml IM to be given one time a day once every 21 days. The error in order transcription resulted in the resident receiving doses of IM Haldol on 2/17/26, 2/18/26, and 2/21/26 . Noted that the investigation report indicated the incorrect dates that Resident #39 received the Haldol injections. Review of Resident #39's Medication Administration Record (MAR) revealed, Haloperidol Decanoate Intramuscular Solution 100 MG/ML (Haloperidol Decanoate) Inject 2.5 ml intramuscularly one time a day starting on the 16th and ending on the 21st every month for schizophrenia every 21-day IM inject. Start date: 2/17/26. The medication was documented as administered by LPN LLL on 2/17/26 and by LPN EE on 2/20/26 and by 2/21/26. During an interview on 3/17/2026 at 12:52 PM, Family Member (FM) MMM reported that Resident #39 had been admitted to the facility on [DATE] after a hospitalization. FM MMM reported that Resident #39 was followed by a (Local Mental Health Authority-company that provided public services for mental health, substance use, and developmental disabilities) and that the Mental Health Authority would review her medications each month and provide her monthly haldol injection. FM MMM reported that on 3/6/26, she was informed by the Mental Health Authority that Resident #39 had received three doses of her monthly haldol injection at the facility in error. FM MMM reported that she was informed by the Mental Health Authority's Nurse (MHAN) BB that she had talked to LPN EE at the facility on 2/27/26 when she called to discuss Resident #39's medication orders, and it was discovered that the facility had transcribed the order wrong and administered multiple does. FM MMM reported that she had not been contacted by the facility until 3/9/26. FM MMM reported that she had noticed a decline in her mother's condition since February when Resident #39 had received the multiple doses of Haldol injections which included a decline in participating in therapy, increased tremors and confusion. During an interview on 3/18/2026 at 4:28 PM, MHAN BB reported that when Resident #39 came in for her medication review appointment on 2/19/26, she had planned to administer Resident #39's monthly Haldol injection, but she was told by Resident #39 that she had just gotten the injection at the facility, so she did not administer the injection and requested Resident #39's medication records from the facility to review. MHANBB reported that she called the facility on 2/27/26 to review Resident #39's medications because she had not yet received Resident #39's medication records from the facility. MHAN BB reported that she spoke to LPN EE on 2/27/26 and reviewed Resident #39's orders with him. MHAN BB reported that when LPN EE read Resident #39's Haldol order to her, she informed LPN EE that the order was incorrect, and Resident #39 should have only received 1 Haldol injection every 21 days. MHAN BB reported that LPN EE told her that he thought the order looked incorrect, so he asked a supervisor about it, and he was told to administer the medication anyway. Review of Resident #39's Nursing Narrative note dated 2/27/26 from the Mental Health Authority revealed, This RN called (Facility) nursing line to inquire about medication records regarding this patient's Haldol 250mg Q3wks (every 3 weeks). This RN spoke to a (LPN EE) who stated that the last time this patient received this medication was on 02/21. (LPN EE) also stated that the order was written as, Haldol 250mg from 02/16-02/21, therefore, this patient received multiple doses within a week. (LPN EE) did state that the patient refused the medication a few times, but states that he knows she got it at least twice from him. (LPN EE) states, I thought the order looked weird. He states that he asked his supervisor at (Facility) for clarification and was told to give the medication as the order stated . Review of Resident #39's Progress Note dated 3/7/26 (8 days after the telephone call with MHAN BB on 2/27/26) and documented by LPN EE revealed, Spoke with nurse at (Local Mental Health Authority) and was asked to do a complete medication review of this resident's medications. During the review, it was brought to the attention of this nurse that there was a discrepancy regarding resident's Haloperidol Deaconate Intramuscular solution 100 mg/ml. The order in (electronic medical record) reads Inject 2.5 ml intramuscularly one time a day starting on the 16th and ending on the 21st of every month for schizophrenia every 21 days which was incorrect. Two doses were administered by this nurse. The nurse was asked about the resident's condition and asked to obtain a set of vitals. The resident was fairly new to this unit, so nurse didn't have knowledge of their baseline . the resident's mental state to the nurse seemed to be AOx 2-3 (alert and oriented) and her vitals were exceptionally great (did not indicate what vital signs were) . During an interview on 3/18/2026 at 3:55 PM, LPN EE reported that he had administered two doses of Resident #39's Haldol injection on 2/20/26, and 2/21/26. LPN EE reported that he recalled questioning the order, and so he had asked his Unit Manager about the order and was instructed to administer the injections anyway. When this writer queried as to which Unit Manager instructed him to administer the injections, LPN EE reported that he could not recall. LPN EE reported that he had been made aware of the medication errors when he completed a medication review with MHAN BB. LPN EE reported that he could not recall the date that he spoke to MHAB BB or when he reported the incident to the facility. LPN EE could not recall if he had contacted the physician to inform him of the medication error. During an interview on 3/18/2026 at 1:51 PM, Nurse Practitioner (NP) OOO reported that she was notified on 3/9/26 regarding the medication errors that occurred in February 2026. NP OOO reported that by the time she had been notified of the medication errors, Resident #39 was planning to discharge from the facility, so she encouraged her to go to the hospital for an evaluation which she was agreeable to. During an interview on 3/19/2026 at 1:33 PM, Nursing Home Administrator (NHA) A reported that the facility had discovered the medication error that had occurred with Resident #39 on 3/6/26. NHA A confirmed that LPN EE had not notified the facility's provider, Resident #39's guardians, or any of the nurse managers of the medication errors that had occurred with Resident #39 when he found out about the errors on 2/26/26.

Based on interview, and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form in 2 of 3 residents (Resident #4 & #13) reviewed for timely provision of notifications, resulting in the potential for frustration and the resident or resident representative to be unaware of changes regarding financial liability.Findings include:Resident #4 Review of a Face Sheet revealed Resident #4 was a male, who admitted to the facility on [DATE], with pertinent diagnoses which included muscle disorder, lack of coordination, cognitive communication deficit (a breakdown in communication resulting from underlying cognitive deficits), diabetes, high blood pressure, and depression. Noted Resident #4 was not his own responsible party.Review of the Census information for Resident #4 revealed Medicare Part A was his primary payer source on 10/1/25. Noted Resident #4's last covered day of Medicare Part A services was on 12/22/25, at which point he remained in the facility and his primary payer source changed to Medicaid Pending on 12/23/25. Review of a SNF (Skilled Nursing Facility) Beneficiary Notification Review form for Resident #4 completed by facility staff revealed .Medicare Part A Skilled Services Episode Start Date: 10/1/25 .Last covered day of Part A Service: 12/22/25 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted . Noted that the question on the form Was a SNF ABN, Form CMS-10055 provided to the resident? was unanswered. Resident #13 Review of a Face Sheet revealed Resident #13 was a male, with pertinent diagnoses which included end stage renal (kidney) disease, muscle disorder, lack of coordination, aphasia (a language disorder that affects how you communicate), diabetes, cognitive communication deficit, heart disease, heart failure, depression, and anxiety. Noted Resident #13 was not his own responsible party. Review of the Census information for Resident #13 revealed Medicare Part A was his primary payer source on 11/21/25. Noted Resident #13's last covered day of Medicare Part A services was on 12/6/25, at which point he remained in the facility and his primary payer source changed to Medicaid on 12/7/25. Review of a SNF Beneficiary Notification Review form for Resident #13 completed by facility staff revealed .Medicare Part A Skilled Services Episode Start Date: 11/21/25 .Last covered day of Part A Service: 12/6/25 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted . Noted that the question on the form Was a SNF ABN, Form CMS-10055 provided to the resident? was unanswered. In an interview on 3/19/26 at 2:41 PM, Business Office Manager (BOM) M reported SNF ABN forms were not provided for Resident #4 or Resident #13. BOM M reported she was unaware of the facility process related to SNF ABN forms. In an interview on 3/19/26 at 2:44 PM, Social Services Coordinator E reported the social workers currently provide Notice of Medicare Non-Coverage forms prior to discharge from Medicare Part A services, however, they do not currently provide SNF ABN forms. Review of the policy/procedure Advanced Beneficiary Notification, dated 3/1/25, revealed .It is the policy of the facility to provide timely written notice to traditional Medicare beneficiaries when it is determined that Medicare will no longer provide coverage for skilled services. The Advanced Beneficiary Notification (ABN) is utilized to convey the cost of services and potential resident financial liability .GENERAL GUIDELINES .Once the provider or resident's health plan determines that Medicare beneficiary will no longer qualify for Medicare skilled services, the Business Office Manager will issue the Advanced Beneficiary Notice form to the resident and/or authorized representative .

This citation pertains to intake 2731057.Based on observation, interview, and record review, the facility failed to maintain a clean and comfortable environment for 3 residents (R8, R108, and R12) of 4 residents reviewed for a sale/clean/comfortable homelike environment, resulting in unclean/unkempt resident rooms and the potential for cross contamination, bacterial harborage, and the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self -esteem. Findings include:R8According to R8's Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact with a BIMS of 13/15. Section GG-Functional Status indicated the resident was dependent on staff for transfers and did not stand or walk during this time of assessment. During an observation on 3/17/26 at 11:25 AM, there was a dresser behind R8's bed that had dust and debris under a bottle of stoma powder lying on its side, a jar of chicken bouillon, various wound and ostomy supplies, and a pair of scissors with plastic wrap on the blades. During an observation and interview on 3/17/26 at 12:18 PM, a bottle of stoma powder was on a dresser behind R8 was lying on its side. The top of the dresser had dust and debris under the bottle of stoma powder. A syringe, scissors that had plastic pieces hanging off the blades, and wound dressings were on top of the dust and debris. Also on the table was a jar of chicken bouillon. R8 stated he could not get out of bed on his own and staff took care of things in his room. Observed on 3/18/26 at 11:33 PM, in R8's room a dresser next to the wall, were piled up supplies, including the stoma powder lying on its side the same as the previous day. Also on the table was a jar of chicken bouillon. Observed on 3/19/26 at 9:33 AM, in R8's room, a dresser next to the wall, were piled up supplies, including the stoma powder lying on its side along with the jar of chicken bouillon the same as the previous day. The dirt, dust, and debris were also clearly seen as from the previous two days. In addition to the clutter on top of the dresser, there were additional various ostomy supplies piled on top with the red-handled scissors still opened with the plastic hanging on the blades. R108 According to R108's Minimum Data Set (MDS) dated [DATE], indicated R108 was unable to complete the BIMS (Brief Interview Mental Status) and was severely cognitively impaired with a score of 00/15. Section GG-Functional Status indicated the resident was dependent on staff for all ADLs (activities of daily living). Review of R108's Care Plan, dated 12/26/25, ADLs self-care deficit related to physical limitations indicated the goal for R108 was to receive assistance necessary to meet ADL needs using interventions that included assist to bath/shower as preferred.assist with daily hygiene, grooming, dressing. Review of R108's Care Plan, dated 2/5/26, included a focus of Need for Feeding Tube, indicating the resident had a resident-specific treatment plan for enteral feeding. During an observation on 3/17/26 at 11:10 AM, in R108's room, under the heat register was a purple container of deodorant. A chair next to the resident's enteral feeding pole was a wadded-up fleece jacket and tube of ointment were all splattered with a dried sticky substance resembling the enteral feeding that was hung on a pole next to the chair. R108's high backed wheelchair had the rubber missing from the right wheel all the way around it. Dirt, dust, and debris along the floorboards, and dressers. Personal belongings of R108 were on the floor next to carrying totes that were in a corner. It resembled someone who had gone through the bags of belongings, spilling items out, and leaving them on the floor without picking them up. During an interview on 3/17/2026 at 1:24 PM, Family Member (FM) PP stated she had concerns regarding R108's hygiene and environment. I have spoken to the facility numerous times about (R108's) personal hygiene. I've agreed to shower her once a week. I saw (R108) yesterday (3/16/26) she was given a shower by staff but she said she still stinks. In between showers on Mondays (R108) does not receive showers. (R108's) linens should be changed at the same time. When staff give her a bed bath the sheets don't get changed. When I come to the facility, I ask staff to put (R108) in her wheelchair and then I end up changing her sheets. Before I started giving (R108) showers, her hair was not washed because it had built up of hair oil. (R108) skin is dry with white flakes. I write grievances that (R108's) skin is dry from her chest up to her face. I always bring in (R108's) hygiene items and shave her armpits. You can tell (R108) doesn't get clean by staff when deodorant clumps up under (R108's) armpits. I bring in body wash, diabetic lotion, Vaseline for her body, vapor rub for her feet, special lotion, and deodorant. The facility does not use it. I put lotion on (R108) and staff does not. It makes her feel like the facility does not care. Although (R108) has had strokes she still knows when her armpits stink and she tells me. When staff provide brief changes and clean (R108) she asks why does her private parts smell so bad. They do smell. There are days (R108) wear the same clothing back-to-back. I found (R108) wearing a hospital gown during the week. I do her laundry and have a sign up in her room asking staff to dress her every day. I've seen used gloves on the floor, dirty wipes left inside the drawers next to her bed, stuff on the floor like spilled hair condition. The chair for visitors is covered with feeding tube (enteral feeding) drippings that I saw yesterday (3/16/26), it was dripping from the bottle. Underneath her bed, smashed on the floor by a wheel from her bed, was a bottle of hair conditioner. It was leaking all over. I saw a staff member put it on the dresser and left it there dripping. I threw it away when I saw they did that. I work in a skilled nursing facility. I would never do this to a resident. It is a dignity issue. This is about dignity and (R108's) personal hygiene. This is about no lotion being put on (R108). Not put on her back and legs or her feet and legs. They need lotion especially since (R108) is diabetic. I washed (R108's) forearms once and the dirt was rolling off in the water. It was disgusting. My mother, (R108) did not live that when she was independent. She does not like smells or body odor and will tell staff and me. I ask the staff why they don't use the items I bring in and they don't answer me. My mother needs to have lotion because of the dry skin and she itches. She can't do it herself and she must lie there until I come in. I work full-time and can't be there every day. During an interview on 3/18/2026 at 10:44 AM, Housekeeping EEE reported resident rooms should be swept, mopped, and items picked up off the floor daily. Observed on 3/18/26 at 11:11 AM, in R108's room, under the heat register was a purple container of deodorant. A chair next to the resident's enteral feeding pole was a wadded-up fleece jacket and tube of ointment were all splattered with a dried sticky substance resembling the enteral feeding that was hung on a pole next to the chair. Dirt, dust, and debris along the floorboards, and dressers. Personal belongings of R108 were on the floor next to carrying totes that were in a corner. It resembled someone who had gone through the bags of belongings, spilling items out, and leaving them on the floor without picking them up. High-backed wheelchair had rubber missing completely around the right wheel. Observed on 3/19/2026 at 10:54 AM, R108 was in bed awake. At bedside was the tube feeding pole with pump. The pump, pole, pole base, floor underneath, and chair next to it were splattered with a dried sticky substance resembling tube feeding. The chair still had the tube of ointment and wadded up fleece jacket in it. On the floor next to the chair were the resident's belonging partially in the tote bags and partially out of the bags on the floor. Underneath the register was a purple container of deodorant. The resident's high-backed wheelchair had no rubber on the right rear wheel. During an interview on 3/19/2026 at 11:19 AM Unit Manager (UM) LL stated, (R108) Her daughter comes on Monday to give her a shower. Floors are the responsibility of housekeeping. Whoever sees the spill or leak should clean up and notify housekeeping to sanitize if needed. The aides and nursing staff are responsible for keeping rooms and belongings neat and tidy, including hygiene items and clothing. Staff are also responsible for respecting resident belongings. Whoever finds an issue with equipment puts it in TELS (a work order system for facility maintenance) and notify maintenance. R12Review of R12's Minimum Data Set (MDS) dated [DATE], revealed R12 had a BIMS (Brief Interview Mental Status) of 15/15 indicating he was cognitively intact. Section GG-Functional Status indicated R12 was dependent on staff for assistance with bed to chair transfer. Diagnoses included debilitating cardiorespiratory conditions. Review of R12's Care Plan Limited Physical Mobility, dated 1/5/26, revealed R12's limited mobility was related to bilateral total shoulder arthroplasties (restoring joint function by replacing joint) and removal of right shoulder. The goal was to remain free of complications using interventions that included providing supportive care and assistance with mobility as needed. During an observation and interview on 3/17/2026 at 10:17 AM, R12 was awake in bed. R12's room was crowded with bedside dresser, walker, wheelchair, bedside commode, and dresser against wall with no clear path to bathroom. On the floor under the bedside commode was a cookie in a wrapper, a plastic hanger, and the lid from the bedside commode. Along the floorboards, where the wall meets the floor, there was an accumulation of dirt and debris. During an observation and interview on 3/18/2026 at 11:48 AM, R12 was awake in bed. A picture was on the floor and the frame was broken. Next to it was the lid of bedside commode, a cookie in wrapper, and a plastic hanger same as day prior. Along the floorboards, where the wall meets the floor, there was an accumulation of dirt and debris. During an interview and observation on 3/19/2026 at 10:44 AM, R12 was in bed. The room had little space to move around with bedside commode, walker, and wheelchair. Underneath the bedside commode was the lid, along with a plastic hanger, in the same spot as the day prior (3/18/26). Along the floorboards, where the wall meets the floor, there was an accumulation of dirt and debris. The room was in the same condition as the two consecutive days prior except for the packaged cookie. There was a cookie on the bedside table that resembled the cookie that had been on the floor.

This incident is linked to intake 2612225.Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 resident (R14) of 3 reviewed for abuse, resulting in facility staff verbally assaulting R14 resulting in feelings of frustration, mental anguish, and a loss of autonomy (freedom from external control or influence). Findings include:According to the Minimum Data Set (MDS) dated [DATE], R14 was cognitively intact as evidence of a score of 15/15 on her Brief Interview Mental Score (BIMS) with a preferred language of Kinyardwanda and needed an interpreter to communicate with doctor or health care staff. R14 was independent with her ADLs (activities of daily living) and had diagnoses that included anemia, diabetes, PTSD (post-traumatic stress disorder), and cirrhosis of liver. Review of R14's Care Plan dated 11/25/25, Communication concerns, Cognitive deficits, Language barrier.speaks Kinyarwanda. The goal for R14 was to continue to communicate at present level with optimal understanding. Interventions to meet the resident's goals included interpretation services and the use of simple questions/commands, ask open-ended questions, and give resident time to respond. Review of R14's Care Plan, Behavior Problem related to history of trauma, dated 11/25/25, revealed the goal for the resident was to have no evidence of behavior problems. Interventions used to meet goal included caregivers to provide opportunity for positive interaction.speak in a calm manner. Review of Progress Note dated 8/15/26 at 4:55 PM, indicated R14 went to the facility Social Services Coordinator to report an incident with a CNA (Certified Nursing Assistant). A translation device was used for communication. R14 gave a detailed report on a verbal exchange with a CNA and alleged a hostile attitude, curse words, and insults were used. R14 reported she was very scared and could not sleep the rest of the night. During an interview on 3/19/26 at 8:52 AM, Social Services Coordinator (former employee) stated, I remember that incident centered around a CNA pulling something away from (R14). (R14) could be kind. During an interview on 3/19/26 at 12:30 PM, Registered Nurse (RN) DD stated, I was working on the night of the incident with (CNA SSS). (CNA SSS) was passing waters to the residents on the 600 hall. (R14) wanted two cups of water while (CNA SSS) explained the water was for other residents and would got get (R14) another cup of water. When (CNA SSS) told (R14) No, (R14) grabbed a cup of water and then grabbed (CNA SSS) by the back of the neck. (CNA SSS) told (R14) Don't touch me. I stepped in and told (CNA SSS) to finish passing waters and to stay at the other end of the hall with me. No other staff were around. It was just me, (CNA SSS) and R14 in the hall during the incident. (Nursing Home Administrator (NHA) A) did not interview me. No one contacted me or said anything to me.During an interview on 3/19/26 at 12:49 PM, NHA A reported he was the Abuse Coordinator. NHA A stated, I interviewed (RN DD) because CNA NN was down by the low 600 hall rooms when CNA SSS was passing waters. CNA NN was in room [ROOM NUMBER] and overheard (CNA SSS) call (R14) a Bitch.During an interview on 3/19/26 at 2:42 PM, CNA NN stated, I was working the night of the incident between (CNA SSS) and (R14). When the incident happened, I was on my way to answer a resident's call light. (CNA SSS) had her ear buds in her ears and was talking. I went into room [ROOM NUMBER]. (R14) was sitting next to (CNA SSS) near the nursing station between 1 AM and 5 PM. (CNA SSS) could not understand (R14) because of the different language (R14) spoke. I heard (CNA SSS) say, This Bitch got me messed up. I don't know who she was talking to. I don't know if she was talking to someone on her earbuds or who she was talking to. I believe (CNA SSS) was talking about (R14). (CNA SSS) had been a bully to me all week and I didn't want to get between her and (R14) so I just turned and walked away. I told the nurse (RN DD) that (CNA SSS) was fussing at (R14) but not until the next morning. I did not check on the resident. My responsibility is to the residents and to keep them safe, but I wanted to stay away from (CNA SSS) because she was a bully. During an interview on 3/19/26 at 3:00 PM, CNA SSS stated, I was passing ice waters on (R14's) end of the hall. When I went into (R14's) room I gave the husband water and I gave (R14) one. R14 wanted two waters. I told (R14) I would get her one when I was done passing water to the other residents. (R14) followed me out to the hall speaking in her language (Kinyarwanda). I picked up a cup of water to go into another room. (R14) snatched it from me and I told her no. She grabbed my shirt. I pulled away from her. I told her NO! You don't grab me. At that point of time, I had the cups labeled with date and room number. So, she had to wait until I was done passing all waters. I wanted to pass the cups of water I had ready before I gave her another cup of water. (R14) was fussing at me in her language. (RN DD) got (R14) water. I did not call (R14) any names. I didn't touch her. I told her not to grab me. It was me and (RN DD), and one other CNA who was coming down the hall during the incident. I've not had any other encounters with (R14). (R14) will tell you about her needs. She knows more English (language) than she lets on. I did not receive abuse education. I have had in-services on abuse 1-2times a year. I've had dementia and behavioral training. I would never harm any resident. It was a language barrier. When I talked to (NHA A), I told him there is no way to communicate with a different language. There was not way to explain what I was doing and for her to understand. Language plays a big part of communication. I did not know there was an app or have a phone to use it. During an interview on 3/19/26 at 4:00 PM, R14 was leery at first speaking to surveyor but with aid of translator was cooperative. R14 stated she remembered the incident when CNA SSS was passing water and would not give her 2 cups of water. I don't know why she could not give me 2 cups of water. She (CNA SSS) said No, those are for the other people. She did not tell me why, just no. I reached for a cup of water and she pushed at me, told me Fuck, Fuck Bitch She was not nice at all. Why did she have to be like that? What she said and did to me did not make me feel good at all. R14 appeared sad and shook her head.

This citation pertains to intake #2608884Based on interview and record review, the facility failed to safeguard credit card numbers for 1 resident (Resident #127) of 3 residents reviewed for abuse, resulting in a staff member making an unauthorized purchase using a resident's credit card.Findings include:Review of an admission Record revealed Resident #127 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: frontotemporal neurocognitive disorder (early onset decline in cognitive function). Review of a Facility Reported Incident (FRI) dated 8/13/25 at 11:08 AM regarding misappropriation for Resident #127 revealed, On 8.13.25 at approximately 10:30am, business office manager (BOM O) was on the phone with the resident's brother (Family Member (FM) SS) who handles the resident's financial transactions for billing. He stated he had had to block his old card and that was why a patient bill amount had been rejected and so he needed to establish a new card. (BOM O) asked him how that had happened, he stated it was because of a purchase at the ([NAME] name omitted) of $205 for a motorcycle battery that had occurred on 7.19.25 over the phone and shipped to this facility. He stated that he brought the concern to (Administrator in Training (AIT) R). Investigation Summary.Regarding (Resident #127) and Former Employee (AIT R).Shortly after the time (FM SS) stated he had come to talk to (AIT R) about this CC (credit card) transaction, he (AIT R) submitted notice of his resignation on 8.3.2025. His last day worked was 8.8.2025 Summary of Incident: On 8.13.2025 at approximately 10:15am, the facility Business Office Manager (BOM O), spoke with the resident's guardian, (FM SS), regarding the declination of his credit card when attempting to process (Resident #127's) payment to the facility for the month. (FM SS) stated that he had to have his card blocked a few weeks ago (approx. end of July 2025) because of a transaction he had noticed on his card. The purchase was for a motorcycle battery at the ([NAME] name omitted) made on 7.19.2025. He stated that when he went to the store to inquire about it they told him that the purchase had been a phone order that had been placed and shipped to this facility's address. (FM SS) brought this information to meet with someone at the facility and was waiting in the hall to talk with the (BOM O) when (AIT R) approached him and said he could assist. (AIT R) received the information about the credit card transaction and told (FM SS) he would follow up on it for him. According to (FM SS), about 1 week later, (AIT R) approached him with cash equivalent to the credit card transaction that had been made and told him it was from a special fund and that he should be all set now and that this kind of thing happens all the time. (FM SS) believed him and was satisfied with the follow up. No details of this situation were ever disclosed or reported by (AIT R) to anyone else in the facility. Immediate Action: (BOM O) reported to the NHA (Nursing Home Administrator A) the suspicious activity. The NHA called (FM SS) and asked if he could come in right away to review his CC statement, which he did. The statement line itemed a purchase at the ([NAME] name omitted) on 7.19.2025 for $204.99. The NHA called the ([NAME] name omitted) and using the facilities main number of (XXX-XXX-XXXX), the sales associate was able to locate an invoice for a phone purchase made with the residents mastercard for $204.99 for a motorcycle battery that was under the name (facility name omitted) with this facility's address for shipping the item. A copy of that invoice was obtained . The NHA attempted to contact (AIT R) via telephone, who answered. When the NHA explained to him what was being inquired about, he refused to answer and stated that he had something going on and needed to go. He stated he would call back but never did. Ongoing Investigation/Action: .Further discussion with (BOM O) revealed that it was sometime back in March 2025 when the residents first monthly payment was due that she received the credit card information from (FM SS) via a text message. She attempted to forward this text to her company email but was not successful. She then forwarded the text to (AIT R), who assisted her with getting the image of the card formatted and copied into an email back to her. To her knowledge (AIT R) was the only other employee outside of the business office that would've had access to this card information. The NHA also recalled that it was around the end of July that (AIT R) had begun riding his motorcycle to work.Conclusion: Evidence strongly suggests due to the nature of the purchase (motorcycle battery), the use of this facilities phone and address to make the purchase, the access to the card that (AIT R) had via text message, along his failure to report anything about it when brought to him by (FM SS), along with his re-imbursement of (FM SS) from an unknown cash source and then resignation shortly after, that a financial misappropriation did occur.In an interview on 03/18/2026 at 10:09 AM, FM SS reported that he had given a copy of Resident #127's credit card that was pre-loaded with his social security funds, to BOM O for his bills at the facility and in July he had noticed a purchase on the card for a motorcycle battery that was made on 7/19/25. FM SS reported that he went to the store where the motorcycle battery was purchased and they printed the invoice for him and said that it was a charge made over the phone from someone at the facility. FM SS reported that he drove to the facility to discuss his concern with BOM O but was approached by AIT R who assured him that it would be taken care of. FM SS reported that a couple weeks later AIT R contacted him and wanted to meet at a gas station to reimburse FM SS for the $205 that was charged to the credit card. FM SS reported that he and AIT R met and he received the cash and didn't think again about it until 8/13/25 when NHA A called FM SS to inform him that they were investigating the unauthorized charges that were made on the credit card. FM SS reported that at the time he did not choose to press charges.In a phone interview on 03/18/2026 at 10:35 AM, Former staff, AIT R reported that he resigned from the facility in August 2025. AIT R replied to all of this surveyor's questions by stating I don't recall or I don't know. This surveyor asked if he was aware of an issue with a resident's credit card being used to purchase a motorcycle battery on 7/19/25, did BOM O ask for his assistance with a credit card image for a resident, did NHA A contact him about an issue with an unauthorized credit card purchase, did he speak with a family member about an unauthorized credit card purchase, and did he meet a family member and/or give a family member cash to reimburse for an unauthorized credit card purchase. AIT R declined to provide any other answers prior to ending the call.In an interview on 03/18/2026 at 12:43 PM, NHA A reported that BOM O had notified NHA A on 8/13/25 about a conversation that she had with Resident #127's guardian FM SS related to having to block a credit card due to an unauthorized charge and that AIT R had reimbursed for the charge. NHA A reported that he had started working at the facility just prior to them finding the issue and AIT R had resigned 5 days before the issue was identified. NHA A reported that Resident #127's guardian FM SS was asked to come into the facility for his statement and the police were called. NHA A reported that they concluded that the misappropriation occurred as a result of AIT R using Resident #127's credit card number for a personal purchase for his motorcycle, based on the evidence from the ([NAME] name omitted) and the consistency in reports from FM SS and BOM O. NHA A reported that after the misappropriation was identified, all resident's that had credit cards on file were assessed and guardians were contacted to ensure that no further misappropriation had occurred. NHA A reported that the facility performs weekly Advocate Rounds with residents, which includes asking if they feel their belongings are safe and secure. NHA A was not able to find the Advocate Rounds tool document to review the questions with this surveyor but said that Concierge BB keeps track of those.In an interview on 03/18/2026 at 1:35 PM, Concierge BB reported that the Advocate Rounds tool did not include any questions related to safety and security of belongings or personal funds and they were instructed to ask the questions word for word.Review of Advocate Rounds Tool blank document which revealed, Ask open ended questions: How are you today? Did you get enough to eat at mealtime? Has the staff been kind, courteous, and friendly? Is your call light answered timely? Are you comfortable? Do you have any questions about your care? Do you need some water? Are you satisfied with your doctor? Has the housekeeping staff been keeping your room clean? Do you have any concerns/issues with your clothing? Is there anything I can do for you?In an interview on 03/19/2026 at 9:16 AM, BOM M reported that she started about 3 months ago and had no knowledge of Resident #127's credit card issue and/or that there was ever an issue with a resident's credit card being used by a staff member.In an interview on 03/19/2026 at 9:41 AM, Former staff, BOM O reported that she was looking into why Resident #127's payment did not process for August of 2025 and contacted his guardian FM SS for more information. BOM O reported that FM SS said that he would have to unlock the card for the payment to process; he had locked in a couple weeks earlier when he noticed an unauthorized charge on 7/19/25. FM SS went on to explain to BOM O that former staff AIT R had assisted him with getting reimbursed for the charge, getting cash from a special fund, because the unauthorized charge had been made by someone at the facility. BOM O reported that she immediately reported the concern to NHA A and it was investigated. BOM O reported that several months prior she had received Resident #127's credit card image because they were applying for Medicaid and due to the unusual card type they required an imagine. BOM O reported that she could not open the image that FM RR had sent, therefore she contacted the former NHA and was instructed to send it to AIT R and that he would print it for BOM O. BOM O reported that normally they do not receive images of credit cards. BOM O reported that AIT R and BOM O would have been the only people at the facility with access to Resident #127's credit card number.

Based on observation, interview, and record review, the facility failed to ensure residents were not prescribed PRN (as needed) psychotropic medications for greater than 14 days for 1 resident (Resident #18) of 5 residents reviewed for unnecessary medications, resulting in lack of monitoring and medical necessity documented to extend use of PRN anti-anxiety medication.Findings include: Resident #18Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with psychotic disturbance. (anxiety was not noted in diagnoses)During an observation on 03/18/2026 at 4:34 PM Resident #18 was independently walking in the hallway near the nurse's station.Review of Resident #18's IDT (Interdisciplinary Team) Progress Note dated 2/8/26 revealed, .review of unwitnessed fall.Resident has diagnosis of dementia and prefers to walk independently on the unit, with occasions of restlessness and is receiving hospice services. Intervention for nursing to offer walks when observed to be restless.Review of Resident #18's Nursing Progress Note dated 2/9/26 at 11:06 AM revealed, .hospice case manager in facility today.initiate for resident increased anxiety/agitation Ativan (anti-anxiety medication) 0.5 mg (milligram)1 tablet every 6 hours PRN.Review of Resident #18's Physician Note dated 2/10/26 at 9:36 AM revealed, .Nursing reports new hospice orders, recommending Ativan 0.5 mg every 6 hours PRN.A/P (assessment and plan): .Anxiety: Start Ativan 0.5 mg PO (by mouth) q (every) 6h (hours) PRN x 14 days per hospice recommendations. Benefit > risks.Eval in 14 d (days) or less.Review of Resident #18's Physician Orders revealed, Ativan (anti-anxiety medication) tablet 0.5 mg give 1 tablet by mouth as needed for anxiety, restlessness; BID (twice daily) PRN for 14 days. Please document non-pharmacologic interventions attempted. 1=redirection, 2=reduce stimulation, 3=reorient, 4=provide basic needs (food, fluids, toileting & comfort) 5=exercise. Start date: 2/10/26. Review of the corresponding Medication Administration Record (MAR) indicated 1 dose was given on 2/12/26 at 9:42 PM after the following interventions: 1 (redirection), 2 (reduce stimulation), and 3 (reorient).Review of Resident #18's Physician Note dated 2/23/26 at 12:27 PM revealed, .Pt (patient) due for Ativan evaluation.A/P: .Anxiety: Ativan evaluated. Patient has had a good response to this medication, and it improves the quality of this resident's life. Medication should be continued despite the potential adverse effects, benefits outweigh risks. There was no documentation related to rationale to prescribe for longer than 14 days.Review of Resident #18's Physician Orders revealed, Ativan (anti-anxiety medication) tablet 0.5 mg give 1 tablet by mouth as needed for anxiety, restlessness; BID (twice daily) PRN for 90 days. Please document non-pharmacologic interventions attempted. 1=redirection, 2=reduce stimulation, 3=reorient, 4=provide basic needs (food, fluids, toileting & comfort) 5=exercise. Start date: 2/23/26. Review of the corresponding Medication Administration Record (MAR) indicated that 3 doses had been given as of 3/19/26. These were the dates: 3/6/26 at 9:56 PM intervention #4 (provide basic needs), on 3/14 26 at 5:07 PM intervention #4, and 3/15/26 at 10:01 PM intervention #1 (redirection). In an interview on 03/19/2026 at 1:46 PM, Agency-Licensed Practical Nurse (A-LPN FFF) reported that on 3/6/26 she administered Ativan to Resident #18 because he had gotten out of bed and was wandering around. A-LPN FFF reported that the aides had not reported that Resident #18 had been having anxiety that night.In an interview on 03/19/2026 at 1:52 PM, A-LPN HHH reported that she had administered Ativan to Resident #18 a few days earlier because he had been wandering around the building a lot. A-LPN HHH reported that Resident #18 was a fall risk.Review of Resident #18's Physician Note dated 3/18/26 at 1:27 PM revealed, .Pt (patient) due for Ativan evaluation.A/P: .Ativan evaluated: Patient has had a good response to this medication, and it improves the quality of this resident's life. Medication should be continued despite the potential adverse effects, benefits outweigh risks.In an interview on 03/19/2026 at 12:50 PM, Nurse Practitioner (NP) II reported that Resident #18's PRN Ativan prescription was a recommendation from hospice and was originally written on 2/10/26 for 14 days and then when it was re-evaluated on 2/23/26 the new order was for 90 days. NP II reported that she re-evaluated Resident #18 twenty-two days later on 3/5/26 and then again on 3/18/26.

This citaiton pertains to intake number MI00134147. Based on interview and record review, the facility failed to monitor and treat pressure ulcers per nursing professional standards for 1 resident (R110) of 3 reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer with the potential for infection and overall deterioration of health status. Findings include: According to the Admission Record, R110 admitted to the facility on [DATE] as his own person with diagnoses that included fracture of left femur fracture, protein-calorie malnutrition, megacolon, heart failure, and chronic kidney disease stage 3/4. Review of R110's Nursing Admission Screening/History 12/9/2022 reported the resident's cognition was intact with a 3 cm (centimeter) x 3 cm area on groin, 1 cm x 8 redness on right iliac crest, and 1 cm x 8 redness on left iliac crest. Review of R110's Order Summary order date 1/16/2023 start date 1/18/2023 bilateral buttocks open area cleanse with NS (normal saline), pat dry, apply collagen to wound bed and cover with foam boarder dressing. Change M-W-F and PRN (as needed) every day shift every day shift every Mon for MASD (moisture associated skin damage). Review of R110's Order Summary Review order date 1/16/2023 start date 1/18/2023 bilateral buttocks open area cleanse with NS (normal saline), pat dry, apply collagen to wound bed and cover with foam boarder dressing. Change M-W-F and PRN (as needed) every night shift every Wed, Fri for MASD. Review of R110's Order Summary order/start date 12/27/2022 Nystatin External Powder 100000 Unit/GM apply to affected areas topically every shift for fungal rash for 30 days please apply to left abdominal fold. It was noted there was no order to apply the Nystatin External Powder to the resident's right abdominal fold. Review of R110's Medication Administration Record/Treatment Administration Record (MAR/TAR) 12/1/2022-12/31/2022 revealed Hydrocortisone External Cream 2.5% apply to affected areas topically two times a day for rash on medial right thigh for 7 days start/order date 12/15/2022. It was noted, this is not an order for the resident's buttock or groin. Further review of R110's MAR/TAR 12/1/2022-12/31/2022 revealed Hydrocortisone External Cream 2.5% was reported to be scheduled for application at 7 AM and 18:00 (6:00 PM) and was applied topically to the resident's groin without an order on: -12/16/2022 at 10:13 (AM) -12/16/2022 at 04:24 (AM) -12/17/2022 at 15:40 (3:40 PM) -12/18/2022 at 00:34 (AM) -12/18/2022 at 09:17 (AM) -12/19/2022 at 07:38 (AM) Review of R110's MAR/TAR 1/1/2023-1/31/2023 revealed - Review of R110's Order Summary order/start date 12/27/2022 Nystatin External Powder 100000 Unit/GM apply to affected areas topically every shift for fungal rash for 30 days please apply to left abdominal fold. It was noted there was no order to apply the Nystatin External Powder to the resident's right abdominal fold. Further review of R110's MAR/TAR 1/1/2023-1/31/2023 revealed that the Nystatin External [NAME] 100000 Unit/GM was applied to the right abdominal fold without an order. Review of R110's Skin Observation Tool: -12/10/2022 Intergluteal cleft 4.0 x 0.2 x 0.0, Intergluteal cleft with MASD -12/21/2022 no new changes in skin integrity -12/28/2022 no new changes in skin integrity -1/4/2023 no new changes in skin integrity -1/11/2023 no new changes in skin integrity -1/16/2023 right buttock MASD 2.5 x 2.5 x 0 Stage II, in-house acquired During an interview on 10/11/2023 at 3:08 PM, Director of Nursing (DON) B stated, There was a QAPI done because skin issues were being missed. After the facility audited for skin issues, we found there were spots in the system that had to be fixed. During an interview on 10/12/2023 at 10:30 AM, Nursing Home Administrator (NHA) A stated, On 1/27/2023, the facility discovered there was an issue with wounds, in-house acquired pressure ulcers were noted but not reported to the licensed nurse and non-licensed staff were practicing outside the scope of standards. An Action Plan was started. On 2/22/2023 we discovered a nurse had made errors, so the Action Plan was changed again to reflect what the facility needed to do to correct these issues. On 3/8/2023, I feel the issue was resolved. Review of R110's Progress Note 12/9/2023 13:30 (1:30 PM) revealed, .barrier cream to bil (bilateral) buttocks to monitor. It was noted there was no order for barrier cream to be applied to resident's buttocks. Review of R110's Progress Note 12/11/2022 03:07 (AM) revealed, .Resident was noted with Intergluteal MASD 4.0 x 0.2 cm, pink blanching base, scant serous drainage, no malodor, peri-wound intact. Cleaned with NS, applied zinc oxide cream. Resident aware. Physician aware. Review of R110's Physician Note 12/12/2022 00:00 (AM) was noted the physician did not discuss the resident's Intergluteal MASD, that was said to have been brought to their attention. Review of R110's Progress Note 12/ 12/2022 13:06 (1:06 PM) Late Entry: revealed, .He has MASD to bottom and treatment is in place . It was noted there were no treatment orders for the resident's bottom. Review of R110's History and Physical Note 12/13/2022 00:00 (AM) was noted the physician did not discuss the resident's Intergluteal MASD, that was said to have been brought to their attention. Review pf R110's Progress Note 12/18/2022 02:39 (AM) reported Dressing to right abdomen changed without an issue. It was noted there was no order for the dressing. Review of R110's Progress Note 12/20/2022 00:00 (AMA) Physician's Note did not report skin issues to Intergluteal fold or abdomen. Review of R110's Progress Note 12/26/2022 00:00 (AM) revealed, .Abdominal .has bandage over RLQ (right lower quadrant over opening (not quite fistula) . It was noted there was no order for a dressing nor was Intergluteal fold skin issue discussed. Review of R110's Progress Note 12/27/2022 11:54 (AM) Left abdominal fold is red .Requested order for Nystatin powder . Review of Progress Note 1/15/2023 15:51 (1:51 PM) .CNA reported to nurse that patient had skin alteration to buttocks .open area to right and left buttocks. Wound bed is red/pink with some blanching noted, skin is peeling, and scant blood noted at edges of peeling skin. Site is tender when touched per patient (resident) R (right) buttocks - 4 x 3 x 0.1, L (left) buttocks 3 x 3.5 x 0.1 . Review of R110's Progress Note 1/17/2023 00:00 (AM) revealed, . MASD on bilateral buttocks .wound team will follow and resident was seen today. Left buttock measures 2.5 x 2.5 x 0.1 and right buttock measures 2.5 x 2.5. 0.1 . Review of R110's Progress Note 1/18/2023 15:37 (1:37 PM) revealed, .abdominal fold open area inferior to umbilicus, [NAME] x 6 cm x 0.1 cm. Left abdominal fold open 0.5 cm x 3 cm x 0.1 cm.Left buttock open area 3 cm x 3 cm x 0.1 cm. Right buttock open area 5 cm x 3 cm x 0.1 cm . Review of R110's Progress Note 1/23/2023 17:30 (5:30 PM) revealed, .Addendum to initial skin alteration note, MASD incorrectly added, actual diagnosis is Stage 2 pressure to bilateral buttocks. Review of R110's Progress Note 1/23/2023 18:04 (6:04 PM) revealed, .being admitted to (name of hospital) . Review of R110's ED to Hospital admitted d 1/23/2023 revealed, .Diagnosis .failure to thrive in adult . urinary tract infection without hematuria .hospitalized presenting with abnormal labs .white blood cell count (WBC) 19 (reference range 4.0-10.0) .multiple superficial sacral ulcers .WOC (wound on-call) nurse consulted for wound on left buttock and coccyx along with groin skin fold and mid lower abdominal wound. Incontinent of bowel and bladder, immobile at baseline. Over the left buttock a partial thickness open wound remains with a pick base .Another open area is present over the midline coccyx, pink in color and partial thickness .left buttock stage 2 pressure injury. Coccyx stage 2 pressure injury .Midline lower abdominal wound present, patient unclear of cause but likely form moisture. Wound bed red, small amount of serosang drainage .area m easures 1.3 x0.2 cm .left groin fold with small linear open area . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included audits, education, and trainings. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI 809. Based on interview and record review, the facility failed to prevent the significant medication errors in 2 of 2 sampled residents (Resident #281 and Resident #113) reviewed for medication errors, resulting in Resident #281 becoming unresponsive, requiring emergency transport and admission to a hospital with intubated and placed on a ventilator and Resident #113 having a [CONDITION(S)] after not recieving his medications for [CONDITION(S)]. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R281 scored 12/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R281 required extensive assistance with all her ADLs (activities-of-daily-living) with the exemption of eating. Review of R281's eINTERACT 10/1/2022 00:45 (AM) reported the resident was sent to the hospital on 10/1/2022 at 00:52 (AM) due to being unresponsive. Review of R281's Progress Note 10/1/2022 01:41 (AM) revealed, On 10/1/2022 at 00:15 (AM) the nurse went into resident room to pass midnight medication and resident was unresponsive. Vital signs were B (blood pressure) 52/32, HR (heart rate) 64, Resp (Respirations) 18 with a brief period of apnea, BS (blood sugar) 118, O2 sat 87%, sternal rub was ineffective .called 911 and resident was transferred by Life EMS paramedics to (name of hospital ER). Review of R281's Hospital Emergency Summary 10/1/2022 2:36 AM reported, Chief Complaint: low blood pressure with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's history of present illness to be resident was found unresponsive and apneic (temporary cessation of breathing). Found to be hypotensive at 50/30 with agonal respirations. Hypothermic at 95 degrees Fahrenheit. R281 arrived at the ER via EMS (emergency medical service/ambulance) with a continued GCS of 3 (Glasgow Coma Scale 3 the lowest possible score and is associated with an extremely high mortality rate) with infrequent spontaneous respiration. There was no evidence of gag reflex, corneal reflex, (brainstem reflexes) on exam with concern for failure to protect her airway and episodes of apnea, the ER elected to proceed with intubation. Labs did not indicate [CONDITION(S)], elevated CO2, or shock. CT scans did not have abnormal findings. R281 was then transferred to the ICU for further evaluation. Review of R281's Hospital ICU Summary 10/2/2022 reported the resident had [CONDITION(S)] with a comprehensive drug screen result with medications not listed on her medication record. Polypharmacy with drug screen positive for cannabinoids and [MEDICATION(S)]/[MEDICATION(S)] ([MEDICATION(S)] (use for [CONDITION(S)]) may occasionally cause serious cardiovascular side effects such as low blood pressure and cardiac or respiratory arrest) ([MEDICATION(S)] ([MEDICATION(S)]) atypical antidepressant) (not part of her home medications). During an interview on 11/16/2022 at 3:30 PM, Nursing Home Administrator (NHA) A stated, The facility did a thorough investigation regarding the medication. The facility found that the nurse gave (R281) her roommate's (R110's) medications in error. The nurse that mixed up the medications has been let go. During an interview on 11/17/22 at 4:51 PM NHA A stated, I believe the nurse may have preset meds. We monitored (R110) for adverse effects of possibly getting (R281's) medications. Director of Nursing (DON) B stated, The nurse told us she gave (R110) the medications first then went to (R281) and gave her medications. These were HS (bedtime) medications. During an interview on 11/18/22 at 8:31 AM Licensed Practical Nurse (LPN) RRR stated, I was the nurse on September 30th (2022). I worked the night shift. I only work once in a while. I still work there as needed. I gave medications to (R110) first then I gave (R281) her medication. (R281) was a diabetic. I gave (R281) her medications in applesauce. I usually do not preset medications. I could not give (R110 and R281) medications at the same time because (R281's) insulin stuff is in a basket and my hands would be full. I would do not do (R110 and R281) medications at the same time anyways because the electronic MAR (Medication Administration Record) is not set to room number order. It is set by resident, so I did not give (R110's) medications to (R281). Review of R110's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R281's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 300 mg 1 capsule for [CONDITION(S)] pain -Insulin [MEDICATION(S)] solution for diabetes mellitus -[MEDICATION(S)] 3 mg 1 tablet for [CONDITION(S)] -[MEDICATION(S)] 40 mg 1 tablet for lipid control -[MEDICATION(S)] 5 mg 1 tablet anticoagulant -[MEDICATION(S)] 50 mg 1 tablet for hypertension -Acetaminophen 500 mg 2 tablets for pain (2200/10:00 PM) Review of R281's [DATE]/30/2022 revealed the side effects for [CONDITION(S)] medication (antidepressant) of any medication classification; including, but not limited to increased sedation, drowsiness, lightheadedness, [CONDITION(S)] . was not documented as being done for the evening shift, 7:15 PM. Resident #113 Review of an Admission Record revealed Resident #113 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 10/14/2022 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #113 was cognitively intact. In an interview on 11/16/2022 at 9:43 AM, Resident #113 reported that staff failed to give him 5 of his [CONDITION(S)] medications on Monday night. Resident #113 reported that staff told him that his medications were not in the drawers or in backup. Review of Resident #113's November 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ([MEDICATION(S)]) Tablet 200 mg, give 3 tablets by mouth at bedtime related to [CONDITION(S)] was not given on 11/13/2022 and 11/14/2022. [MEDICATION(S)] ([MEDICATION(S)]) tablet 100 mg, give 2 tablets by mouth two times a day for seizures was not given the evening of 11/11/2022 and on 11/12/2022. Review of Drugs.com revealed, [MEDICATION(S)] is an anti-epileptic drug. Do not stop using [MEDICATION(S)] suddenly or you may have increased seizures. Titrate in increments of 100 mg (50 mg twice a day) no more frequently than once a week based on clinical response and tolerability [MEDICATION(S)] is used to treat partial onset seizures in people with [CONDITION(S)]. Do not stop using [MEDICATION(S)] suddenly, even if you feel fine. Stopping suddenly may cause serious medical problems or increased seizures. Follow your doctor's instructions about tapering your dose [MEDICATION(S)] is used to treat partial-onset seizures in adults. Do not stop using [MEDICATION(S)] suddenly. Stopping suddenly may cause increased seizures or unpleasant withdrawal symptoms. Follow your doctor's instructions about tapering your dose Titration of [MEDICATION(S)]: 25 mg orally once a day for weeks 3 and 4; 50 mg orally once a day for weeks 5 and 6; 100 mg orally once a day for weeks 7 and 8; 150 mg orally once a day for weeks 9 and 10 .titration should not be exceeded because of the potential for serious adverse reactions Review of the hospital Emergency Department record dated 11/15/22 revealed, pt (Patient) a/ox4 (alert and oriented times 4) called EMS because he woke up from a nap stating he urinated himself, which he says happens when he has a [CONDITION(S)]. Pt states SKLD didn't have some of his [CONDITION(S)] meds for the last two days. Missing five doses. Pt hx of [CONDITION(S)] and has brain shunt .Patient is a [AGE] year-old male with extensive history of seizures, has shunt in place, presenting from a skilled nursing facility because he did not receive his antiepileptic medications since last night. Patient is worried because he has a history of status epilepticus including a 4 month stay last year. Patient notes that remote monitoring shows that he has a [CONDITION(S)] every day, but the shunt is able to suppress it. Patient is concerned about not receiving his antiepileptic medications, and has no other questions or concerns today . In short, this is a [AGE] year-old male with a history of seizures who takes for [CONDITION(S)] medications daily. At his facility last night, a couple of his medications were not given to him and he had a [CONDITION(S)] this morning. The previous resident spoke to neurology and they would like to give all for of his medications now since it is not clear which once he missed. The plan is after he gets his medication doses he can go back to the facility. Patient care is contacting the facility to discuss why he missed his doses in to make sure that does not happen again. Currently, patient is in stable condition and back to baseline. Patient received his [CONDITION(S)] medications. Care management spoke to the patient and is going to work out a plan to possibly have him transferred to a different care facility. Patient is stable to discharge after getting his [CONDITION(S)] medications because his seizures were most likely caused by missing doses of his medicine last night and his seizures were unlikely to be caused by a secondary source. Patient has a history of status epilepticus so we did not want to delay providing patient with anti epileptic medications and risk a [CONDITION(S)] or status epilepticus. According to John's Hopkins medicine, status epilepticus is defined as A [CONDITION(S)] that lasts longer than 5 minutes, or having more than 1 [CONDITION(S)] within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death. In an interview on 11/18/2022 at 11:26 AM, Nursing Home Administrator (NHA) A reported that at the time of these medication issues the facility was switching to a new pharmacy and working through issues. NHA A reported that Resident #113's missed doses of medications were documented as not being available. NHA A reported that nursing staff attempted to contact the pharmacy but did not document this.

Based on interview, and record review, the facility failed to operationalize policies and procedures to ensure all staff were fully vaccinated for COVID-19 or possessed an approved exemption in a timely manner, in 2 of 20 staff members reviewed for COVID-19 vaccination status, resulting in the potential for transmission of COVID-19 to a vulnerable population. Findings include: Review of a COVID-19 Staff Vaccination Matrix, provided by the facility on 11/17/22, revealed Receptionist FF was highlighted in red (indicating exempt per the document key), with no COVID-19 vaccination information or exemption information documented on the form. Review of a COVID-19 Staff Vaccination Matrix, provided by the facility on 11/17/22, revealed Registered Occupational Therapist (OTR) FFF was highlighted in red (indicating exempt per the document key), with no COVID-19 vaccination information or exemption information documented on the form. In an interview on 11/17/22 at 1:54 p.m., Director of Nursing (DON) B reported eight residents had tested positive for COVID-19 since 11/12/22. DON B reported all current COVID-19 positive residents were placed on Transmission-Based Precautions on the 300 Hall. DON B reported no hospitalization s or deaths related to the current COVID-19 outbreak at the facility. Requested vaccination/exemption documentation for Receptionist FF and OTR FFF, along with additional sampled staff members, on 11/17/22 at 3:10 p.m. via email. Reviewed vaccination/exemption documentation provided by facility staff via email. Noted no documentation provided for Receptionist FF. Noted a request for a religious exemption for OTR FFF, however, no documentation provided to verify whether or not the request was approved. In an interview on 11/18/22 at 2:52 p.m., with Administrator A and DON B, Administrator A stated in regard to the documentation requested for Receptionist FF .It appears she applied for an exemption and it was not approved . Administrator A and DON B reported there was no follow-up after the exemption was denied. Administrator A and DON B reported Receptionist FF had applied for the exemption in January of 2022. DON B stated in regard to OTR FFF's request for a religious exemption .I reached out to our Director of Rehab .I asked for something that says whether it is approved or denied .She is waiting for her company to get back to her . No additional vaccination/exemption documentation provided for Receptionist FF and OTR FFF prior to survey exit. Review of the policy/procedure Mandatory COVID-19 Vaccinations, dated 10/10/22, revealed .It is the policy of this facility/company to require all staff members to comply with the COVID19 vaccination requirements, in conjunction with all state and/ or federal requirement(s) .PURPOSE: To prevent the spread of the COVID19 virus and to ensure the health and safety of residents and staff members .As a condition of employment all staff members must receive the COVID19 vaccination or possess an approved exemption .If a staff member declines immunization because it conflicts with held religious beliefs, the staff member must complete the Staff- Covid Vaccine Religious Accommodation Request and Response Form .Exemptions will be approved or disapproved based on the EEOC Compliance Handbook .The approval or disapproval of the Medical or Religious Exemptions will be communicated back to the staff member via email .The facility/company will track all staff members vaccination statuses or exemption statuses on a Vaccination Tracking Tool .The facility/company will validate and obtain the vaccination cards or exemptions for all current staff members by 01/27/2022 .The facility/company will obtain documentation of a granted exemption from vaccination to include the type of exemption and the supporting documentation .

This citation pertains to intake #MI 919. Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers, and provide pressure ulcer treatments and monitoring consistent with professional standards of practice for 3 of 3 residents (Resident #103, #105, and #106) reviewed for pressure injuries, resulting in the unidentified pressure injuries for Resident #103 and Resident #106, and the worsening of a Stage I pressure ulcer for Resident #105, and the potential for further skin breakdown and infections. Findings include: Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE]. Review of a Facility Reported Incident (FRI) revealed, Facility incident report received via online submission on: 5/23/22 .Incident Summary: Family member made allegation of resident neglect .(Resident #103's Durable Power of Attorney (DPOA) stated that the hospital (name omitted) was investigating the facility for neglect of (Resident #103) .On 5/21 (Resident #103) was emergently transferred to (hospital) after he was found unresponsive, hypotensive (low blood pressure), and low oxygen saturation. He was admitted to the hospital for severe [CONDITION(S)] and [CONDITION(S)] (urinary tract infection). During interview with (DPOA), she stated she didn't realize how bad his dementia had got and didn't know it was to the point of him not being able to eat. She also stated that he had development a wound on his coccyx .The staff that have worked directly with (Resident #103) did notice a decline in him over the last few months, they have also noticed skin break down on him. He received a bed bath on both 5/12 and 5/19 and no skin issues were noted .He does have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital records do show a stage 2 coccyx wound .After the investigation was concluded it was determined that the allegations can be substantiated due to facilities failure to follow the companies skin protocol. Immediate skin sweeps were done throughout the facility with no other issues. Skin sweeps will now be conducted weekly for 4 weeks and then once a month for 2 months. Daily shower sheets will be reviewed daily at stand-up meeting . Review of Resident #103's Hospital Records from 5/21/22-5/29/22 revealed .admitted from SNF (skilled nursing facility) and noted to have wounds on buttock. Right elbow wound has healed .Assessment .Pressure injury of sacral region, stage 2 . The attached image revealed a large open wound covering both sides of the sacral area.HOSPITAL COURSE: .He was transferred out of the ICU (intensive care unit) on 5/25/22. He continued to have poor oral intake and required tube feedings .Pt. (patient) signed onto hospice and remained inpatient for comfort measures. He passed away on 5/29/2022 at 10:55pm . Review of Resident #103's Progress Note dated 5/21/22 revealed, Resident admitted to (hospital name omitted) with severe [CONDITION(S)], +[CONDITION(S)], [CONDITION(S)] (low blood pressure) . Review of Resident #103's facility Skin Observation Tool dated 5/10/22 revealed, .Non-Pressure .right elbow . There was no record that Resident #103 had a wound on the buttock. Resident #105 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 6/5/22 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #105 was cognitively impaired. Review of Resident #105's Care Plan revealed, Resident has potential/actual impairment to skin integrity .Current break in skin integrity (left inner calcaneus) (heel) .Date Created: 07/06/2022 .Interventions: .Follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Provide pain management with treatments as needed. Date Initiated: 07/06/2022 .Pressure relieving boots to bilateral lower extremities while in bed. Date Initiated: 07/06/2022 .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage) and any other notable changes or observations. Date Initiated: 07/06/2022 . Review of Resident #105's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 7/5/22 and blue boots on while in bed every shift for prevention. Order date 7/03/22. Review of Resident #105's eTAR (electronic treatment administration record) for July 2022 revealed that the above noted physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/20/22 at 5:01 A.M., Certified Nursing Assistant (CNA) T reported that Resident #105 and #106 did not have any open wounds and stated, .no one on this hall does . During an interview on 7/21/22 at 11:25 A.M., LPN HH reported that Resident #105 did not have any orders for wound treatments and stated, .she does not have any wounds that I am aware of . During an interview on 7/21/22 at 11:28 A.M., Unit Manager (UM) D reported that Resident #105 had a blister on her left heel that opened and was bleeding and stated, .now it is just a scab .it is healed now .no infection .it's not something that the wound doctor would follow anymore . Reviewing the physician orders, UM D reported that Resident #105 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . UM D reported that the nursing staff would not have known to provide wound care unless the treatment order was on the eTAR. During an interview on 7/21/22 at 12:03 P.M., UM E reported that Resident #105's original wound treatment was [MEDICATION(S)] and stated, .but if it wasn't on the eTAR the nurses wouldn't do it . UM E reported that she, along with Wound Doctor (WD) PP saw Resident #105 for the first time on 7/18/22, and at that time the wound was not covered with a dressing, and it was scabbed over, and therefore WD PP discontinued the order for [MEDICATION(S)] and ordered Skin Prep (strengthens skin) to the area, but that order had not been entered in the computer yet. UM E reported that WD PP's visit notes were not available at this time. During an observation and interview on 7/21/22 at 12:19 P.M. Resident #105 was in her wheelchair in her room and reported that her left foot hurt and stated, .it feels like I have a staple in it . UM D removed Resident #105's left shoe to reveal a bandage on the left heel dated 7/20/22 with the DON's initials on the dressing. UM D removed the dressing, and the wound was observed open, approximately the size of a quarter, the wound bed was covered in slough (dead tissue), the surrounding tissue was macerated and the entire heel was discolored pink. UM D stated, .I guess they think its [CONDITION(S)] (skin infection) now .I just found out looking through her notes .she has an antibiotic ordered . UM D reported that Resident #105 had not started the antibiotic due to waiting for physician confirmation of the order in the computer. During in interview on 7/21/22 at 2:59 P.M., DON reported that Resident #105's left heel wound was first identified and documented on 7/2/22 in a pain assessment, then (Physician Assistant (PA) QQ) saw Resident #105 on 7/5/22 and ordered a wound treatment. DON reported that the wound orders were not put in the computer correctly and therefore were not performed. DON reported that WD PP saw Resident #105 for the first time on 7/18/22. DON reported that Resident #105 was not evaluated by the wound doctor prior to 7/18/22, because UM D did not think it was necessary. DON reported that the nursing staff would be expected to continue monitoring Resident #105's left heel until the wound was completely healed and the scab had resolved. This surveyor requested to review documentation from WD PP and/or any documentation that Resident #105's wound was being monitored between 7/7/22 and 7/20/22, when [CONDITION(S)] had been discovered. There was no documentation received prior to exit. Review of Resident #105's Pain Evaluation dated 7/2/22 revealed, left heel, open area like fluid filled sac burst, no hurt . Review of Resident #105's Physician Assistant Note dated 7/5/22 revealed, .Also seen for blister that popped on L (left) heel. No drainage or pain noted at this time, order placed for dressing changes and offloading boots Blister (nonthermal), left lower leg .Order placed to cleanse with NSS (normal saline), pat dry with gauze, and apply [MEDICATION(S)] until healed. Offloading boots while resting in bed. Continue to monitor and treat as indicated . Review of Resident #105's Risk Management Report dated 7/6/22 revealed, .On 7/2/2022, Blister (nonthermal) left lower leg (Left inner calcaneus). Facility Response / Corrective Action Taken to Date: 7/2/2022 Boots to feet, 7/5/2022 Order placed to cleanse with normal saline, pat dry with gauze, and apply [MEDICATION(S)] until healed. I was offloading boots while resting in bed. On 7/6/2022 facility will update the care plan to reflect stage two wound to the left heal .The facility is developing an action plan for skin - to assess all residents in the facility. Review of Resident #105's Skin Alteration Evaluation dated 7/7/22 revealed, .blister, left calcaneous (heel), 1.0 cm x 1.0 cm, Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.), date of onset 7/7/22, 100% of wound covered-surface intact, stable, healable . Review of Resident #105's Progress Note dated 7/7/22 at 17:16 (5:16 P.M.) revealed .IDT (Interdisciplinary Team) review: .On 7/2/2022, a Blister (nonthermal) left lower leg (Left inner calcaneus) (heel). Measured 1x1 with intact blister. No drainage noted, peri skin intact and blanchable. No [CONDITION(S)] noted to lower extremities. Area cleansed with normal saline and form dressing placed. ETAR updated to new order. CP (care plan) updated. Pressure reliving boots applied, while resident in bed and as resident allows, registered dietitian eval and consult made to wound specialist. IDT to continue with weekly monitoring and update plan of care as appropriate . Review of Resident #105's most recent Skin Observation dated 7/19/22 indicated no skin concerns. There was no documentation of assessment or monitoring of Resident #105's left heel wound between 7/7/22-7/20/22. Review of Resident #105's Physician Assistant Note dated 7/21/22 revealed, .She is seen today returning from (hospital name omitted) emergency room after fall evaluation .Returned with order for [MEDICATION(S)] (antibiotic) 500 mg 4 times daily x5 days for [CONDITION(S)] of left lower extremity. Noted to have penicillin allergy, changed order to [MEDICATION(S)] (antibiotic) . Review of Resident #105's Skin Alteration Evaluation dated 7/21/22 at 14:28 (2:28 P.M.) revealed, .left heel, blister open, 1 cm x 1 cm, in house acquired, 100% of wound covered in slough (dead tissue), drainage-moderate, slow to heal . This documentation indicates worsening of the wound. The documentation was completed by the facility after it was requested by this surveyor. Resident #106 Review of an Admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 7/20/22 at 7:43 A.M., Resident #106 was lying in bed with blue pressure relieving boots on both of his feet, and a pillow under each hip to offload coccyx wound. Resident #106 is unable to move, with the exception of his head, due to a medical condition. Resident #106 reported that the wound on his coccyx is getting better and stated, .I guess the one on my foot is too . During an observation on 7/20/22 at 8:31 A.M. Resident #106 was lying in his bed and CNA G and CNA SS were performing a bed bath and incontinence care. At 9:00 A.M. LPN H was in the room to change Resident #106's wound dressing on his bottom. LPN H reported that Resident #106 does not have a wound on his feet and stated, .it is closed, we just put skin prep on it . Resident #106's socks were removed at the request of this surveyor and revealed, a large thick scab on the top of the left great toe, a large thick scab on the tip of the left and right great toes, and an open area that was bleeding on the right 2nd toe. LPN H reported that he was not aware of these skin concerns and that he would follow up with the unit manager. During an observation on 7/21/22 at 10:02 A.M. Resident #106 was lying in bed with blue boots on both feet. Resident #106 was not wearing socks and his right 2nd toe was stuck to the side of the blue boot with dried blood. During an interview on 7/21/22 at 10:14 A.M., LPN HH reported that Resident #106 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .we put it right over those big scabs . During an interview and observation on 7/21/22 at 10:18 A.M., UM E reported that Resident #106 did not have any open areas on his toes and stated, .if it's scabbed over then maybe there was a wound at one time . Resident #106's toes were observed and UM E stated, .there were obviously wounds there before .we wouldn't follow a wound that was scabbed over .it's closed . UM E reported that the wound on Resident #106's right second toe is new, caused by pressure from how his foot is laying and should be covered because it is susceptible to infection. UM E cleaned the new wound and applied a dressing, and indicated that she wound add the wound to the wound doctors list. During an interview on 7/21/22 at 10:33 A.M., UM D reported that Resident #106 had a wound on his left great toe in the past, but that it was healed out in April 2022. During an interview on 7/22/22 at 11:03 A.M., DON reported that on 3/28/22 was the last time Resident #106 was seen for his left great toe wound. DON reported that the nursing staff was expected to continue monitoring Resident #106's wounds until they were completely healed and stated, .no, scabs are not considered healed . DON reported that she had spoken to staff today and they reported that Resident #106's feet rub on the end of the bed a lot and stated, .we will get him a longer bed to help . Review of Resident #106's Wound Doctor Visit dated 3/28/22 revealed, .Assessment: .Left Great toe deep tissue injury at 1.7 x 1.2, nummular stable purple black .Plan: .apply skin prep to the left great toe deep tissue injury and leave it open to air . Review of Resident #106's Skin Observation Tool dated 7/19/22 indicated that there were no new or current skin alterations. Review of Resident #106's Skin Alteration Evaluation dated 7/21/22 at 14:47 (2:47 P.M.) revealed, right toes, type: pressure, 1.0 cm x 1.0 cm, Stage 1, in-house acquired, 10% of wound filled with eschar (hardened dead tissue), Progress: new . According to the State Operations Manual with a revised date of 11/22/17 revealed an unstageable pressure ulcer is defined as: Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss 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.

This citation pertains to intake MI 407. Based on interview and record review, the facility failed to perform post fall assessments according to professional standards for 1 resident (Resident #104) of 4 residents reviewed for quality of care, resulting in a delay in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #104 Review of an Admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 4/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #104 was cognitively intact. Review of the Functional Status revealed that Resident #104 was totally dependent requiring 2 person physical assistance during transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). During an interview on 5/11/22 at 2:24 P.M., Resident #104 reported that he had fallen on 5/3/22 during a therapy session, and sustained multiple fractures to his right leg. Resident #104 reported that he had heard a loud ripping noise when he fell , followed by feeling severe pain in his legs and stated, .they used the hoyer to get me up .I screamed in pain .they put me to bed and gave me [MEDICATION(S)] (pain medication) .I think I was in shock .I should have gone to ER (emergency room ) . Resident #104 reported that staff did not ask him about where his pain was, or assess his legs for pain and/or ROM (range of motion). Resident #104 reported that the next day 5/4/22, the therapist found swelling in his right leg, and therefore the doctor ordered an x-ray. Resident #104 reported that the x-ray did not show any fractures. Resident #104 reported that the facility wanted to restart physical therapy on 5/5/22, but he refused due to the excruciating pain in his right leg, and then he requested to be sent to the hospital for further evaluation. Review of Resident #104's Hospital Records from Emergency Department visit on 5/5/22 at 11:20 A.M. through discharge on 5/5/22 at 9:50 P.M. revealed, .Chief Complaint: LEG PAIN Right leg swelling and pain .Leg feels warm .Physical Exam: .Musculoskeletal: .There is tenderness at the right knee, right ankle, and right foot. There is also mild tenderness at the anterior aspect of the left knee and left ankle. There is [CONDITION(S)] of the right knee when compared to the left. There is ecchymosis (bruise) in the plantar (bottom) aspect of the right foot .complaining of right leg pain since a fall couple of days ago. He does appear uncomfortable on initial examination and has tenderness primarily in the knee and the ankle. X-rays apparently had been performed at the rehabilitation facility but then not able to access these .I did order a CT (CAT Scan: images) of the patient's right lower extremity to evaluate for hemarthrosis (bleeding in joint spaces) or large hematoma (collection of blood under the skin due to trauma). This showed: 1. Fractures of the proximal fibular diaphysis (main or mid-section of the lower leg bone). Lateral and posterior malleolus (bone on the side of the ankle) fractures at the ankle. Fractures at the tarsometatarsal (joints in the foot) joints including likely Lisfranc (injury of bones and ligaments of the foot) injury. 2. Large knee joint effusion with possible hemorrhagic component . During an interview on 5/12/22 at 8:56 A.M., PT G reported that Resident #104 had fallen on 5/3/22 during a therapy session in the residents room. PT G reported that Resident #104 reported that his head hurt and complained of pain in both of his legs after the fall and stated, .I put a pillow under his head .I went and got the nurse .I did not do any assessments .he was not doing well .moving him to get back into bed was very painful for him . During an interview on 5/12/22 at 10:23 A.M., Licensed Practical Nurse (LPN) O reported that Resident #104 had a witnessed fall on 5/3/22 during therapy and that LPN O assisted PT G to get Resident #104 onto the hoyer lift pad and then transferred to bed after the fall. LPN O reported that Resident #104's vital signs were assessed prior to transferring him to bed and stated, .I did not do any specific ROM assessment .he said that he had pain all over .it was very painful to him when we transferred him to bed .if he had needed to go to ER or have an x-ray I think he would have made that clear .no, the doctor did not see him until the next day . LPN O reported that she did not document the neurological checks and the incident report accurately following Resident #104's fall and stated, .I did not do the best ROM assessment . LPN O reported that as the day went on Resident #104 continued to complain of pain and was emotionally upset knowing that he was not going to be able to stay at the facility now for therapy. Review of Resident #104's Incident Report dated 5/3/22 at 13:00 (1:00 P.M.), revealed, Attended fall .Therapist came and got this nurse stating that he assisted pt (patient) onto floor during a therapy transfer .Pt states that his legs felt weak and knees buckled .Immediate Action Taken: PT (patient) assisted back into bed, Vitals and Neuro (neurological) checks initiated. Patient Taken to Hospital? N (no). Injuries Observed at Time of Incident: Abrasion, Right Upper Arm .Injuries Report Post Incident: No injuries Observed Post Incident. Level of Pain: (not documented) .Witnesses Statement: (PT G): I was assisting pt from his bed to his w/c (wheelchair). We were using the walker and he felt weak, knees buckled and I assisted his (sic) to the floor and got the nurse . This report was inconsistent with interviews with Resident #104 and PT G. Review of Resident #104's Post Fall Report dated 5/3/22 at 13:00 (1:00 P.M.) revealed, .Is there a previous history of fall? YES .Was this fall an isolated event? Yes .Was this fall an assisted fall? Yes .Injuries related to this fall? Yes .Is there any pain during ROM or ambulation? YES .New Interventions: IDT (interdisciplinary team) will determine the most appropriate intervention: We are leaning toward having this resident as a +2 assist during therapy transfers .Initiated neurological assessment for an unwitnessed fall or fall resulting in head injury? No. Review of Resident #104's Post Fall Neurological Evaluation documentation from 5/3/22 at 13:00 (1:00 P.M.) through 5/6/22 at 9:00 A.M. revealed, Yes for Motor Movement Evaluation of all 4 extremities, indicating that Resident #104 was able to move all 4 extremities (which was directly negated by the hospital CT scan). Review of Resident #104's Progress Notes dated 5/3/22 at 15:14 (3:14 P.M.) revealed, Event Note: Therapist came to this nurse and stated that pt had an assisted fall .Nursing staff assisted pt into bed using hoyer lift. VS (vital signs) assessed and stable. Neuro checks initiated and WNL (within normal limits). Pt obtained a skin abrasion to RUE (right upper extremity). He c/o (complains of) general soreness and pain 10/10 from fall. PRN (as needed) Tylenol given followed by PRN [MEDICATION(S)] (pain medication) shortly after . Review of a facility policy Fall dated 7/11/18 revealed, It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. PROCEDURE: 1. Resident will not be moved until a nurse evaluates the resident's condition. 2. Check resident for any abnormalities: i.e. a. Deformed, discolored or painful body parts .4. Complete Range of Motion (ROM) to unaffected extremities only without overt signs of fracture. 5. Initiate neurological checks for any fall where a resident hit his/her head or for any unwitnessed fall .

This citation pertains to intakes MI 407 & MI 206. Based on interview and record review the facility failed to prevent avoidable accidents for 2 of 4 residents (Resident #104 & #105) reviewed for accidents, when the facility 1). failed to provide a safe transfer for Resident #104, resulting in a fracture of Resident #104's leg, and 2). failed to implement care plan interventions for bed mobility for Resident #105, resulting in Resident #105 falling out of bed and sustaining a [CONDITION(S)]. Findings include: Resident #104 Review of an Admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] ([CONDITION(S)]) and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 4/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #104 was cognitively intact. Review of the Functional Status revealed that Resident #104 was totally dependent requiring 2 person physical assistance during transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Review of Resident #104's Care Plan revealed, FOCUS: Resident at risk for falls r/t (related to) hx (history) of falls, [CONDITION(S)], pain in right shoulder, and tremors. Date Initiated: 4/25/22. Interventions: .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 4/25/22. Follow facility fall protocol. Date Initiated: 4/25/22 .FOCUS: Resident has limited physical mobility .Date Initiated: 4/25/22. INTERVENTIONS: Transfer: The resident is totally dependent on (2) staff for transferring. HOYER LIFT (a mechanical assistive device used for transfers) Date Initiated: 4/25/22 . Resident #104 was totally dependent for transfers prior to the fall on 5/3/22. During an interview on 5/11/22 at 2:24 P.M., Resident #104 reported that he had fallen on 5/3/22 during a therapy session, and sustained multiple fractures to his right leg. Resident #104 reported that he stood up next to the bed using his walker, then began to pivot into his wheelchair and stated, .I have to quick fall into my chair, that's what I always do, but this time it wasn't there .(Physical Therapist (PT) G) was trying to move stuff out of the way and grab the chair .I had to go forward to get to the chair .my legs gave out .I went flying . Resident #104 reported that he had never actually taken steps before and had only been out of bed twice with therapy since he had admitted to the facility. Resident #104 reported that he was not able to recall if there had been a gait belt around him and stated, .(PT G) wasn't even near me .he was trying to get the wheelchair .he should have had another person in here . Review of Resident #104's Hospital Records from Emergency Department visit on 5/5/22 at 11:20 A.M. through discharge on 5/5/22 at 9:50 P.M. revealed, .Chief Complaint: LEG PAIN Right leg swelling and pain .Leg feels warm .Physical Exam: .Musculoskeletal: .There is tenderness at the right knee, right ankle, and right foot. There is also mild tenderness at the anterior aspect of the left knee and left ankle. There is [CONDITION(S)] of the right knee when compared to the left. There is ecchymosis (bruise) in the plantar (bottom) aspect of the right foot .complaining of right leg pain since a fall couple of days ago. He does appear uncomfortable on initial examination and has tenderness primarily in the knee and the ankle. X-rays apparently had been performed at the rehabilitation facility but then not able to access these .I did order a CT (CAT Scan: images) of the patient's right lower extremity to evaluate for hemarthrosis (bleeding in joint spaces) or large hematoma (collection of blood under the skin due to trauma). This showed: 1. Fractures of the proximal fibular diaphysis (main or mid-section of the lower leg bone). Lateral and posterior malleolus (bone on the side of the ankle) fractures at the ankle. Fractures at the tarsometatarsal (joints in the foot) joints including likely Lisfranc (injury of bones and ligaments of the foot) injury. 2. Large knee joint effusion with possible hemorrhagic component . Review of Physical Therapy Note dated 5/2/22 revealed, .Pt has improved bed mobility and transfer. Pt continues with limitations due to pain and shortness of breath. Pt with orthostatic (low blood pressure) changes with mobility with symptoms .Pt with dizziness with transitions, impaired strength, decreased balance and unable to ambulate .requires assist with mobility .fall risk .hx (history) of multiple falls . During an interview on 5/12/22 at 8:56 A.M., PT G reported that Resident #104 had fallen on 5/3/22 during a therapy session in the residents room. PT G reported that Resident #104 required stand by assist of one person contact during transfers with therapy and stated, .it was just me in the room .I don't know if nursing staff did transfers with him .I believe his care plan was 1 person assist . PT G reported that Resident #104 had done a handful of transfers with other therapist and stated, .he has done side stepping and walking next to the bed .that's why we were doing some walking . PT G reported that he was unaware that Resident #104 had been care planned for hoyer lift. PT G reported that normally walking is not attempted with someone that is a hoyer lift and stated, .that would require 3 people and use of the parallel bars . PT G reported that Resident #104 had fallen sideways, at the end of the bed, while walking towards the wheelchair. PT G reported that Resident #104 stated that his head hurt and complained of pain in both of his legs after the fall and stated, .I put a pillow under his head .I went and got the nurse .I did not do any assessments .he was not doing well .moving him to get back into bed was very painful for him . During an interview on 5/12/22 at 10:23 A.M., Licensed Practical Nurse (LPN) O reported that Resident #104 had a witnessed fall on 5/3/22 during therapy and that LPN O assisted PT G to get Resident #104 onto the hoyer lift pad and then transferred to bed after the fall. LPN O reported that Resident #104's vital signs were assessed prior to transferring him to bed and stated, .I did not do any specific ROM assessment .he said that he had pain all over .it was very painful to him when we transferred him to bed .if he had needed to go to ER or have an x-ray I think he would have made that clear .no, the doctor did not see him until the next day . LPN O reported that she did not document the neurological checks and the incident report accurately following Resident #104's fall and stated, .I did not do the best ROM assessment .it was not an attended fall . LPN O reported that as the day went on Resident #104 continued to complain of pain and was emotionally upset knowing that he was not going to be able to stay at the facility now for therapy. During an interview on 5/12/22 at 1:10 P.M., PT M reported that during therapy sessions, Resident #104 required physical assistance of one person for pivot transfers and stated, .it required physically holding him up with the gait belt .with his walker he was able to side step down the bed and turn to sit in the chair . PT M reported that Resident #104 had not yet progressed to taking forward steps and stated, .when I saw him the day before his fall he took 5 side-steps along the bed .I didn't feel like it was safe for me to step away .he needed my support .if he wanted to walk I would have needed an extra person . Review of Resident #104's Incident Report dated 5/3/22 at 13:00 (1:00 P.M.), revealed, Attended fall .Therapist came and got this nurse stating that he assisted pt (patient) onto floor during a therapy transfer .Pt states that his legs felt weak and knees buckled .Immediate Action Taken: PT (patient) assisted back into bed, Vitals and Neuro (neurological) checks initiated. Patient Taken to Hospital? N (no). Injuries Observed at Time of Incident: Abrasion, Right Upper Arm .Injuries Report Post Incident: No injuries Observed Post Incident. Level of Pain: (not documented) .Witnesses Statement: (PT G): I was assisting pt from his bed to his w/c (wheelchair). We were using the walker and he felt weak, knees buckled and I assisted his (sic) to the floor and got the nurse . This report was inconsistent with interviews with Resident #104 and PT G. Review of Resident #104's Post Fall Report dated 5/3/22 at 13:00 (1:00 P.M.) revealed, .Is there a previous history of fall? YES .Was this fall an isolated event? Yes .Was this fall an assisted fall? Yes .Injuries related to this fall? Yes .Is there any pain during ROM or ambulation? YES .New Interventions: IDT (interdisciplinary team) will determine the most appropriate intervention: We are leaning toward having this resident as a +2 assist during therapy transfers .Initiated neurological assessment for an unwitnessed fall or fall resulting in head injury? No. Review of Resident #104's Post Fall Neurological Evaluation documentation from 5/3/22 at 13:00 (1:00 P.M.) through 5/6/22 at 9:00 A.M. revealed, Yes for Motor Movement Evaluation of all 4 extremities, indicating that Resident #104 was able to move all 4 extremities. Review of Resident #104's Progress Notes dated 5/3/22 at 15:14 (3:14 P.M.) revealed, Event Note: Therapist came to this nurse and stated that pt had an assisted fall. Therapy was moving pt from the bed, using walker and gait belt, and walking to the w/c. When pt got close to the w/c and began to turn, pts (patient) legs became weak and his knees buckled. therapist assisted pt to floor. Nursing staff assisted pt into bed using hoyer lift. VS (vital signs) assessed and stable. Neuro checks initiated and WNL (within normal limits). Pt obtained a skin abrasion to RUE (right upper extremity). He c/o (complains of) general soreness and pain 10/10 from fall. PRN (as needed) Tylenol given followed by PRN [MEDICATION(S)] (pain medication) shortly after . Review of Resident #104's Fall Risk assessment dated [DATE] indicated that the resident had not fallen in the past, had no ambulatory aids such as a walker, had a normal gait (walking), and was at low risk for falls. This information was not an accurate reflection of Resident #103's status prior to the fall on 5/3/22. During an interview on 5/12/22 at 12:35 P.M., Resident #104 reported that he was being discharged home today due to his health insurance not approving his stay any longer and stated, .because I can't bear weight for 12 weeks I can't have therapy, and that's what I was here for . Resident #104 expressed concern regarding being able to care for himself at home. During an interview on 5/12/22 at 12:45 P.M. Social Worker (SW) V reported that Resident #104 came to the facility for therapy, but due to the fracture from his fall can no longer participate in therapy and therefore the insurance will no longer cover the stay. Resident #105 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: spastic quadriplegic [CONDITION(S)] (muscle stiffness and spasm of all 4 limbs). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 2/24/22 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #105 was cognitively intact. Review of the Functional Status revealed that Resident #105 required extensive physical assistance of 2 people for bed mobility. Review of Resident #105's Care Plan revealed, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) balance/trunk control problems secondary to contractures to right shoulder, left shoulder, and left knee and right ankle .Date Initiated: 10/29/18, INTERVENTIONS: .Bed mobility: dependent on x2 staff members Date Initiated: 10/28/20 . Review of Resident #105's Incident Report dated 4/13/22 at 8:40 A.M. revealed, .Patient fall out of bed at 0840 (8:40 A.M.). CNA (Certified Nursing Assistant) was changing patient's brief, in bed, rolled on his left side. The patient rolled out of bed and hit the left side of his head. Patient sustained a laceration on the left side of his scalp and was bleeding . Review of Resident #105's emergency room Visit dated 4/13/22 revealed, .Patient presents to the emergency room from skilled nursing facility after falling out of bed during brief changing this morning. He did have direct contact with his head to the floor. He has a laceration about an inch and a half in length and about a centimeter in depth which is repaired at bedside using 5 staples . During an interview on 5/11/22 at 3:54 P.M., Resident #105 reported that his fall out of bed on 4/13/22 was unfortunate and resulted in him getting staples in his head. Resident #105 reported that he was not able to move at all and that the facility should require 2 people when they take care of him and stated, .they never did until after the fall . During an interview on 5/12/22 at 8:45 A.M., CNA I reported that Resident #105 fell out of bed during cares on 4/13/22 and stated, .it was because we didn't have 2 people .we usually just have 1 person when we change him in bed . CNA I reported that when he was changing his gloves, Resident #105 fell off the side of the bed, between the bed and the wall. CNA I reported that according to Resident #105's care plan, Resident #105 only required assistance of 1 person for bed mobility and stated, .I thought I was following the care plan .so I didn't do anything wrong . CNA I reported that the facility talked to him after Resident #105's fall and explained that a resident who cannot move by themselves should be care planned for 2 person assistance at all times. During an interview on 5/11/22 at 3:45 P.M. Occupational Therapist (OT) H reported that Resident #105 does not have control of his body, except for his head. During an interview on 5/12/22 at 9:58 A.M. Nursing Home Administrator in Training (NHA-T) C reported that Resident #105's fall on 4/13/22 was determined to be the result of the CNA not following the care plan for bed mobility, and Resident #105 was sent to the emergency room for staples to repair a [CONDITION(S)]. NHA-T C reported that CNA I was suspended from work during the investigation and then educated regarding care plans. This surveyor requested documentation of the education that was provided. During an interview 5/13/22 at 8:49 A.M., NHA-T C reported that there was no specific education provided to staff following Resident #105's fall and stated, .when (Resident #105) fell , we were already doing education throughout the facility as part of the POC (plan of correction) from the last survey . NHA-T C reported that staff received general care plan education, and no specific education related to falls, or assistance for bed mobility and transfers. This surveyor requested any and all documentation to verify staff were education on falls after 4/13/22, including but not limited to education materials, sign-in sheets, and QAPI (quality assurance and performance improvement) meeting minutes. No documentation was provided prior to exit. Review of a facilit policy Fall Prevention dated 7/11/18 revealed, It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents PURPOSE: .2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls .PROCEDURE: .4. The Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions .6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments .7. The Director of Nursing/designee will conduct a weekly Fall Committee Meeting consisting of Interdisciplinary Team members. They will review the falls for the week to identify issues and/or trends. The minutes of all Fall Committee meetings will be documented on the FALL COMMITTEE MINUTES. The Fall Committee Meeting minutes will be maintained in the Fall Committee Manual . Review of a facility policy Fall dated 7/11/18 revealed, It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. PROCEDURE: 1. Resident will not be moved until a nurse evaluates the resident's condition. 2. Check resident for any abnormalities: i.e. a. Deformed, discolored or painful body parts .4. Complete Range of Motion (ROM) to unaffected extremities only without overt signs of fracture. 5. Initiate neurological checks for any fall where a resident hit his/her head or for any unwitnessed fall .

This citation pertains to MI 773, MI 060, MI 189, and MI 463. This citation has 3 Deficient Practice Statements (DPS) A & B & C DPS A Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety for 1 of 8 residents (Resident #111) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on [DATE] at approximately 2:00 PM, Resident #111 who was identified as an elopement risk, was let out of the facility by facility staff who did not identify her as an elopement risk at 12:31 pm where she walked across a 5 lane 45mph road approximately ,d+[DATE] mile to the gas station and ,d+[DATE] mile back and was seen sitting near the entrance to the facility near a busy highway by a staff member and was brought back into the facility at 1:14 pm. This deficient practice placed 8 residents, identified as At Risk for Elopement, at risk for serious harm, injury, and/or death. Findings include: On [DATE] at 2:54 pm, NHA A was notified of an immediate jeopardy that began on [DATE] due to the failure to ensure the safetly and identify Resident #111 as enlopement risk, who left the facility unattended by staff for approximately 45 minutes and the likelihood for serious harm, injury, and/or death. On [DATE], the surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Resident #111 is currently residing in the facility without injuries and had an updated wander risk assessment completed along with new identification photo in the wander risk book. 2. Current residents residing in the Facility that score at risk (which is defined by a score of 9 or greater) on their wander risk assessment have the potential to be affected. 3. An audit of wander risk assessment scores was completed by the IDT on [DATE]. The IDT reviewed each identified resident that are at risk for eloping to ensure they remain safe and are appropriately identified in the wander book as needed. 4. The facility will supervise and monitor all residents for exit seeking behaviors to prevent elopements. If the resident is actively seeking to exit the facility (name omitted) will assign a staff member to provide one on one supervision until the resident is no longer exit seeking. 5. Individual education was provided to the employee involved in the incident that included how to identify a resident vs visitor and the elopement policy. 6. In-servicing for all staff was started on [DATE] by the DON/designee. At this point 68 out of 166 staff members have been in-serviced. Staff will not be able to work the floor until they are in-serviced. The in-service addressed the following: a. Elopement Policy and Procedure. Specifically, the facilities practices on how to identify a resident that is actively exit seeking, the wander book, how to identify a visitor and the LOA process. 7. All new hires Nurses and CENA will receive training on the facilities practice on how to handle residents with exit seeking behaviors, wandering, and the elopement policy. 8. DON/Designee will randomly review 5 residents weekly times 4 weeks and then monthly thereafter times 3 months to ensure adherence to the facility policies and practices in regard to the Elopement Policy and Procedure. 9. Administrator/maintenance director wall conduct one elopement drill a week for 1 month. Results will be reported to the QA committee for monitoring and follow-up The facility alleges the immediacy of these discrepancies have been removed on [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency, not all staff had received education, and Resident #106's fall with harm injury. Resident #111 Review of a Face Sheet revealed Resident #111 had pertinent diagnoses which included: Dementia, unsteadiness on feet, lack of coordination and weakness. Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, out of a total possible score of 15, which indicated Resident #111 had mild cognitive impairment. The MDS revealed Resident #111 was able to walk 10 feet with supervision or touching assistance, but greater distance was not attempted due to medical condition. Review of the Elopement care plan dated [DATE] revealed Resident is an elopement risk .r/t (related to) unspecified demential with behavioral disturbances. Resident with a history of going to the entrance door and asking to 'go outside for a walk'. Interventions included, assist with scheduled outdoor activities and resident triggers for wandering/eloping are her desire to go outside, per her previous routine, and go for a walk. Review of the Fall care plan dated [DATE] reealed Resident #111 was at risk for falls and used a walker as an assistive device. Review of a Facility Reported Incident dated [DATE] revealed: On [DATE] at approximately 2 PM resident (Resident #111) was let out of the facility by (Central Supply (CS) H) who was working the front desk as receptionist. (Resident #111) told (CS H) she (Resident #111) was going outside and would be right back. (Resident #111) was seen in the driveway sitting on her 4 wheeled walker. (Resident #111) did not exit or attempt to leave the facility. (Resident #111) sat and watched traffic. A (Certified Nurse Aide CNA D) went out and got (Resident #111) and brought her (Resident #111) back into the facility. (Resident #111) was dressed appropriately and wanted to go outside. Guardian wants resident (Resident #111) to go outside. As an intervention the resident (Resident #111) gets a walk outside with other residents and activities when weather and dress is appropriate. (Resident #111) remains in the facility with no concerns. During an interview on [DATE] at 1:10 PM., Resident #111 reported when she went for walk last week she went to the gas station down the street to get a candy bar and a cherry coke, because they (the facility) doesn't have cherry coke was the kind of pop she (Resident #111) likes. Resident #111 reported she walked out the door, and told the lady at the door she was going to the store and would be right back. Resident #111 stated it was a nice day for a walk, I love being outside. Resident #111 described the street, the gas station she went to and that the road was very busy, but she (Resident #111) paid attention to the cross-walk sign, and when it light up, she (Resident #111) crossed. Resident #111 reported she was gone about 45 minutes. During an interview on [DATE] at 1:04 PM., Resident #111's Guardian YYY reported no call or email was given to her in regards to Resident #111 eloping or being let out of the facility on [DATE]. Guardian YYY reported a call was made from the facility on [DATE] from a staff asking permission to take Resident #111 outside for walks, because Resident #111 really enjoys the outdoors. Guardian YYY reported she was not told that it was an actual mistake of a staff member who did not recognize Resident #111 as a resident, and let her (Resident #111) out of the building because she (Resident #111) said she was going to the store and would be right back. Guardian YYY reported she would have never given permission for Resident #111 to leave the facility without supervision. Guardian YYY stated this is shocking, especially because Resident #111 has a diagnosis of vascular dementia. During an interview on [DATE] at 12:15 PM., Central Supply Clerk (CS) H reported on [DATE] she was working as the screener (Covid-19 facility entrance door for screening visitors). CS H reported the door alarms throughout the building were going off (alarming) for quite some time. CS H reported around lunch time, there were a lot of visitors, and some were leaving. CS H reported Resident #111 approached her (CS H) and said, I'm going to the store, I'll be right back. CS H reported Resident #111 walked with a 4-wheeled walker and ambulated quickly. CS H reported after Resident #111 exited the building, CS H reported she thought Resident #111 was a visitor, and she did not check the elopement binder or even knew about an elopement binder (elopement/wander risk resident names/photos). CS H reported she does not recall a binder being around the screening area desk and there was a lot of commotion due to the door alarms going off. CS H reported a while later Certified Nurse Aide (CNA) D came into the building and told her (CS H) that Resident #111 was sitting on her walker up near the entrance of the facility. CS H reported she looked outside into the parking lot and could not see Resident #111. CS H reported she told CNA D to go get Resident #111. CS H reported CNA D went outside, and a short time later brought Resident #111 into the building. CS H stated I really thought she was a visitor, once (Resident #111) was back in the building no staff or code (an overhead paging system to identify emergent issues in the facility) was called. CS H reported she worked [DATE] from 4:00 am-4:00 pm and it wasn't until the following Monday [DATE] that management asked her about the incident, and she (CS H) wrote a written statement. CS H reported she did not have any class, or computer training of elopement after the incident on [DATE]. CS H stated besides being asked about the situation with (Resident #111), and a written statement, everything resumed back to normal. Review of a time-line dated [DATE] created by NHA A (that he retrieved from the facility security camera) the times of Resident #111 eloping the facility on [DATE] revealed: .Resident #111 leaves facility at 12:31 pm., (out of door) Resident #111 leaves campus (driveway near busy road) at 12:33 pm., Resident #111 returns to campus (entrance off sidewalk near busy road) at 1:12 pm., .Resident #111 returns to the facility (inside the door) at 1:14 pm.this surveyor asked to review the security camera footage, and was denied access. DPS B Based on observation, interview and record review, the facility failed to monitor adult electronic monitoring safety devices (Wanderguard) in 2 of 8 residents (Resident #117 and Resident #122) reviewed for safety/supervision, resulting in the potential for elopement unbeknownst to facility staff. Findings include: During an interview on [DATE] at 11:13 AM, Director of Nursing (DON) B reported Residents #117 and #122 should have had their wander alert bracelet's function being documented in the medication and treatment administration record and confirmed they were not. DON B confirmed the care plan addressed the wander bracelet's function was to be checked. DON B reported wander bracelet's function should be checked each shift. During an observation and interview on [DATE] at 10:26 AM, Registered Nurse (RN) GGGG located on the 100s room hall was asked for a wander bracelet function checker to check Residents #117 and #122's wander bracelet function. RN GGGG searched her medication cart and couldn't find one and then checked the treatment cart a few doors down and it wasn't there either. RN GGGG proceeded to leave the 100s unit and went to the 200s unit and checked the medication cart and couldn't find it. Resident #117 During an observation on [DATE] at 10:31 AM, Resident #117 had a wander alert bracelet affixed to her wheelchair located next to her while she was asleep in bed. Review of Resident #117's Wandering Risk Scale evaluation, dated [DATE], was noted to be At Risk To Wander. Review of Resident #117's physician orders, undated, included no order to check the function of the wander bracelet and therefore wasn't in the medication/treatment administration record and being documented. Review of Resident #117's elopement care plan, dated [DATE], stated, (Resident #122) is an elopement risk r/t (related to) impaired safety awareness. Resident has a dx (diagnosis) of vascular dementia which contributes to her impaired safety awareness. This care plan had an intervention, dated [DATE], WANDER ALERT: . Check for placement q (every) shift and function per policy. Resident #122 During an observation on [DATE] at 10:23 AM, a wander management device was observed on Resident #122's right ankle. Review of Resident #122's progress note, dated [DATE], stated, Nursing staff reports that he is usually calm in the morning, but later in the evening he starts exit seeking and impulsivity. Review of Resident #122's progress note, dated [DATE], stated, Resident has been exit seeking. Resident difficult to redirect and very aggressive towards staff. Resident redirected after about a half hour and took four staff members to help alleviate his anxiety. Review of Resident #122's elopement care plan, revised [DATE], stated, (Resident #122) is an elopement risk and/or exhibits wandering behavior as he is disoriented to place, will talk about wanting to discharge to his old apartment. He also will state he wants to go to (Church name) and will attempt to find a door he can meet his taxi at when he has not called anyone for a ride. This care plan had an intervention, dated [DATE], that stated, WANDER ALERT: . Check for placement q (every) shift and function per policy. Review of Resident #122's Wandering Risk Scale evaluation, dated [DATE], was noted to be High Risk To Wander. Review of Resident #122's physician orders, undated, showed orders for Alert bracelet - check function and Alert bracelet - check placement Q (every) shift was discontinued on [DATE] and [DATE]. There were no current orders to check the alert bracelet and therefore wasn't in the medication/treatment administration record and being documented. Review of the facility's Elopement Prevention document, undated, stated, Residents with an adult electronic monitoring safety device will be checked each shift to ensure device is in place. Review of the facility's Elopement policy, revised [DATE], stated, Residents with an adult electronic monitoring safety device will be checked every shift to ensure device is in place. Adult electronic monitoring safety device will be checked weekly to ensure the device is functioning properly and are not expired. DPS C Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 of 8 residents (Resident #106) reviewed for accidents/hazards, resulting in a fall with injury for Resident #106. Findings include: Review of a Face Sheet revealed Resident #106 had pertinent diagnoses which included: high blood pressure, muscle spasms and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, out of a total possible score of 15, which indicated Resident #106 had mild cognitive impairment. The MDS assessment for Activities of Daily Living (ADL's) Assistance Functional status coding for the following functional areas revealed: .A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. 3. Extensive assistance - resident involved in activity, staff provide weight-bearing support 3. Two+ person's physical assist. B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). 4. Total dependence - full staff performance every time during entire 7-day period. 3. Two+ person's physical assist Review of a Progress Note dated [DATE] 14:26 General Progress Note Text: Pt (Resident #106) was observed on the floor around 1330, pt (Resident #106) was lying on his back, there was blood on the floor behind his head as well as emesis Per resident he (Resident #106) stated that he was throwing up in his bed when he turned to his side and rolled out of the bed, falling to the floor. There was a 2 cm (centimeter) abrasion noted above his right eyebrow, this was cleansed with saline and dressed with steri strips . Review of a Incident Report dated [DATE] at 14:27 (pm) revealed: Incident Description: Nursing Description: Pt (Resident #106) observed on floor around 1330, pt (Resident #106) was lying on his back, there was blood on the floor behind his head as well as emesis (vomit). Pt (Resident #106) stated he was throwing up in his bed when he turned to his side and rolled out of the bed, falling to the floor. There was a 2 cm laceration noted above his right eyebrow . (Resident #106) voiced he wanted to be sent to the (hospital) . Review of a Progress Note dated [DATE] 05:58 (am) revealed: General Progress Note Text: Resident (Resident #106) returned from hospital via EMS (ambulance) at 2:15 am Resident (Resident #106) has 5 sutures in place that are to be removed in 5 days. All (vitals), patient given [MEDICATION(S)] for c/o pain to laceration area. Review of a Hospital After visit summary dated [DATE] printed -[DATE] 6:30 PM for Resident #106 revealed: Summary: A laceration is a cut that may go through all layers of the skin and into the tissue that is right under the skin .Have your 5 sutures removed in 5 days by your PCP (primary car physician) . Review of a Physicians Progress Notes revealed: Date of Service [DATE] General: (Resident #106) is seen today after a fall He (Resident #106) was found lying on his back, there was blood on the floor behind his (Resident #106) head as well as emesis (vomit) There was a 2 cm laceration noted above his (Resident #106) right eyebrow (Resident #106) Requested to be transferred to the hospital returned from hospital at 2:15 AM on [DATE] . Review a facility IDT interdisciplinary post fall follow up report for Resident #106's [DATE] fall with injury dated [DATE] revealed: root cause analysis 3. Corrective Actions and/or Interventions. A-Was this fall preventable? No (was checked) B-What changes do we need to make when caring for resident (Resident #106) to prevent him/her from experiencing the same type of fall? IDT in agreement with immediate intervention, in conjunction with resident (Resident #106) is now to be a 2 person assist with all bedside cares. Review of a Incident Report dated [DATE] at 04:22 (am) revealed: Incident Description: Nursing Description: this nurse called to the residents (Resident #106's) room where the CNA reported he had fell off the bed during patient care. This nurse observed the resident lying on the floor face down. Patient Description: Patient (Resident #106) unable to give description. Immediate Action Taken: Description: vitals were taken. ROM (range of motion) was performed, and the resident skin was assessed. (Resident #106) stated he hit his head and was yelling out loud when I touched his left hip. (Resident #106) was sent by ambulance to ER (emergency department). Witnesses: CNA stated she was changing the resident (Resident #106) and when she went to roll him the bed unlocked causing the resident to fall to the floor. Review of a Progress Note dated [DATE] 04:38 (am) revealed General Progress Note Text: This nurse was called to the (Resident #106) room where I observed him (Resident #106) face down on the floor on the side of his bed. The CNA stated while doing patient care the bed unlocked while (Resident #106) was turned on his side causing him (Resident #106) to fallout of bed. During my assessment (Resident #106) stated he hit his head and was yelling out when I touched his (Resident #106) left hip. (Resident #106) sent to emergency room (ER) at 8:30 PM Review of Resident #106's current Care Plan revealed: FOCUS-(Resident #106) At risk for falls due to history of falls, impaired balance/poor coordination, potential medication side effects, poor safety awareness, weakness, unsteady gait, noncompliance with preventative measures, incontinence with refusal to wear incontinence products Date Initiated: [DATE] Created on: [DATE] Revision on: [DATE]. Further review of Resident #106's care plan revealed no new Interventions were put into place or updated to reflect Falls/Falls with injury. Noted the interventions that were updated were as follows: staff to have (Resident #106) up in w/c by 6 am Date Initiated: [DATE] Created on: [DATE] . Offer (Resident #106) to be up on Broda chair in the morning. Date Initiated: [DATE] Created on: [DATE] Review of Resident #106's MDS's dated: [DATE], [DATE] [DATE], [DATE] and [DATE] all revealed: Resident #106's MDS assessments for section F- Functional status Activities of Daily Living (ADL's) Assistance . coding for the following functional areas: .A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. 3. Extensive assistance - resident involved in activity, staff provide weight-bearing support 3. Two+ person's physical assist. B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). 4. Total dependence - full staff performance every time during entire 7-day period. 3. Two+ person's physical assist Review of a facility Incident Report dated [DATE] revealed: (Resident #106) Nursing Description: At 1330 (Resident #106) observed on the floor by nursing staff .(Resident #106) stated he hit his head and was pointing to the left side of his head (Resident #106) asked assistance to be up on his wheelchair prior to the fall, (Resident #106) resident stated that he wanted to get up .Patient Description: head to toe assessment performed, resident complained of pain to left side of head, no redness, bumps, or open areas noted to resident's head, no other injuries noted to resident's body, resident was transferred to his wheelchair from the floor via mechanical hoyer lift,. On call PCP notified of the fall . On call (physician) ordered to put ice to the left side of (Resident #106) head that he (Resident #106) was complaining of pain . Review of a Progress Notes revealed: [DATE] 15:02 Event Note Text: Patient (Resident #106) yelling out in room. Found (Resident #106) on all 4's yelling. (Resident #106) Stated staff took too long to come to him Per (Resident #106) took too long to come to my room. Review of a Physicians Progress Notes revealed: Date of Service: [DATE] General: (Resident #106) .He (Resident #106) is seen today for right arm pain follow up. Pain began after a fall that occurred on ,d+[DATE], CNA witnessed (Resident #106) rolling out of bed and was unable to stop him (Resident #106). (Resident #106) Landed on right side and reports pain with palpation of right proximal humerus. Unable to rate pain on scale, wincing noted with (range of motion) ROM ., no injury, swelling or discoloration noted. X-ray of right arm ordered, negative for acute fx (fracture) of dislocation, mild soft tissue swelling During an interview on [DATE] at 1:00 PM., Unit Manager/Registered Nurse (UM/RN) NN reported Resident #106's care plan, should have been updated and interventions put into place that were resident specific. UM/RN NN reported she has not updated Resident #106's care plan to reflect all of his falls. UM/RN 'NN reported there should be immediate interventions, and Resident #106's fall with injury could have been prevented if there were 2 staff together doing cares on him. UM/RN NN reported most likely there was not enough staff to assist, or the CNA doing the cares was unaware that Resident #106 was a 2 person assist. UM/RN NN reported Resident #106 has always been a 2 person assist with bed mobility, transfers and dressing. During an interview on [DATE] at 1;45 PM., Licensed Practical Nurse (LPN) W reported. He (LPN W) was told he fell (Resident #106) out of bed. If he (Resident #106) went to the ER his Care Plan should have been updated to reflect the falls. LPN W reported the unit managers, Director of Nursing and staff were aware of the falls Resident #106 has had recently. LPN W reported any residents care plan can be updated whenever something changes. LPN W reported (after looking at Resident #106's care plan with this surveyor) (Resident #106's) falls care plan should be updated to the status of the resident. LPN W reported each time Resident #106 has had a fall, the care plan should be looked at to either update the focus area, or interventions put in place to keep Resident #106 safe. Review of a facility Policy / Procedure Adopted [DATE] revealed: Nursing Clinical Section: Routine Procedures-Subject: Mechanical Lifts. POLICY: It is the policy of this facility to move a resident by a mechanical means as needed. PROCEDURE: Supplies: o Mechanical lift o Sling o Wheelchair/ Chair 1. Gather supplies. 2. Explain procedure to resident. 3. Provide privacy. 4. Wash hands, apply gloves. 5. Follow Manufacturer's guidelines on how to operate machine. 6. Check the machine battery before proceeding to ensure smooth transition of transfer. 7. Use sling compatible with mechanical lift and appropriate size. 8. There will always be 2 staff to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface. 9. Place machine close to resident's bed/wheelchair and lock brakes. 10. Place sling on resident's back. Ensure that it is properly placed for support. 11. Prompt resident to fold arms on chest. 12. Hook sling loops on metal hooks and pull sling down to ensure security. 13. Prompt resident prior to lifting to ensure readiness. 14. Position resident to ensure comfort. 15. Remove gloves, wash hands. 16. Discard equipment or return it to the appropriate location. 17. Document all appropriate information in medical record.

This citation pertains to intakes MI 237, MI 114, and MI 463. Based on interview and record review the facility failed to ensure residents received treatment in accordance with professional standards for 3 of 30 residents (Residents #113, #102, and #101), when the facility failed to communicate with hospice, assess an injury timely, and/or had a delay in treating an injury of unknown origin for Resident #113, failed to accurately assess and monitor a pacemaker for Resident #102, and failed to effectively assess and monitor hospice status for Resident #101, resulting in pain and delay of treatment, and the potential for negative outcomes due to lack of assessment and monitoring. Findings include: Resident #113: Review of Resident #113's hospice notes, with a fax date of 2/16/2022 at 9:21 AM (The hospice notes were not a part of the resident's records prior to the surveyor asking for them) included a note, dated 1/14/22, that stated, Fingers were not bruised at last visit. Patient states fingers are broken due to improper (mechanical lift brand name) transfer when patient's room was changed. and Patient (Resident #113) has increased [CONDITION(S)] but RN (Registered Nurse) unable to quantify [CONDITION(S)] due to patient's intolerance of having legs/feet touched. Patient's left hand has bruising on pinky, ring & middle fingers. Patient states they transferred her with a (mechanical lift brand name) when they moved her room & her fingers were pinched. She feels her fingers are broken. Reports they are painful. The hospice note, dated 1/21/22, stated RN spoke with guardian who requested patient (Resident #113) be evaluated at the hospital due to drastic change in condition & her distrust of facility staff. During an interview on 2/16/22 at 11:19 AM, Nursing Home Administrator (NHA) A confirmed there was no progress notes from 1/11/2022-1/15/2022 and that Resident #113 had no documented falls around the injury of unknown origin identified by hospice on 1/14/2022. NHA A confirmed Resident #113 didn't' get up often. On 2/16/2022 at 2:15 PM, NHA A confirmed the hospice notes indicated hospice observed the injuries to Resident #113's left hand and bilateral feet and didn't know why facility staff had no documentation of such injuries until the next day, 1/15/2022. NHA A reported he wasn't informed of this and stated, This should have been told to me. During an interview on 2/16/22 at 1:51 PM, Registered Nurse (RN) NN reported Resident #113 usually refused to get up. RN NN, reported Resident #113 became tearful during the room change, actively started sliding down in her wheelchair purposefully, staff got the mechanical lift's sling on her, the resident reached out forcefully and grabbed the mechanical lift's metal bar, and wouldn't cross her arms. RN NN reported she doesn't know how Resident #113 broke her finger. RN NN reported Resident #113 had no history of falls or finding the resident on the floor. RN NN stated, She (Resident #113) did not want to leave that bed (in regards to her usual daily activity). During an interview on 2/17/2022 at 10:53 AM, Registered Nurse (RN) LL reported she assessed Resident #113's injuries on 1/15/2022. RN LL reported she went into Resident #113's room on 1/15/2022 and the resident reported her hand and feet hurt, they were fractured, and they were fractured during her room move. RN LL reported during the assessment Resident #113 had very swollen feet more so than her usual foot [CONDITION(S)], bruising to the hand (left), the areas didn't look normal, and an x-ray was ordered. RN LL reported Resident #113 was dependent on staff for transferring, dressing, and the majority of her care needs. RN LL stated, She (Resident #113) was always in bed and rarely got out of bed. RN LL reported Resident #113's feet were very bruised, was surprised they weren't broken, and the swelling was so bad on the left top of the foot. During an interview on 2/17/2022 at 10:25 AM, DON B, Unit Manager U, and Regional Nurse Consultant C reported hospice notes were supposed to be in the miscellaneous tab in the medical record. Review of Resident #113's electronic medical record revealed no hospice documentation for 1/14/2022. During an interview on 2/18/2022 at 9:01 AM, Director of Nursing (DON) B reported the nurse working on 1/14/2022 reported the hospice nurse never spoke to her on that shift. DON B confirmed there was no communication form or documentation to show communication between hospice and the facility occurred on 1/14/2022. Review of the facility's facility incident report, stated, Type of Alleged Incident: Injury of Unknown Source and Date/Time Incident Occurred: 1/10/2022 11:48 PM. Incident Summary: Resident (Resident #113) had hand and foot pain after her room move. Xrays ordered by doctor. Feet xrays were negative however she had some bruising. Hand has a metacarpal fx (fracture) and is being placed in a splint. Resident claims the pain started after the room move. Review of Resident #113's #1690 Other investigation form, dated 1/15/2022, stated, Nursing Description: purple discoloration noted on bilateral lower feet and swelling. Bilateral feet are tender to the touch. Pt (patient; Resident #113) also has green and yellow discoloration on top of left hand .Patient Description: I broke my feet and hand when I changed rooms the other day. Notes: c/o (complain of) pain to bilateral feet/and left hand. Other info .recent room change from station 2 to station 1. Pt (patient) states her feet/hand got hurt during the transfer. Pt is dependent on staff for mobility. (mechanical lift brand name) transfer per kardex. Review of Resident #113's pain tool, dated 1/15/2022, stated, Left hand (back) yellow/green discoloration of skin, tender to the touch .Other (specify) right and left foot/toes - swelling with purple discoloration .What makes the pain better? Not touching her feet, no blankets on her feet .What makes the pain worse? When they are touched or moved. If blankets are over them. Review of Resident #113's pain scale scores, dated 12/1/2021-1/23/2022, revealed the highest pain score of 10 (on a 10 point scale) on 1/11/2021 at 4:19 PM. The resident's pain was not scored at a 10 any other time in that time frame. Review of Resident #113's census sheet, undated, indicated Resident #113 had a room change on 1/11/2022 and hospice services began on 9/4/2021. Review of Resident #113's activities of daily living (ADLs) care plan, revised 1/23/22, stated, ADLs: 2 assist, Bed mobility: 2 person, and Transfer: (mechanical lift brand name) lift. Review of Resident #113's most recent brief interview for mental status score, dated 10/27/21, was scored 14 which reflected intact cognition. Review of Resident #113's face sheet, dated 2/17/2022, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's hospice policy, dated 7/11/2018, stated, The goal of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/17/22 at 9:22 A.M., Family Member (FM) FFF reported that Resident #102 passed away in the facility and stated, .I have concerns that her pacemaker wasn't being checked .I told them (facility) about it and gave them the papers when she first came there .she had fallen a few times just before she passed away .I wonder if the pacemaker was even working . During an interview on 2/18/22 at 3:20 P.M., Unit Manager (UM) FFFF reported that she could not find any documentation in Resident #102's record of a pacemaker and stated, .if she had a pacemaker .we should have documentation that she had a monitor at the bedside . Review of Resident #102's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #102's Care Plan revealed, no Pacemaker care plan developed. Review of Resident #102's Incident Reports revealed, a fall on 11/16/21 with no injuries, a fall on 11/23/21 with no injuries, and a fall on 11/24/21 which resulted in being sent to the emergency room for a laceration to her face. During an interview on 2/18/22 at 3:04 P.M., Unit Secretary (US) Y reported that the last documentation in Resident #102's record of her pacemaker was a fax received on 10/9/2020, from the cardiologist and a communication sheet from the residents last visit on 1/8/20. Review of a faxed letter from Resident #102's Cardiologist dated 10/9/20 revealed, .We have not received a download from your pacemaker since we saw you in clinic this past January. Could you please send one as soon as you can . Review of Resident #102's communication sheet Consultation/Appointment Information Form dated 1/8/2020 revealed, Reason for visit: Pacemaker Check. Findings: Normal pacemaker function. Battery integrity 8-27 months. Recommendations: Remote check with her carelink monitor 4/28/2020 . Review of Resident #102's Nursing Admission Screening/History dated 12/9/21 revealed, .Cardiac/Circulation: Relevant history/dx (diagnosis): PACEMAKER . Review of Resident #102's Nursing Admission Screening/History dated 4/6/20 revealed, .Cardiac/Circulation: Relevant history/dx (diagnosis): NONE . There was no documentation of a pacemaker. Review of Resident #102's Cardiologist Visit Note dated 1/8/20 revealed, .Problems: .Complete atrioventricular block, heart block - 3rd degree .Surgical history: .Pacemaker implantation .pacemaker was implanted .5/24/10 . This surveyor spoke with DON B on 2/23/22 at 1:03 P.M. and requested further documentation regarding Resident #102's pacemaker. No documentation was received prior to exit. Review of a facility policy Care of Pacemaker dated 7/11/18 revealed, .Purpose: To have a system of monitoring residents with permanent pacemakers. Procedure: .Take apical and radial pulses once daily for one full minute .3. Examine pacemaker pocket monthly .Use of Telephone transmitter for pacemaker testing: .The contact number of the pacemaker lab should be indicated on the equipment and for reference should be record on the resident's health care plan . Resident #101 Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/15/22 at 12:03 P.M., Legal Guardian (LG) DDD reported that she attempted to contact the facility to schedule a care conference for Resident #101 and the facility would not return calls for months and stated, .they eventually told me that they were short a Social Worker (SW) and they weren't doing care conferences at that time . LG DDD reported that an activities person eventually set up a video call and stated, .I (LG DDD) was very concerned with her appearance .(Resident #101) looked frail .lost weight .they said that they weren't weighing her since she was on hospice . LG DDD reported that Resident #101 had been discharged from hospice on 7/25/21 due to improvement in her condition. LG DDD reported that she came in for a window visit on 11/16/21 out of concern and stated, .the next day I got a call that (Resident #101) had passed away . Review of Resident #101's Hospice Communication Notes dated 7/23/2021 at 11:26:28 A.M. revealed, . Joint visit provided by this writer (Hospice Social Worker (HSW) OOOO) and (Hospice Registered Nurse (HRN) PPPP) for patient discharge due to improved prognosis .We collaborated with facility (SSD I) regarding discharge- she verbalizes understanding. Reinforced availability to reevaluate should patient's condition change . Review of Resident #101's Hospice Discharge Summary revealed, .Discharge Effective date: 7/25/21. Reason for Discharge: Not eligible for hospice services. Condition: Fair .Summary: .Collaborated with (Social Services Director (SSD) I), to advise of discharge from hospice due to improved prognosis and inability for patient to experience comfort from hospice visits. Contact information provided and hospice will reach out periodically to evaluate the need for future services . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/15/21 indicated Yes to receiving Hospice Care during the past 14 days. During an interview on 2/16/22 at 11:21 A.M., Hospice Quality Manager (HQM) EEE reported that Resident #101 was discharged from hospice services on 7/25/21 due to condition improving and no longer qualifying for services. HQM EEE reported that they (Hospice) collaborated with (SSD I) at the facility and sent the discharge documents to the facility. During an interview on 2/16/22 at 12:36 P.M., SSD I reported that she did not recall speaking with hospice in July 2021 regarding Resident #101 and stated, .that would have been my first week .I would have put a note in about it . SSD I reported that Resident #101's last care conference was on 4/8/21 and stated .(Resident #101) was due for a care conference in July 2021 .that was right when I started .there may have been a lapse . During a subsequent interview on 2/18/22 at 3:44 P.M., SSD I reported that the last communication the facility had with Resident #101's guardian (LG DDD) was on 10/26/21 and stated, .we were returning her call about scheduling a care conference . Review of Resident #101's Social Services Note dated 10/26/2021 at 12:14 P.M. revealed, This writer returned voicemail from residents guardian who requested an update on the resident. Voicemail left with guardian offering to schedule a care conference for the resident or to provide update per request. Provided call back number for guardian. There was no documentation of additional communication with the resident's guardian. During an interview on 2/23/22 at 2:34 P.M., Facility Accountant (FA) NNNN reported that on 9/9/21 the facility received a notice from hospice that Resident #101's last covered day was 7/25/21 and stated, .one of our billers then changed the payer to Medicaid in the computer as of 7/26/21 . FA NNNN stated, .I would normally communicate that with the nurses and the MDS nurse if I was in the building .at the time the business office manager was regional and not in the building . During an interview on 2/16/22 at 12:47 P.M., Unit Manager (UM) FFFF reported that the nurses or UM's keep in communication with the hospice staff when they are in the facility and stated, I don't see any documentation regarding hospice visits after July 2021 . UM FFFF reported that weights should be obtained monthly for all residents, as a standard of care and regardless of hospice services and stated, .it doesn't look like we were getting (Resident #101's) weights . Review of Resident #101's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Hospice to eval & treat - (Hospice company name omitted) Hospice with start of service 10/10/2020. Verbal Active 08/16/2021 . Review of Resident #101's Care Plan revealed, Focus: The resident has a terminal prognosis r/t (related to)Multiple chronic medical conditions. Resident has signed on with (Hospice Company name omitted). Date Initiated: 10/13/2020 Created on: 10/13/2020 Revision on: 10/15/2021 .INTERVENTIONS: .Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Adjust plan of care as indicated. Date Initiated: 10/13/2020 During an interview on 2/23/22 at 2:30 P.M., Registered Dietician (RD) F reported that Resident #101's last dietary assessment was on 7/6/21. RD F reported that weights would continue to be evaluated monthly, unless a resident has a waiver on file and stated, .(Resident #101) did not have a waiver for weight checks . Review of Resident #101's latest Dietary Quarterly Evaluation dated 7/6/21 revealed, .Nutritional Supplements: None .Most Recent Weight: 178.8 lbs (pounds) 4/14/21 .Loss of 5% or more in the last month or loss of 10% or more in last 6 months: No or unknown .Additional information: Hospice . Resident #101 did not have a dietary evaluation following her discharge from hospice. Review of Resident #101's Weight Record indicated the last weight recorded was 178.8 lbs on 4/14/21, and prior to that the last weight recorded was 182 lbs on 10/4/20. Resident #101's weight was not being monitored. Review of Resident #101's Provider Progress Note dated 10/25/2021 revealed, Visit Type: 60-Day Follow Up .Patient is on hospice .ASSESSMENTS AND PLANS: .PALLIATIVE CARE: Patient is on hospice. Continue [MEDICATION(S)] (pain medication) [MEDICATION(S)] (pain medication) as comfort measures .

This citation pertains to intake #: MI 758 Based on observation, interview and record review, the facility failed to implement interventions that are consistent with resident needs, resident goals, and professional standards of practice and monitor and evaluate the impact of the interventions for 1 of 9 residents (Resident #101) reviewed for the risk for the development of pressure injuries, resulting in the development of a pressure ulcer, and the potential for infection and overall deterioration in health status. Findings include: Review of the facility policy Pressure Injury Management dated 2/1/21 revealed, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate .3. Assessment of Pressure Injury Risk . c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and as needed .4. Interventions for Prevention and to Promote Healing a. The interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. B. Interventions will be based on factors identified in the Braden scale assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Evidence-based interventions for prevention will be implemented for all residents who are assessed at high risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces .d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. i. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue .f. Interventions will be documented in the care plan and communicated to all relevant staff . According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book ([NAME] Locations - ). Elsevier Health Sciences. [NAME] Edition. Pressure ulcer, pressure sore, decubitus ulcer, and bedsore are terms used to describe impaired skin integrity related to unrelieved, prolonged pressure. The most current terminology is pressure ulcer which is consistent with the recommendations of the pressure ulcer guidelines written by the Wound, Ostomy and Continence Nurses Society (WOCN, 2010). A pressure ulcer is localized injury to the skin and other underlying tissue, usually over a bony prominence (e.g., sacrum, greater trochanter), as a result of pressure or pressure in combination with shear and/or friction. A number of contributing factors are also associated with pressure ulcers; the significance of these factors is not yet clear (NPUAP, EPUAP, PPPIA, 2014). Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/ or poor nutrition is at risk for pressure ulcer development. Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 4/2/21 revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of the Functional Status revealed that Resident #101 required extensive two person assist for bed mobility, transfer, dressing, toileting, and personal hygiene. Review of Resident #101's Braden Skin Assessment for Predicting Pressure Ulcers dated 4/21/21 revealed a score of 8 indicating Resident #101 was very high risk for the development of a pressure ulcer. Review of Resident #101's Care Plan revealed, Resident has potential impairment to skin integrity r/t incontinence Date Initiated: 03/30/2021 . Elevate heels off bed surface while at rest in bed. Date Initiated: 03/30/2021 . There was no documentation in the care plan to indicate a turning/repositioning schedule or type of support surface for Resident #101 to reduce the likelihood of pressure injury. According to the National Pressure Injury Advisory Panel (NPIAP), Pressure Injury Prevention Points .Risk Assessment: Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface .Repositioning and Mobilization: Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual ' s preferences. Consider lengthening the turning schedule during the night to allow for uninterrupted sleep. Turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed. Avoid positioning the individual on body areas with pressure injury. Ensure that the heels are free from the bed . Review of Resident #101's Weekly Skin assessment dated [DATE] revealed, Patient has NEW alteration in skin integrity? NO. Review of Resident #101's Skin progress note dated 4/22/21 revealed, Location:: X2 areas to left buttock. Type of Skin Change/Impairment:: Open areas Measurement(s):: 2x1cm and 1x0.6cm. Both are less than 0.1 cm in depth. Description: include tissue type, drainage [CONDITION(S)], [CONDITION(S)], surrounding tissue, etc.: Min serous dng (minimal serous drainage). Wound bed red. Edges not approximated. Skin surrounding wnl (within normal limits). Current Treatment(s):: Topical cream. Review of Resident #101's Weekly Skin assessment dated [DATE] revealed, Patient has NEW alteration in skin integrity? Yes .Site-Left buttock .Type-Pressure .Length 2cm .Width 1cm .Depth 0.0 .Stage-II .Left buttock .Type-Pressure .Length 1cm .Width 0.6 .Depth 0.0 .Stage-II .Open areas to buttocks not well approximated. Wound bed red with very min serous dng (drainage). Cream applied to buttocks. Res (resident) propped on pillow for pressure relief. Review of Resident #101's Weekly Skin assessment dated [DATE] revealed, Patient has NEW alteration in skin integrity? Yes .Site-Sacrum .Type-Pressure .Length 4.3(cm) .Width 3.3(cm) .Depth (blank) .Stage (blank) . Review of Resident #101's Skin & Wound Evaluation dated 5/5/21 (lock date 5/17/21) revealed, Type: Pressure .Stage: Stage 2 .Location Right Buttock .In House Acquired .How long has the wound been present? New .Area 1.1cm2-Length 1.9cm-Wideth 0.8cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin & Wound Evaluation dated 5/5/21 (lock date 5/17/21) revealed, Type: Pressure .Stage: Stage 2 .Location-Left Buttock .In House Acquired .How long has the wound been present? .New .Area 0.8cm2-Length 1.3 cm-Width 0.8cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin & Wound Evaluation dated 5/5/21 (lock date 5/17/21) revealed, Type: Pressure . Stage: Stage 2 .Location-Sacrum . In House Acquired .How long has the wound been present? .new .Wound Measurements Area 5.8cm2-Length 4.0cm-Width 1.8cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Incident Report dated 5/5/21 revealed, Resident assessed by this nurse and wound physician due to change in skin alteration. Area now non-blanchable with depth of 0.1 (cm) .Treatment updated by wound physician, AMP (alternating pressure mattress) ordered .Injury Type-Pressure .Injury Location-Sacrum . Review of Resident #101's Skin & Wound Evaluation dated 5/11/21 revealed, Type: Pressure .Location-Left Buttock .In House Acquired .How long has the wound been present? .1 week .Wound Measurements 1. Area 0.8 cm2-Length 1.3 cm-Width 0.9cm-Depth 0.1cm .Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration . Review of Resident #101's Skin & Wound Evaluation dated 5/11/21 revealed, Type: Pressure . Stage: Stage 2 .Location-Sacrum . In House Acquired .How long has the wound been present? .1 week .Wound Measurements Area 12.8cm2-Length 7.0cm-Width 3.2cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin/Wound Evaluation dated 5/11/21 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Left Buttock. Wound measurements are: Area - 0.8 cm2, Length - 1.3 cm, Width - 0.9 cm, Depth - 0.1 cm . Review of Resident #101's Skin progress note dated 5/13/21 revealed, Location: Sacrum Left Buttock Right Buttock - resolved/healed Type of Skin Change/Impairment: Pressure Injury - Stage 2 . (No other progress note related to sacral or other wounds documented on 5/13/2021) During an interview on 05/18/2021 at 1:05 P.M., Wound Nurse (WN) R reported that there was a wound identified on 4/22/21 for Resident #101 and the wound was no longer moisture associated. Resident #101 originally had 3 separate wounds and on 5/11/21 the right buttock wound had merged with the sacral wound and turned into 1 wound. WN R reported that the care plan for impaired skin integrity was not initiated until 5/10/21 but nurses and Certified Nursing Assistants (CNA's) should still be following professional standards of practice for repositioning immobile residents. WN R reported that the standard of practice for immobile residents is to reposition every 2 hours as well as providing incontinence care at least every 2 hours if required. WN R reported that just because a resident has [CONDITION(S)] it does not mean the resident will get a wound. It just puts her at high risk. WN R stated that sometimes with interventions in place they (pressure ulcers) are unavoidable. During an interview on 05/18/2021 at 4:25 P.M., Wound Physician (WP) S reported that initially Resident #101 had MASD (Moisture Associated Skin Damage) skin breakdown. WP S reported that on 5/5/21 he performed an assessment and found Stage II breakdown on Resident #101's left buttock, right buttock, and central sacral area. WP S reported that at that time he ordered collagen wound dressings to the affected area to be changed Monday, Wednesday, and Friday. WP S reported that Resident #101 was examined on 5/12/21 and the right buttock wound had coalesced (merged) with the sacral wound. WP S reported that Resident #101 had many unavoidable factors such as [CONDITION(S)] and [CONDITION(S)], incontinence, cognitive impairment, low hemoglobin and [MEDICATION(S)], diabetes, and protein calorie malnutrition. WP S reported that the goal of treatment is to try to offset and reverse that risk factor as much as possible. WP S reported that he instructed facility staff to keep the area clean and dry, perform ordered treatments, and frequent repositioning to offload the sacral area. Review of Resident #101's Care Plan revealed, Resident has actual impairment to skin integrity r/t (related to) Current break in skin integrity of a stage 2 (pressure ulcer) to her sacrum Date Initiated: 05/10/2021 . Encourage and assist resident to participate in mobility activities per additional plan of care. Date Initiated: 05/10/2021 . Follow physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Provide pain management with treatments as needed. Date Initiated: 05/10/2021 . Note no intervention for resident repositioning. Resident #101's pressure injury was identified on 4/22/21 and the care plan for Actual Skin Impairment was not created until 5/10/21 (18 days). During an observation on 05/17/2021 at 9:04 A.M., Resident #101 was in bed on her back. Resident #101's head of bed was at 19 degrees. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/17/2021 at 11:06 A.M., Resident #101 was in bed on her back. Resident #101's head of bed was at 19 degrees. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/17/2021 at 11:36 A.M., Resident #101 was in bed on her back. Resident #101's head of bed was at 17 degrees. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/17/2021 at 12:41 P.M., Resident #101 was in bed on her back. Resident #101's head of bed was at 23 degrees. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/17/2021 at 1:21 P.M., Resident #101 was in bed with a pillow behind her right side. Resident #101's head of bed was at 22 degrees. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/17/2021 at 1:40 P.M., Resident #101 was in bed with a pillow behind her left side. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/17/2021 at 3:56 P.M., Resident #101 was in bed with a pillow behind her left side. Resident #101's head of bed was at 25 degrees. Resident #101's heels were on the bed with no offloading devices in place. During an observation on 05/18/2021 at 8:51 A.M., Resident #101 was in bed with a pillow under her left side. Resident #101's head of bed was at 25 degrees. Resident #101 had a pressure relieving boot on her right foot and her left heel was on the bed with no offloading device in place. During an observation on 05/18/2021 at 10:31 A.M., Resident #101 was in bed with a pillow under her left side. Resident #101's head of bed was at 25 degrees. Resident #101 had a pressure relieving boot on her right foot and her left heel was on the bed with no offloading device in place. Resident #101 was loudly moaning, moving her extremities, and grimacing in pain. During an observation and interview on 05/18/2021 at 11:15 A.M., in Resident #101's room, Certified Nursing Assistant (CNA) H reported that Resident #101 was loudly moaning. Resident #101 did not have barrier cream or the ordered treatment dressing covering the wound. Resident #101 had a large irregular shaped wound on her left buttock/sacrum. Observed half of the wound on the left buttock with an area of connection to the sacral area of the wound. The wound was open, and the wound bed had red tissue noted. Approximately ¼ of the wound contained slough and in the center of the slough there was dark green tissue noted. The wound was irregular in shape but was approximately 4cm in diameter. There was a moderate amount of serosanguinous (watery fluid that is blood tinged) fluid noted on Resident #101's brief. Under the left buttock wound there was a pencil eraser sized open area with a bright red wound bed. During an observation and interview on 05/18/2021 at 11:18 A.M., Licensed Practical Nurse (LPN) E reported that Resident #101's wound had worsened since the last time she observed it. During an observation and interview on 05/18/2021 at 11:23 A.M., Unit Manager (UM) J reported that Resident #101's wound was ongoing. UM J reported that nurses perform weekly skin assessments on all residents and the wound care team rounds on Wednesdays with the wound physician for measurements. UM J measured Resident #101's wound and reported the length of the wound was 4cm, width was 3.75, and the depth was 0.2cm. UM J reported that it is measured as 1 wound and the wound is measured by diameter. The additional wound (size of a pencil eraser) was not measured at that time. Review of Resident #101's Evaluation of Pressure Sore Unavoidability dated 5/5/21 revealed, CONDITIONS THAT MAKE PRESSURE ULCER(S) UNAVOIDABLE: (check all that apply .Coma, Semi-coma or Supor (sic) .[CONDITION(S)], [CONDITION(S)], [CONDITION(S)] .Urinary Incontinence, continuous .AGGRAVATING FACTORS: (check all that apply) .Memory/Cognitive Deficits .[MEDICATION(S)] less than 3.5 .Bowel incontinence .Hemoglobin (less than) 10 (female) .Treatment, HOB (Head of Bed) elevation (greater than) 30 degrees required .Total protein 6.1, Type 2 DM (Diabetes Mellitus) (with) Diabetic [CONDITION(S)]. Review of Resident #101's Physician Note dated 5/5/21 revealed, Patient is an [AGE] year old female seen and examined at (facility) along with the wound care team and nurse manager for Stage 2 left buttock ulceration measuring 1.3cm x 0.8cm x 0.1cm, Stage 2 right buttock ulceration measuring 1.9cm x 0.8cm x 0.1cm, Stage 2 sacrum ulceration measuring 4.0cm x 1.8cm x 0.1cm. [CONDITION(S)] makes wounds unavoidable .Plan .3. PT (patient) should be encouraged to participate in activities outside of room on a daily basis to the best of the patients ability .5. If patient is in bed, appropriate offloading mattress with frequent turning and positioning every two hours to the best of the patients ability .7. Apply collagen dressing to wounds, cover with sacral foam dressing, change MWF/PRN (Monday, Wednesday, Friday, and as needed). Review of Resident #101's Physician Note dated 5/12/21 revealed, Patient is an [AGE] year old female seen and examined at (facility) along with the wound care team and nurse manager for Stage 2 left buttock ulceration measuring 1.3cm x 0.9cm x 0.1cm, Stage 2 right buttock ulceration now healed/resolved, Stage 2 sacrum ulceration measuring 7.0cm x 3.2cm x 0.1cm. [CONDITION(S)] makes wounds unavoidable . Plan .3. PT (patient) should be encouraged to participate in activities outside of room on a daily basis to the best of the patients ability .5. If patient is in bed, appropriate offloading mattress with frequent turning and positioning every two hours to the best of the patients ability .7. Apply collagen dressing to wounds, cover with sacral foam dressing, change MWF/PRN (Monday, Wednesday, Friday, and as needed). According to the State Operations Manual the definition of unavoidable revealed, Unavoidable means that the resident developed a pressure ulcer/injury even though the facility had evaluated the resident's clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Note Resident #101's head of bed was not greater than 30 degrees during observations, resident was not repositioned every 2 hours, there was no bandage on Resident #101's sacrum during the observation, Resident #101's heels were not offloaded, and there were no care planned interventions for repositioning. Indicating Resident #101 did not meet the definition of unavoidable pressure ulcer/injury. According to Nursing Times (VOL: 98, ISSUE: 11, PAGE NO: 41. [NAME], S.K PhD). Part 1. Causes of pressure ulcers .Pressure ulcers occur when soft tissues (most commonly the skin) are distorted in a fixed manner over a long period. This distortion occurs either because the soft tissues are compressed and/or sheared between the skeleton and a support, such as a bed or chair when the person is sitting or lying .Immobility is rarely the primary cause of pressure ulcers. During an interview on 05/18/2021 at 10:33 A.M., CNA H reported that at that time there were only 3 CNA's working on the entire 600 unit. CNA H reported that it is impossible to get to the immobile residents and reposition them every 2 hours with the number of staff working each shift. CNA H reported that Resident #101's bottom has been getting worse and worse because we can't reposition like we need to. CNA H reported it started as 1 wound, then 4 wounds, and now it's all big and open. CNA H stated, I know (Resident #101) got the pressure ulcer because she's not repositioned, but we did everything we could .it's impossible with staffing. During an interview on 05/18/2021 at 12:29 P.M., LPN E reported that because of the short staffing the facility aides cannot get to repositioning the immobile residents on the unit. During an interview on 05/13/2021 at 11:21 A.M., CNA N reported that there were not enough staff to meet the needs of the residents. CNA N reported that most residents on the 600 Unit were extensive 2 person assist and needed frequent repositioning and incontinence care. CNA N reported that the staff could not keep up and meet the needs of the residents. During an interview on 05/13/2021 at 3:06 P.M., CNA U reported that there were only 3 CNA's for the entire 600 unit for 2nd shift. CNA U reported that 3 CNA's and 2 nurses was not enough to meet the needs of the residents. CNA U reported that at times they have to put residents to bed before dinner in order to get all residents to bed before the end of shift. CNA U reported that the staff attempt to get to the immobile residents to check and change and reposition but reported it was difficult without enough staff. CNA U reported that the 600 Unit had many 2 person assist residents.

This citation pertains to intake #'s: MI 758, MI 665, and MI 011 Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet resident needs for 2 of 9 residents (Resident #101 and Resident #102) and all residents residing on the 600 Unit reviewed for care needs, resulting in unmet care needs and the potential for impaired physical, mental, and psychosocial well-being. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #101's Braden Skin Assessment for Predicting Pressure Ulcers dated 4/21/21 revealed a score of 8 indicating Resident #101 was very high risk for the development of a pressure ulcer. Review of Resident #101's Weekly Skin assessment dated [DATE] revealed, Patient has NEW alteration in skin integrity? Yes .Site-Left buttock .Type-Pressure .Length 2cm .Width 1cm .Depth 0.0 .Stage-II .Left buttock .Type-Pressure .Length 1cm .Width 0.6 .Depth 0.0 .Stage-II .Open areas to buttocks not well approximated. Wound bed red with very min serous dng (drainage). Cream applied to buttocks. Res (resident) propped on pillow for pressure relief. Review of Resident #101's Weekly Skin assessment dated [DATE] revealed, Patient has NEW alteration in skin integrity? Yes .Site-Sacrum .Type-Pressure .Length 4.3(cm) .Width 3.3(cm) .Depth (blank) .Stage (blank) . Review of Resident #101's Skin & Wound Evaluation dated 5/5/21 (lock date 5/17/21) revealed, Type: Pressure .Stage: Stage 2 .Location Right Buttock .In House Acquired .How long has the wound been present? New .Area 1.1cm2-Length 1.9cm-Wideth 0.8cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin & Wound Evaluation dated 5/5/21 (lock date 5/17/21) revealed, Type: Pressure .Stage: Stage 2 .Location-Left Buttock .In House Acquired .How long has the wound been present? .New .Area 0.8cm2-Length 1.3 cm-Width 0.8cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin & Wound Evaluation dated 5/5/21 (lock date 5/17/21) revealed, Type: Pressure . Stage: Stage 2 .Location-Sacrum . In House Acquired .How long has the wound been present? .new .Wound Measurements Area 5.8cm2-Length 4.0cm-Width 1.8cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin & Wound Evaluation dated 5/11/21 revealed, Type: Pressure .Location-Left Buttock .In House Acquired .How long has the wound been present? .1 week .Wound Measurements 1. Area 0.8 cm2-Length 1.3 cm-Width 0.9cm-Depth 0.1cm .Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration . Review of Resident #101's Skin & Wound Evaluation dated 5/11/21 revealed, Type: Pressure . Stage: Stage 2 .Location-Sacrum . In House Acquired .How long has the wound been present? .1 week .Wound Measurements Area 12.8cm2-Length 7.0cm-Width 3.2cm-Depth 0.1cm . Goal of Care: 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Turning/repositioning program . Review of Resident #101's Skin/Wound Evaluation dated 5/11/21 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Left Buttock. Wound measurements are: Area - 0.8 cm2, Length - 1.3 cm, Width - 0.9 cm, Depth - 0.1 cm . Review of Resident #101's Skin progress note dated 5/13/21 revealed, Location: Sacrum Left Buttock Right Buttock - resolved/healed Type of Skin Change/Impairment: Pressure Injury - Stage 2 . (No other progress note related to sacral or other wounds documented on 5/13/2021) During an interview on 05/18/2021 at 1:05 P.M., Wound Nurse (WN) R reported that there was a wound identified on 4/22/21 for Resident #101 and the wound was no longer moisture associated. Resident #101 originally had 3 separate wounds and on 5/11/21 the right buttock wound had merged with the sacral wound and turned into 1 wound. WN R reported that the care plan for impaired skin integrity was not initiated until 5/10/21 but nurses and Certified Nursing Assistants (CNA's) should still be following professional standards of practice for repositioning immobile residents. WN R reported that the standard of practice for immobile residents is to reposition every 2 hours as well as providing incontinence care at least every 2 hours if required. WN R reported that just because a resident has [CONDITION(S)] it does not mean the resident will get a wound. It just puts her at high risk. WN R stated that sometimes with interventions in place they (pressure ulcers) are unavoidable. During an observation and interview on 05/18/2021 at 11:15 A.M., in Resident #101's room, Certified Nursing Assistant (CNA) H reported that Resident #101 was loudly moaning. Resident #101 did not have barrier cream or the ordered treatment dressing covering the wound. Resident #101 had a large irregular shaped wound on her left buttock/sacrum. Observed half of the wound on the left buttock with an area of connection to the sacral area of the wound. The wound was open, and the wound bed had red tissue noted. Approximately ¼ of the wound contained slough and in the center of the slough there was dark green tissue noted. The wound was irregular in shape but was approximately 4cm in diameter. There was a moderate amount of serosanguinous (watery fluid that is blood tinged) fluid noted on Resident #101's brief. Under the left buttock wound there was a pencil eraser sized open area with a bright red wound bed. During an interview on 05/18/2021 at 10:33 A.M., Certified Nursing Assistant (CNA) H reported that at that time there were only 3 CNA's working on the entire unit. CNA H reported that it is impossible to get to the immobile residents and reposition them every 2 hours with the number of staff working each shift. CNA H reported that Resident #101's bottom has been getting worse and worse because we cant reposition like we need to. CNA H reported it started as 1 wound, then 4 wounds, and now it's all big and open. CNA H stated, We cannot do what we need to do with 3 aides. I have to pick the heavy wetters and some residents get pressure ulcers because we cant get to them. Then we get in trouble even when we say we need help. We cant do it all. CNA H reported that there are many 2 person assist residents on the 600 Unit, CNA H reported that on top of the multiple 2 person assist residents they also have to shower all the residents (2 showers per week for residents), set up meal trays, feed multiple residents, perform brief changes and repositioning, and intervene with resident behaviors. CNA H reported that with the prior owners of the facility there were 6 aides and at times an additional shower aide. CNA H reported that was perfect and residents received better care. Resident #103 Review of a Face Sheet revealed Resident #103 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 4/2/21 revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of the Functional Status revealed that Resident #101 required extensive two person assist for bed mobility, transfer, dressing, toileting, and personal hygiene. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 3/16/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. During an interview on 05/18/2021 at 8:27 A.M., Resident #103 reported that he had concerns with the facility being short staffed. Resident #103 reported that he was sitting in a wet brief and had asked for assistance all morning. Resident #103 reported that he had had a wet brief since 3:00 A.M. Resident #103 reported that normally there were only 1-2 CNAs on the Unit for each shift. Resident #103 stated, Because state is here, they have extra staff on during the day. During an interview on 05/13/2021 at 12:38 P.M., Licensed Practical Nurse (LPN) M and LPN O reported that they were the nurses covering split units. LPN O reported that because the facility was short staffed on that day they had to cover additional Units. LPN M reported that it wasn't safe to work with the shortage for the residents. LPN O reported nursing staff could not complete tasks timely and residents would often have to wait. LPN O reported the 600 Unit had high acuity residents with high needs. LPN O reported that when they are fully staffed it is fine but when the nurses cover additional units the nursing staff cannot meet resident needs timely or at all. LPN O reported that medications were passed late that day because of being short staffed. LPN O reported as needed pain medications are not administered when residents request them at times and residents shouldn't be punished because of it (short staffing). During an interview on 05/13/2021 at 3:06 P.M., Certified Nursing Assistant (CNA) U reported that there were only 3 CNA's for the entire 600 unit for 2nd shift. CNA U reported that 3 CNA's and 2 nurses was not enough to meet the needs of the residents. CNA U reported that at times they have to put residents to bed before dinner in order to get all residents to bed before the end of shift. CNA U reported that the staff attempt to get to the immobile residents to check and change and reposition but reported it was difficult without enough staff. CNA U reported that the 600 Unit had many 2 assist residents. During an interview on 05/13/2021 at 11:21 A.M., CNA N reported that there were not enough staff to meet the needs of the residents. CNA N reported that most residents on the 600 Unit were extensive 2 person assist and needed frequent repositioning and incontinence care. CNA N reported that the staff could not keep up and meet the needs of the residents. CNA N reported that 4 CNAs scheduled for 44 residents, with many that required 2 person assist, was too difficult to handle. CNA N reported that many days there were only 3 CNAs scheduled for the 600 Unit. During an observation and interview on 05/18/2021 at 11:18 A.M., LPN E reported that it is not safe to care for as many residents as they are. LPN E reported that medications are consistently administered late because of the number of residents the nurses are responsible for. During an interview on 05/18/2021 at 12:29 P.M., LPN E reported that because of the short staffing the facility aides cannot get to repositioning the immobile residents on the unit. During an observation and interview on 05/18/2021 at 3:26 P.M., CNA L reported that at that time there were only 2 CNA's schedule for 2nd shift on the 600 Unit for approximately 44 residents. CNA L reported that the other CNA scheduled at that time was on her break which left her to be alone on the 600 Unit. CNA L reported she was doing the best she could but could not assist 2 person assist residents when she was the only aide and the nurses were also short staffed and busy. Observed 6 call lights on at the time of the interview. Review of the facility schedule dated 5/18/21 revealed that on 5/18/21 there was only 1 CNA scheduled on the 600 Unit for the 2nd shift. CNA L extended her shift to assist with coverage. Review of the Facility Matrix revealed that on 5/17/21 there were 44 residents on the 600 Unit. Review of a list provided by the facility on 5/17/21 revealed that there were 23 residents on the 600 Unit that required 2 person assist for cares.

This citation pertains to Intake # MI 658 & # MI 234. Based on observation, interview, and record review, the facility failed to: 1.) ensure residents received comprehensive wound care, and 2.) implement a physician's order for a wound treatment in 2 of 8 residents (Resident #101 and #106) reviewed for quality of care, resulting in the decline of a physical condition and the worsening of symptoms. Findings include: Review of the facility policy Change in a Resident's Condition or Status dated 10/5/20 revealed, POLICY: The facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status. 1. The nurse will notify the resident ' s Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident ' s physical/emotional/mental condition; e. need to alter the resident ' s medical treatment significantly; f. refusal of treatment or medications outside of the residents normal pattern (2) or more consecutive times g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident ' s condition. 2. A significant change of condition is a major decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident ' s health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make observations and gather relevant and pertinent information for the provider. 4. Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident ' s physical, mental, or psychosocial status; c. There is a need to change the resident ' s room assignment; d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident ' s medical/mental condition or status. 6. Regardless of the resident ' s current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #101's Progress Note dated 9/15/2020 at 12:04 P.M. written by Wound Care Nurse (WCN) CC revealed, Patient was seen by wound care for LLE s/p AKA (Left Lower Extremity Surgical Above Knee Amputation). Surgical incision is approximated, 33 staples visible and intact, skin around incision has purple discoloration and couple serous fluid filled blisters, no drainage noted. Swabbed incision with Iodine and covered with dry drsg/ABD (dressing). Resident was also noted to have bruising to upper inner thigh and serous fluid filled blister that appears to be where her shrinker ends. Left shrinker off for time being, contacting surgeon's office to possibly schedule follow up this week. Patient has follow up scheduled for Monday 9/21. Patient received pain medication. Physician aware. Review of Resident #101's Progress Note written by Physician Assistant (PA) KK on 9/15/20 revealed, (Resident #101) is seen today to reassess her left AKA (Above Knee Amputation) incision site. Last week there was a little blistering noted to the medial edge superiorly, but otherwise the incision appeared healthy She states the stump continues to be quite painful .Resident also noted to have linear areas of purple discoloration to the left medial thigh, one area with an intact flaccid bullous lesion (blister) .Incision on left BKA (below knee amputation) is well approximated, however the purple discoloration and the linear areas of discoloration which appear to be from the stump shrinker are concerning for poor circulation to the stump, while the linear areas would be considered pressure injuries from the stump shrinker, I do not think she would have developed the tissue damage if she had appropriate circulation to the stump. Will leave the stump shrinker off for now, she has an appointment with her vascular surgeon in 6 days, will have staff call to see if they can get her in sooner. Will continue to have staff cleanse the incision with iodine, cover with ABD pads (type of wound dressing) and secure with type, change every 3 days. During an interview on 11/10/2020 at 3:00 P.M., WCN CC reported that she had assessed Resident #101's wound on 9/15/20 with PA KK. WCN CC reported that she had directed Unit Secretary (US) PP to notify Resident #101's vascular surgeon that Resident #101 needed an appointment sooner. WCN CC reported that US PP was to notify the vascular surgeon's office of the worsening of the condition of the wound. During an interview on 11/10/2020 at 3:39 P.M., US PP reported that she did remember calling the Resident #101's vascular surgeon to get Resident #101 in the office for an assessment earlier. US PP reported she would not have reported any changes in the condition as she is not a licensed nurse. Review of Resident #101's Physician assessment dated [DATE] revealed, .to follow up with vascular surgery 9/21/20. Review of Resident #101's Physician assessment dated [DATE] revealed, .to follow up with vascular surgery 9/18/20 and for evaluation of wound. (Indicating the appointment was rescheduled). Review of Resident #101's Medical Practitioner Note dated 9/16/20 revealed, .subsequent visit for acute pain s/p left AKA . Received message from facility about concerns with patient with slight confusion since her admission and a recent fall without injury. Pain medication changes were made a week ago .Patient nurse reported patient to be somewhat alert, answered questions, and requested pain medication. Patient is in bed and aroused for visit. She reported occasional sharp pain in left stump at 7/10, resolved by pain medications .Findings: Reviewed wound note on left stump, bruising, dried blood on staples . Review of Resident #101's Therapy Notes dated 9/17/20 (no time) revealed, .During cares therapist noticed open area and blisters on medial thigh and notable bleeding on distal end of stump. Notified nursing about areas of concern, nursing staff came in and covered the areas and will call the patients surgeon. Review of Resident #101's Progress Note written by Registered Nurse (RN) II and dated 9/17/2020 at 12:00 P.M. revealed, pt (patient) continues to have purple/black coloring around her staples at the end of her stump. pt also has redness/purple noted on the inner aspect of her upper left thigh. pt reports that her leg has burning feeling and is painful at times. pt is f/u (follow up) with her surgeon tomorrow - apt (appointment) is scheduled. in house wound nurse is aware of skin changes. (Indicating the worsening of the wound). During an interview on 11/10/2020 at 3:42 P.M., RN II reported that she had been the nurse for Resident #101 on 9/17/20. RN II reported that therapy staff had requested she assess Resident #101's wound because they had noticed a change in color. RN II stated, I'm not a wound specialist but I noticed something wasn't right. She had discoloration on the front of them stump up the thigh. RN II reported that Resident #101's left stump was purple-ish reddish with dark discoloration. RN II reported that Resident #101 was complaining of a burning and tingling sensation in her stump. RN II reported that she had WCN CC assess Resident #101. RN II reported that she did not speak to the vascular surgeon but had been notified Resident #101's appointment had been moved to 9/18/20. RN II reported that any time there is a change in the condition of a wound the physician is notified immediately. RN II reported that she had spoken with Resident #101's Family Member (FM OO) because Resident #101 had called her and told her she wanted to go to the hospital. RN II reported that FM OO was concerned with the increase in pain that Resident #101 was reporting. During an interview on 11/13/2020 at 11:19 A.M., Certified Occupational Therapy Assistant (COTA) QQ reported that she was the staff assisting Resident #101 with therapy on 9/17/20. COTA QQ reported that she had noticed a change in Resident #101's wound. COTA QQ reported that there was an appearance of bruising, indentation of the skin, and the skin was dark purple around the incision. COTA QQ reported that the wound was bleeding and nursing staff came down and covered the wound. During an interview on 11/10/2020 at 3:00 P.M., WCN CC reported that she assessed Resident #101's wound while Resident #101 was in Therapy on 9/17/20. WCN CC reported no further action taken at that time because Resident #101 was set to see her vascular surgeon in the morning the following day (9/18/20). During an interview on 11/13/2020 at 9:00 A.M., PA KK reported that she is the facility's wound Physician Assistant. PA KK reported if there were concerns the Wound Care Nurse would notify her. PA KK reported she last assessed Resident #101's wound/incision on 9/15/20. PA KK reported Resident #101's wound/incision looked worse and she had a concern about the circulation to the wound. PA KK reported that at that time it did not appear to be infected but she had requested the appointment for the Vascular Surgeon be moved up. PA KK reported she was not notified about Resident #101's wound/incision bleeding or a change in the wound appearance. PA KK reported she would expect the staff to notify either her (PA KK) or the resident's physician if there was a change in the condition of the wound. PA KK reported that with the description of the wound in the progress notes, If it was still during the day, I would want her to go to the (vascular surgeon) office. If it was later in the day, I would have had them send her in (to the emergency department). PA KK reported that if she is notified of a resident concern the nurses document it in a progress note. During an interview on 11/13/2020 at 3:05 P.M., Medical Doctor (MD) LL reported that he was not notified of a concern with Resident #101's wound on 9/17/20. MD LL reported that WCN CC and PA KK are in charge of wound care and manage any concerns with wounds. MD LL reported that the expectation is that WCN CC and PA KK monitor the wounds and notify him if there is a change in condition if necessary. MD LL reported that if he was notified of a change in Resident #101's wound nursing staff would write a progress note. Review of Resident #101's Progress Notes revealed no documentation that PA KK or MD LL were notified of a change in Resident #101's wound on 9/17/20. Review of Resident #101's Progress Note dated 9/17/2020 at 5:48 P.M. revealed, (FM OO) called asking about (Resident #101). (FM OO) states that (Resident #101) called her and asked her to call 911 -stating that she wants to leave and is in pain. (FM OO)states that she called x2 other people for the same reason. nurse spoke to (FM OO) and explained that Tylenol was recently given and [MEDICATION NAME] was just given since Tylenol was not effective. pt has been repositioned. (FM OO) requested nurse to have her mom call her. nurse went down into pt's room and spoke to her. nurse asked if she was in pain, she said no, well my [MEDICAL CONDITION]. nurse told her that (FM OO) wants to talk to her. nurse helped dial the phone. pt spoke to (FM OO) saying call 911. after pt got off the phone - pt stated my hearts just broken nurse spoke to pt and asked her what was wrong and why is her heart broken. pt stated you won't believe me, no one does nurse told her that she could talk to her if she wanted to. then pt's phone rang. she stopped crying and answered the phone. nurse told pt if she needed anything to let staff know. pt said okay and continued to talk to her family member. nurse went to find social worker and notified her. social worker went into room to speak to pt. (No documentation of social work assessment in Resident #101's progress notes). During an interview on 11/13/2020 at 8:53 A.M., FM OO reported that on 9/17/20 Resident #101 had called her requesting to go the hospital because of the concerns she had with her stump. FM OO reported that Resident #101 was reporting increased pain in her stump and a concern that her stump was becoming infected. FM OO stated, I don't know why they didn't send her (to the emergency room ). FM OO reported that the facility staff were aware she wanted to be sent to the hospital and FM OO also requested that she be seen in the hospital. FM OO reported that once she arrived to the hospital, following her vascular appointment, she had to have an additional surgery to remove more of her leg because of the infection. During an interview on 11/10/2020 at 3:42 P.M., RN II reported that she had spoken with Resident #101's Family Member (FM OO) because Resident #101 had called her and told her she wanted to go to the hospital. RN II reported that FM OO was concerned with the increase in pain that Resident #101 was reporting. Review of Resident #101's Progress Notes revealed no documentation the physician was notified that Resident #101 wanted to go to the hospital for evaluation. Review of Resident #101's Hospital Record dated 9/18/20 revealed, . There were also reportedly some concerns for wound care staff that the patient's LEFT AKA site was becoming ischemic/infected in the past few days. Today the patient had an appointment with vascular surgery and mentioned to the front desk that she was not being treated well at her facility. For this reason she was sent to (hospital). There was also some concern that she was increasingly confused for the past two days. Vascular surgery was able to evaluate the patient in the (hospital) and were concerned for ischemia vs infection .Reason for Admission: Nonhealing wound and gangrene of amputation stump, UTI (Urinary Tract Infection) .Impression: [AGE] year old female s/p left AKA (status [REDACTED]. Post op patient had been residing at (facility). She presented 9/18/20 to the vascular surgery clinic for routine follow up and was found to have a dusky, painful left stump. She was found to have gangrene and failure of left AKA skin flap requiring high left AKA (additional surgery) on 9/20/20. .Health care provider-initiated interventions are dependent nursing interventions, or actions that require an order from a health care provider. The interventions are based on the health care provider's response to treating or managing a medical diagnosis .As a nurse you intervene by carrying out the health care provider's written and/or verbal orders. Administering a medication, implementing an invasive procedure (e.g., inserting a Foley catheter, starting an intravenous (IV) infusion) and preparing a patient for diagnostic tests are examples of health care provider-initiated interventions . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. .The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #106 Review of an Admission Record revealed Resident #106 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 11/1/20, revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a current Care Plan for Resident #106, with a print date of 11/10/20, revealed the Focus .The resident has potential/actual impairment to skin integrity r/t (related to) chronic disease processes, Fragile/Thin skin, Hx (history) of skin injuries, immobility and incontinence . last revised 9/2/20, with interventions which included .Follow physician orders for treatment of [REDACTED]. Review of an ELECTRONIC ORDER with E-SIGNATURE document for Resident #106, received from a physician visit at an outside appointment, dated 10/5/20, revealed .Outpatient Medication Detail .zinc oxide ([MEDICATION NAME]) 40% PSTE .1 Tube .Start 10/5/20 .Apply 1 Application to affected area twice daily .Sacrum - Topical .Frequency: Routine BID (twice daily) 10/05/20 - Until Discontinued . Note this document had Nurse Practitioner (NP) UU's initials and the date 10/6 handwritten on the bottom right hand corner. Review of an Order Summary Report of active orders for Resident #106 as of 10/1/20, revealed no physician order for [REDACTED].#106's outpatient appointment on 10/5/20. Review of the Progress Notes revealed no documentation related to Resident #106's outpatient order for .zinc oxide ([MEDICATION NAME]) 40% PSTE . and no information related to why the order was not transcribed into the electronic medical record/treatment record. Review of an Order Summary Report of active orders for Resident #106 as of 10/1/20, revealed a current order for .Triad [MEDICATION NAME] Wound Dress Paste (Wound Dressings) Apply to coccyx b/l (bilateral) buttocks topically every shift for wound care . with a start date of 7/30/19. In an observation on 11/10/20 at 10:35 a.m., observed Registered Nurse (RN) II as she prepared supplies to complete Resident #106's treatment orders. Observed RN II retrieve a small amount of .Triad . paste from the treatment cart and enter Resident #106's room to apply the paste with Certified Nursing Assistant (CNA) O. RN II and CNA O turned Resident #106 onto her side to apply the paste. Noted several small open areas on Resident #106's buttocks. RN II stated .it looks like a little MASD (Moisture-Associated Skin Damage) .the skin is open a little bit . Observed RN II cleanse Resident #106's buttocks and apply the .Triad . paste to the surface of the buttocks and coccyx. Resident #106's brief was replaced, and Resident #106 was repositioned onto her right side to offload pressure on her buttocks. In an interview on 11/10/20 at 10:55 a.m., RN II reported Resident #106 has a history of MASD, however RN II was unaware that the areas were open. RN II reported Wound and Infection Control Nurse CC and NP UU will be notified of the change in wound condition. Review of a Skin Progress Note for Resident #106, dated 11/10/20 at 2:17 p.m., revealed .Resident was seen today by wound care for moisture related [MEDICAL CONDITION] to coccyx area with several small scattered superficial open areas with pink blanchable bases, without drainage. Cleaned with NS (Normal Saline), patted dry with gauze, applied Triad paste .Resident with h/o (history of) recurrent MASD . In an interview on 11/10/20 at 3:00 p.m., Wound and Infection Control Nurse CC reported Resident #106 has a history of [MEDICAL CONDITION] and MASD (Moisture-Associated Skin Damage). Wound and Infection Control Nurse CC reported the open areas on Resident #106's buttocks are superficial and blanchable. Wound and Infection Control Nurse CC reported the Physician Assistant (PA) assessed the wounds earlier today. Wound and Infection Control Nurse CC reported no changes were made to Resident #106's treatment orders, and stated that the Triad cream remains in place as .it seems to work for her . Wound and Infection Control Nurse CC reported she was not notified of any new open areas for Resident #106 in the past few months or any new orders for zinc oxide, and stated .the last time we saw her was for her toe . approximately a month or two ago. Wound and Infection Control Nurse CC reported for outside appointments with new orders, the nurse who receives the paperwork should enter the new order into the electronic medical record. In an interview on 11/13/20 at 11:32 a.m., Unit Manager JJ reported if a resident were to receive new Physician orders after attending an outside appointment, those orders should be implemented by the nurse assigned to the resident. Unit Manager JJ reported the Physician at the facility would also be notified of any new orders received from appointments, and that new orders should be implemented immediately. In an interview on 11/17/20 at 4:33 p.m., Nurse Practitioner (NP) UU reported when new orders are obtained from a Physician after an outside appointment, nursing staff will enter the orders into the computer. NP UU reported the paperwork from those visits is generally placed into the Med Staff book for either her or the Physician to review. NP UU reported after the new orders are reviewed, and the documents initialed, the paperwork is given to the secretary who then scans the documents into the electronic medical record. NP UU reported it is typically the nurses responsibility to ensure that the new orders are entered into the computer. NP UU reported if she were to disagree with a new order, she would typically make a notation on the paperwork. NP UU reported it is .rare . for her to disagree with a specialist, and stated typically .I'm going to follow the specialist's order .

This citation pertains to Intake # MI 466 & # MI 507. Based on observation, interview, and record review, the facility failed to perform a lift transfer per plan of care, provide adequate supervision to prevent falls, and complete comprehensive fall investigations in 2 of 8 residents (Resident #105 and #107) reviewed for falls, resulting in an unsafe transfer, a fall with a femur fracture for Resident #105, a fall with a [MEDICAL CONDITION] for Resident #107, and the potential for future falls due to incomplete/inaccurate fall investigations. Findings include: Review of the policy/procedure Fall, adopted 10/22/20, revealed .It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care .Resident's (sic) will be evaluated after a fall .Evaluate for cause of fall .and attempt to place an intervention in place to prevent further falls .Document all appropriate information in the medical record . .High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #105 Review of an Admission Record revealed Resident #105 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 9/18/20, revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment, with a reference date of 9/18/20, revealed Resident #105 exhibited disorganized thinking, required extensive assistance of two staff members for transfers, and was unsteady and only able to stabilize with staff assistance for transfers on and off the toilet. Review of a Care Plan for Resident #105, with a print date of 11/6/20, revealed the Focus .The resident is at risk for falls r/t (related to) cognitive deficit, impaired gait/balance/mobility, poor safety awareness, pain, incontinence, use of diuretics, non-compliance with call light use . initiated 4/7/19. Review of a Fall Risk Assessment for Resident #105, dated 7/10/20, revealed .High Risk for Falling .MENTAL STATUS .Mental Status measures the residents self assessment of his/her own ability to ambulate. Ask the resident, Are you able to go to the bathroom alone, or do you need assistance? Does the resident's response to the above indicate they know the limits of their abilities to ambulate safely? Overestimates or forgets limits . Review of a General Progress Note for Resident #105, dated 9/19/20 at 9:30 a.m., revealed .AT (sic) approximately 0930 (9:30 a.m.) this morning the aide was transferring patient to the toilet with the (sit-to-stand lift), and (Resident #105's) legs were too weak to hold her up. She slipped down to her knees and through the sling to the floor. Upon assessment she did not report being painful . Review of a Post Fall Assessment for Resident #105, with an effective date of 9/19/20 at 9:30 a.m., revealed .New Interventions .PT (Physical Therapy) to eval (evaluate) and treat for safe lift transfer status . Review of an Incident Report, dated 9/19/20, revealed Resident #105 had a fall in her room at 9:30 a.m. with no injuries. Per the report, under the section Predisposing Situation Factors the box Other had been checked, with .Using (sit-to-stand lift) for transfer . entered into the text box. Under the Witnesses section of the report, the statement from CNA Z revealed .Resident was in the sit to stand lift and was being transferred from bathroom to her chair when her legs gave out. I attempted to grab her chair but was unable to grab it in time, and she slid to the floor, landing on her bottom and then rolling to her right side . No additional information was noted within CNA Z's statement in regard to the timing of Resident #105's fall, or the presence of only one CNA for the sit-to stand lift transfer. Review of an Interdisciplinary Post Fall Follow Up assessment for Resident #105, dated 9/22/20, revealed .Date and Time of fall .09/19/2020 09:30 .Root Cause(s) and Contributing Factors as determined by IDT (Interdisciplinary Team) .Resident was being transferred from the bedside commode to the wheelchair. Resident was being transferred with the (sit-to-stand lift) and 1 CENA. The residents legs gave out and the resident slid down and the CENA could not stop her from falling .Was this fall preventable? Yes .Possible prevention if 2 CENA's were present .Review and updated transfer status to a (dependent) lift . Review of a General Progress Note for Resident #105, dated 9/19/20 at 10:30 a.m., revealed .At approximately 1030 am (10:30 a.m.) this morning (Resident #105) tried to transfer herself from her WC (wheelchair) to the toilet in her bathroom and fell to the floor in the process of transferring. Upon assessment (Resident #105) had right hip, thigh, and knee pain. I called the on-call physician who ordered x-rays of Hip, thigh, and knee. The x-ray tech came but was unable to complete the x-rays due to patients weight .Therefore patient was sent to the (Hospital Name) ED (Emergency Department) for imaging and treatment. Guardian notified . Review of a Post Fall Assessment for Resident #105, with an effective date of 9/19/20 at 10:30 a.m., revealed .New Interventions .Sent to ED . Review of an Incident Report, dated 9/19/20, revealed Resident #105 had a fall in her bathroom at 10:30 a.m. Per the report, Registered Nurse (RN) U .Completed head to toe assessment and ROM (Range of Motion). Patient had excessive pain in right upper leg from her hip to her right knee. Contacted on-call physician and guardian. Attempted to get x-rays in the facility but she exceeded weight limit for mobile x-ray. Sent patient to (Hospital Name) ER (emergency room ) for imaging and treatment . Under the Witnesses section of the report, the statement from CNA Z revealed .Resident was in her wheelchair, stated she had to go to the bathroom after lunch. I told her I had to get help from another staff member to assist her with me to the bed to use the bed pan as she has already slid out of the lift once and was not safe to use it. resident stated that she had to go now, I told her I would be right back with help. upon reentering the room with another CNA resident was in the bathroom, and halfway off her wheelchair trying to get onto the toilet. the wheelchair brakes were not locked, by the time I made it to her she had already landed on the floor, landing on her right hip . Under the Witnesses section of the report, the statement from Hospitality Aide R revealed .(CNA Z) came and got me for assistance to help her get the resident into bed to use the bed pan. we walked into the bathroom and saw resident attempting to self transfer from her wheelchair to the toilet, wheelchair brakes were not locked. we tried to catch her from falling to the floor but she landed on her right hip before we could catch her . Further review of this Incident Report revealed .Immediate intervention send to ED. X-ray (positive) for Femur FX (fracture). Care Plan updated for fall risk and new FX upon return from hospital with new interventions .Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance . In an interview on 11/10/20 at 2:30 p.m., RN U reported he was Resident #105's assigned nurse on 9/19/20 during the time frame within which she experienced two falls. RN U reported Resident #105's assigned Certified Nursing Assistant (CNA) that day was CNA Z. RN U reported he was notified of Resident #105's first fall .immediately afterwards . by CNA Z. RN U reported CNA Z had attempted to transfer Resident #105 with the sit-to-stand lift, and Resident #105 slid through the sling to the floor. RN U reported Resident #105 did not complain of pain after the first fall. RN U could not recall if any other staff were present at the time of Resident #105's first fall, beyond CNA Z. RN U reported Resident #105 was on a two-hour toileting schedule because she .seemed to have a psychological need to urinate frequently . RN U reported for Resident #105's second fall on 9/19/20, she had attempted to self-transfer from her wheelchair to the toilet without staff assistance. RN U reported that Resident #105 complained of right leg pain from her hip to her knee after the second fall on 9/19/20. RN U reported the Physician was notified, and orders were obtained for X-rays. RN U reported the X-rays were unable to be completed due to Resident #105's weight, therefore she was transferred to the hospital for further evaluation/treatment. In an interview on 11/12/20 at 9:08 a.m., CNA Z reported Resident #105's first fall on 9/19/20 occurred at approximately 10:30 a.m., and the second fall occurred at approximately 12:30 p.m., after lunch. CNA Z reported she had previously notified RN U that the times in the reports were incorrect. CNA Z reported she and CNA GG had transferred Resident #105 to the bathroom with the sit-to-stand lift at approximately 10:00 a.m., prior to the end of CNA GG's shift, and stated .but I got her (Resident #105) out by myself .I told (RN U) this .I told (RN U) I'm not supposed to use it (the sit-to-stand lift) by myself. I told him and he said OK and kept on walking . CNA Z reported two staff members are required for lift transfers, however stated .I was the only one (CNA) on the floor . CNA Z reported CNA GG completed her shift at approximately 10:00 a.m., and Hospitality Aide R came in at 11:00 a.m. CNA Z reported that for that hour, she was responsible for all of the residents on the 200 hall. CNA Z reported Resident #105 .had been in the bathroom for a while . when she went to transfer the resident without additional staff assistance at approximately 10:30 a.m. CNA Z reported as she wiped Resident #105's bottom, the resident began to state .I can't hold on, I'm tired, I'm tired, I'm falling . CNA Z stated .I tried to get around to get her chair and I was too late . CNA Z reported Resident #105 slid down through the sling, and stated .I tried to catch her but she was so heavy . CNA Z reported Resident #105 did not complain of pain after the fall, and stated she and CNA P (who was working on another hall) transferred Resident #105 back to her wheelchair using the dependent lift after Resident #105 was assessed by RN U. CNA Z reported Resident #105 would ask .almost every hour . to use the bathroom, and was on a 2-hour toileting schedule. CNA Z reported for Resident #105's second fall on 9/19/20 at approximately 12:30 p.m.she put her light on and I answered her light. I told her she had to wait because I had to get some help .she didn't wait . CNA Z reported when she answered the call light initially, Resident #105 was .already heading toward the bathroom . CNA Z reported that by the time she returned to the room with Hospitality Aide R, Resident #105 was already in the process of self-transferring to the toilet. CNA Z stated .we saw the fall but we weren't able to catch her .Sometimes she waits when asked .sometimes she doesn't . CNA Z reported approximately 5-6 minutes passed between when she originally responded to the call light for Resident #105 and when she returned to the room with Hospitality Aide R. CNA Z stated .maybe I should have waited in her room with her . CNA Z reported Resident #105 has a history of falls and stated .she don't ever wait. Sometimes we catch her halfway on the toilet . CNA Z reported the second fall on 9/19/20 occurred after lunch, and stated .I know it was after lunch because we picked the trays up . CNA Z reported after the second fall, Resident #105 complained of her .leg hurting . and after assessing Resident #105, RN U called to get an order for [REDACTED]. In an interview on 11/12/20 at 9:38 a.m., Housekeeper BB reported she was working on the 200 hall around the time of Resident #105's first fall on 9/19/20 at approximately 10:30 a.m. Housekeeper BB reported she overheard CNA Z ask RN U for help with a transfer, and stated RN U .really didn't respond like he should have . In an interview on 11/12/20 at 10:07 a.m., CNA GG reported she and CNA Z were assigned to the 200 Hall on 9/19/20 in the morning. CNA GG reported Resident #105 utilized a sit-to-stand lift for transfers, and reported she assisted CNA Z with a transfer to the toilet for Resident #105 at approximately 10:00 a.m. CNA GG reported there should always be at least two staff members present for lift transfers. CNA GG reported she completed her shift shortly after 10:00 a.m., and stated that Resident #105's transfer to the toilet was one of the last things she did before the end of her shift. CNA GG reported that as of the time she completed her shift on 9/19/20 shortly after 10:00 a.m., Resident #105 had not yet experienced any falls that day. In an interview on 11/12/20 at 11:00 a.m., CNA P reported she assisted CNA Z with a dependent lift transfer for Resident #105 in the resident's room after a fall on 9/19/20, sometime after 10:00 a.m. CNA P reported she and CNA Z transferred Resident #105 from the floor to the wheelchair. CNA P reported she was assigned to a different hall at the time. CNA P reported lift transfers should be completed with two staff members present. In an interview on 11/12/20 at 2:11 p.m., Hospitality Aide R reported she was charting on 9/19/20 when CNA Z came to ask her for help to transfer Resident #105. Hospitality Aide R stated .by the time we got there she was already falling. We tried to grab her but we couldn't . Hospitality Aide R reported Resident #105 would attempt to self transfer to the toilet .a lot of times .I guess she thought she could do it herself . Hospitality Aide R reported Resident #105 complained of pain after the fall and was assessed by RN U. Hospitality Aide R reported she started her shift at approximately 11:00 a.m., and believes the fall occurred after lunch. Hospitality Aide R reported after RN U assessed Resident #105, she and CNA Z transferred Resident #105 into her bed using the dependent lift. Hospitality Aid R reported in regard to Resident #105, if she is trying to get to the bathroom actively, staff should attempt to get someone to assist. Hospitality Aide R reported she would not feel comfortable leaving Resident #105 alone in her room if she was actively attempting to get to the bathroom. In an interview on 11/12/20 at 2:37 p.m., RN U reported Resident #105's falls occurred within an hour of each other, and stated he does not recall the exact times. RN U reported he does not recall CNA Z asking for help with a transfer for Resident #105 on 9/19/20. RN U stated if CNA Z asked for help .I would have helped her . RN U reported he did not recall anyone mentioning to him that the times documented for Resident #105's falls on 9/19/20 were incorrect. RN U reported sit-to-stand lifts and dependent lifts are a two person job. In an interview on 11/13/20 at 9:53 a.m., Assistant Director of Nursing (ADON) AA reported that when on call, she is notified of any falls that occur, and provides assistance to the nurses with development of interventions and steps to take for the fall investigation. ADON AA reported falls are then discussed each morning, during the Interdisciplinary Team (IDT) meeting, to ensure that all necessary parts of the investigation are completed. ADON AA reported in regard to Resident #105's first fall on 9/19/20, the CNA did a one person lift transfer, when there should have been two staff present. ADON AA reported the CNA was educated in regard to safe lift transfers after the incident. ADON AA reported typically interviews are completed with staff involved after a fall occurs. ADON AA reported that after a fall, the IDT reviews the documentation and if adequate information is documented in the medical record sometimes no further interviews are necessary. ADON AA stated .sometimes if the information is vague we do additional interviews . Review of the Hospital Imaging Results for Resident #105, dated 9/19/20, revealed .DR KNEE RIGHT 3 VIEWS .INDICATION: fall .Impression: Likely nondisplaced [MEDICAL CONDITION] metaphysis of the femur. This could be confirmed with CT . Review of a General Progress Note for Resident #105, dated 9/20/20 at 2:00 a.m., revealed .Called for update at (Hospital Name), patient kept c/o (complaining of) bilateral leg pain, Xray and CT confirmed right distal femur fx (fracture), patient will be admitted to the hospital and an (orthopedic) consult will be done to see if surgery is appropriate . Review of a General Progress Note for Resident #105, dated 9/20/20 at 2:33 p.m., revealed .Hospital PA called and confirmed the distal femur fracture and Ortho is not going to move forward with surgery as they feel the resident is not a good candidate to have the surgery. Hospital is going to treat patient for the pain and will call facility later this week to discuss discharge plans back to the facility with rehab options . Resident #107 Review of an Admission Record revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 8/6/20, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment, with a reference date of 8/6/20, revealed Resident #107 required supervision for walking in her room and in the hallways on the unit. In an observation on 11/10/20 at 12:22 p.m., observed Resident #107 as she sat in her scoot chair in her room. Noted a long, darkened scar on the right side of Resident #107's forehead. Resident #107 appeared comfortable, with no signs of pain noted. Review of a General Progress Note for Resident #107, dated 10/14/20 at 9:50 p.m., revealed .Res (Resident #107) was observed on the floor by 100 hall nurse, who stated that she heard Resident screaming in 100 hall dinning (sic) area. Upon an assessment laceration was noted to Res' forehead, about 7 cm long and 1/2 cm deep and was bleeding .no other injuries noted. Res was sent to ER (emergency room ) for sutures . Review of a Care Plan for Resident #107, with a print date of 11/10/20, revealed the Focus .At risk for falls due to hx (history) URI (Upper Respiratory Infection), [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION], dementia, inappropriate toileting on the floors, abnormal labs, prefers to wear sandals, hoards items in room leading to clutter, language barrier - Spanish speaking, Does not ask for assistance . last revised 6/3/19, with interventions which included .Keep walk areas free from clutter . revised 6/3/19, and .Scoot chair for positioning purposes . initiated 8/7/20. The intervention .TRANSFER/AMBULATION - Independent . had been previously resolved from the fall Care Plan on 8/7/20. Review of a Care Plan for Resident #107, with a print date of 11/10/20, revealed the Focus .The resident is at risk for falls r/t (related to) Incontinence of B&B (bowel and bladder), impulsive, dementia, language barrier (Spanish speaking), unsteady gait/balance, and medication side effects. Resident chooses to not wear footwear . initiated 4/3/20 and revised on 10/14/20, with interventions which included .Anticipate and meet resident's needs . initiated 4/3/20 and .Minimize risk factors in environment: areas free of spills and clutter; adequate, glare-free light; personal items within reach when in bed/chair, etc . initiated 4/3/20. Review of a Care Plan for Resident #107, with a print date of 11/10/20, revealed the Focus .The resident is an elopement risk and/or exhibits wandering behavior r/t (related to) Impaired safety awareness, dementia, high risk for wandering. Resident may stand at doors and look out windows. Resident also has history of wandering into other resident's rooms and looking through their things . last revised 8/18/20, with interventions which included .Distract resident when increased wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc. per resident preferences . initiated 6/3/19. Review of an Incident Report for Resident #107, dated 10/14/20 at 8:55 p.m., revealed .Res was observed on the floor by 100 hall nurse, who stated that she heard Resident screaming in 100 hall dinning (sic) area. Upon assessment laceration was noted to Res' forehead, about 7 cm long and 1/2 cm deep and was bleeding .no other injuries noted. Res was sent to to ER for sutures .Immediate Action Taken .laceration was cleansed with NS (Normal Saline), and covered with clean gauzes to stop the bleeding .Predisposing Situation Factors .Wanderer . Review of a Post Fall Assessment for Resident #107, dated 10/14/20 at 8:55 p.m., revealed .New Interventions .close observation .left a message to DON (Director of Nursing) about locking/key pad to the 100 hall door so that Res can not easily wonder (sic) there . Review of the Hospital Records for Resident #107, with a date of service of 10/14/20, revealed .This patient is a [AGE] year-old female with a history of [MEDICAL CONDITION] on Eliquis and dementia that presents to the emergency department for evaluation after sustaining a fall. Patient does reside in a nursing facility and was found in a construction area this evening. Patient is unable to recall the events that led up to her fall. She does have significant laceration to her right forehead and bleeding from her left middle toe. Patient does deny any pain elsewhere. Patient is reportedly at her baseline mentation. History limitation secondary to dementia and language barrier .Approximately 7 cm laceration to the right anterior forehead over hairline .Patient does have abrasion to the left middle distal toe .Patient's laceration was cleaned and repaired . Review of a General Progress Note for Resident #107, dated 10/15/20 at 4:11 a.m., revealed .Res returned from ER at 0211 (2:11 a.m.), with 12 sutures to scalp laceration, tetanus shot given in ER, head CT scan with no acute injuries . In an interview on 11/12/20 at 4:01 p.m., Licensed Practical Nurse (LPN) EE stated in regard to Resident #107's fall on 10/14/20 .to the best of my knowledge there were no witnesses .We heard her yelling and we thought it was someone outside. She was actually in the area of the old dining room . LPN EE reported she was working on Station 1 at the time of the fall, and Resident #107 resided on Station 2. LPN EE explained Station 1 and Station 2 are connected by a dining area that is currently under construction, and closed to residents. LPN EE reported she realized the yelling wasn't coming from outside, and went into the dining area to finding Resident #107 laying on the ground in the smaller room off of the dining area, which she described as a sitting area. LPN EE reported that when she and Certified Nursing Assistant (CNA) H arrived Resident #107 was on the ground, with a cut noted on her forehead. LPN EE reported there were no other staff or residents nearby, and she was unsure how long Resident #107 had been in the area. LPN EE reported there were long metal pieces of construction material on the floor beside Resident #107. LPN EE reported Resident #107's assigned nurse, Agency LPN I was notified and responded to the fall, and Resident #107 was sent out to the hospital for further evaluation/treatment. LPN EE reported there was no wheelchair or any other assistive device present near Resident #107, and it appeared she had walked independently across the dining room before she fell in the sitting area. LPN EE reported Resident #107 was unable to explain what happened, as she speaks primarily Spanish and was .too upset . LPN EE reported she was not asked to write a witness statement, and no management staff have talked to her about Resident #107's fall since it occurred on 10/14/20. In an interview on 11/13/20 at 10:46 a.m., Agency LPN I stated in regard to Resident #107's fall on 10/14/20 .She fell in the dining room where the construction was happening . Agency LPN I reported she was working on Station 2 at the time of the fall, and reported the nurse from Station 1 came to notify her that Resident #107 was laying on the floor and screaming in the dining room. Agency LPN I reported she arrived to the scene, assessed Resident #107, and sent her to the hospital for further evaluation/treatment. Agency LPN I stated in regard to Resident #107 .She has dementia, she couldn't explain (what happened) . Agency LPN I reported there was a significant amount of construction material throughout the dining area, and stated it .looked like she (Resident #107) tripped . Agency LPN I reported she had observed Resident #107 walking independently in the hallway on Station 2 approximately 15 minutes prior to the fall. Agency LPN I reported the doors to the dining area, which was under construction, were unlocked at the time the fall occurred. Agency LPN I reported she completed the incident report, but did not obtain statements from any of the other staff members involved. In an interview on 11/13/20 at 12:15 p.m., Director of Nursing (DON) B reported the expectation after a fall is that the on-call nurse is notified. DON B reported the IDT reviews fall reports and discusses the circumstances surrounding each fall. DON B reported witness statements/interviews completed should be with witnesses to the fall. DON B stated for an unwitnessed fall .I would expect the nurse and CNA and potentially anyone who had seen that particular resident last . to be interviewed. DON B reported in regard to Resident #107's fall in the dining area on 10/14/20, the doors to the dining area were unlocked. DON B reported the doors should have been locked at the time the fall occurred, and after the fall were immediately secured. In an interview on 11/13/20 at 12:34 p.m., Assistant Administrator C reported the IDT monitors to ensure that all incidents/falls are fully investigated. Assistant Administrator C reported Resident #107's fall on 10/14/20 was discussed in an IDT meeting, where the circumstances of the fall, risk reports, and new interventions were reviewed. Assistant Administrator C reported one intervention was to lock the dining room door immediately. Assistant Administrator C reported prior to the fall, the door to the main dining area, which was under construction, had been locked. Assistant Administrator C reported no witness statements were obtained after Resident #107's fall on 10/14/20 because no one witnessed the event. In an interview on 11/13/20 at 3:03 p.m., Assistant Administrator C reported in regard to Resident #107's fall on 10/14/20 it was identified during IDT discussion that the only two people with keys to the main dining room doors at the time the fall occurred were the head of maintenance and housekeeping. Assistant Administrator C reported the housekeeping department staff had been in the main dining room earlier that day (on 10/14/20) and had not returned to lock the doors. Review of an Interdisciplinary Post Fall Follow Up assessment for Resident #107, dated 10/17/20, revealed .Date and Time of fall: 10/14/2020 20:55 (8:55 p.m.) .Resident was identified by the 100 hall nurse (LPN EE) in the main dining room (construction area). It was determined that housekeeping had entered the construction area and was transferring supplies to units. While housekeeping was out of the area the resident ambulated into the area. The resident was heard yelling and was observed on the floor with a laceration to her forehead. There were several items surrounding the resident that may have cause the laceration. Resident was observed by her assigned nurse 15 minutes prior to being on the floor in the MDR (Main Dining Room). No other staff or residents were noted near the resident when observed on the floor. Resident does wander throughout the facility .Housekeeping has been educated to keep the MDR doors closed if not in the area and a double lock system has been initiated in construction areas . In an interview on 11/13/20 at 4:20 p.m., Assistant Administrator C reported management staff are currently in the process of calling the staff involved in Resident #107's fall on 10/14/20 to obtain statements over the phone. Assistant Administrator C reported statements from staff should typically be obtained at the time the event occurs.

This citation pertains to intake #s: MI 527 and MI 483 Based on observation, interview and record review, the facility failed to provide care per professional standards of practice to prevent the development of an avoidable unstageable pressure ulcer for 1 of 15 sampled residents (Resident #105) reviewed for alterations in skin integrity, resulting in the development of an avoidable pressure ulcer and the potential for delaying wound healing, infection, and overall deterioration in health status. Findings include: Review of the facility policy Skin Monitoring and Management- Pressure Ulcer dated 7/11/18 revealed, POLICY: It is the policy of this facility that: *A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and *A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing. PURPOSE: The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services to: *Promote the prevention of pressure ulcer development; *Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and *Prevent the development of additional, avoidable pressure ulcers .B. Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure ulcers which include, but are not limited to: *Impaired/decreased mobility and decreased functional ability *Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus *Drugs, such as steroids, that may affect wound healing *Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency *Resident refusal of some aspects of care and treatment *Cognitive impairment *Exposure of skin to urinary and fecal incontinence *Nutrition, malnutrition, and hydration deficits *History of a healed pressure ulcer and its stage (if known). C. All risk factors identified on assessment should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown. *Those risk factors which contribute to the possibility of unavoidable skin breakdown or unavoidable pressure ulcers should also be documented in the resident's clinical record .2. PREVENTION- In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: A. Stabilize, reduce or remove any existing underlying risks. B. Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition. C. Reposition the resident . Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 6/26/20 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #105 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #105 required extensive 2 person assist with bed mobility, dressing, toileting, and personal hygiene. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 3/19/20 revealed, Section M Skin Conditions .Risk of Pressure Ulcers/Injuries .Yes .Unhealed Pressure Ulcers/Injuries-Does this resident have one or more unhealed pressure ulcers/injuries .No. (Indicating the pressure ulcer/injury was facility acquired). Review of Resident #105's Care Plan revealed, The resident has pressure ulcer to sacrum r/t (related to) Immobility, incontinence, decreased oral intake Date Initiated: 05/13/2020 . The resident needs assistance to turn/reposition Date Initiated: 05/13/2020 . The resident has pressure ulcer to right heel r/t Disease process, Immobility, Impaired nutritional status. Date Initiated: 06/09/2020 . The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. Date Initiated: 06/09/2020 . END OF LIFE: The resident has a terminal prognosis r/t Multiple chronic medical conditions. Resident has signed on with (Name Omitted) Hospice. Date Initiated: 06/15/2020 . Reposition for comfort as needed. Follow skin management plan. Date Initiated: 06/15/2020. Review of Resident #105's Incident Report dated 5/12/20 revealed, Incident Description .Open area on coccyx area, measuring 1.5 cm x 2.5 cm. Review of Resident #105's Incident Report dated 5/13/20 revealed, Incident Description .Resident have (sic) developed unstageable pressure ulcer to sacrum. On 5/13/20, resident seen by wound care for sacral PU (pressure ulcer) that measures 2.6 (cm) x 2.0 (cm) x 0.1 (cm), 90 % yellow and brown necrotic (dead) tissues .Immediate Action Taken .Treatment order in place, CP (care plan) updated, air mattress ordered. Review of Resident #105's Pain Tool dated 5/13/20 revealed, Location (of pain) Sacrum Wound .WHAT MAKES THE PAIN BETTER .pain medication, repositioning. Review of Resident #105's Skin/Wound Evaluation dated 5/19/2020 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 3.1 cm2, Length - 2.5 cm, Width - 1.8 cm, Depth - 0.1 cm. Amount of exudate (secretion) is Moderate, type of exudate is Serosanguineous (thin, pink, and watery secretion), and odor noted after cleansing was Faint. Review of Resident #105's Skin/Wound Evaluation dated 6/10/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 10.9 cm2, Length - 5.7 cm, Width - 3.0 cm, Depth - 2.0 cm. Amount of exudate is Moderate, type of exudate is Serosanguineous, and odor noted after cleansing was Faint. Review of Resident #105's Wound Progress note dated 6/10/20 revealed, (Resident #105) is seen today to f/u (follow up) on the wound on her sacrum. The wound began as a pressure injury to the coccyx area on 5/12. I had put resident on [MEDICATION NAME] (antibiotic/fungal) for infection of the wound on 5/19, however on 5/27 the infection appeared to be significantly worse and involved the entire sacral area and right buttock. I sent resident to the ED (emergency department) as she was likely going to need significant debridement (removal of damaged tissue). IN the hospital resident was seen by ID (Infectious Disease), colorectal surgery, general surgery, plastic surgery and wound team. In the end it was felt that if they did debridement of the wound resident would require diverting [MEDICAL CONDITION] and it was felt that resident was a poor candidate for the procedure .On 5/27 I had also noted new wounds on the resident's feet. She had pressure injuries to bilateral heels and a bullous lesion on the right foot. At this time resident is lying in her bed. She admits that the wound on her bottom is sores (sic). She states she does have pain in her feet .noted to be a poor historian d/t (due to) [MEDICAL CONDITION] (difficulty speaking) and cognitive deficits 2/2 (secondary to)[MEDICAL CONDITION](Stroke) .Resident also noted to have an ulcer on the right medial buttock, it measures 0.5 x 1.1 x 0.1 cm .There is nonblanchable (reddening of the skin that does not turn white when touched indicating pressure ulcer) dark red discoloration on the left heel that measures 3.4 x 3.5cm .There is nonblanchable dark red discoloration on the right heel that measures 4.5 x 11.0 (cm) .On the right foot at the base of the 1st metatarsal (toe) there continues to be an intact, flaccid, serous filled bulla (blister) measuring 2.7 x 1.8 cm .On the right lateral foot there is an area of nonblanchable dark red discoloration measuring 1.9 x 3.5 cm .cooperative with exam .I note since her readmission resident has not been eating very well, overall I feel the prognosis for the wound is poor as resident has had an overall decline, she has been referred to Palliative care for pain management. Continues to have unstageable pressure injuries to bilateral heels and now to the right lateral foot as well, bulla remains to right medial foot, will have staff apply skin prep to all areas daily, resident to wear pressure relieving boots at all times. Review of Resident #105's Skin/Wound Evaluation dated 6/17/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 8.5 cm2, Length - 6.4 cm, Width - 2.3 cm, Depth - 0.8 cm. Review of Resident #105's Skin/Wound Evaluation dated 6/24/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 7.2 cm2, Length - 6.2 cm, Width - 2.1 cm, Depth - 1.5 cm. Review of Resident #105's Skin/Wound Evaluation dated 6/29/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 5.9 cm2, Length - 3.8 cm, Width - 2.7 cm, Depth - 2.0 cm. Review of Resident #105's Skin/Wound Evaluation dated 7/7/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 3.6 cm2, Length - 2.3 cm, Width - 2.1 cm, Depth - 1.5 cm. Review of Resident #105's Skin/Wound Evaluation dated 7/15/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 5.1 cm2, Length - 3.5 cm, Width - 2.1 cm, Depth - 0.8 cm. Review of Resident #105's Skin/Wound Evaluation dated 7/21/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 5.0 cm2, Length - 3.1 cm, Width - 2.2 cm, Depth - 0.5 cm Review of Resident #105's Skin/Wound Evaluation dated 7/27/20 at 12:04 P.M. revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 4.6 cm2, Length - 2.8 cm, Width - 2.1 cm, Depth - Not Applicable. Review of Resident #105's Skin/Wound Evaluation dated 7/27/20 at 12:08 P.M. Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 2.9 cm2, Length - 2.5 cm, Width - 1.8 cm, Depth - 2.0 cm. Review of Resident #105's Skin/Wound Evaluation dated 8/3/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 3.3 cm2, Length - 2.4 cm, Width - 1.8 cm, Depth - 0.8 cm. Review of Resident #105's Skin/Wound Evaluation dated 8/17/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 3.7 cm2, Length - 2.7 cm, Width - 1.8 cm, Depth - 1.0 cm. Review of Resident #105's Skin/Wound Evaluation dated 8/24/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 2.1 cm2, Length - 2.0 cm, Width - 1.3 cm, Depth - 1.0 cm. Review of Resident #105's Skin/Wound Evaluation dated 9/9/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 2.1 cm2, Length - 2.0 cm, Width - 1.3 cm, Depth - 1.0 cm. Review of Resident #105's Skin/Wound Evaluation dated 9/14/20 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 3.0 cm2, Length - 2.4 cm, Width - 1.7 cm, Depth - 0.7 cm. Review of Resident #105's Skin/Wound Evaluation dated 9/21/20 revealed, Wound location is Sacrum. Wound measurements are: Area - 4.4 cm2, Length - 2.8 cm, Width - 1.9 cm, Depth - 0.8 cm. During an observation on 09/16/2020 at 10:56 A.M., Resident #105 was in her bed on her back with her knees bent, right leg on top of left leg, facing the window. During an observation on 09/16/2020 at 1:48 P.M., Resident #105 was in her bed on her back with her knees bent, right leg on top of left leg, facing the window. During an observation on 09/16/2020 at 1:50 P.M., Certified Nursing Assistant (CNA) E reported that he was going to reposition and change Resident # 105's brief. CNA E reported that Resident #105 is to be repositioned every 2 hours. CNA E placed a pillow under Resident #105's right side, with her knees bent, right leg on top of left leg, facing the window. During an observation on 09/16/2020 at 3:38 P.M., was in bed with a pillow under right side, with her knees bent, right leg on top of left leg, facing the window. During an observation/interview on 09/16/2020 at 3:51 P.M., Resident #105 was in bed on her back with her legs straightened (pressure relieving boots in place). Resident #105 reported that her buttocks was sore. Resident #105 reported that she required assistance with repositioning. During an observation on 09/17/2020 at 9:12 A.M., Resident #105 was in bed with a pillow behind her left side. During an observation on 09/17/2020 at 11:40 A.M., Resident #105 was in bed with a pillow behind her left side. During an observation on 09/17/2020 at 11:59 A.M., Resident #105 was in bed with a pillow behind her left side. During an observation on 09/17/2020 at 2:32 P.M., Resident # 105's buttocks was observed. The wound was approximately the diameter of a D Battery with depth noted (unable to measure). The wound bed was bright red. The bandage that was removed had some green/brown/yellow drainage noted with a mild foul odor. During an interview on 09/17/2020 at 2:40 P.M., CNA F reported that Resident #105 should be repositioned every 2 hours. During an observation on 09/22/2020 at 8:37 A.M., Resident #105 was in bed with a pillow under her left side. During an observation on 09/22/2020 at 11:12 A.M., Resident #105 was in bed with a pillow under her left side. During an interview on 09/17/2020 at 1:53 P.M., CNA N reported residents that are immobile should be repositioned at least every 2 hours. During an interview on 09/22/2020 at 11:15 A.M., Registered Nurse (RN) J reported that CNA's frequently work short which makes it difficult to reposition the residents timely. During an interview on 09/23/2020 at 12:40 P.M., Licensed Practical Nurse (LPN) M reported that the night shift staff frequently work short. LPN M reported that being short staffed causes an increase in skin breakdown because residents are not being repositioned timely. LPN M reported that the resident acuity is not considered when the schedule is produced. During an observation on 09/22/2020 at 11:12 A.M., Resident #105 was in bed with a pillow under her left side.

This citation pertains to MI 599. Based on interview and record review the facility failed to meet professional standards of nursing practice for 1 of 3 residents (Resident #102) reviewed for professional standards resulting in a medication error. Findings include: Review of the Textbook Fundamentals of Nursing revealed the Process for Medication Reconciliation 1. Obtain, Verify, Document: Obtain a comprehensive and current list of a patient's medications whenever he or she experiences a change in health care setting (e.g., during admission, transfer, discharge). Include all current prescriptions and over-the-counter (OTC) medications. 2. Consider and Compare: Review what the patient was taking at home or preadmission and make sure that the list of medications, dosages, and frequencies is accurate. Compare this list to the current ordered medications and treatment plan to ensure accuracy. Include family caregiver in this discussion when appropriate. 3. Reconcile: Compare new medication orders with the current list; investigate any discrepancies with the patient's health care provider and document changes. 4. Communicate: Ensure that all the patient's health care providers have the most updated list of medications. Communicate and verify changes in medications as with the patient. (taken from Potter, [NAME] A.; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.) Review of the Face Sheet revealed Resident #102 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. The Face Sheet further revealed Resident #102 was not responsible for making decisions. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was not able to complete the interview for mental status. Review of the Admission/Re-Admission check list un-dated revealed staff were to Have 2nd nurse verify admission orders [REDACTED] Review of the hospital Physician order [REDACTED].#102 was ordered to be given [MEDICATION NAME] (Keflex, antibiotic) 500 mg (milligram) .4 times daily for 5 days. Review of the physician's orders [REDACTED].#102 was ordered to be given Keflex capsule 500 mg by mouth .4 times a day. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Medication Error Report dated 5/22/19 at 8:06 pm, revealed Resident #102 .was prescribed antibiotic for UTI (urinary tract infection) by (discharge hospital) for 5 days. The med (Keflex) was started on 5/14/19 and was to be completed on 5/18/19. Resident was still taking the medication on 5/22/19. Resident received extra doses of the medication. In an interview on 6/5/19 at 3:37 pm, Licensed Practical Nurse (LPN) CC stated, I put the antibiotic order into the computer and did not have a stop date for the antibiotic. LPN CC stated, I didn't check or double check the orders with another nurse. In an interview on 6/5/19 at 3:0 5 pm, Unit Manager (UM) BB stated Resident #102 received 3 to 4 days extra dosage antibiotics due to medication error. UM BB stated the Keflex antibiotic was started on 5/14/19' and was ordered by physician to be completed on 5/18/19 but was still ordered on [DATE]. UM BB stated the nurse (LPN CC) who admitted him (Resident #102) forgot the end date (stop date on the antibiotics). UM BB stated nursing staff were .supposed to have a 2nd nurse review and double check all physician orders [REDACTED]. UM BB stated Resident #102 could have had side effects of overuse of antibiotics due to the multiple days of additional antibiotic dosages given. In an interview on 6/5/19 at 2:43 pm, Infection Control Nurse (ICN) AA stated, the nursing process was the floor nurse checks the physician orders [REDACTED].did not put in a stop date on the Keflex (antibiotic) order. ICN AA stated nursing staff did go past a coupe of extra days of dosage of antibiotics for Resident #102. ICN AA stated Resident #102 could be more at risk for future infections and we don't ever want to over give antibiotics which can effect kidney and the immune system.

Based on observation, interview and record review the facility failed to provide care ([MEDICAL CONDITION] medication) to maintain resident well being for 1 of 11 residents (Resident #503) resulting in medication not administered, [MEDICAL CONDITION] and hospitalization . Findings include: Review of the Policy Clinical Nursing .Physician order [REDACTED]. Review of the Face Sheet revealed Resident #503 was an [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #503 had severely impaired cognition and had an active [DIAGNOSES REDACTED]. In an observation on 7/31/19 at 9:11 AM Resident #503 was noted to be in his wheelchair in his room. Bruising was observed around the bilateral eyes and around the nose of Resident #503 with yellowing and dark purple coloring to all of the bruising. Review of the hospital discharge summary dated 5/17/19 revealed Resident #503 was sent to the emergency department on 5/15/19 and had partial [MEDICAL CONDITION] and epilepti[DIAGNOSES REDACTED]s with complex partial [MEDICAL CONDITION] as a present problem. The hospital discharge summary further revealed for Resident #503 to continue taking these medications of Levetiracetam 750 mg 1 tablet 2 times daily upon discharge to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the physician's orders [REDACTED].Levetiracetam 500 mg for Resident #503. There was no indication of why the medication was discontinued. Review of the Nurses Notes dated 7/14/19 at 6:24 AM revealed Resident #503 was .observed having mild [MEDICAL CONDITION] last night .This morning he had another [MEDICAL CONDITION] which lasted approximately 3-5 minutes . Review of the Nurses Notes dated 7/15/19 at 18:59 PM revealed, Nurse Practitioner reported a medication error. [MEDICATION NAME] 750 mg tablet- take 1 tablet my mouth 2 times daily was part of the resident's discharge medication list from hospital discharge on 5/17/19. The nurses note further revealed, This order was not transcribed upon readmission on 5/17/19. Review of the Hospital notes dated 7/15/19 at 7:47 PM revealed Resident #503 was from .facility .for an unwitnessed fall from bed . and Resident #503 was Concerning for peri-orbital eccymosis (black eyes from trauma) and the fall was likely due to breakthrough [MEDICAL CONDITION] activity. The Hospital notes revealed Resident #503 was also hypoxic (low oxygen blood levels) on admission to the emergency department. The hospital notes further revealed Resident #503 was .admitted last May (May 15th 2019) of this year [MEDICAL CONDITION] (body infection) and breakthrough [MEDICAL CONDITION] .[MEDICATION NAME] levels were found to be low and .was increased and pt (patient, Resident #503) was sent home. In an interview on 7/31/19 at 1:16 PM, Licensed Practical Nurse (LPN) M stated, yes he (Resident #503) had a med (medication) error. LPN M stated Resident #503 went to the hospital on May 15th and the hospital changed medications (Levetiracetam Resident #503 was supposed to have been up to 750 mg but it (Levetiracetam) was not given at all upon readmission to the facility on [DATE]. LPN M stated Resident #503 was not getting [MEDICATION NAME] (Levetiracetam) from time he got back until 7/14, July (indicated nearly 2 months without medication). LPN M stated Resident #503 needed the Levetiracetam because he had [MEDICAL CONDITION]. In an interview on 7/31/19 at 2:10 PM, Director of Nursing (DON) B stated, the [MEDICATION NAME] was left off Resident #503's physician orders [REDACTED]. DON B stated Resident #503 should have been on the [MEDICATION NAME] that's probably why he had the [MEDICAL CONDITION]. Review of the CMS 2567 dated 6/5/19 revealed a citation written for transcription of antibiotic orders for a readmitted resident on the survey sample. The facility Plan of Correction was written: Facility Director of Nursing or designee will audit all residents currently receiving antibiotic therapy to ensure that orders identify end date as appropriate. Facility licensed nursing personnel will be educated by Director of Nursing or designee on facility Medication Administration policy by 7/1/19, any staff member not educated will be educated prior to returning to work duties on the floor. Facility Director of Nursing or designee will complete random audits of antibiotic orders three times a week for four weeks and then monthly times three months . The facility chose not to review all residents with readmission/admission orders [REDACTED]

Based on observation, interview and record review the facility failed to provide care ([MEDICAL CONDITION] medication) to maintain resident well being for 1 of 11 residents (Resident #503) resulting in medication not administered, [MEDICAL CONDITION] and hospitalization . Findings include: Review of the Policy Clinical Nursing .Physician order [REDACTED]. Review of the Face Sheet revealed Resident #503 was an [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #503 had severely impaired cognition and had an active [DIAGNOSES REDACTED]. In an observation on 7/31/19 at 9:11 AM Resident #503 was noted to be in his wheelchair in his room. Bruising was observed around the bilateral eyes and around the nose of Resident #503 with yellowing and dark purple coloring to all of the bruising. Review of the hospital discharge summary dated 5/17/19 revealed Resident #503 was sent to the emergency department on 5/15/19 and had partial [MEDICAL CONDITION] and epilepti[DIAGNOSES REDACTED]s with complex partial [MEDICAL CONDITION] as a present problem. The hospital discharge summary further revealed for Resident #503 to continue taking these medications of Levetiracetam 750 mg 1 tablet 2 times daily upon discharge to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the physician's orders [REDACTED].Levetiracetam 500 mg for Resident #503. There was no indication of why the medication was discontinued. Review of the Nurses Notes dated 7/14/19 at 6:24 AM revealed Resident #503 was .observed having mild [MEDICAL CONDITION] last night .This morning he had another [MEDICAL CONDITION] which lasted approximately 3-5 minutes . Review of the Nurses Notes dated 7/15/19 at 18:59 PM revealed, Nurse Practitioner reported a medication error. [MEDICATION NAME] 750 mg tablet- take 1 tablet my mouth 2 times daily was part of the resident's discharge medication list from hospital discharge on 5/17/19. The nurses note further revealed, This order was not transcribed upon readmission on 5/17/19. Review of the Hospital notes dated 7/15/19 at 7:47 PM revealed Resident #503 was from .facility .for an unwitnessed fall from bed . and Resident #503 was Concerning for peri-orbital eccymosis (black eyes from trauma) and the fall was likely due to breakthrough [MEDICAL CONDITION] activity. The Hospital notes revealed Resident #503 was also hypoxic (low oxygen blood levels) on admission to the emergency department. The hospital notes further revealed Resident #503 was .admitted last (MONTH) (May 15th 2019) of this year [MEDICAL CONDITION] (body infection) and breakthrough [MEDICAL CONDITION] .[MEDICATION NAME] levels were found to be low and .was increased and pt (patient, Resident #503) was sent home. In an interview on 7/31/19 at 1:16 PM, Licensed Practical Nurse (LPN) M stated, yes he (Resident #503) had a med (medication) error. LPN M stated Resident #503 went to the hospital on (MONTH) 15th and the hospital changed medications (Levetiracetam Resident #503 was supposed to have been up to 750 mg but it (Levetiracetam) was not given at all upon readmission to the facility on [DATE]. LPN M stated Resident #503 was not getting [MEDICATION NAME] (Levetiracetam) from time he got back until 7/14, (MONTH) (indicated nearly 2 months without medication). LPN M stated Resident #503 needed the Levetiracetam because he had [MEDICAL CONDITION]. In an interview on 7/31/19 at 2:10 PM, Director of Nursing (DON) B stated, the [MEDICATION NAME] was left off Resident #503's physician orders [REDACTED]. DON B stated Resident #503 should have been on the [MEDICATION NAME] that's probably why he had the [MEDICAL CONDITION]. Review of the CMS 2567 dated 6/5/19 revealed a citation written for transcription of antibiotic orders for a readmitted resident on the survey sample. The facility Plan of Correction was written: Facility Director of Nursing or designee will audit all residents currently receiving antibiotic therapy to ensure that orders identify end date as appropriate. Facility licensed nursing personnel will be educated by Director of Nursing or designee on facility Medication Administration policy by 7/1/19, any staff member not educated will be educated prior to returning to work duties on the floor. Facility Director of Nursing or designee will complete random audits of antibiotic orders three times a week for four weeks and then monthly times three months . The facility chose not to review all residents with readmission/admission orders [REDACTED]

This citation pertains to intake #MI 1884 Based on observation, interview and record review the facility failed to prevent resident to resident sexual abuse for 1 of 12 residents (Resident #105) reviewed for abuse, from a total sample of 12 residents, resulting in fear and anxiety, and a potential decline in psychosocial well-being for Resident #105, and other residents residing in the facility. Findings include: Review of State Operations Manual, Appendix PP revealed: Sexual abuse, is defined at §483.5 as non-consensual sexual contact of any type with a resident. further review revealed abuse defined as: Willful, as defined at §483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #105 Review of a facility Face Sheet revealed: Resident #105 was originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed 3/27/19 revealed Resident #105 needed assistance from one staff for ambulation (wheelchair bound, unable to self-propel) A Brief Interview for Mental Status (BIMS) dated 3/27/19 Revealed resident #105 had a score of 14/15 which indicated Resident #105 was cognitively intact. Review of a Facility Reported Incident (FRI) investigation dated 2/28/19 revealed: Unusual Occurrence Report I (Licensed Practical Nurse Supervisor-LPN-S) O was assisting (Resident #105) when reported an incident that happened on Tuesday 2/26/19. (Resident #105) reported that a male resident (Resident #106) approached her in the dining room approximately 1:15 PM., the male resident (Resident #106) made inappropriate comments to her. The male resident (Resident #106) stated if she could rub his balls. The male resident then placed his hand on her right thigh and knee area. She (Resident #105) stated she said NO to the male resident (Resident #106's) comments and then the male resident (Resident #106) exposed his private areas (genital area) to her. The male resident (Resident #106) removed himself once he noticed someone was coming into the dining area. During an interview/observation on 5/20/19 at 3:45 PM., Resident #105 indicated a few months ago (Resident #106) came up to her in the dining room after lunch. The staff and other resident were moving out of the dining room at the time. Resident #105 indicated she is typically one of the last residents to move from the main dining room. Resident #105 indicated that lunchtime is her time out of her room, she enjoys taking a little longer talking with other residents and considers it her social hour. Resident #105 indicated she needs staff assistance getting back to her room. Resident #105 reported she sticks to a schedule and likes to be in her room doing her own thing after lunch for a nap and her quiet time as she does not sleep well during the night due to restless leg syndrome. Resident #105 stated when (Resident #106) approached me, he (Resident #106) had his back turned toward me, he turned around and said hello, we started chatting. (Resident #106) said the staff beats me, when I Said NOOO!! I have been here a long time, they are nice, I don't believe you. He (Resident #106) said do you know where else they beat me. I said no, he (Resident #106) said they (staff) beat my balls .do you want to beat them? I was like NO! he (Resident #106) kept making lewd comments, I just kept asking him to stop talking to me that way. (Resident #106) then said Do you want to see my balls; do you want to touch them? I just kept looking up, when he exposed his privates. I (Resident #105) was so shocked and did not want to see that/them/him in any way like that. He placed his hand on my thigh and knee area, and then exposed his penis to me. After a few minutes which seemed like forever, but it wasn't, staff came in and asked if I was ready to go to my room. Resident #105 indicated at that time she answered yes, please do, I am very ready to go to my room. Resident #105 indicated she did not tell anyone about the incident for a few days. Resident #105 reported she felt embarrassed, violated, and traumatized. Resident #105 indicated she was just so very shocked. and couldn't bring herself to talk about it. Resident #105 indicated a few days later she couldn't take it anymore, stating the thought of him (Resident #106) doing to that to some of the elderly ladies, or any ladies/men that cannot speak for themselves sickened me. Resident #105 reported she decided when she felt comfortable, and the right staff member was working she would report it. Resident #105 indicated she told Licensed Practical Nurse/Supervisor (LPN) O. Resident #105 (with tears in her eyes) indicated if she can make a difference and help anyone avoid this, she was bound and determine to advocate for others who may not be able too. Resident #105 indicated she really had trouble sleeping after the event, and even now when it crosses her mind, she gets anxiety, and fears he will come up to her again, or enter her room. Review of a facility Grievance and Satisfaction Form dated 3/19/19 revealed Resident #105 upset that (Resident #106) is able to ambulate throughout the building, continues to make her (Resident #105) feel uncomfortable Further review of the form revealed: resolution-(Resident #106) allowed to walk on unit, not in rooms. The resolution portion of the form was dated 5/14/19, the Nursing Home Administrator signed the form 5/15/19 nearly two months after the original concern. Resident #106 Review of a facility Face Sheet revealed: Resident #106 was originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. A (MDS) assessment completed on 3/29/19 revealed Resident #106 needed 1 staff to assist for transfers, set up for ambulation in wheelchair (can self-propel wheelchair) A BIMS revealed Resident #106 had a score of 8/15 which indicated he was cognitively impaired. During an interview on 5/20/19 at 4:00 PM., Resident #106 indicated he recently went to a psychiatric facility. When asked the reason why, Resident #106 stated well its Psychiatric Facility Name you look smart, figure it out. Resident #106 reported he didn't know why he went, but it was probably a precautionary incarceration. I don't recall making any comments, but if someone accuses me of it, I probably did it because I have been known to be flirtatious at times. I must have been delirious. During an interview on 5/20/19 at 4:15 PM., Licensed Practical Nurse (LPN) I reported Resident #106 is very smart. LPN I indicated Resident #106 he has some cognitive memory deficits, but LPN I indicated it appears to be situational. LPN I reported Resident #106 crosses a lot of boundaries, we (nursing staff) try to talk to him, re-educate him when he is inappropriate with female staff. LPN I indicated Resident #106's sexual comments towards staff is constant. LPN I indicated the incident a few months ago with Resident #105 was traumatic for Resident #105. LPN I indicated Resident #105 was fearful to go to lunch, she did go, but voiced her concerns about being left alone or re-approached by Resident #106. LPN I reported in her clinical judgment Resident #105's demeanor appeared to reveal that specific incident gave Resident #105 increased anxiety. LPN I indicated Resident #105 has gotten better, has not isolated to her room, but the first days, and weeks following the event Resident #105 was tearful, voiced many times she (Resident #105) couldn't believe what happened, and often said it was so shocking. Review of Resident #106's progress notes from 1/23/19 -5/21/19 revealed the following: · 1/23/2019 4:1 PM., Mood/Behavior Note: Staff member reports that PT (resident #106) made sexually inappropriate comments and gestures towards her. PT (resident #106) placed on psychiatric list for evaluation/follow up. Patient (PT) placed on alert charting to monitor mood/behavior x 2 weeks. · 2/6/2019 2:35 PM., Mood/Behavior Note: (Certified Nurse Aide) CNA reported that (resident #106) was sexually inappropriate towards her and became agitated w/ redirection, CNA reported that (resident #106) eventually calmed down and returned to his room. · 2/26/2019 1:36 PM., Mood/Behavior Note: Staff reported that (resident #106) has made several sexually inappropriate comments today, very difficult to redirect. PT (resident #106) defensive when confronted about behavior, denies any wrongdoing. Will continue to monitor. · 2/27/2019 10:39 PM., Mood/Behavior Note: episodes of confusion and excitement. Early in this shift, PT (resident #106) came to the nurse station with stool on his pants and hands. Redirected to his room and pm care provided. PT (resident #106) has been most of the night self-wheeling around stations, talking loud at the halls and making jokes and inappropriate statements. Education and redirection provided each time behaviors occurred. Communication left to (Social Worker)-SW to evaluate and f/u (follow up) · 3/1/2019 4:30 PM., Mood/Behavior Note: Informed by member of housekeeping staff that resident had been agitated and using foul language in the MDR (main dining room) after bingo. (resident #106) was asked to leave by staff and eventually calmed down. · 3/8/2019 8:45 AM., Mood/Behavior Note: 1:1 staff sitting with (resident #106) last night reports that resident attempted to engage him in inappropriate conversation of a sexual nature. 1:1 staff reported he discouraged inappropriate topics of conversation and attempted to redirect. · 3/15/2019 11:43 AM., General Progress Note: (resident #106) returned to facility via paramedic around 11 am. (resident #106) was in good spirits as he was being taken back to his room. During the readmission skin assessment res. became sexually inappropriate by asking nurse to massage head and touch penis. When (resident #106) was told No res. insisted that he was not being inappropriate. · 3/20/2019 1:40 AM., Mood/Behavior Note: (resident #106) episodes of forgetfulness. but easily reoriented. Early in this shift PT (resident #106) was making inappropriate, sexual oriented jokes while this nurse was administering his meds and during assessments. PT (resident #106) was educated and he apologized to this nurse. He self-wheeled around stations for a while and later, PT (resident #106) came to the nurse station and continue to make inappropriate statements. · 3/20/2019 12:24 PM., General Progress Note: (resident #106) dialogued conversations of inappropriate behavior when asked to obtain his vital signs. He (resident #106) replied that he would only allow it if the (certified nurse aide-CNA) sat on his lap. The CNA declined and instructed (resident #106) that he cannot continue that line of conversation on that particular subject matter and asked again if she could obtain his vitals. · 3/20/2019 4:28 PM., General Progress Note: (resident #106) was observed in the hallway in front of the med-cart asking the (CNA's) and this nurse if we knew who (a well-known news case of when a wife cut her husband penis off for having an affair/cheating on her in approximately 1993) was? When told that we would not continue this line of conversation. (resident #106) then said, well do you know what she did? Again, this nurse redirected (resident #106) that this conversation was very inappropriate and that we will not engage. (resident #106) continues to pursue this conversation by saying Well you do know who her husband is and why he had to have surgery right? This nurse told (resident #106) that the conversation will now stop. And walked away. · 3/23/2019 7:06 PM., Social Services Late Entry: Patient (resident #106) was verbally sexually inappropriate with staff and was requiring constant redirection. Patient (resident #106) would get agitated and loud when behavior was addressed. · 3/29/2019 4:32 PM., Mood/Behavior Note: Pt (resident #106) made an inappropriate comment about this writer to male CNA. When confronted about unacceptable behavior PT (resident #106). initially denied making an inappropriate comment, then apologized to this writer. · 4/16/2019 12:49 PM., Mood/Behavior Note: (resident #106) displayed sexually inappropriate behaviors and comments towards female CNA staff. The staff member did leave the room at that time. · 5/21/2019 9:49 AM., Social Services (SS) U Note: (SS U) followed up with (resident #106) resident after writer (SS U) received information that resident had exposed himself to others (housekeeper). When asked about the specific situation (resident #106) stated, I cannot dispute that, but I don't remember that happening. Writer (SS- U) informed (resident #106) that he cannot continue to have inappropriate behaviors and must keep firm boundaries an invisible line between himself, staff and other residents. (resident #106) became angry with writer (SS- U) and said whatever. (SS- U') will continue to monitor resident for additional behaviors or any changes in mood or behavior. During an interview on 5/21/19 at 2:00 PM., LPN-Supervisor O revealed he was walking the through the main dining room on (MONTH) 28 th. Resident #105 called my LPN O name said hi, I (LPN O) asked (Resident #105) if she needed a ride back to her room, as we were walking, she said you won't believe what happened to me the other day. (Resident #106) approached me after lunch he made some sexual comments to me. (Resident #105) reported (Resident #106) was asking her to rub his genital area, she had said no to (Resident #105) and that was inappropriate. (Resident #106) went on to touched her (Resident #105's) right upper thigh. (Resident #105) said she pushed his hand away; the next thing she knew he exposed himself (his penis). (Resident #105) said another person walked in the dining room, he (Resident #106) covered up right away. The person was talking to her, and that is when he (Resident #106) moved away, and she was escorted back to her room. (Resident #105) didn't recall the staff member who assisted her. LPN O reported that incident happened on a Tuesday 2/26/19 and the day she spoke with LPN O was Thursday 2/28/19. LPN O asked if (Resident #105) told anyone, she said no LPN O asked her why. LPN O reported Resident #105 said she didn't feel comfortable, and was fearful at that time. LPN O indicated Resident #105 relayed maybe I was in shock. LPN O revealed he thinks Resident #105 reported to him because LPN O used to be the unit manager on her unit, and they have known each other a long time and have a very comfortable rapport with one another. LPN O reported he immediately assessed the resident and then walked to Nursing Home Administrators (NHA) office to report. LPN O reported Resident #106 does make sexual inappropriate comments to staff almost every day. LPN O indicated Resident #106 he gets out of his room for lunch and mostly self propels throughout the facility in the evening hours, until about midnight. LPN O reported Resident #106 has a private room because he doesn't get along with roommates. LPN O indicated he has worked with Resident #106 since his admission, and this sort of behavior (sexual inappropriate comments) has been an ongoing issue. LPN O reported it is typically towards female staff. During an interview on 5/22/19 at 9:15 AM., CNA Q reported Resident #106 makes very sexual comments a lot, he acts like its a joke, or plays he cannot remember. CNA Q indicated she works with him on a regular basis. CNA Q reported he has made inappropriate sexual comments to herself, as well as other female staff, and Resident #106 will make it a point to expose himself if female staff enter his room to assist with care, deliver his meal, clean. at times he able to redirect. CNA Q reported whenever we say that is inappropriate. (Resident #106) will say things like what, I (resident #106) don't know what you're talking about, or I don't remember doing anything wrong. During an interview on 5/22/19 at 9:30 AM., LPN H reported Resident #105 was just so shocked that sort of incident happened to her. (Resident #106) is very cognitive, he knows exactly what he is doing, and then plays coy. Yesterday a housekeeper was in there cleaning his bathroom and instead of asking her to leave while he went to bathroom, he blocked her exit, stood behind her and disrobed himself. During an interview on 5/22/19 at 9:45 AM., LPN R reported Resident #106 always has a joke to tell, usually the are sexual jokes. LPN R indicated Resident #105 was deeply bothered by the incident between the two of them. LPN R indicated she could tell as initially (Resident #105) spoke of it a lot- (Resident #105) told me that he wanted her to look at his penis. (Resident #105) was very shocked. LPN R reported when Resident #105 spoke of it her tone of voice would crack, like a lump in her throat and her facial expressions displayed disturbance. Resident #105 would repeat what (Resident #106) said, and Resident #105 kept saying can you believe that. During an interview on 5/22/19 at 12:30 PM., Former employee-Social Worker (SW) T reported Resident #106 was tricky. SW T stated I believe this is who he is as a person, I believe he knows what he is doing, he likes to act like he doesn't remember, but I (SW) T know he does. SW T indicated Resident #106 was very coy & intelligent.

This citation pertains to facility reported incident (FRI) MI 686 Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview and record review the facility failed to ensure that staff utilized enough assistance while providing care for 1 resident (Resident #1) out of 5 residents reviewed for increased assistance with Activities of Daily Living (ADL's) from a total sample of 5 residents resulting in Resident #1 falling out of bed and sustaining bilateral knee cap fractures and an ankle fracture. Findings: Resident #1 Review of a facility Admission Record Report dated 1/4/17 indicated Resident #1 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact with some evidence of altered level of consciousness and would at times have delusions. Resident #1 needed the extensive assistance of two people for bed mobility and was totally dependent on two people for transfers. Resident #1 also needed also needed extensive assistance from one person for dressing, toilet use and personal hygiene and was totally dependent on one person for bathing. Review of a Care Plan initiated 8/16/16 indicated Resident #1 had an ADL self care deficit as evidenced by requires staff assistance for cares related to physical limitations, obesity and left sided weakness. Interventions included 2 assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of a Progress Note dated 1/4/17 indicated On 1/3/17 while nursing assistant was completing bed bath to Ms. Castillo at approximately 9:40 p.m., (Resident #1) was turned facing the left side in bed when certified nurse aide (CNA) was on her right side. While CNA was putting on the attends with attempts to get resident to face to the right side, resident moved resulting in CNA attempting to prevent the fall buy going over the bed onto the left side of bed to break fall. CNA held resident up by the arms stopping resident from hitting her head and resident landed on her knees. Resident remained on floor thus received orders to send to ER for evaluation related left ankle swelling and complaints of pain. During pain assessment, (Resident #1) was given Ultram prior to being sent to ER for evaluation. ER evaluations and assessment with results of resident to have obtained bilateral patella fractures of the knee and a left ankle fracture by the tibia. Additionally resident noted to be profound osteopenia as reported by son resident has been immobile for [AGE] years approximately due to [DIAGNOSES REDACTED] and hemiparesis following cerebral infarction (stroke) affecting left dominant side. Resident returned to the facility without surgical interventions but with immobilizers bilateral lower extremities and left ankle with brace. Medical Director evaluated resident with orders based on bone density status for serum 25-OH vitamin D level with a new added [DIAGNOSES REDACTED]. PT/OT (physical therapy/occupational therapy) will evaluate and treat as indicated and nursing staff will continue to monitor for signs and symptoms of pain. (Resident #1) has a BIMS (brief interview for mental status) of 15 (indicating she was cognitively intact) and was able to articulate fall event. No signs of emotional discomfort voices. Resident voiced she felt safe at the facility. Review of a facility Statement documented on 1/4/17 with CNA C reflected that CNA C was assigned to care for Resident #1 at the time the fall occurred. CNA C reported she had been changing Resident #1's brief while Resident #1 was turned to her left side when she turned to put skin cream on the table. CNA C described placing a brief under Resident #1, then pulling Resident #1 toward her when Resident #1's lower extremities were moved more to the left when she started to fall and reported she jumped over the bed and grabbed under Resident #1's arms and kneeling on the floor to break her fall and lowered her onto her back. During an interview on 2/22/17 at 2:50 p.m., CNA C reported she had been assigned to care for Resident #1 on 1/3/17 and was familiar with her care provision. CNA C said she had changed Resident #1 by herself twice earlier in the shift and mentioned Resident #1 was alert and oriented and able and willing to help with bed mobility. CNA C then said she was preparing to give Resident #1 a bed bath at approximately 9:30 p.m. or 9:40 p.m. on 1/3/17. CNA C said she was putting barrier cream (used to protect the skin from moisture) back onto Resident #1's bedside table when Resident #1 started slipping out of bed. CNA C said she literally jumped over the bed to break Resident #1's fall. CNA C said Resident #1's head and upper body never hit the floor and believed Resident #1's knees hit her night stand. CNA C said the only obvious injury Resident #1 sustained was to her ankle which was swollen. CNA C said she got the nurse right away and sat with the resident until she was transferred to the hospital. CNA C said as soon as she provided a statement to the Director of Nursing (DON) B she was suspended pending investigation into the matter. When asked, CNA C reported she recalled Resident #1's Kardex (used to tell staff how to provide care to residents) indicated she was to have extensive assistance from one person for ADL's, extensive assistance from two people for bed mobility and was a total assist of two staff for transfers. CNA C also reported that she would sometimes use two people to provide care to Resident #1 depending on Resident #1's cognitive status which would fluctuate. During an interview on 2/22/17 at 9:25 a.m., DON B said that as a result of the investigation into Resident #1's fall, the facility Quality Assurance Team identified there were discrepancies between a resident's transfer and bed mobility status and the amount of assistance a resident needed for ADL care. As a result of this, the facility implemented immediate action to prevent an occurrence like what had happened to Resident #1. The facility implemented the following measures which was considered PAST NON-COMPLIANCE by the State Agency: -The facility identified the CNA needed to roll the resident toward her while providing care and that the CNA should have used two care givers to provide assistance (bed mobility). -The facility identified that ALL residents at the facility could potentially be at risk for the identified root cause of the fall resulting in a complete audit (all resident's reviewed) for mobility status and Kardex intervention consistency. -The facility educated all nurses and CNA staff on the bed mobility status and would not allow any staff not educated by 1/12/17 to work until education was received. -Audits (observations) were initiated related to the staff education and consistency with the Kardex and were ongoing. On 2/22/17 this surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 1/12/17.

Based on observation, interview and record review, the facility failed to prevent pressure ulcer in 1 of 4 residents reviewed for pressure ulcers out of a total sample of 24 residents resulting in Resident #2 developing a stage II pressure ulcer to the right buttock and failed to accurately assess and re-evaluate to prevent an unstageable pressure ulcer from developing on the left buttock. Findings include: Review of the Skin Practice Guide (undated or timed) reflected, " The purpose of the Skin Practice Guide is to describe the process steps for identification of patients at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations ...Presence of a pressure ulcer: patients with an existing pressure ulcer are considered at-risk for the development of additional pressure ulcers ...Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer ...skin evaluations are documented in the clinical record. " Resident #2 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #2 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #2 had moderate cognitive impairment and required staff assistance with his activities of daily living which included ambulation and transfers. In an interview and observation on 6/3/14 at 2:45 PM, Resident #2 was observed to be seated in a chair, near the nurses desk. Resident #2 was unable to answer questions regarding the multiple pressure ulcers on his buttock. Review of the readmission assessment on 2/5/14 at 10:59 PM reflected Resident #2 had fallen at the facility on 1/31/14 and sustained a left [MEDICAL CONDITION] (broken bone) which was surgically repaired at the hospital and was subsequently readmitted to the facility on [DATE]. The readmission assessment reflected that Resident #2 required staff assistance for bed mobility, bathing, dressing, toileting and transferring and the skin assessment reflected surgical wound that consisted of 8 staples (4.5 cm in length). No other skin alterations were identified but Resident #2 was identified as being at risk for skin alteration related to occasionally moist skin, inability to reposition self without staff assistance, inability to bear weight on left lower extremity, nutrition was adequate, but a potential problem for friction and shear was identified due to the required need for staff assistance to reposition and sliding against the sheets or other surfaces. Review of the facility incident report 2/19/14 at 5:55 AM and corresponding progress note for the same time reflects that a 0.6 cm (centimeter) blister was observed on the right upper/inner buttock. Staff identified incontinence of urine and stool, and that Resident #2 was resistive to reposition due to pain with movement. Progress note reflected that the routine [MEDICATION NAME] (pain medication) and the as needed dose of [MEDICATION NAME] was administered at that time. The Medication Administration Record [REDACTED]. The progress note further reflected that Resident #2 refused to reposition due to the pain which was documented as, " 10/10 (extreme high rate of pain) with movement. " Review of the physician progress notes [REDACTED]. Review of the facility incident report dated 2/25/14 at 11:00 PM and progress note for the same time, reflected a new open area on the skin to the left buttock that measured 10 cm long by 4 cm wide. The physician progress notes [REDACTED].#2, " is a [AGE] year old male with multiple pressure ulcers. L (left) buttock 6 X 2.3 with 80% slough (according to the facility skin practice guide is defined as 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) unstageable (unable to assess stage of wound due to the slough that covers the wound bed). R (right) buttock top = 2 X 1.8 stage II (extending through the top layer of the skin) and R buttock bottom = 1.0 X 0.8 stage II ...Hx (history of DM (diabetes),[MEDICAL CONDITION](high blood pressure) and [MEDICAL CONDITIONS] are all stable. In an interview on 6/5/14 at 11:30 AM, Physician Assistant (PA) " AB " stated that he was the first practitioner to assess Resident #2 ' s pressure ulcers on 2/27/14. PA " AB " stated that he identified pain (from the left [MEDICAL CONDITION] on 1/31/14 and surgical repair) as a contributing factor for Resident #2 resisting changing positions, allowing dressing changes and not eating well. PA " AB " stated, " We started to pre-medicate him (Resident #2) and as time went on the pain was not as much of an issue. " When PA " AB " was asked if he reviewed the daily skin assessments, PA " AB " stated, " I did not find any skin assessments. " In an interview on 6/5/14 at 1:15 PM, Registered Nurse (RN) " AA " stated that after the discovery of the stage II pressure ulcer on 2/19/14 the intervention of the use of a maxislide for transferring and repositioning was added to the care plan to reduce shearing and daily skin assessment was initiated on the treatment administration record. RN " AA " stated that a pressure redistributing device was added to the bed on 2/27/14 (after the discovery of the stage II on 2/19/14 and the additional stage II and unstageable pressure ulcer were documented on 2/25/14). Review of the treatment administration record reflects a nurse's initial for each day (2/19, 2/20, 2/21, 2/22, 2/24, and 2/25/14) that the skin was checked but the progress notes did not reflect the assessment nor measurement of the wound or wounds. The first documented measurement and assessment were noted on the nursing note on 2/25/14 at 11:00 PM and the physician progress notes [REDACTED]. (# )

Based on observation, interview and record review, the facility failed to assess, monitor, implement interventions, conduct a root cause analysis and adequately supervise 4 of 15 residents reviewed for falls and safety (Resident #2, #10, #18, and #20) out of a total sample of 24 residents resulting in Resident #2 sustaining repeated falls with serious injuries, Resident #10, #18 and #20 sustaining repeated falls with minor injuries and failed to accurately assess and re-evaluate the safety risks for Resident #2, #10, #18, and #20 placing these residents at increased risk for additional falls and serious injuries. Findings include: Review of the facility "Falls Practice Guide" (undated) reflected, "The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls...Assess, plan, implement and evaluate...patient falls are tracked by time, location and causative factors." Resident #2 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #2 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #2 had moderate cognitive impairment and required staff assistance with his activities of daily living which included ambulation and transfers. During an interview and observation on 6/3/14 at 2:45 PM, Resident #2 was observed seated in a scoot chair (chair with wheels that was slightly reclined), in the hallway in front of the nurses desk and had his right arm in a sling. Resident #2 was unable to answer questions regarding his recent falls. During an interview on 6/3/14 at 10:00 AM the following facility incident reports for falls (7) were reviewed with Registered Nurse (RN) "AA": Review of the facility incident report dated 12/6/13 at 3:30 AM, reflected Resident #2 was found on the floor in front of the toilet attempting to transfer without staff assistance. RN "AA" stated that Resident #2 required staff assistance to ambulate and transfer safely. Review of the progress note dated 12/6/13 at 10:48 AM reflected "Resident (#2) was noted on the BR (bathroom) floor attempting to self transfer without staff assistance and resident is a SBA (stand by assist) with transfers and ambulating...Resident (#2) relates that he can do everything for himself and can be impulsive, suffering from cognitive losses (severe memory impairment and unable to learn/remember new tasks)...he (Resident #2) is reminded to use his call light for help prior to transferring and lock his w/c (wheelchair) before transfers. Review of the Falls care plan dated 10/14/11 reflected the added intervention on 12/6/13 "Resident reminded to use call light in the middle of the night. Staff not to leave resident unattended while utilizing the toilet." Review of the progress note dated 12/8/13 at 12:10 AM reflect "Pt (Resident #2) does not consistently put his call light on to get help up to BR (bathroom)." Progress notes on the same day reflect that he is reminded and re educated to use the call light. Progress note on 12/13/13 at 3:41 PM reflect that staff provided Resident #2 with a urinal to use at night time. Review of the progress note dated 12/17/13 at 1:48 PM reflected that Resident #2 had severe cognitive deficits and that his spouse was designated as his decision maker due to his memory issues. Review of the facility incident report dated 1/11/14 at 5:00 PM reflected, "(Resident #2's) Left wrist noted as swollen. Patient states twisted his hand while attempting to self transfer to use restroom on 1/10/14." The incident report reflected, "Resident (#2) was attempting to self transfer and twisted his wrist." Review of the facility incident report dated 1/31/14 at 4:00 PM reflected, "Patient (Resident #2) noted by nurse exiting room without walker, Patient appeared confused stated to self, 'where's my car?' Patient looked out the window at the end of the 400 hallway. Patient turned around lost balance and fell on left side...Educated resident to call for assistance when needed." In the report, RN "AA" stated that Resident #2 fractured (broken bone) his left hip and subsequently was sent to the hospital for surgical repair. RN "AA" stated that when Resident #2 returned to the facility he was not allowed to bear full weight on his left leg and required extensive staff assistance. Review of the Falls care plan dated 10/14/11 reflected the new intervention dated 2/1/2014, "Sign on patient's wall to call for help when needed." Review of the facility incident report dated 3/11/14 at 1:45 AM reflected that Resident #2 was observed on the floor, with legs on bed and upper body on the floor...yelling for help." In the report, RN "AA" stated the following interventions were put into place on the care plan: bed in lowest position and a body pillow to be on the side the resident is facing. Review of facility incident report dated 4/10/14 at 12:29 AM reflected that Resident #2's family attempted to assist Resident #2 with a transfer to the bathroom and the resident fell . The report indicated RN "AA" stated that Resident #2's family was educated to request staff assistance for all transfers. Review of progress note dated 4/14/14 at 10:54 PM reflected, "noted transferring self from wheelchair to toilet." Review of progress note dated 4/15/14 at 8:34 AM reflected, "Pt (Resident #2) can be forgetful and forgets limitations such as needs assistance with transfers/ambulation." Review of the facility incident report dated 4/18/14 at 10:00 PM reflected that Resident #2 was found on the bathroom floor. The report reflected, "Resident (#2) transferred self to bathroom without staff assistance. Noted to have had a bowel movement-loose." The progress note for same date and time reflected, "The call light was within reach on his bed, but the call light was not on." RN "AA" stated that the physician did change Resident #2's bowel management medications. The falls care plan did not reflect any updates/interventions after the 4/18/14 fall, to prevent reoccurrence of the incident (self transferring without staff assistance). Review of progress note dated 4/20/14 at 4:22 AM and 2:39 PM reflected that staff found Resident #2 self transferring multiple times without assistance. Review of the facility report dated 4/22/14 at 9:45 PM reflected, "Resident (#2) transferred himself without staff assistance to bathroom and fell ...skin tears to the right and left elbows" An interview on 6/3/14 at 10:00 AM with RN "AA" stated that grippy socks on at all times was added to the care plan. When RN "AA" was asked what the root cause of the falls on 4/18/14 and 4/22/18 was RN "AA" replied, "He was self transferring without staff assistance." When RN "AA" was asked if grip socks would prevent Resident #2 from self transferring without staff assistance, RN "AA" stated, "No." Review of the progress note dated 4/25/14 at 12:04 AM reflected, "Patient (Resident #2) transfer to room 401-1 (closest room to nurses desk) for safety. Patient was noted self transferring to bathroom X 2 (twice) by this nurse. Patient was immediately assisted and re educated on the use of the call light." Review of the facility report dated 4/29/14 at 5:30 PM reflected that Resident #2 was found on the floor between the bathroom and the bed, yelling for help. The call light was noted to be in reach but not on. The incident report reflected, "Resident (#2) was attempting to transfer self to bathroom from bed and fell obtained a fx to right humeral (broken arm)...sent to ER (emergency room ). RN "AA" stated that Resident #2 was transferred back to the facility on [DATE] and the following interventions were put into place: scoot wheelchair, bladder diary PRN (as needed), frequent checks, sensor pad call light, non weight bearing to the right upper extremity, and orthostatic blood pressures (blood pressures taken to detect significant drops when standing). When RN "AA" was asked on 6/3/14 at 10:00 AM, what the frequency of the intervention "frequent checks" was, RN "AA" stated, "no specific time." When asked how often routine resident checks were done, RN "AA" stated, "every 2 hours." RN "AA" agreed that Resident #2 had cognitive impairment and forgot to use the call light. RN "AA" stated, "The sensor pad call light is to be clipped to his (Resident #2's) shirt so if he attempts to move the call light will activate." In an observation on 6/3/14 at 4:20 PM, Resident #2 was observed seated in the scoot chair approximately 2-3 feet from the over the bed table where the sensor pad call light laid (not attached to Resident #2 and out of reach). (# ) Resident #10 According to the MDS/Minimum Data Sets, dated 11/04/13 and 5/07/14, Resident #10 had memory problems, needed assistance with transfers, had a history of [REDACTED]. Review of Resident #10's Incident Reports revealed Resident #10 had 8 unwitnessed/unassisted falls in her room between 11/26/13 - 5/09/14 (in the past 6 months). The reasons, documented by DCD "K", as the "Root cause analysis" on the incident reports included: "Dropped glasses on floor" (2/03/14), "Attempted to get into closet when wheelchair didn't fit thu space" (2/17/14), "Pain in knees" (3/22/14), "Poor safety" (4/02/14), "Hallucinations" (4/27/14), "fell asleep in wheelchair" (5/01/14), "Phone not accessible because cord short" (5/04/14), and "Crawling onto floor to retrieve chap stick" (5/05/14). The reports did not document whether the call light was on at the time of the falls. On 6/02/14 at 9:00 AM, this Surveyor observed Resident #10's privacy curtain was pulled around her bed. Resident #10 was sitting in her wheelchair next to the bed that was at knee height (approximately 2 1/2 feet from the floor). Resident #10 cheerfully reported to this Surveyor that she did "bed walking". Resident #10 stood, bent over at the waist to the level, placed her hands on her bed and began walking around her bed (she sat down in her wheelchair when Surveyor asked her if she was supposed to be walking alone). Resident #10 pointed to her bed, smiled broadly and said, "See the hand marks all the way around my bed. That's what I do; bedwalking". There were visible wrinkles at close intervals all around the perimeter of the bed. Resident #10's call light was not on and her roommate was not in the room. In an interview, on 6/03/14 at 9:20 AM, DCD (Director of Care Delivery) "K" reported the facility was "alarm free" and did not use personal care alarms (tab alarms, pressure sensitive alarms, and motion sensing alarms). In an interview, on 6/03/14 at 9:20 AM, DCD "K" stated Resident #10 was falling because, "her knees buckle spontaneously", that Resident #10 was not allowed to have her walker at bedside because she was not safe transferring to her walker without assistance, but was allowed to have her wheelchair at bedside because she could safely transfer herself to her wheelchair without assistance. DCD "K" stated Resident #10 "frequently gets to her wheelchair...doesn't use the call light because she doesn't want to give up her independence". DCD "K" reported she had not assessed whether a pressure alarm or body alarm would be beneficial for Resident #10, but that Resident #10 was in a "space retrieval program with speech therapy to impregnate in her mind to use the call light" for assistance. DCD "K" stated staff did "frequent checks" and Resident #10 had a roommate that would let staff know if Resident #10 was walking in her room without assistance. DCD "K" clarified that the facility's standard of care for checking on residents was every two hours, and more frequent than every two hour checks were not care planned for for Resident #10.When asked what "Frequent checks" (listed as an intervention on Resident #10's care plan) meant, DCD "K" reported: "Frequent checks means...Best practice is every 2 hours. I think its adequate (for Resident #10)". DCD "K" also reported that, "(Resident #10) uses her call light faithfully. (Resident #10) knows when she needs to use the bathroom; besides, her roommate lets us know when she's up alone". When asked, DCD "K" reported "I haven't assessed whether a pressure alarm or body alarm would be beneficial (to help prevent falls for (Resident #10)". On 6/03/14 at 10:30 AM, this Surveyor observed wheelchair foot pedals on the floor in front of the bay window in Resident #10's side of the room. On 6/03/13 at 10:35 AM, SW/Social Worker "L" reported , "Ideally, foot pedals should be in the closet on in a bag in (Resident #10's) wheelchair". According to a Therapy Discharge Communication, dated 3/10/14, Physical Therapy recommended that Resident #10 be "Walk to dine, Walk from bed to bathroom, Walk from room to Station 3 and back...Once a day". In addition, it was documented on the Therapy Discharge Communication, that Resident #10 "has home exercise program". In an interview, on 6/03/14 at 10:52 AM, DCD "K" reported Resident #10 needed limited assist to walk with her walker, and said, "We walk her...to the bathroom". DCD "K" rescinded her previous statement that Resident #10's knees buckled and stated, "Therapy didn't identify buckling of Resident #10's knees...the Physical Therapy assessment on 3/26/14, when Physical Therapy ended, showed strength (in Resident #10's legs) was not a concern". Review of Resident #10's fall care plan and nurse aide care guide instructed staff that Resident #10 required "1 person limited assist with transfers to and from wheelchair"; this was contrary to what DCD "K" reported (safe to transfer to wheelchair without assistance). The care guide did not contain interventions to encourage or monitor Resident #10's "home exercise program", nor did interventions include: "Walk to dine, Walk from bed to bathroom, Walk from room to Station 3 and back". In an interview, on 6/03/14 at 2:40 PM, DCD "K" reported Physical Therapy had completed a re-screen on Resident #10 just then, and found she was able to walk 200 feet or more (an increase from 1200 ft documented on the last Physical Therapy screen on 3/10/14) with her walker, and the assistance of one staff and the use of a gait belt. DCD "K" also reported, "The team got a bag for (Resident #10's) foot pedals". In an interview, on 6/03/14 at 4:15 PM, Nurse Aide "Z" reported she was assigned to Resident #10 and had helped Resident #10 to her bathroom 2 times that since 7:00 AM. Nurse Aide "Z" said she had not done any walking with Resident #10 other than taking her to the bathroom. In an interview, on 6/04/14 at 4:25 PM, the DON confirmed that the phrase "Frequent checks" meant every 2 hours. DON stated, "We can't increase supervision; we can't have everybody on 1:1. We have had a significant decrease in falls in this building". When asked why supervision had not been increased for Resident #10, DON stated, "If a resident needs more supervision, the aide should anticipate their needs and check on them more often. They monitor (Resident #10) like crazy. Anyone will tell you (Resident #10) is a fall risk". DON reported the facility was using call lights as pressure alarms by strategically placing pad style call lights on beds in the hopes that residents attempting self transfer would accidentally engage the call light and alert staff. DON reported she was unaware of any monitoring systems (such as pager systems or head phone systems) that could alert staff if a resident had gotten up without assistance. On 6/05/14 at 2:50 PM, this Surveyor observed that Resident #10's privacy curtain was pulled, and upon entering beyond the pulled curtain this Surveyor observed Resident #10 walking in her room, using her tray table and the wall to assist her; she walked to the corner of the room and bent over and placed a paper in a folder and picked up a photo album stored on the floor and then went to her bed and sat down. The call light was not on and her roommate was not in the room. In an interview, on 6/03/14 at 9:20 AM, the DON reported the she thought the DCDs looked at falls in more detail than required by the State Surveyors. However, in an interview, on 6/05/13 at 10:30 AM, the DON/Director of Nursing reported she tracked the time and unit the facility falls occurred, but did not track or trend the root cause of the facility falls. DON stated, "The DCDs look at the reason for the falls more closely than I do...The DCDs look at, and do the root cause analysis". ( ) Resident #23 According to the MDS/Minimum Data Sets, dated 12/07/13 and 3/09/14, Resident #23 was admitted to the facility on [DATE], had memory problems, needed assistance with transfers, had a history of [REDACTED]. According to Resident #23's Care Area Assessment, dated 6/06/13, "Resident (#23)...has had 3 falls since last review, with no injuries. Falls seem to be related to impulsivity and attempting to transfer himself with no assistance or not waiting for assistance, and often are due to needing to use the toilet..." Review of Resident #23's Incident Reports revealed Resident #23 had 9 unwitnessed/unassisted falls in his room 9 times between 9/20/13 - 4/19/14 (in the past 6 months): ? 9/20/13 at 2:41 PM ? 9/21/13 at 9:10 PM (evening) ? 10/15/13 at 9:15 AM (call light not within reach noted on incident report/new room) ? 12/09/13 at 5:45 PM ? 12/12/13 at 5:30 PM ? 12/26/14 at 6:45 PM ? 1/11/14 at 12:00 AM (midnight) ? 2/28/14 at 12:00 AM (midnight) ? 4/19/14 at 11:03 AM ("during shift change" noted on incident report) ? 4/19/14 at 9:45 PM (evening) It was not documented on the above Incident Reports whether the call light was on (except on 10/15/13), or if there was evidence that Resident #23 was seeking the bathroom, TV, or was wearing appropriate footwear at the time of the falls. In a telephone interview, on 6/04/14 at 1:51 PM, with Resident #23's wife (first responsible party) and daughter, they reported "He tries to get out of bed; he's not supposed to...They were giving him a medication that made him dizzy and didn't tell us they were giving it to him". Resident #23's wife and daughter stated Resident #23 enjoyed watching certain television shows after supper such as Jeopardy but, "He's not walking well. Staff don't know to turn on his TV for him...Before they moved him to this Unit, someone stole his shoes...We brought in a pair that fit him, but staff kept putting on someone else's shoes that were way too big. He kept falling. He wears a size 7. They were putting on shoes that were size 9 or 10...He shakes really bad now. Now they are keeping him awake so he'll sleep through OK through the night...He used to get up (and walk) in the hallway but now he's always in the wheelchair now". According to www.tvguide.com, (checked 6/09/14), Jeopardy airs at 7:30 PM in the facility's accessible TV stations. However, Resident #23's care plan and nurse aide care guide did not contain interventions reflecting to turn on Resident #23's television at that time of day. Review of Resident #23's Fall Care Plan, dated 5/30/13, also revealed: "Implement use of preventative device - sensor alarm to bed and chair while pt (patient) adjust(s) to new enviro (environment)"; "RESOLVED" ON 8/13/12 and not re-implemented. And, dated 7/19/12, "Check resident more frequently, especially at night...", but frequency intervals of the "frequent checks" was not specified. ( ) Resident #18 Review of Resident #18's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on 3-24-14. Review of Resident #18 Brief Interview for Mental Status (BIMS) score dated 5-11-14 revealed she scored 2/15 (severe cognitive impairment). Review of Resident #18's, "Resident Incapacity To Give Informed Consent and To Exercise Resident Rights" form dated 9-11-13 revealed Resident #18 lacked the ability to give informed consent, make medical decision and to understand her rights. Review of Resident #18's Durable Power of Attorney (DPOA) for Personal and Medical Care Decisions form dated 4-25-13, listed two family members as (DPOA). Review of Resident #18's Incident Reports revealed she had 4 falls from 4-10-14 through 6-2-14. (4-10-14, 5-17-14, 5-19-14 and 6-2-14). During an interview with Unit Manager "A" on 6-5-14 at 2:50 p.m. this Surveyor reviewed the fall documentation with UM "A". For the fall dated 4-10-14 UM "A" said Resident #18 slid backward when reaching back for her walker and the root cause of the fall was Resident #18 trying to sit back on walker and the brakes need to be checked. The new intervention for safety was to fix Resident #18's walker. Resident #18 had no injuries from the fall dated 4-10-14. For the fall dated 5-17-14 UM "A" said Resident #18 fell face down with the wheelchair behind her and the root cause of the fall was Resident #18 was getting out of her wheelchair and it slid out from under her. The new intervention for safety was to have Occupational Therapy (OT) evaluate the wheelchair. UM "A" could not find any documentation to show OT evaluated resident #18's wheelchair. Resident #18 suffered bruises from the fall 5-17-14. For the fall dated 5-19-14 UM "A" said Resident #18 was observed sitting on the floor in the 100 hall, head back against the wall and wheelchair beside her and the root cause of the fall was Resident #18 was self propelling and was at edge of wheelchair. The new intervention for safety was to have Occupational Therapy (OT) evaluate the wheelchair. UM "A" could not find any documentation to show OT evaluated resident #18's wheelchair. Resident #18 suffered rib pain and a bruise to her right eye from the fall 5-19-14 For the fall dated 6-2-15 Resident #18 stood up for a scootchair and leaned against the wall and slid to the floor and the root cause of the fall was Resident #18 was attempted to stand up. The new safety intervention was to have Resident #18 tilted back in her scootchair when unsupervised. Resident #18 had no injuries from the fall 6-2-14. ( )

This citation pertains to MI 091. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 5 residents (Resident #103) reviewed for wandering, from a total of 5 sampled residents, resulting in and Immediate Jeopardy when Resident #103, who was a known elopement risk, eloped from the facility on 4/04/13 at approximately 4:50 PM unbeknownst to facility staff, was found by joggers approximately 1/5 hours later alongside a busy 4 lane, 55 mph road, and picked up by her family member at 6:45 PM and returned to the facility at 9:45 PM. This deficient practice placed 16 additional residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: According to the facility Wander Patient Practice Guide policy and procedure, dated 4/2008, "Unsafe wandering does not just occur when a patient attempts to exit seek, but is evident when patient enters an area that is potentially hazardous...While alarms can help to monitor a patient's activities...Alarms do not replace necessary supervision...Exit doors...are alarmed...During periods of agitation or increased frequency of behaviors the following interventions can be helpful in managing behaviors like exit seeking/unsafe wandering and may include, but are not limited to: one-on-one supervision; an "alarm buddy"; supervised walking; activities based on patient's personal preference..." In a telephone interview, on 6/13/13 at 2:13 PM, Quality Assurance Consultant #31 reported that an "alarm buddy" was a Secure Care bracelet. Review of Resident #103's MDS/Minimum Data Set, dated dated [DATE], revealed Resident #103 was admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Per Resident #103's Care Plan, dated 3/21/13, "Wandering/Pacing related to: change in environment, anxiety, confusion d/t (due to) dementia. Verbalizes that family left her here and that she wants to go home and exit seeking behaviors. Goals: Will wander only within the facility..." Per Resident #103's Care Plan, dated 3/21/13, "At risk for falls due to dementia, leg cramps, anxiety, new environment, wandering, poor safety awareness, medication side effects..." According to the Facility Investigating Report - 5 Working Days, dated 4/11/13, "On 4/04/13 (Resident #103) exited the building unattended...(Resident #103) was last seen at the Nurses's Station approximately (4:55 PM). At approximately (5:10 PM) a staff member going home for the day called the facility to report she sees a lady who resembles (Resident #103) walking down the street...(Resident #103) was found (name of street) at approximately (6:35 PM) by passerby. The family is called and picks up (Resident #103) and takes her out to dinner...At (6:45 PM) it is discovered the Secure Care door alarm on 200 Hall (door #14) was not functioning. The door is manned and Maintenance Director (#4) resets the circuit breaker and the door alarm is working. Maintenance Director (#4) calls Electrician (#8) to assess root cause of circuit breaker tripping. (Resident #103) returns to the facility at approximately (9:45 PM) and is given a head to toe assessment finding no injuries and vital signs within normal levels." Review of an e-mail, sent 6/10/13 at 2:22 PM, Resident #103's family member #11 reported Resident #103, "had on tennis shoes, a grayish sweat shirt and some blue pants" when she retrieved Resident #103 on 4/04/13. On 4/04/13 at 5:35 PM, it was partly cloudy outside, the temperature was 52 degrees Fahrenheit, and the wind speed was 17.3 miles/hour with wind gusts to 23 miles/hour." (http://www.wunderground.com/history/airport/KGRR/2013/4/4/DailyHistory.html?req_city=NA&req_state=NA&req_statename=NA). In an interview, on 6/04/13 nurse aide #17 stated, "(Resident #103) likes to seek exits." In an interview, on 6/04/13 at 2:10 PM, nurse aide#18 reported she had worked at the facility for [AGE] years and, "knew (Resident #103) well". Nurse aide #18 reported, "I heard Resident #103 eloped out the front door (door #11)". In a telephone interview, on 6/05/13 at 9:11 AM, family member #12 stated, "They (unnamed facility staff) didn't know if she (Resident #103) walked out by other people or by herself. A (unnamed) lady saw her by (name of a college with multiple locations/exact location not given). We've told them, if its a sunny day, she likes to go out for a walk. They've called (family member #9) a couple of times to tell her (Resident #103) wanted to go outside and walk." In a telephone interview, on 6/05/13 at 3:34 PM, family member #9, "Three days before, they (unnamed facility staff) called and said four times she (Resident #103) tried to go out that day. (Resident #103) crossed (divided highway). I have no idea how she did that...I don't think they really know how she exited the building." In an interview, on 5/06/13 at 11:46 AM, nurse aide #5 reported she was assigned to Resident #103 on 4/04/13, "after (Resident #103) moved from Room #617 to Room #627 around lunchtime". Nurse aide #5 stated, "(Resident #103) was fine in the morning, but when they moved her she became agitated, talking about leaving and wanted to call her sisters. I told her to wait a few minutes and we would call her. She had her own cell phone so I told her to get it. She went and got her purse. We never did call her sisters. I last saw her about 3:00 PM. (Resident #103) wanders on 200 Hall and to Activities in the Main Dining Room (near Station 1) and Activities are usually about 3:00 PM. (Resident #103) pushed on (an exit door) before 2:30 PM (on 4/04/13). I told (LPN/Licensed Practical Nurse #6) (Resident #103) was exit seeking. Dinner is at 5:20 (PM); (Resident #103) was not there and that's the same time we got a call to check on her. I was training a new person and it was a busy day also." Nurse aide #5 reported LPN #6 did not instruct her to monitor Resident #103. According to the facility Statement, dated 4/07/13, Administrator #1 documented that RN/Registered Nurse/Unit Manager (RN #10) on the unit Resident #103 resided reported she observed Resident #103 in the facility on 4/04/13 at 4:57 PM. However, according to the facility Time Line, dated 4/04/13, "16:50 (4:50 PM) (Resident #103) last seen at Sub Station 3 Nurses Station". In an interview, on 6/04/13 at 2:15 PM, RN #10 reported she saw last saw Resident #103 at approximately 4:50 PM, and she was the staff member who called the facility after leaving the facility and arriving at her destination on the opposite side of town (time unknown) because, at approximately 5:10 PM on 4/04/13, she saw a woman walking down the road who was carrying a purse that looked like the one Resident #103 owned. RN #10 reported she did not turn her car around to check to see if the woman was Resident #103 because she was in "the outside lane" and she did not phone the facility immediately because she "had to pick up her son". RN #10 stated, "(Resident #103) was consistently asking to leave and how to leave...she's a power walker." In a telephone interview, on 6/05/13 at 3:15 PM, LPN #6 reported she checked the functionality of Resident #103's Secure Care bracelet on the afternoon of 4/04/13 and it was "working properly". LPN #6 reported nurse aide #5 reported to her that she (nurse aide #5) had seen Resident #103 trying to exit that day; (LPN #6) stated she "did not need to (instruct nurse aide #5 to monitor Resident #103) because, "(Resident #103) had on a wanderguard (Secure Care bracelet) on." On 6/04/13 at 12:30 PM, this surveyor measured the distance from the facility to the sidewalk Resident #103 was reported by Administrator #1 to be found; it was 1? miles north of the facility adjacent to a 4 lane, 55/mile/per/hour road in a metropolitan area of the city. Review of an e-mail, sent 6/05/13 at 7:49 PM, Resident #103's family member #11 reported, "...My mother (Resident #103's sister #9) called me at work and indicated that (Resident #103) had gotten out of the facility. Since the facility was on (divided highway), and I work downtown, I told her I would leave right away and approach the facility from the north (heading south) and drive down the (divided highway) toward the facility in hopes of recovering her. I received a second call from my mother (family member #9)...that someone had found her by (inner city lake) entrance off of the (divided highway). I turned around to retrieve her. My aunt (Resident #103) and a Samaritan couple - a God send for sure - were standing on the side of the west side of the road. Lots of folks were out power walking that day as it was a nice but still a bit chilly April day. The couple that reached out to her indicated that she was walking in the center of the road - the grassy area - when they recovered her. She appeared very disoriented to the women and was hunching over as if she was exhausted...When I reached them my aunt (Resident #103)...told me that she was very cold. She didn't know where she was and said that she got confused...kept asking the whereabouts of her suitcase as she was going on a trip to Tennessee...She was trembling a bit as she was not dressed for an outside excursion. She got in the car and continued to have shivers. We stopped for a hot cup of coffee before driving to my mother's home (family member #9)...Later that evening, after having an extremely emotional family conference...and discussing if we could actually keep (Resident #103), we returned to the facility. We conferred with (Administrator #1) and (DON/Director of Nursing #2)...They indicated that they searched for her...mostly south...No one was sent north on (the divided highway). They initially thought that she slipped out when a visitor opened the door but later found the sensor...alarm not working...while we were there aide staff, one particular, seemed a little casual and non-responsive. When (Administrator #1) was opening and closing doors and no one seemed to pay attention...We had some discussion about moving her room to another which was initially their recommendation. However, when we all walked to the new room, our assessment was the room they were recommending was right by a door which might be tempting..." In an interview, on 6/04/13 at 11:44 AM, Maintenance Technician #7 reported he checked the 200 Hall door (door #14) at noon on 4/04/13 and it was functioning properly, and the same breaker that failed causing the loss of power to (door #14), had tripped (shut down) approximately 6 months before and he reset it but did not report the tripped breaker to Maintenance Director #9 or investigate what caused the breaker to trip. When asked what he thought the reason door #14 failed on 4/04/13, Maintenance Technician #7 stated, "When I was leaving at 6:15 PM, I noticed some lights above the time clock were out and apparently they were in the system that went out. I personally think that people generate an energy field. I think the breaker popped when she pushed out the door." In a telephone interview, on 6/04/13 at 2:30 PM, facility contracted Master Electrician # 8 stated, "The ballast (transformer) usually won't short out a circuit, but we determined this one possibly did. I talked with (Maintenance Director #4); he said it happened before with the breaker and it was reset and he never found the reason it tripped..." In a telephone interview, on 6/04/13 at 2:52 PM, Secure Care Systems Service Representative #39 stated, "When you take power away from the 500 or 1000 panel, a 9 volt rechargeable batter turns on the power; it should take over and stay active for the alarm. Basically, they have 1 hour to figure that out. It should be changed once a year per our preventative maintenance recommendations. It was recommended to facility when the system was installed. Typically, maintenance (personnel in facilities) changes (batteries) on a periodic basis." In an interview, on 6/04/13 at 3:11 PM, Maintenance Director #9 reported he had worked at the facility over [AGE] years, and the door alarm system was installed 5 years ago. Maintenance Director #9 reported there was "no routine" to change the backup batteries in the door alarms on exit doors in the building, and had no record of them ever being changed until after Resident #103 eloped from the facility. When asked if the 200 Hall door alarm battery was working on 4/04/13 at the time that Resident #103 eloped from the facility, Maintenance Director #9 stated, "No". Maintenance Director #9 reported the facility had no surveillance cameras to verify which door, and at what time, Resident #103 exited on 4/04/13. According to the facility Time Line (not dated), on 4/05/13 at 6:30 AM, "Circuit breaker for the Secure Care device on 200 Hall (door #14) trips, (RN/Registered Nurse #RN) resets the circuit breaker..." In an interview, on 6/05/13 at 10:30 AM, Administrator #1 reported, "We (the facility) now have a new annual preventative maintenance contract for Secure Care to do maintenance check yearly." In a telephone interview, on 6/06/13 at 11:17 AM, EE/Electrical Engineer #23 stated, "The facility wanted me to speak to you about when lighting ballast fails. Typically it won't trip a breaker." When asked if he had investigated the cause of the breaker repeatedly tripping, EE #23 said, "No, I'm coming next Wednesday to look at the building. I would assume it wasn't an overload; it shouldn't short circuit. I didn't not know it happened 6 months ago. I will work on a solution and results so that it doesn't happen again." On 6/10/13 at 8:45 AM, Administrator #1 reported AIT/Administrator in Training #36, conducted an actual experiment on 6/06/13, and determined a new/fresh emergency backup battery in the door alarm on door #14 lasted 3.5 hours and confirmed there was no warning alert when the the battery was drained or becoming ineffective. On 6/12/13 at 10:50 AM, surveyor observed the alarm box on door #14 was labeled 500 Series. On 6/12/13 at 9:15 AM, in a joint interview, EE #23 reported although he, "had not visually inspected" the actual rewiring of the door #14, "It meets code". EE #23 reported the back up Secure Care alarm boxes beep to alert when they are low; Administrator #1 corrected his misconception. Director of Plant Operations #29 reported that all of the exit doors in the facility were equipped with 1000 Series Secure Care wandering devices, and Administrator #1 corrected him and told him there were only two doors, the front entrance (door #11) and the 300 Hall (door #1) that were equipped with he 1000 Series. On 6/11/13 at 10:50 AM, accompanied by Maintenance Director #4, this surveyor observed a 1000 Series Secure Care alarm box on door #8 (in an alcove north of the north main dining room). Maintenance Director #4 reported the 1000 Series Secure Care alarm box on door #8 had been deactivated because it was not in use. However, when tested with the Secure Care testing device, the device functioned properly. On 6/11/13 at 11:05 AM, Administrator #1 reported he did not know there was a 1000 Series Secure Care alarm on door #8. On 6/04/13 at 9:35 AM, during a facility tour with a facility map in hand, this surveyor asked Maintenance Director #9 about a door that was shown to be in a conference room in the 300 Hall (door #21). Maintenance Director #9 stated, "The map is wrong; there is no door there." On 6/04/13 at 10:15 AM, this surveyor found an unlocked sliding door (door #21), in unlocked conference room on the 300 Hall, leading to an unsecured lawn area. On 6/04/13 at 10:35 AM, MDS Coordinator #16, was observed sitting at a desk directly opposite the hall of the conference room containing door #21; MDS Coordinator #16 stated the conference room (approximately 6 feet across the hall) door "normally is not locked". In an interview, on 6/04/13 at 11:44 AM, Maintenance Technician #7 measured the door #21's opening to be 9 inches, and surveyor observed Maintenance Technician #7 walk through (door #21) the conference room slider door's 9 inch opening to the unsecured area outside without difficulty when he turned sideways. Maintenance Technician #7 reported the facility had a rule that the slider door could be opened 8 inches and stated he opened the door wider for for a State surveyor (#33) in May, 2013, "because the surveyor wanted to go outside". In an interview, on 6/05/13 at 8:45 AM, Administrator #1 reported there was no facility policy allowing the slider door to be open 8 inches. In a telephone interview, on 6/06/13 at 10:15 AM, LPN #21 she was aware the slider door (door #21) was open in the conference room in the 300 Hall and reported she thought Resident #103, "could possibly get through a door that was only open 6 inches". In an interview, on 6/10/13, Quality Consultant #31 reported it was possible that staff may have been using door #21 to go outside and smoke at night. On 6/03/13 at 4:00 PM, this surveyor observed that the 300 Hall (door #1) was on the same hall as door #21, and at the very end of a hall of offices across from the Therapy Room. On 6/04/13 at 9:35 AM, during a facility tour with a facility map in hand, surveyor asked Maintenance Director #9 which of the 21 facility doors were equipped with Secure Care Alarms (wandering alarms); Maintenance Director #9 reported, "Just 2 - the front entrance door and the 300 Hall door (door #1)". In a telephone interview, on 6/06/13 at 10:15 AM, LPN #21 reported that "(Resident #103) is always walking trying to find a way out. Everyday, absolutely (Resident #103) is down 300 Hall checking doors." In an interview, on 6/06/13 at 10:45 AM, PT/Physical Therapist #22 reported no other staff were in the Therapy Room so she shut the Therapy Room door before she left, and was in the building doing resident assessments in the residents' rooms on 4/04/13 between 4:45 PM and 5:15 PM, and therefore did not hear an alarm at (door #1). On 6/06/13 at 9:00 AM, Administrator #1 went through door #1; surveyor stood approximately 10 feet behind him and as Administrator #1 went through the door way, the door opened and surveyor, holding a Secure Care device to simulate a Secure Care alarmed resident, walked behind Administrator #1, grabbed the open door, setting off the Secure Care alarm, and continued to walk to the unsecured parking lot outside. On 6/12/13 at 11:00 AM, accompanied by Maintenance Director #4, this surveyor observed the alarm box on door #1 was labeled "1000 Series". Maintenance Director #4 reported, unlike the 500 Series, the 1000 Series boxes contained the receive the radio waves that Secure Care bracelets transmit, and reported there were 3 doors in the building that had the 1000 Series boxes on them, neither the 500 Series or the 1000 Series boxes beeped when the batteries were low. Maintenance Director #4 stated the 1000 Series box on door #8, north of the North Dining room, was not activated for use with the Secure Care wander device. However, when surveyor and Maintenance Director #4 tested door #8 with the wander tester, a yellow light began to blink and the door locked when the wander tester was 4 feet away. Further testing of the 1000 Series boxes on the main entrance (door #11) and the 300 Hall (door #1) revealed the lights began blinking yellow and the doors locked when the wander tester was 3 feet away from both. Maintenance Director #4 reported that, of the 21 doors in the building, 16 doors were equipped with the 500 Series box that, (when working properly, alarmed when the bar on the door was pushed/opened after 15 seconds), 3 doors had the 1000 Series box (additionally equipped with receivers for wander bracelets), and there were 2 sliding door that were not alarmed (door #21 and an unlabeled slider door, in a day room, that was secured with a stopping device that prevented opening it). According to the Installation Manual (for the Secure Care 1000 Series), dated 11/27/07, "...wandering resident locking system is designed to augment your policy regarding wandering residents...PM Function: This allows you to program the panel to lock and unlock the door automatically at certain times of the day whether a monitored resident is near the monitored area or not. Loiter Alarm feature: The feature when activated will create an alarm condition whenever a monitored resident remains within the detection range of the system for a predetermined period...Advanced Security Mode...will not allow the escort of a monitored resident...If a Push Button is used...it will not allow access while a monitored resident is in detection range..." In a telephone interview, on 6/17/13 at 4:20 PM, Administrator #1 reported door #1 was locked at 7:30 PM and opened at 8:00 AM, and the Push Button feature and a posted notice about exit seeking residents were present "for years" at door #1. On 6/06/13 at 11:30 AM, Administrator #1 was notified of the Immediate Jeopardy that was identified on 6/5/13 and began on 4/04/13 at 4:57 PM for Resident #103, who was identified at risk for elopement, and eloped from the facility 4/04/13 at approximately 4:57 PM, unbeknownst to facility staff. On 6/10/13 the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy on 6/06/13: 1. On 4/04/13 at 17:15 PM a Code Green/missing patient drill was initiated. Resident #103 unable to be located within the facility; all other residents were accounted for. Resident #103 was returned to the facility on [DATE]. Resident #103 returned to room 617 (the room resident was admitted to and not the room that she had been moved to earlier that day) and head to toe assessment completed finding no injuries and vital signs within normal limits and Resident #103 was placed on one to one supervision. The Secure Care device on Resident #103 was found in place and functioning. 2. On 4/04/13 at 18:45 PM, an audit of all exit doors completed by the AIT/Administrator In Training #36; found door #14 alarm on 200 Hall not functioning, and continuous observation of door #14 began. 3. On 4/04/13 at 18:55 PM Maintenance Director #4 identified circuit breaker #36 to be tripped. The circuit breaker was reset by Maintenance Director #4, alarm checked for functionality, and a (contracted electrician) was called. 4. On 4/04/13 at 19:00 PM, 13 patients using Secure Care bracelets were tested and found to be functioning correctly. 5. On 4/04/13 at 20:00 PM, every 15 minute checks were initiated on all exit doors to ensure the secure care door alarms were functioning properly. 6. On 4/04/13 at 21:55 PM, facility Social Workers and Nursing assessed all patients within the facility to determine "like residents" and ensure precautions were in place; one resident was added to the elopement risk "Center Watch" book. 7. On 4/04/13 at 23:00 PM, electrician #37 replaced circuit breaker that had tripped repeatedly. Facility established a house wide system for all exit doors to be checked every 15 minutes. 8. On 4/04/13 at 23:30 PM, staff education was initiated on elopement risk management strategies from the Wander Practice Guideline policy and procedure. (22) Employees were educated on the Wander Practice Guideline on 4/4/2013. All 222/222 staff members employed at the time of incident were educated prior to working assigned shifts and completed by 5/3/13; new staff will be trained upon hire. 9. On 4/05/13 at 06:30 AM, the circuit breaker for the Secure Care device on door #21 tripped, and RN #27 reset the circuit breaker; continuous observation of door #21 begins again. 10. On 4/05/13 at 12:00 PM, electrician #37 rewired door #21's Secure Care alarm to a different circuit breaker. 11. On 4/05/13 at 17:15 PM Secure Care Health Systems, Inc. Technician #38 checked all Secure Care door devices, replaced rechargeable back up batteries in each Secure Care alarm. 12. On 4/06/13 at 18:00 PM, (after more than 30 hours of door alarms functioning properly), the monitoring of facility doors is reduced to twice daily checks. 13. On 6/06/13 at 2:00 PM, Maintenance Director #4 adjusted the "stopper" on the bottom of the conference room sliding door (door #21) to prevent the door from being able to be opened. 14. Continuing on 4/04/13, a notice was posted on the inside/adjacent wall next to door #1. On the recommendation of surveyor, on 6/10/13 at 11:00 AM, Administrator #1 changed location of the notice; it was moved to the center of door #1 at eye level, and the alert to visitors to be vigilant when leaving the facility that residents are not following them out of the facility was placed in bold font and moved to the top of the notice. Although the Immediate Jeopardy was removed on 6/06/13, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to sustained compliance had not been verified by the State agency. ( )

This citation pertains to intake MI 452. Based on interview and record review, the facility failed to provide adequate supervision to prevent falls in 1 of 4 sampled residents (Resident #101) review for falls, from a total of 4 sampled residents, resulting in Resident #101 sustaining bilateral subacute subdural hematomas (a collection of blood on the surface of the brain) and bilateral hygromas (an accumulation of cerebrospinal fluid in the subdural space after head injury) after a fall. Findings include: Review of Resident #101's medical record revealed he was an [AGE] year old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #101's facility face sheet revealed he was discharged to the hospital on [DATE] and readmitted on [DATE]. His minimum data set ((MDS) dated [DATE] indicated he was moderately impaired with cognitive skills, and required extensive assistance of one person for transfers, ambulation, dressing and personal hygiene. Review of Resident #101's falls care plan dated 10/2/12 indicated he was at risk for falls due to a history of falls, unsteady gait, use of multiple medications, unfamiliar environment, use of antianxiety medications, very poor safety awareness related to dementia, cognitive deficits, cardiac meds, with interventions to include implement use of preventative device, keep walker within easy reach, will switch to seated walker at this time (dated 10/2/12 - no resolved date), provide assist to transfer and ambulate as needed (dated 10/2/12 - no resolved date). Review of Resident #101's mobility care plan dated 10/2/12 indicated Resident #101 was to be encouraged to walk and use railing in hallways or use walker when ambulating (resolved date of 1/8/13). Review of the Physical therapy summary for Resident #101 dated 10/24/12 indicated Resident #101 was modified independent with transfers, and could ambulate greater than 400 feet with assistive device at modified independence with occasional stand by assistance. Review of the Facility incident report for Resident #101 dated 11/14/12 at 9:00 am indicated Resident #101 was observed on the floor on his right side with his sweater over his head, complaining of shoulder pain. The incident report indicated Resident #101 stated he was going into the bathroom and he fell backwards. Review of the Facility incident report for Resident #101 dated 11/15/12 at 5:15 pm indicated Resident #101 was observed sitting on the floor in another resident's room. Review of the Nurse's notes for 11/15/12 at 6:34 pm indicated Resident #101 stated to the nurse he entered another resident's room because he thought he had seen his wife, went to sit down on his walker seat, but there was no seat there, and fell , at which time he hit his head. The nurse's note indicated Resident #101 had a pulse of 40 (normal being 60 to 100) and blood pressure of 83/56 (normal 90/60). Review of the physician progress notes [REDACTED].#101 had a hypotensive (low blood pressure) episode yesterday but resolved. Review of the Facility incident report dated 11/22/12 at 9:30 pm indicated Resident #101 wandered to another unit of the facility, and fell on the floor of the other unit. Review of the Nurse's notes for Resident #101 dated 11/22/12 at 11:41 pm indicated Resident #101 ambulated to another unit with his walker and apparently thought a seat was behind him, tried to sit and fell . The nurse's notes indicated over the span of an hour Resident #101's blood pressure dropped as did his oxygen level, while his heart rate increased. Review of the Facility incident report dated 11/24/12 at 3:00 am indicated Resident #101 was observed lying prone (face down) in his bathroom and Resident #101 stated he lost his balance and fell when walking out of the bathroom. The incident report indicated the resident continued to be impulsive, has had some difficulty with fluctuations in his pulse rate and doesn't remember to request help, especially at night. Review of the Facility incident report dated 11/27/12 at 7:00 am indicated Resident #101 was found lying face down on the floor next to his bed, was assisted with three staff members and placed back in bed. Review of the Nurse's note dated 11/27/12 at 06:55 am indicated Resident #101 was observed face down on floor by bed side with blood pressure of 141/77 (normal 90/60 to 120/80). Review of the Nurse's note dated 11/27/12 at 2:13 pm indicated Resident #101's blood pressure results were: Right arm: lying 116/69, sitting 110/52, standing 92/42 and Left arm: lying 110/58, sitting 98/52, standing 84/48 with pulse rates which varied 58 through 128. Review of the physician progress notes [REDACTED].#101's blood pressure medications. Review of the Facility incident report for Resident #101 dated 12/1/12 at indicated Resident #101 lost his balance and fell in the bathroom landing on his back and head, sustaining a wound to the head. Review of the Nurse's notes for Resident #101 dated 12/1/12 indicated Resident #101 lost his balance and fell on to his back and head, and sustained 2 centimeter (cm) subcutaneous collection of blood with 1/8 cm superficial cut in skin to left posterior (back) head. Review of the physician progress notes [REDACTED]. Review of the Facility incident report for Resident #101 dated 1/1/13 at 5:00 pm indicated Resident #101 was observed on his back in front of the nurse's desk with no immediate injury noted. Review of the Nurse's note dated 1/1/13 at 7:08 pm indicated Resident #101 was noted to be on the floor by other residents. The nurse's note indicated Resident #101 was assisted to a chair, no injuries were present, and then Resident #101 got up from the chair, attempted to leave the facility and was extremely agitated. The nurse's note indicated Resident #101 then complained of neck, chest and back pain and Resident #101 was sent to the hospital per physician's orders [REDACTED]. In an interview on 2/8/13 at 3:00 pm, certified nurse aide #8 (CNA #8) stated on 1/1/13 while she was sitting with another resident, providing 1:1 supervision, she heard another resident screaming in the hall. CNA #8 stated she ran into the hall and observed Resident #101 laying on the floor with his head by the wall and his feet by the nurse's station. CNA #8 stated shortly after she arrived, LPN #7 arrived, so she (CNA #8) went back in the room to supervise her Resident. CNA #8 stated she didn't recall Resident #101 saying anything. In an interview on 2/8/13 at 11:30 am, Licensed Practical Nurse #7 (LPN #7) stated he heard someone tell him on 1/1/13 that he had a resident on the floor. LPN #7 stated he couldn't remember who told him that. LPN #7 stated he observed Resident #101 on his back with his knees bent on the floor in front of the nurse's station, with a phone by him. LPN #7 stated Director of Nursing #2 (DON #2) had sat Resident #101 in a chair by the nurse's station earlier and Resident #101 had been quite agitated and exit seeking most of the evening. LPN #7 stated he had no idea who had given Resident #101 the phone. LPN #7 stated he and another nurse did an assessment of Resident #101, then took him to his room, did a skin assessment, where there were no obvious injuries. LPN #7 stated Resident #101 was then able to ambulate back to a chair at the nurse's station, where he sat for a moment then stood and began to wander. LPN #7 stated Resident #101 then complained of chest, back and neck pain, so LPN #7 stated he notified the physician and Resident #101 was immediately sent to the hospital. LPN #7 stated upon initial assessment, Resident #101 denied pain. LPN #7 stated he did do a neurological assessment of Resident #101 while he was still on the floor, which was negative. In an interview on 2/7/12 at 11:25 am, non-sampled Resident A was identified as a witness to resident #101's fall and the surveyor asked Resident A if she remembered observing Resident #101 falling by the nurse's desk. Resident A stated she did not remember that. Review of the Nurse's notes on 11/14/12, 11/15/12, 11/19/12, 11/20/12, 11/23/12, 11/24/12, 11/26/12, 11/27/12, 11/29/12, 11/30/12, 12/1/12, 12/2/12, 12/3/12, 12/5/12, 12/6/12, 12/9/12, 12/15/12 indicated Resident #101 was observed ambulating without his walker or needed to be reminded to use his walker. Review of the Radiology report for a computed tomography (CT) scan of Resident #101's head on 1/1/13 indicated an impression of bilateral subdural fluid collections, most consistent with subacute subdural hematomas/hygromas. Review of the Hospital history and physical report dated 1/1/13 for Resident #101 indicated Resident #101 suffered an unwitnessed fall at the facility and the CT of his head showed bilateral subacute subdural hematomas and small vessel disease, with neurosurgery to be consulted. Review of the Facility nurse's note dated 1/28/13 at 12:33 pm indicated a call was received from consulting neurosurgeon's office who indicated Resident #101 would need surgery on 2/1/13. Review of Resident #101's falls care plan and mobility care plan did not reveal a change in Resident #101's ability to ambulate independently with a walker until 1/8/13. In an interview on 2/8/13 at 12:00 pm, Unit Manager #3 (UM #3) stated she was the unit manager for the unit where Resident #101 resided while he was at the facility. The surveyor reviewed each of Resident #101's falls listed above with UM #3 and had UM #3 review the incident report for each fall, along with Resident #101's mobility and falls care plans. The surveyor then asked UM #3 if Resident #101's ability to safely ambulate independently with a walker was re-evaluated after any of his above listed falls and UM #3 stated no. The surveyor asked UM #3 if Resident #101's ability to safely ambulate independently with a walker was re-evaluated after he fell on [DATE] and sustained bilateral subdural hematoma's which required hospitalization and UM #3 stated yes. When the surveyor asked UM #3 why Resident #101's ambulatory status was re-evaluated after this fall and not his other falls, UM #3 stated because he had returned from the hospital and was no longer ambulatory. When the surveyor asked UM #3 why Resident #101 was not re-evaluated for safe ambulation until he had sustained a serious head injury, when he had experienced multiple falls, had new [DIAGNOSES REDACTED].#3 stated, "I couldn't tell you", and she thought maybe the ball was dropped on Resident #101. In an interview on 2/8/13 at 12:50 pm, Rehabilitation Director #4 (RD #4) stated she attended the morning staff meetings at the facility at the director of therapy. RD #4 stated resident falls were discussed in the morning staff meeting, and she did remember Resident #104's falls being discussed in the meeting. RD #4 stated the reason therapy decided not to re-evaluate Resident #101, even though she was aware he had experienced multiple falls, was due to that fact that his falls were caused from medical issues, not issues that therapy could help. RD #4 stated it was decided therapy could not help Resident #101 because his problem was not a strength issue, it was a medical issue. Review of the Facility "Falls Practice Guide Flowchart" dated 2011, provided to the surveyor by Director of Nursing #2 (DON#2) on 2/7/13, indicated if there is a change in a patient's risk factors or fall occurrence, a fall evaluation is to be completed, interdisciplinary care plan is to be revised or developed as applicable and then implemented, ongoing fall prevention strategies done, patient/family/staff education completed and then an evaluation is to be done. #

This citation pertains to MI 707. Based on interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls in 1 of 4 sampled residents (Resident #104) who were at risk for falls, from a total of 4 sampled resident, resulting in Resident #104 sustaining a fractured nose after a fall. Findings include: According to hospital Occupational Therapy notes, dated 7/02/12 Resident #104 had a "Fall prevention alarm". Per the Minimum Data Set, dated dated [DATE], Resident #104 was admitted from the hospital to the facility on [DATE], and had moderate cognitive impairments with inattention and altered level of consciousness, weakness on one side of her upper and lower body, was unable to walk, and had [DIAGNOSES REDACTED]. Per the Care Area Assessment data, dated 7/10/12, Resident #104 a Fall Risk Assessment was done upon admission, had difficulty maintaining sitting balance, difficulty making herself understood and difficulty understanding others. Per physician progress notes [REDACTED]. Per the "Investigation Report", dated 8/08/12, Resident #104, "...(on 8/06/12) at approximately 6:40 (AM) staff heard (Resident #104's roommate/off sample resident #1) yelling for help, and (Resident #104) was found on the floor. Nursing staff assessed (Resident #104), moved (Resident #104) to her bed, attempted a cold cloth to nose, (Resident #104) declined. Vital signs taken...Fall was witnessed by (roommate/resident #1) who stated (Resident #104) was attempting to stand up, but does not have the strength to do this independently so she fell ...(Resident #104) admitted she was attempting to stand up so she could walk to the cafeteria. This indicates her cognitive impairment and poor safety awareness as there is no cafeteria and she is not able to walk at this time..." Per Resident #104's nursing Progress Notes, dated 7/23/12, at 1:33, "Alert and oriented to name, able to make needs known..." According to Resident #104 's Physical Therapy notes, dated 7/18/12, "(Resident #104's) sitting balance is currently P/P- (poor to poor minus) with max (maximum) physical and verbal cues for trunk control." According to Resident #104's "At risk for falls due to impaired balance/poor coordinating, poor safety awareness, hx (history) of CVA (stroke) with left sided hemiparesis (weakness/paralysis), DM (Diabetes), HTN (hypertension), history of falls (created 7/03/12)", the only "Interventions" in place on the care plan on 8/06/12 were: Provide assist to transfer, Arjo (mechanical) lift; Refer to the Therapy Plan of Treatment in the medical record for more detail; and Reinforce need to call for assistance, call light to be placed on resident's right side". Review of Physical Therapy and Occupational Therapy notes for Resident #104 between her admission to the facility and 8/05/12 revealed additional no fall prevention details such as positioning or positioning device recommendations, or monitoring or monitoring device recommendations. In a telephone interview, on 9/19/12 at 1:10 PM, Licensed Practical Nurse (LPN) #2 stated she was assigned to care for Resident #104 on 8/06/12 at 6:40 AM, found Resident #104 on the floor, and completed an assessment. When asked if Resident #104's call light was in reach, LPN #2 stated, her (Resident #104's) tube feeding was going on..." When asked why she did not chart whether or not Resident #104's call light was sounding in her incident report, LPN #2 stated, "I do not know about her call light...I should have charted that". When asked what she thought was the cause of Resident #104's fall, LPN #2 replied that she remembered, "...the foot pedals were off (Resident #104's) wheelchair". In an interview, on 9/19/12 at 2:00 PM, DON/Director of Nursing #3, told this Surveyor that Resident #104 did not have a fall alarm and had not been assessed for a fall alarm because facility had been "alarm free for the last 3 months". DON #3 said, "Originally we thought (Resident #104) was reaching for her tube feeding pole, but after our root cause analysis, we realized she needed more supervision...(Resident #104) wasn't realizing her weakness...The Wedge cushion was added to her wheelchair. It is slanted so she wouldn't slide/get out of her wheelchair". DON #3 stated that roommate #1 was not available for interview because she had recently been discharged to the hospital with pneumonia. In an interview, on 9/19/12 at 3:00 PM, DON #3, told this Surveyor, there was no way to retrieve the "Patient Information Worksheets" that the nurse aides had available to them on 8/06/12 to guide them with Resident #104's care. DON #3 stated, "Unfortunately, it was not put in the investigation file". In a telephone interview, on 9/19/12 at 3:15 PM, nurse aide #7 told this Surveyor she had never provided care for Resident #104 before 8/06/12, and she identified herself as the nurse aide that assisted nurse aide #4 with the transfer of Resident #104 into her wheelchair on 8/06/12 at approximately 6:00 AM. Nurse aide #5 said, "I think (Resident #104) tried to get up. Her weak side - she fell on that side. The foot pedals were supposed to be on; the foot pedals helps so (Resident #104) doesn't fall forward." Nurse aide #5 said, "(Resident #104) was yelling I broke my nose, I broke my nose. When the nurse asked (Resident #104) she how fell , (Resident #104) couldn't tell her". In a telephone interview, on 9/19/12 at 3:28 PM, nurse aide #4 stated she was assigned to Resident #104 "2 nights a week", and said she was the nurse aide assigned to Resident #104 on 8/06/12 at 6:40 AM. When asked if Resident #104's call light was on and within reach, nurse aide #4 stated she had, "To tell you the truth, there was so much blood, I have no clue where it (Resident #104's call light) was when we found her". Nurse aide #4 stated she remembered that Resident #104 had left sided weakness and said Resident #104 did not use her call light. Nurse aide #4 said, "After she fell , a couple of day shift girls (nurse aide #5 and #6) came up to me and told me, why did you get (Resident #104) up and leave her alone in the wheelchair; she always wiggles around and tries to get out of her chair". Nurse aide #4 said, "It was a requirement for therapy...to have her washed, dressed, and up in the chair...she was a 2 person and we transferred her with the Arjo....made sure she wasn't leaning. If sitting there for awhile she would lean". In a telephone interview, on 9/19/12 at 4:12 PM, nurse aide #5 said she worked the day shift and was "frequently" assigned to Resident #104. Nurse aide #5 stated, "(Resident #104) would slide down, scrunch down, slide forward. Everybody knew about it. We would put a "steady grip/rubber pad" in her chair, prior to her fall, on days (day shift). It should have been on the care guide. I told the charge nurse, but I don't remember her name. (Resident #104) was very fidgety. Yes, (Resident #104) knew how to put her call light on." When this Surveyor asked nurse aide #5 how she kept Resident #104 safe she replied, "She was considered a fall risk. I checked on her every 30 minutes and would always put her back into bed in the low position with fall mats on both sides. A number of times, I found her on the edge of her wheelchair. That was a fall waiting to happen". In a telephone interview, on 9/19/12 at 4:05 PM, nurse aide #6 stated she worked the day shift and was assigned to Resident #104 about 3 days a week. Nurse aide #6 commented, "(Resident #104) on occasion, would wiggle around after being up for awhile, and yes, she tried to get up before the day she fell . The first day after (Resident #104) fell , I was told not to keep her up unless she was in a supervised area". When asked if she ever recorded Resident #104's attempts to get up, nurse aide #6 said, "The nurse aides don't really have a place to write things like that down; that's on the nurses' end". When asked if Resident #104 used her call light, nurse aide #6 stated, "All the time! Once, she didn't have her call light but was pointing to the bed and I asked her if she want to lay down. She said yes. Resident #104 has some challenges with words but if you are patient with her, she can tell you what she needs". In an interview, on 9/20/12 at 1:55 PM, PT/Physical Therapist #8 told this Surveyor that it was the responsibility of the Occupational Therapist to make recommendations and care plan recommendations regarding fall prevention such as positioning and positioning devices, and monitoring and monitoring devices for Resident #104. In an interview, on 9/20/12 at 2:24 PM, nurse aide #5 told this Surveyor the nurse aides had no special orders for positioning or monitoring Resident #104 prior to her fall on 8/06/12. In an interview, on 9/20/12 at 2:55 PM, OT/Occupational Therapist #9 identified herself as the OT that worked with Resident #104 and that Resident #104 had therapy 5 days/week. OT #9 stated she did not know that Resident #104 had a fall alarm at the hospital prior to her admission to the facility, and she did not know that the facility conducted Fall Risk Assessments. OT #9 said, "Does nursing do that?". OT #9 also said she made no recommendations to prevent Resident #104 from falling, made no recommendations as to how long she could be left sitting in the wheelchair, and made no positioning recommendations until after Resident #104. OT #9 said she added a grip pad under a gel cushion in Resident #104's wheelchair for comfort, but that she (OT #9) "never" put those items on residents' care plans. In an interview, on 9/20/12 at 3:13 PM, DON #3 stated the Fall Risk Assessment used by the facility did not have a rating scale to rate the severity of a residents' fall risk. DON #3 also stated she knew that Resident 104's fall care plan was not adequate to prevent Resident #104's fall on 8/06/12, and that the facility investigation was not completed the way she would have liked. ( )

This citation pertains to MI 707. Based on observation, interview and record review, the facility failed to provide supervision and assistive devices to prevent falls for 1 (#205) of 3 sampled residents from a total sample of 5 residents, resulting in Resident #205 falling from her wheelchair and sustaining a bump on the left side of her forehead, and bruising to the left side of her head, her left eye, shoulder, arm and hip. Findings include: Review of Resident #205 s medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital records for Resident #205 revealed a history and physical note for Resident #205 dated 11/10/12 which indicated Resident #205 sustained an un-witnessed fall at her previous facility and was noted to have left sided weakness and left sided facial droop, with slurred speech. A physician consultation note for Resident #205 dated 11/11/12, listed an assessment of acute right subcortical (below the outer surface of the brain) stroke. Facility physician's progress note for Resident #205 dated 11/17/12 indicated Resident #205 had a CVA (stroke) with left sided hemiparesis (weakness on one side of the body). Physical therapy evaluation for Resident #205 dated 11/17/12 indicated Resident #205 had sustained a fall at her previous facility with notable left sided weakness and facial droop, and was status [REDACTED]. The evaluation described Resident #205 as being lethargic and leaning to the left in the wheelchair. Nurse's note for Resident #205 dated 11/16/12 at 5:29 pm, signed by Unit Manager #3 (UM #3) indicated Resident #205 had a history of [REDACTED]. Nurse's note for Resident #205 dated 11/17/12 at 2:16 pm, signed by LPN #7 indicated Resident #205 had been leaning forward and been repositioned several times and within staff sight. The note indicated that later Resident #205 was observed laying on her right side on the floor, with a big bump on the left side of her forehead. The note also indicated that an ice pack was applied to Resident #205's forehead, and that she (Resident #205) was placed in a broda chair (reclining wheelchair) to prevent further falls. Nurse's note dated 11/19/12 at 7:33 am indicated Resident #205 had developed bruising from fall on 11/17/12 to the point where the left side of head, her left eye, shoulder, arm, and hip were bruised. Falls care plan for Resident #205, with date initiated of 11/16/12 identified her (Resident #205) to be at risk for falls due to unsteady gait, sensory partial vision in one eye due to CVA (Cardiovascular Accident) deficit, and history of falls, with interventions listed to include administer medications per physician's orders [REDACTED].); additional interventions added included -nurse just made resident safe to prevent further falls by putting resident in a broda chair that reclines backwards to prevent resident from leaning forward and falling (11/17/12), and if resident is leaning forward in chair assess for unmet needs -toileting, need for nap, need for repositioning (11/18/12). A facility incident report dated 11/17/12 with a time of 12:50 pm indicated Resident #205 was observed laying on her left side on the floor in front of the nursing station and had a "big bump" on the left side of her forehead. In an interview on 11/28/12 at 9:15 am, UM #3 stated she saw and assessed Resident #205 upon her admission to the facility on the evening of 11/16/12. UM #3 stated she observed Resident #205 sitting in her wheelchair, and as she (Resident #205) sat in her wheelchair, Resident #205 became fatigued and started to lean. UM #3 stated Resident #205 had not been sitting in her wheelchair long before she began to lean. UM #3 stated she did think that Resident #205 would be at risk for falling out of her wheelchair when she (UM #3) saw her (Resident #205) leaning in the wheelchair. UM #3 stated the chair didn't even fit Resident #205 appropriately. The surveyor asked UM #3 if she (UM #3) had put any interventions into place to prevent Resident #205 from falling out of her wheelchair before she (UM #3) left the facility that day and UM #3 stated she didn't know. In an interview on 11/28/12 at 9:50 am, LPN #7 stated on 11/17/12, Resident #205 kept leaning forward in her wheelchair, and that she and the aides kept repositioning Resident #205. LPN #7 stated each time she and the aides would reposition Resident #205, she would soon be leaning forward in her wheelchair again. LPN #7 stated Resident #205 was in her wheelchair near the nurse's desk, and she (LPN #7) had to walk down the hall to assist another resident. LPN #7 stated as she walked down the hall she heard a bump and turned around to observe Resident #205 on the floor, next to her wheelchair, with a big bump on her forehead. LPN #7 stated she assessed Resident #205 for other injuries and found none, started neurological checks, which were within Resident #205's normal, called the doctor and family, put ice on Resident #205's head, and then put Resident #205 in a Broda chair (reclining wheelchair). LPN #7 stated she put Resident #205 in the Broda chair for safety, so she wouldn't lean and fall out of the chair, and positioned her with pillows for comfort. LPN #7 stated it didn't occur to her to put Resident #205 in the Broda chair for safety until after her fall. LPN #7 stated she could have prevented Resident #205's fall if she (LPN #7) would have put her (Resident #205) in the Broda chair before the fall. #

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE ADEQUATE SUPERVISION TO PREVENT FALLS FOR 1 OF 8 RESIDENTS REVIEWED FOR FALLS (#9) FROM A TOTAL OF 25 SAMPLED RESIDENTS, RESULTING IN FALLS, A FRACTURE, AND AN INCREASED FEAR OF FALLING FOR RESIDENT #9. FINDINGS INCLUDE: ACCORDING TO THE "SOCIAL WORK ASSESSMENT AND HISTORY" DATED 1/28/11, RESIDENT #9 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] "FOLLOWING ACUTE hospitalization FOR A FALL." RESIDENT #9 HAD PREVIOUSLY RESIDED WITH FAMILY AND HIS FAMILY REPORTED HE WAS "CONTINUOUSLY FALLING," AND HIS FAMILY WAS "FINDING IT MORE DIFFICULT TO CARE FOR HIM IN THE HOME ENVIRONMENT." THIS SAME ASSESSMENT REFLECTED HE PRESENTED WITH BOTH LONG AND SHORT TERM MEMORY DEFICITS AND HAD A [DIAGNOSES REDACTED]. THIS SAME ASSESSMENT ALSO REFLECTED RESIDENT #9 "SEEKS TO EXIT AND HAS A SECURE GUARD IN PLACE." INCIDENT AND ACCIDENT REPORTS DATED 1/28/11 THROUGH 7/5/11 REFLECTED HE fell 27 TIMES. RESIDENT #9 fell 6 TIMES ON 1/28/11. ON 7/27/11 AT 11:30 AM, DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) SHE REVIEWED EACH FALL AND EACH INTERVENTION FROM 1/28/11 THROUGH 05/2011. DURING THIS INTERVIEW WITH THE DON, SHE STATED HE HAD ONE TO ONE SUPERVISION ON 1/28/11 BUT IT HAD BEEN DISCONTINUED. DOCUMENTATION OF THE ONE TO ONE SUPERVISION AND WHY IT WAS DISCONTINUED WAS REQUESTED BUT THAT INFORMATION WAS NEVER PROVIDED. THE DON STATED THE INFORMATION WAS IN THE NURSING NOTES FOR THAT TIME PERIOD, REVIEW OF NURSING NOTES FOR JANUARY 2011 AND FEBRUARY 2011, DID NOT REFLECT ANY ONE TO ONE SUPERVISION FOR 1/28/11. THE INCIDENT AND ACCIDENT REPORT DATED 5/14/11 REFLECTED RESIDENT ATTEMPTED TO GET OFF OF THE TOILET WITHOUT SEEKING ASSISTANCE, HOWEVER THE DIRECTOR OF NURSING STATED DURING AN INTERVIEW ON 7/27/11 AT 11:30 AM, THAT THE NURSE AIDE LEFT HIM IN THE BATHROOM UNSUPERVISED, EVEN THOUGH HIS CARE PLAN INSTRUCTED NOT TO LEAVE HIM ALONE IN THE BATHROOM. THE FALL CARE PLAN DATED 1/28/11 AND REVISED 7/15/11 REFLECTED "STAFF TO STAY WITH RESIDENT WHEN IN BATHROOM" THIS INTERVENTION WAS INITIATED 3/30/11. ON 7/27/11 AT 11:30 AM, DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON), STATED THE FALL THAT OCCURRED ON 5/25/11 OCCURRED WHEN NURSE AIDE "V" TRANSFERRED HIM FROM HIS WHEELCHAIR TO THE TOILET, THEN NURSE AIDE "V" TURNED TO TURN OFF HIS ALARM, WHILE HER BACK WAS TURNED RESIDENT #9 fell AND FRACTURED HIS FACE. THE DON STATED NURSE AIDE "V" WAS EDUCATED TO DISCONNECT THE ALARM FIRST, THEN SECURE THE RESIDENT. REVIEW OF THE PERSONNEL RECORDS ON 7/29/11, REFLECTED THE NURSE AIDE "V" HAD BEEN EMPLOYED AT THE FACILITY SINCE 2006 AND HAD AN COMPETENCY PERFORMANCE EVALUATION ANNUALLY. NURSING NOTES DATED 5/25/11 REFLECTED RESIDENT #9 WAS "ON FLOOR IN THE BATHROOM @ 10:15 PM, HAS LACERATION ON RIGHT EYES AND FACE, SKIN TEAR ON RIGHT ELBOW. ASSESSED RESIDENT. CLEAN LACERATIONS ..." THE NURSES NOTES ON 5/25/11 ALSO REFLECTED RESIDENT #9 WAS SENT TO THE HOSPITAL LATER THAT DAY AT 11:00 PM. THE NURSING NOTES DATED 5/26/11 REFLECTED RESIDENT #9 RETURNED FROM THE HOSPITAL WITH ORDERS FOR RIGHT ELBOW AND ICE PACK TO FACE AS NEEDED FOR FACIAL FRACTURES.... SKIN assessed with [REDACTED]. THE NURSES NOTES DATED 6/12/11 REFLECTED "RESIDENT WAS NOTED ON FLOOR OF BEDROOM BACK AGAINST THE WALL SITTING ON FLOOR... DENIES HITTING HEAD." NURSES NOTES DATED 6/13/11 REFLECTED RESIDENT #9 WAS "FOUND ON THE BATHROOM FLOOR SITTING DOWN AT 7:20 PM." NURSING NOTES DATED 6/17/11 REFLECTED RESIDENT #9 "WAS LETHARGIC ON DAY SHIFT AND NEEDED TO BE FED WHICH WAS QUITE A CHANGE FOR HIM..." NURSING NOTES DATED 6/19/11 REFLECTED THAT RESIDENT #9 WAS "CONFUSED, REQUIRED 3 (STAFF) ASSIST TO GET INTO CHAIR. UNCOOPERATIVE WITH LIFT." NURSING NOTES DATED 7/5/11 REFLECTED HE HAS "HAD A DECLINE IN HIS ABILITY TO TRANSFER SELF. PRIOR TO 6/17/11 NEEDED MINIMAL ASSIST OF ONE WITH TRANSFER. ACCORDING TO THE PHYSICAL THERAPY EVALUATION DATED 7/7/11 AND SIGNED BY PHYSICIAN ON 7/13/11, REFLECTED THAT THIS "PT (PATIENT) IS A [AGE] year OLD MALE LTC (LONG TERM CARE) RESIDENT HERE...WHO RECENTLY HAD A DECLINE IN TRANSFER INDEPENDENT PER NURSING. PT (PATIENT) WAS PREVIOUSLY MINIMUM ASSIST X 1 FOR STAND-PIVOT TRANSFERS WHEELCHAIR TO BED WITH NURSING STAFF CURRENTLY PT (PATIENT) IS MAX A (MAXIMUM ASSIST) X 2 FOR SQUAT - PIVOT TRANSFERS WHEEL CHAIR, BED, DEMO (DEMONSTRATES) A SIG (SIGNIFICANT) DECLINE IN FUNCTION. PT.'S (PATIENT'S) LOWER EXTREMITY STRENGTH IS BELOW NORMAL, HOWEVER, IT IS ESSENTIALLY UNCHANGED FROM THE TIME PT. (PATIENT) WAS LAST ON THERAPY CASELOAD. PT (PATIENT) DOES HAVE SOME DECLINE IN SITTING BALANCE AND APPEARS TO HAVE AN INCREASED FEAR OF FALLING..." RESIDENT #9'S CARE PLANS TO PREVENT FALLS INCLUDED MULTIPLE DEVICES SUCH AS ALARMS, ALARMING SEAT BELTS AND THE EXPECTATION THAT HE WOULD USE HIS CALL LIGHT WHEN HE DEMONSTRATED REPEATEDLY THAT HE WOULD NOT USE THE CALL LIGHT WHEN HE NEEDED ASSISTANCE. THE FACILITY PLACED HIM CLOSER TO THE NURSES STATION AND NEAR THE NURSE IN THE MORNING, HOWEVER, THIS MINIMAL AMOUNT OF SUPERVISION WAS NOT ENOUGH TO PREVENT FURTHER FALLS. ( )