Every finding on record at Optalis Health & Rehabilitation at Leonard

Based on observation, interview, and record review the facility failed to ensure menus were consistently followed for 5 (Residents #26, 50, 55, 3, and 63) of 15 residents reviewed for dining and 9 of 11 residents from a confidential resident council meeting with the potential to affect all residents who consume food/beverages from the facility's kitchen resulting in dissatisfaction with meals, being provided incorrect foods, and/or being provided incorrect serving sizes with the potential for decreased oral intake and weight loss.Findings include:Resident #26: Review of Resident #26's diet order, dated 12/7/25, stated, Diabetic (condition that affects blood sugar levels) / Consistent Carb (carbohydrate) / Controlled Carb diet . (A consistent carbohydrate diet meal plan is one that aims to provide a consistent amount of carbohydrates at each meal.) Review of Resident #26's brief interview for mental status, dated 2/18/26, was scored 15 which reflected she was cognitively intact.During an interview on 04/07/2026 at 9:23 AM, Resident #26 reported her meal ticket (a meal ticket indicated the residents' diet order, what items to serve from the menu, and other information to guide meal service) wasn't followed consistently. During an observation and interview on 04/09/2026 at 8:32 AM, Resident #26 was served breakfast in her room. On Resident #26's meal tray was a meal ticket that indicated she was on a diabetic consistent carbohydrate diet and should have received 1/2 a banana, but she was served a full banana. Review of the facility's Menu Spreadsheets Report, for breakfast on 4/9/26, indicated a diabetic consistent carbohydrate diet was supposed to have received .1/2 banana 1 each and the regular diet (not carbohydrate controlled) was to receive a Banana 1 each (a full banana). Resident #50:Review of Resident #50's physician order page indicated she was readmitted to the facility on [DATE] with a primary diagnosis of pulmonary hypertension (condition that affects the blood vessels in the lungs) due to lung diseases. Her diet order, dated 6/3/25, stated, NAS (No Added Salt) diet, Regular texture, Thin consistencyReview of Resident #50's brief interview for mental status, dated 3/4/26, was scored 13 which reflected she was cognitively intact. Review of the facility's Menu Spreadsheets Report, dated 4/6/26-4/12/26, indicated .Sausage Link 2 each. should have been the serving size for Resident #50's breakfast on 4/8/26. During an observation and interview on 04/08/2026 at 8:21 AM, Resident #50 was seated upright in bed for breakfast in her room. Resident #50's meal ticket on the tray stated, .HOT.Sausage Link – 2 each. Resident #50's breakfast was served with only 1 sausage link and Resident #50 reported she wanted the full serving, 2 sausage links. Resident #50 reported it was irritating not knowing if her meals would be delivered with everything she was supposed to get. During an interview on 04/08/2026 at 10:09 AM, Registered Dietitian (RD) LL confirmed Resident #50 should have received two sausage links for breakfast on 4/8/26 as indicated on the menu and meal ticket. RD LL reported Resident #50 wasn't on small portions or any restriction that would have limited her to 1 sausage link. RD LL summarized the meal service process and reported one dietary aide on the tray line reads off pertinent information from residents' meal tickets to the cook plating the meal. RD LL confirmed if something was missed (Food/beverage item(s) given in error or item(s) left off the tray in error) it could have been due to a breakdown in communication between the two dietary staff. Resident #55:Review of Resident #55's diet order, dated 5/27/25, indicated he was to receive Regular diet, Regular texture, Thin consistency. Review of Resident #55's brief interview for mental status, dated 1/15/26, was scored 15 which reflected he was cognitively intact. Review of the facility's Menu Spreadsheets Report, dated 4/6/26-4/12/26, indicated .Sausage Link 2 each. should have been the serving size for Resident #55's breakfast on 4/8/26. During an observation and interview on 04/08/2026 at 8:40 AM, Resident #55 was lying in bed with his breakfast served to him on his bedside table. Resident #55 was served 1 sausage link on the plate/tray. During an observation and interview on 04/08/2026 at 10:47 AM, Resident #55 reported he only received one breakfast sausage for breakfast that morning, 4/8/26. Resident #55's meal consumption was observed to be approximately 100 percent. Resident #55 reported he wanted 2 sausage links and would have eaten 2 sausage links if they had been provided. Resident #55 reported his meals were served with inaccuracies approximately 60 percent of the time and felt dietary staff was not organized enough to strictly follow the meal ticket. During an interview on 04/08/2026 at 10:09 AM, Registered Dietitian (RD) LL confirmed Resident #55 should have received two sausage links for breakfast on 4/8/26 as indicated on the menu and meal ticket. RD LL reported Resident #55 wasn't on small portions or any restriction that would have limited him to 1 sausage link.Resident #3:Review of Resident #3's brief interview for mental status, dated 4/3/26, was scored 8 which reflected he had moderate cognitive impairment. During an observation and record review on 04/09/2026 at 12:06 PM, Resident #3 was eating lunch in his room. Resident #3's meal ticket on the tray indicated he was on a diabetic consistent carbohydrate diet with mechanical soft texture (designed to have soft and easy to chew foods for those with difficulty chewing and/or swallowing) and was to be served Lunch .HOT .Peas and Carrots. Resident #3 was served diced cooked carrots but there were no peas. At that time, the facility's menus were reviewed and the facility's Menu Spreadsheets Report, dated 4/6/26-4/12/26, indicated mechanical soft diets for lunch on 4/9/26 should have been served Guacamole 2 ounces. During an observation and interview on 04/09/2026 at 12:17 PM, RD LL reported she had approved a change of the menu yesterday (4/8/26) afternoon which was to serve peas and carrots instead of guacamole. In the kitchen on the tray line, there were two pans that contained carrots. One pan was mechanical soft carrots (diced cooked carrots) and the other was pureed carrots. Neither carrot dish had any peas in it and there was no separate pan of peas. [NAME] MM reported the facility only had carrots and didn't have any peas to prepare/serve. RD LL confirmed the menu for 4/9/26 for mechanical soft diets, such as for Resident #3, were supposed to have received peas and carrots, but only received carrots. RD LL reported the cooks were provided production sheets that reflected the change and it indicated to provide peas and carrots instead of guacamole. Resident #63: During an observation on 04/09/2026 at 12:40 PM, Resident #63 was served lunch in her room and her meal ticket indicated she was on a mechanical soft diet and should have received HOT .Peas and Carrots . Resident #63 was served only diced cooked carrots with no peas. During a confidential resident council interview on 04/08/2026 at 1:00 PM, 9 of 11 residents in attendance reported they didn't feel the menus were consistently followed and were bothered by this. The group reported dinner meals each day and weekend meals were the worst when it came to the menu not being followed. Review of the facility's Resident Council Meeting Minutes, dated 1/7/26, stated, .Discussion of Old Business .Area identified for Improvement .Kitchen running out of menu items. Review of the facility's Portion Control Policy, reviewed date 4/1/26, stated, .The clients/residents will receive the appropriate portions of food on the corporate menu. Control at the point of service is necessary to ensure that the standard portions of nutritionally adequate meals are served .The menu should list the specific portion size for each food item by using the menu calendar with portion sizes added or spreadsheets and be made accessible to the cooking staff . On 4/7/26 at 11:20 AM, a review of the lunch menu in the dining room found that residents were to have Lemon Chicken and [NAME] soup, Chili Dogs, Curly Fries, and [NAME] pudding. On 4/7/26 at 11:35 AM, an interview with Dietary Manager OO found that tickets are reviewed by staff while meals are plated and put on trays. The cook plating meals is told what the next meal is and then the plate is put together and reviewed by two staff on the tray line as they are adding drinks, desserts, and specialty items that the resident may request. A final review should happen from staff on the floor as they deliver the trays to residents. On 4/7/26 at 11:40 AM, observation of lunch service found that instead of curly fries, tater tots were being offered and instead of rice pudding, tapioca pudding was being offered. At this time, an interview with Dietary Manager (DM) OO found that they had extra potato and pudding products that they wanted to use up, and this was the reason for the slight menu change. On 4/7/26 at 11:41 AM, kitchen staff realized that part of the main lunch entrée of Lemon Chicken and [NAME] soup had not been prepared yet for residents on a puree diet texture. DM OO stated that staff will reheat tomato soup for those residents instead of pureeing the Lemon Chicken and [NAME] soup that is on the menu. On 4/7/26 at 3:30 PM, an interview with Registered Dietitian LL, regarding the use of tomato soup for puree residents for lunch, found that puree residents should receive the same menu items as regular texture diets.

Based on observation, interview, and record review the facility failed to ensure food preferences were consistently honored for 4 (Residents #26, 1, 24, and 50) of 15 residents reviewed for dining and 11 of 11 residents from a confidential resident council meeting resulting in dissatisfaction with meals and the potential for decreased oral intake and weight loss. Findings include:Resident #26:Review of Resident #26's brief interview for mental status, dated 2/18/26, was scored 15 which reflected she was cognitively intact.During an interview on 04/07/2026 at 9:23 AM, Resident #26 was in her room and reported her meal tickets (a meal ticket indicated the residents' diet order, food preferences and other information to guide meal service) weren't followed consistently.During an observation and interview on 04/08/2026 at 8:11 AM, Resident #26 was served breakfast in her room. Resident #26's meal ticket on the tray indicated under .MEAL PREFERENCES. to provide 6 ounces of coffee and 8 ounces of sugar free punch. Resident #26 did not receive either beverage and the only beverage served was milk which was used for the cold cereal served with the meal. Resident #26 proceeded to contact Certified Nurse Aide V and informed her that the meal was missing her two beverages and requested what she wanted to drink.Resident #1:Review of Resident #1's brief interview for mental status, dated 4/8/26, was scored 14 which reflected intact cognition.Review of Resident #1's diet order, dated 2/6/25, included Order .Regular diet .Directions .NO MILK. Review of Resident #1's nutrition care plan, dated 2/2/26, included interventions of Dislikes: Milk ., Food Intolerance: Lactose, and .No .snacks with milk for Snacks per (Resident #1's) request . During an interview on 04/07/2026 at 10:23 AM, Resident #1 reported he can't have any dairy (containing or made from milk or milk products) or any products that contain dairy because if consumed they could cause him to vomit and/or experience excessive stools (bowel movements). Resident #1 reported the facility served him items with dairy in error approximately 1 meal a day. Resident #1 expressed concern that the facility staff wasn't following his food preferences/meal ticket.During an observation and interview on 04/08/2026 at 8:01 AM, Resident #1 was served breakfast and eating independently in his room. Resident #1's meal ticket stated, Breakfast.COLD.Butter Pat - 1 each.ALLERGENS DAIRY Products Milk.MEAL PREFERENCES.Margarine Pat. Resident #1 was not served a margarine pat and instead was served salted butter which contained milk. Resident #1 reported he received the suitable margarine here and there (not consistently).During an interview on 04/08/2026 at 10:09 AM, Registered Dietitian LL reported the butter Resident #1 was served at breakfast on 04/08/2026 contained milk.During an observation on 04/09/2026 at 8:25 AM, Resident #1 was served breakfast in his room and he was eating independently. Resident #1's meal ticket stated, .MEAL PREFERENCES.Peanut Butter Packet - 1 each. There was no peanut butter packet served with the meal and Resident #1 confirmed he did not receive a peanut butter packet at the meal. Resident #1 appeared visibly frustrated and reported he has gotten used to not getting what he was supposed to.Resident #24:Review of Resident #24's brief interview for mental status, dated 3/20/26, was scored 14 which reflected she was cognitively intact.During an interview on 04/08/2026 at 8:15 AM, Resident #24's breakfast meal was served on her bedside table. The meal ticket on Resident #24's meal tray indicated to give COLD.Banana - 1 each. No banana was served with the meal.During an interview on 04/08/2026 at 10:26 AM, Resident #24 confirmed she never got a banana with her breakfast that morning. Resident #24 appeared frustrated and reported they (facility staff) didn't follow the ticket, so she didn't expect to receive the correct items anymore. Resident #50:Review of Resident #50's physician order page indicated she was readmitted to the facility on [DATE] with a primary diagnosis of pulmonary hypertension (condition that affects the blood vessels in the lungs) due to lung diseases. Her diet order, dated 6/3/25, stated, NAS (No Added Salt) diet, Regular texture, Thin consistency.Review of Resident #50's brief interview for mental status, dated 3/4/26, was scored 13 which reflected she was cognitively intact.During an observation and interview on 04/08/2026 at 8:21 AM, Resident #50 was seated upright in bed for breakfast in her room. Resident #50's meal ticket on the tray indicated she should have received cream of wheat, have no added salt, and been provided with 3 creamer packets and 4 sugar packets. Her meal was served with an added salt packet, and the cream of wheat was missing. Resident #50 reported she only received 1-2 packets of creamer and sugar and had to request and wait for more. Resident #50 reported it was irritating not knowing if her meals would be delivered with everything she was supposed to get and reported this occurred almost every day. During an observation on 04/09/2026 at 8:36 AM, Resident #50 was served and eating breakfast independently in her room. Resident #50's meal ticket indicated under .MEAL PREFERENCES. to give frosted flakes (sugar coated cold cereal) but instead was given circular O-shaped cold cereal instead. Resident #50 reported she wanted and preferred the frosted flakes. The meal ticket indicated not to give a salt packet, but a salt packet was provided on Resident #50's meal tray.During a confidential resident council interview on 04/08/2026 at 1:00 PM, 11 of 11 residents in attendance reported concerns about their meal ticket's food preferences not being followed. 5 out of the 11 residents reported they felt their food preferences not being honored were getting worse recently. One resident questioned why they even bother telling the facility their food dislikes and preferences if they weren't going to get followed. Another resident reported they felt like dietary staff didn't look at resident meal tickets and instead just gave them what they wanted to serve. Review of the facility's Resident Council Meeting Minutes, dated 1/7/26, stated, .Discussion of Old Business .Area identified for Improvement .No condiments on trays.Review of the facility's Resident Council Meeting Minutes, dated 2/11/26, stated, .Discussion of New Business .Dining Services .working with evening meal staff for consistency w/ (with) trays.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include: On 4/7/2026 at 9:15 AM, an initial tour of the kitchen was conducted with Dietary Manager (DM) O. An interview with DM OO found that he has been in the position for a couple of months.On 4/7/26 at 9:37 AM, observation of the can opener on the preparation table found that the blade was covered in dried red debris. When asked if the can opener had been used today, DM OO asked staff working the in the kitchen, and stated no. On 4/7/26 at 9:43 AM, observation of the underside of the juice machine found accumulations of debris where the spouts are mounted to the unit. DM OO agreed he could see the accumulation on the underside of the machine and stated it should get cleaned daily. On 4/7/26 at 9:55 AM, observation of the clean utensils found one mechanical scoop with dried on food debris in the ladle portion of the scoop.On 4/7/26 at 10:00 AM, observation of the inside of the milk cooler found increased accumulation of white and yellow staining and debris on the bottom and sides of the cooler. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 4/7/26 at 12:20 PM, an interview with DM OO found that some items from lunch service might be saved if there is enough. When asked about the soup, DM OO looked at how much was still left on the steam table and stated it would probably be kept for another couple days.On 4/7/26 at 2:59 PM, a follow up tour of the kitchen found a 12-quart container of Lemon Chicken and [NAME] soup, left over from lunch, in the two-door reach in cooler with the lid ajar for venting. At this time, the temperature of the soup was 115F in the center of the container.On 4/7/26 at 3:02 PM, an interview with DM OO found that the soup was saved after lunch but was not exactly sure when it started cooling. When asked the time temperature frequency for proper cooling, DM OO stated it needed to get down to 41F but was unsure of how long the process could take. DM OO took a temperature of the product at this time and found it to be over 100F. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.

Based on observations, interview, and record review, the facility failed to ensure: 1.) facility staff's use of Personal Protective Equipment (PPE) for enhanced barrier and transmission based precautions, 2.) cleaning of shared resident equipment, and 3.) cleaning of respiratory equipment for 5 (Residents #17, #30, #50, #39 and #5 ) of 24 resident reviewed for infection control practices, resulting in the potential for the introduction of infection, cross-contamination, and disease transmission.Findings include:Enhanced Barrier Precautions Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and chronic pain syndrome. Review of Resident #39's Care Plan revealed, (Resident #39) requires enhanced barrier precautions related to: Indwelling medical device. Date Initiated: 03/27/2026. Interventions: Staff will wear a gown and gloves during high contact resident activities. Date Initiated: 03/27/2026. During an observation on 4/09/2026 at 8:14 AM, Licensed Practical Nurse (LPN) G entered Resident #39's room and assisted Resident #39 with repositioning in her bed. LPN G then placed a blood pressure cuff on Resident #39's arm and assessed Resident #39's blood pressure. Noted that LPN G was not wearing a gown or gloves when providing care to Resident #39. After LPN G exited Resident #39's room, she placed the blood pressure cuff that she used on her medication cart. It was noted that LPN G did not clean the blood pressure cuff after she used it on Resident #39. Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer, unstageable (a full thickness wound where the actual depth cannot be determined because it is covered by dead tissue.) Review of Resident #5's Care Plan revealed, Focus: (Resident #5) has a Stage 3 pressure ulcer to her right shoulder. Date Initiated: 03/26/2026. It was noted that there were no interventions related to Enhanced Barrier Precautions. During an observation on 4/8/2026 at 8:49 AM, Unit Manager (UM) I and Wound Care Nurse Practitioner (WCNP) E entered Resident #5's room. UM I removed Resident #5's wound dressing and began to clean the wound on Resident #5's shoulder. UM I reported to WCNP E that the drainage from Resident #5's wound looked much better. After UM I cleaned Resident #5's wound, WCNP E measured and took photos of Resident #5's wound. After WCNP E took photos of Resident #5's wound, UM I applied a new dressing. It was noted that UM I and WCNP E did not wear gowns during the wound care treatment for Resident #5. During an interview on 4/8/2026 at 2:19 PM, UM I reported that the facility had not initiated Enhanced Barrier Precautions for Resident #5 because the drainage coming from Resident #5's wound was not a type of drainage that would require precautions. UM I confirmed that Resident #5 did have an open wound. Resident #17 Review of an admission Record revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses that included: unspecified disorders of the lung and unspecified asthma (chronic incurable inflammatory disease of the airways that causes breathing difficulties such as wheezing and coughing). Review of a Minimum Data Set (MDS) assessment for Resident #17 with a reference date of 3/6/26, 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 #17 with a reference date of 3/31/26 revealed the following focus/goal/interventions: Focus: Actual infection of COVID 19(coronavirus disease 2019) .Goal: Resident will have no adverse outcomes r/t (related to) current infection. Interventions: Isolate r/t active COVID 19 Infection: Maintain airborne and contact precautions while using proper PPE including: N95, goggles or face shield, gown and gloves.wear PPE per facility protocol. During an observation on 4/7/26 at 1:20pm, signage on Resident #17's door stated Airborne Precautions.Put on a fit-tested N-95 or higher-level respirator before room entry.door to room must remain closed.Sequence for putting on PPE.1. Gown. 2. Mask 3. Goggles or Face Shield. 4. Gloves. During an observation on 4/7/26 at 1:24pm, housekeeper (HSK) II entered Resident #17's room without donning googles. HSK II's cart was parked in the middle of the hallway. HSK II walked out of Resident #17's room several times while wearing the same gown, gloves and N-95 mask, retrieved supplies from her cart and then returned to the room. The room door remained open throughout the time HSK II cleaned the room. At one point, HSK II exited Resident #17's room, removed her soiled gloves, retrieved supplies from her cart with her unwashed hands, then donned (put on) new gloves without washing her hands, before re-entering the room. During an observation on 4/8/26 at 9:57am, Licensed Practical Nurse (LPN) BB donned PPE, excluding googles or a face shield, and entered Resident #17's room with the portable vitals monitor. LPN BB then exited the room at 10:00am as she pushed the portable vitals monitor. LPN BB doffed (removed) her PPE and pushed the vitals monitor down hall. LPN BB parked the vitals monitor near the medication cart. During an observation on 4/8/26 from 10:00am-10:36am, the soiled portable vitals monitor sat unattended in the 200 hallway. During an observation on 4/8/26 at 10:48am, LPN BB used the portable vitals monitor on a resident in room [ROOM NUMBER]. After taking the resident's vital signs, LPN BB exited the room with the vitals monitor, sanitized her hands and parked the soiled vitals monitor next to medication cart again. LPN BB then walked away. In an interview on 4/8/26 at 10:58am, Certified Nursing Assistant (CNA) V reported all staff who entered an isolation room should wear the PPE that was posted on the door. CNA VV confirmed staff should wear gown, gloves, N95 mask and googles or a face shield when entering Resident #17's room. CNA V reported staff were expected to use disposable equipment or equipment already in the room to monitor Resident #17's vital signs, rather than taking the portable vitals monitor that was shared with other residents. In an interview on 4/8/26 at 11:32am, Housekeeping Manager (HM) GG reported all staff should wear a gown, gloves, N95 mask and goggles or a face shield when entering Resident #17's room. HM GG reported the housekeeping staff should take all the supplies they needed with them when they entered the room to clean, rather than going back and forth to their cart. HM GG reported the door to the room should remained closed while the housekeeper cleaned. In an interview on 4/9/26 at 10:10am, Infection Preventionist (IP) I reported staff were expected to use disposable stethoscopes and equipment assigned specifically to Resident #17 to monitor her vital signs, not the portable vitals tower that was used for everyone else on the hall. IP I reported any equipment used for Resident #17 should immediately be disinfected and left to sit and dry for 2 minutes before using it for anyone else. When further queried, IP I reported staff were expected to immediately clean all shared equipment after use and then return the equipment to the hallway. IP I reported staff understood that if equipment was in the hallway, that meant it has been cleaned and was ready for use again. IP I reported all staff were expected to wear a gown, gloves, N-95 mask and goggles or a face shield when entering Resident #17's room. When queried about the procedure the housekeeping staff should follow when cleaning Resident #17's room, IP I reported they should follow the whatever protocol HM GG recommended. Review of a Covid-19 policy with a reference date of 2/3/26 revealed Policy Overview: To establish a facility wide-system for the prevention.and control practices designed to minimize transmission of Covid-19.Covid-19 PPE Usage.N95 masks, eye protection, gown, and gloves should be worn.during care of a resident in transmission based precautions for confirmed or suspected Covid-19. Review of the facility's Enhanced Barrier Precautions policy dated 2/6/26 revealed Policy Overview: The purpose of this policy is to provide guidelines for the use of enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). General Guidelines: Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions involve gown and glove use during high-contact resident activities for residents known to be colonized with a CDC targeted MDRO (where contact precautions do not apply) as well as those residents at increased risk of MDRO acquisition, such as chronic wounds or indwelling medical devices . Wounds: Wound - in relation to enhanced barrier precautions wound does not include shorter-lasting open wounds such as scratches, abrasions, skin tears, etc. covered with a band aid or similar dressing. It refers to more chronic wounds with skin opening(s) that require a dressing including but not limited to; Stage 3/ 4, or unstageable pressure injuries . High contact resident activities include (for all residents on Enhanced Barrier Precautions): dressing, bathing/showering, transferring, providing hygiene . wound care: any skin opening requiring a dressing . Oxygen Concentrator R30 According to the MDS dated [DATE], R30 scored 13/15 on his BIMS, indicating he was cognitively intact. R30 was dependent on staff for ADLs (activities of daily living). Diagnoses included stroke, traumatic brain injury, and a trachea-esophageal fistula following a tracheostomy (a rare but serious complication involving an abnormal connection between the trachea and esophagus). During an observation and interview on 4/8/26 at 9:08 AM, R30 was awake in bed. Next to the bed was an oxygen concentrator (a medical device that provides supplemental oxygen to people with breathing disorders by filtering and concentrating oxygen from the surrounding air) running a 2 lpm (liters per minute). R30 was wearing a nasal cannula (NC) that was connected to the oxygen concentrator via clear tubing dated 4/5 (Sunday). The oxygen concentrator was covered with splatters of multi-colored dried substances, and accumulation of dirt, dust, and debris including substances that resembled food crumbs. Observations 4/9/26 at 9:30 AM, R30 in bed wearing an NC attached to an oxygen concentrator via tubing dated 4/5. Oxygen was running at 2 lpm. The oxygen concentrator was covered with splatters of multi-colored dried substances, and accumulation of dirt, dust, and debris including substances that resembled food crumbs. During an observation and interview on 4/9/26 at 11:40 AM, Facility Respiratory Therapist FF stated, (Name of respiratory equipment supply company) is responsible for keeping oxygen concentrators clean and wiping them down weekly. I am here at the facility on Tuesday and Thursday each week. I change oxygen tubing weekly. Last week, I saw how dirty (R30's) oxygen concentrator was and sent the (respiratory equipment supply company) a picture of (R30s) oxygen concentrator. The condition of (R30's)the oxygen concentrator was unacceptable. The concentrator was dirty and had dribbles of a dried substance. I can wipe down oxygen concentrators, but I did not wipe down (R30's) last week. The company replied they would be out by the end of the day (Thursday 4/2/26). I did not tell any facility staff about (R30's) oxygen concentrator nor did I follow up on it when I was here this week on Tuesday. During an observation and interview on 4/9/26 at 11:45 AM, Director of Nursing (DON) B stated while observing R30's oxygen concentrator. Anyone can wipe down and clean equipment they see is dirty, including the facility respiratory therapist. You don't tell someone else to do something you can do. The concentrator should have been cleaned right when it was found to be dirty for infection control reasons. Yes, (R30's) oxygen concentrator is dirty and it should have been cleaned right away. Resident #50: Review of Resident #50's physician orders, included Bilevel positive airway pressure (BiPAP; device used to assist with breathing) to be used at night, dated 3/20/26, and Clean BIPAP per policy.every day shift every Thu (Thursday), dated 3/5/26. Review of Resident #50's oxygen care plan, dated 3/12/26, stated, (Resident #50) has oxygen therapy r/t (related to) COPD (Chronic Obstructive Pulmonary Disease; breathing-related problems), chronic hypoxic respiratory failure (insufficient oxygen levels), with hypercapnia (undesirable high levels of carbon dioxide in the blood) & pulmonary edema (too much fluid in the lungs) . The care plan included an intervention, dated 3/12/26, that indicated the BiPAP was to be used each night. Review of Resident #50's brief interview for mental status, dated 3/4/26, was scored 13 which reflected she was cognitively intact. During an observation and interview on 04/07/2026 at 10:41 AM, Resident #50's BiPAP machine's tubing and face mask were draped over the bedside oxygen concentrator and resting directly on the floor. The BiPAP machine was placed past the head of the bed out of the resident's reach and in the corner of the room on a nightstand. There was an empty clear plastic equipment storage bag attached to the BiPAP machine. Resident #50 was lying in her bed and reported she could not reach her BiPAP machine or face mask and staff were needed to help her put on and take off the mask. The mask was visibly soiled with unknown white debris/build up and some red flakes. Resident #50 reported Respiratory Therapist (RT) FF took care of her BiPAP equipment. During an observation on 04/07/2026 at 2:33 PM, Resident #50's BiPAP mask was in the clear plastic storage bag attached to the BiPAP machine in the corner of the room. The mask appeared visibly soiled as it had been on 04/07/2026 at 10:41 AM. During an observation and interview on 04/07/2026 at 4:01 PM, Resident #50 was lying in bed, her BiPAP mask was in the storage bag attached to the BiPAP machine, and the mask in the bag was still visibly soiled with white and red debris. Resident #50 confirmed she did not put the dirty BiPAP face mask back into the storage bag and confirmed it would have been staff who would have done it. During an observation and interview on 04/08/2026 at 7:55 AM, Resident #50's BiPAP mask was in the clear plastic storage bag attached to the BiPAP machine. The mask remained visibly soiled and presented with the white and red debris on the mask as it was observed the day prior, 04/07/2026. Resident #50 confirmed she used her BiPAP machine the night of 04/07/2026. During an observation and interview on 04/09/2026 at 8:01 AM, Resident #50 was awake in bed and her BiPAP face mask was in the clear storage bag attached to the BiPAP machine in the corner of the room. The mask remained visibly soiled with white and red debris as had been observed on 04/07/2026 and 04/08/2026. Resident #50 confirmed she used her BiPAP machine the night of 04/08/2026. During an interview on 04/09/2026 at 8:11 AM, Licensed Practical Nurse X reported it was her understanding that BiPAP face masks would be cleaned daily and not cleaned only once a week. During an interview on 04/09/2026 at 1:29 PM, RT FF reported BiPAP and CPAP (Continuous Positive Airway Pressure; device used to assist with breathing) machines were sterilized by her on Thursdays. RT FF confirmed if a BiPAP or CPAP face mask was visibly soiled before the scheduled cleaning it should be cleaned.

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 1(Resident #39) of 24 residents reviewed for reviewed for dignity and respect ; and 6 of 11 residents from the confidential group meeting resulting in unmet care needs and the potential for feelings of diminished self-worth, sadness, and frustration. 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 muscle weakness and chronic pain syndrome (a persistent, long-term pain condition lasting 3–6 months or more, often continuing after an initial injury has healed). Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 3/10/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #39 was cognitively intact. Review of Resident #39's Care Plan revealed, Focus: (Resident #39) has ADL self-care deficit related to (r/t) impaired mobility . Date initiated: 1/11/26. Interventions: ADL (Activities of Daily Living) assist of 2 staff. Date initiated: 3/27/26 . Review of Resident #39's Behavior Tracking Log indicated that No behaviors were observed for Resident #39 (including accusing of others) in April 2026, and one behavior of accusing of others was documented in March 2026. During an observation on 4/8/2026 at 7:55 AM, Resident #39 was calling out for help from her bed. Director of Nursing (DON) B entered Resident #39's room and told Resident #39 she would get someone to come help her. DON B then exited Resident #39's room. It was noted that Resident #39's call light was not on as DON B exited her room. DON B continued down the hallway and did not ask the Licensed Practical Nurse (LPN) or Certified Nursing Assistant (CNA) on the hall to assist Resident #39. At 8:07 AM, Resident #39 began yelling out for help again. It was noted that LPN G remained in the hallway near Resident #39's room but did not check on Resident #39 when she was yelling out for help. During an observation at 8:10 AM, this writer entered Resident #39's room. Resident #39 was lying in her bed on her back and leaning over the right side of her bed near her tray table. It noted that Resident #39's call light was on the ground under her bed and out of her reach. Resident #39 reported that she was yelling out for help because she did not have her call light. Resident #39 reported that she had asked DON B for assistance to get straightened up in bed and that DON B had told her that she would get someone to help her. During an interview on 4/8/2026 at 8:13 AM, LPN G reported that she was aware that Resident #39 had been yelling out for assistance and stated, that is just (Resident #39), sometimes she yells out for help, and sometimes she uses her call light. Noted that LPN G did not go assist Resident #39. During an interview on 4/8/26 at 8:57 AM, Resident #39 reported she felt like some of the staff at the facility did not care for her or want to take care of her because she was high maintenance. This writer queried as to what Resident #39 about what her belief of high maintenance, Resident #39 reported she required two staff members to assist her with ADL care, so she required more time from staff. Resident #39 reported staff would often turn her call light off and tell her that they would be back but would not always return to assist with her needs. Resident #39 reported it was also common for staff to forget to give her a call light, so she would have to yell out for help. During an observation on 4/9/2026 at 8:23 AM, Resident #39 was yelling out for help. LPN G entered Resident #39's room and Resident #39 reported that she had spilled a cup of water. Noted that there was water on the floor surrounding Resident #39's bed. LPN G told Resident #39 that she would turn on Resident #39's call light to have someone come clean up the spilled water. LPN G then exited Resident #39's room. During an observation on 4/9/26 at 8:33 AM, LPN G returned to Resident #39's room to administer medications to Resident #39. It was noted that Resident #39's call light was off, but the water on the floor in her room had not yet been cleaned up. Resident #39 queried LPN G about her floor being cleaned up, and LPN G reported staff would be in to take care of it. LPN G then exited Resident #39's room. Noted that Resident #39's call light remaimed off. During an interview on 4/9/2026 at 11:46 AM, CNA D reported the facility staff would often turn off call lights without addressing the resident's needs. CNA D reported that she had residents voice concerns to her about their needs not being met and having to turn their call lights back on. CNA D reported this was something that she had reported to management. CNA D reported she knew residents had complained to others about this. CNA D confirmed that Resident #39 had voiced concerns to staff about staff turning off her call light without addressing her care needs. During an interview on 4/9/26 at 12:30 PM, Unit Manager (UM) I reported that she was aware that residents had voiced concerns about staff turning off their call lights without addressing the resident's need. UM I reported that the facility had been working on educating staff to ensure that they are not turning off call lights without assisting residents first. During an interview on 4/9/2026 at 12:48 PM, DON B reported that she was aware that residents had voiced concerns about staff turning off call lights without addressing the resident's needs, and staff reporting that they would be back and not returning timely. DON B reported her expectation for when staff turned off a call light before meeting a resident need would depend on what the request was. Review of the facility's Dignity policy dated 2/3/26 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 . Review of the facility's Call Light policy dated 2/2/26 revealed, Policy Overview: The purpose of this policy is to assure that the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response . Process: . turn off call light when resident's request is met. During a confidential resident council interview on 04/08/2026 at 1:00 PM, 6 of 11 residents in attendance reported a concern that at times staff would turn off their call lights, tell them they'd come back to complete the care need being requested, staff wouldn't return, they'd have to put their call light back on, and have to wait for staff to respond to their call light/care need request again.Review of the facility's Resident Council Meeting Minutes, dated 3/4/26, stated, .Discussion of New Business .Nursing .(2 Confidential Resident Council Attendees/Residents were listed as having the concern) - call light concerns, turn off light, need not met. Review of the facility's Resident Council Meeting Minutes, dated 2/11/26, stated, .Discussion of New Business .Nursing .(3 Confidential Resident Council Attendees/Residents were listed as having the concern) - aid (Certified Nurse Aide) comes in and turns off call light and leaves, eventually come back.

Based on observation, interview and record review, the facility failed to honor resident preferences for customary routines and activities for 1 (Resident #39) of 24 reviewed for self-determination resulting in feelings of frustration and the potential for diminished quality of life.Findings include:Resident #39Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and chronic pain syndrome. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 3/10/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #39 was cognitively intact. Review of Resident #39's Care Plan revealed, Focus: (Resident #39) has ADL self-care deficit related to (r/t) impaired mobility . Date initiated: 1/11/26. Interventions: ADL (Activities of Daily Living) assist of 2 staff. Date initiated: 3/27/26 . Focus: (Resident #39) needs assistance for meeting emotional, intellectual, physical, and social needs r/t Physical Limitations r/t weakness- needs assistance in w/c (wheelchair). Date Initiated: 03/27/2026. Goal; The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Date Initiated: 03/27/2026. Interventions: The resident needs assistance/escort to activity functions. Date Initiated: 03/27/2026.During an interview on 4/8/2026 at 8:57 AM, Resident #39 reported she felt like some of the staff at the facility did not care for her or want to take care for her because she was high maintenance. This writer queried as to what Resident #39 about her belief of high maintenance, Resident #39 reported she required two staff members to assist her with ADL care, so she required more time from staff. Resident #39 reported she liked to eat breakfast in her room and then get up for the day so she could attend morning activities at the facility which usually started at 10:00 AM. Resident #39 reported that she often was not able to get up until 10:00 AM- 12:00 PM. Resident #39 reported that she thought the staff would wait to complete her care last because she required two staff members to assist her. In an observation on 4/8/26 at 10:16 AM, staff entered Resident #39's room to assist her with her morning care. During an interview on 4/9/2026 at 11:16 AM, Certified Nursing Assistant (CNA) V' reported that staffing for the CNA's at the facility had been difficult lately, and when the facility had call ins, it was much harder to get residents up at their preferred times, especially if the resident required two person staff assistance. CNA V confirmed that Resident #39 preferred to get up for the day after she ate breakfast, but she did have to wait until lunch time often. During an interview on 4/9/2026 at 11:35, Licensed Practical Nurse (LPN) G confirmed Resident #39 liked to get up for the day after she ate breakfast, and that staff were not always able to get Resident #39 up when she requested. LPN G reported she was aware that Resident #39 had voiced concerns about not getting up at the time of day she preferred and stated (Resident #39) is very persistent, she gets very upset when we cannot get her up when she wants to get up. During an interview on 4/9/2026 at 12:01 PM, CNA D reported she was aware that Resident #39 liked to get up in the morning after she ate breakfast so that she could attend the morning activities at the facility. CNA D confirmed that staff were not usually able to get Resident #39 up until later in the morning or afternoon because she required two-person assistance, and the facility did not always have the staff to accommodate this. CNA D reported that the staff were supposed to pick up breakfast trays before they got residents up, and that was time consuming, and often delayed resident care as well. During an interview on 4/9/2026 at 10:15 AM, CNA R reported she frequently cared for Resident #39 and she was aware that Resident #39 liked to get up for the day after she had breakfast. CNA R reported that it was common for Resident #39 to have to wait to get up for the day after her preferred time, and sometimes she did have to wait until lunch time (12:00 PM). During an interview on 4/9/2026 at 10:24 AM, CNA NN reported she frequently cared for Resident #39 and was aware that she preferred to get up for the day after breakfast. CNA NN reported that this was difficult for staff to accommodate because Resident #39 required two-person assistance, as did several other residents on the unit, and Resident # had to wait until between 10:00 am and 12:00 PM to get up for the day. CNA NN reported there were other residents on the same unit as Resident #39 that had to get up to attend dialysis (medical treatment that removes waste, toxins, and excess fluid from the blood when the kidneys are unable to perform this function) appointments, and on the days when those residents needed to get ready for dialysis, they were not able to get Resident #39 up until after they helped the other residents, so Resident #39 typically would get up later than she preferred on the days when other residents on the unit had to attend dialysis. Review of Resident #39's Psychiatry Note dated 3/5/26 at 9:51AM revealed, . (Resident #39) is waiting to get up with the aide and states that she feels like they are too slow. She did notify her aide but was told they must pick up food trays first During an interview on 4/9/26 at 12:30 PM, Unit Manager (UM) I reported she was aware of Resident #39's ongoing concern about not being able to get up in the morning at the time she preferred. UM I reported that because Resident #39 required two-person assistance, staff had to prioritize and find a middle ground to accommodate all residents on the unit, because other residents were expressing concerns that they had to wait to get up too. UM I reported Resident #39 was typically not getting up once or twice a week due to staffing and the need to prioritize other residents. During an interview on 4/9/2026 at 12:48 PM, Director of Nursing (DON) B reported she was aware that Resident #39 had voiced concerns about not being able to get up for the day at her preferred time. DON B reported that she felt that Resident #39's preferences varied based on her cognition, but that she felt that staff were typically able to accommodate her request to up when she wanted to.During an interview on 4/9/2026 at 2:16 PM, Activity Director (AD) E reported Resident #39 enjoyed attending morning activities at the facility. AD E confirmed that there were occasions where Resident #39 missed morning activities or got to the activity late because she was waiting for staff to get her up for the day.

Based on observation, interview and record review, the facility failed to ensure resident rooms were kept clean and in good repair for 3 (Resident #21, #22 and #30) of 24 Residents reviewed for home-like environment, resulting in emotional distress and a potential for increased risk of infection and/or injury.Findings include: Resident #21 Review of a Minimum Data Set (MDS) assessment for Resident #21 with a reference date of 3/1/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section GG revealed Resident #21 was independent with self-propelling her wheelchair up to 50 feet. During an observation on 4/8/26 at 12:31pm, the walls in Resident #21 were noted to be in disrepair. Approximately 6 dime sized holes were noted in the walls of Resident #21's room, along with multiple areas of deep gouges and scraped off paint, including an area above the head of bed that contained sections 2x4 (inches) gouges in which the paint was scraped off, exposing the white drywall underneath. An area approximately 2'x3' (feet), to the right of Resident #21's sink in her room, was covered with deep scrapes, gouges, and peeling paint. The metal corner bead (piece of steel used for protecting and finishing external 90-degree corners) was exposed in several areas from the base of the floor to approximately 3'high. Resident #21 sat in her wheelchair near the exposed, rough metal corner bead that was at the same level as her lower leg. During an observation and interview on 4/7/26 at 10:47am, Resident #21 sat in her wheelchair in her room, the clothing she wore left her legs exposed and a bandage was noted on her right shin. Resident #21 reported she did not like condition of the walls in her room. When queried, Resident #21 reported the damaged walls in her room were depressing and she wished her room was better maintained. Resident #21 reported she always wore clothing that left her legs exposed and her skin broke open easily, so she was concerned she could injure herself on the exposed metal corner near her sink. Resident #21 confirmed she usually sat in the same spot in her room. During a tour of the facility on 4/7/26 at 9:21am the shared bathroom between rooms [ROOM NUMBERS] was noted to have dried drops of brown liquid scattered across 6 wall tiles, behind the base of the toilet. There was a strong smell of urine in the bathroom. Thick brown buildup was present on the sealant around the base of the toilet. During a tour of the facility on 4/8/26 at 12:28pm, in the shared bathroom between rooms [ROOM NUMBERS], the tiles behind the base of the toilet remained soiled, 10 dried drops of a brown substance were noted on the tiles. Thick brown buildup was present on the sealant around the base of the toilet. In an interview on 4/8/26 at 11:32am Housekeeping Manager (HM) GG confirmed the resident bathrooms should be cleaned daily. Resident #22:Review of Resident #22's brief interview for mental status score, dated 3/18/26, was scored 7 which indicated severe cognitive impairment. During an observation and interview on 04/07/2026 at 4:27 PM, Resident #22 was in his room in his bed. Resident #22 was confused and unable to answer questions about the state of his wall. The wall that the head of the bed was closest to had approximately 10 areas of gouges and/or missing paint. The areas of disrepair on the wall ranged in size from thin scratches to an area of missing paint that measured approximately 8 inches long by half an inch wide. During an observation on 04/09/2026 at 7:55 AM, Resident #22's wall in disrepair presented the same way it did on 04/07/2026 at 4:27 PM. Applying the reasonable person concept, an individual would want their living environment to be maintained in good repair and likely would have feelings of discontent if it was not maintained in such a manner. Resident #30 (R30) According to the MDS dated [DATE], R30 was cognitively intact as evidenced by a BIMS score of 13/15. During an observation and interview on 4/8/26 at 9:00 AM, R30 was awake in bed. It was difficult to get next to R30's bed due to a high-backed wheelchair, oxygen concentrator, bedside table and visitors straight chair lined up to the right of the resident's bed. The left side of R30's bed was against the wall. The wall was gouged with peeling and missing paint. R30 said, That doesn't look good. I'd like it painted. During an observation and interview on 4/8/26 at 9:08 AM, R30 was awake in bed. On the wall to the left of R30 were multiples gouges with peeling/missing paint. Maintenance Q observed R30's wall, stating, Yes, I know that wall needs repair. When (R30's) head of bed was there, it would gouge up the wall when staff moved the bed around. Even though the paint I use to paint resident rooms is low fumes, I don't like to paint when the residents are in the room. I know there are other rooms that need to be painted too, but I can only do so much. During an interview on 4/8/26 at 3:50 PM, Guardian CC stated, (R30's) room does have missing paint on the wall right by his bed. It does not look nice. I would expect it to be taken care of. During an observation and interview on 4/9/26 at 10:15 AM, Maintenance L stated while observing R30's bed area, The rooms in this building are small. Beds get smashed into walls when staff move them to care for residents. If I put a wider bed in (R30's) room, it will take up more room and gouge up the wall on two sides of the room. I don't like how nursing has the bed positioned in here now (left side of bed against wall). Staff ram the beds into the walls when having to do cares and staff really don't have room here to do that. I have enough to paint now. During an observation and interview on 4/9/26 at 11:45 am, Director of Nursing (DON) B stated while observing R30's bed area, The walls are gouged up. The walls may get scratched up, but maintenance can fix them. During a tour of the facility on 4/7/26, rooms 301 (beds 1 and 2), 302 (beds 1 and 2), and 304 (beds 1 and 2), multiple gouges and scratches in the walls by the head of the bed (HOB) with peeling and mission paint. On 4/7/26 at 1:43 PM, observation of the 100-hall spa, with Maintenance Director L and Housekeeping Manager (HM) GG, found multiple wet washcloths on the dry floor of the shower and resident's dirty clothes to the side and under the sink. An interview with HM GG found that her staff would come in daily to sweep and mop the room, take out trash and clean surfaces, but typically Nursing would clean and tidy up shower rooms as needed between residents. On 4/7/26 at 2:21 PM, observation underneath the mattress of the shower bed in the 300-spa room, found accumulations of dirt and debris from previous residents, including wet pieces of paper and trash, pieces of plastic debris, a small metal spring, a studded diamond looking [NAME], and a nickel coin.

Based on interview and record review, the facility failed to ensure proper discharge notifications were completed in 1(Resident #39) of 2 residents reviewed for discharge process, resulting in Resident #39 not receiving written notice of bed hold when she was discharged from the facility to the hospital. Findings include:Resident #39Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and chronic pain syndrome. Review of Resident #39's Electronic Medical Record (EMR) revealed that Resident was transferred to the hospital on 1/16/26. This writer was unable to locate documentation of written notice of bed hold for Resident #39's transfer on 1/16/26. This writer requested documentation of written notice of bed hold for Resident #39's transfer on 1/16/26 via email to Nursing Home Administrator (NHA) A on 4/8/26 at 4:20 PM. During an interview on 4/8/2026 at 4:27 PM, NHA A and Director of Nursing (DON) B reported that the nurse caring for Resident #39 on 1/16/26 had not given Resident #39 written notice of a bed hold transfer. The facility was granted a Past Non-Compliance at the time of exit due to the facility's identification of the failure to provide a written notice of bed hold, verification of re-education for the nursing staff, and the clarification Admissions Coordinator's responsibility to initiate contact with the hospital and/or responsible party within 24 hours of transfer. The resident census was reviewed to ensure that all residents who had been transferred to the hospital had documented evidence of written notice of bed hold notification and appropriate follow-up communication. Any missing documentation was immediately reconciled. The facility reviewed their Bed Hold Policy to clearly outline staff responsibilities, including nursing's requirement to provide and document written notice of bed hold rights at the time of transfer, and Admissions Coordinator's responsibility to contact the hospital or responsible party within 24 hours and continue communication throughout the hospitalization. A standardized Bed Hold Notification form and Hospital Transfer Checklist were posted at the nurse's station.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration that included administration and monitoring of a narcotic medication by a licensed professional in 1 (Resident #20) of 5 residents reviewed for medication administration, resulting in the potential for narcotic diversion, unrelieved pain, and the worsening of medical conditions. Findings include: Resident #20Review of an admission Record revealed Resident # 20 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia (diagnosis used when cognitive decline, memory loss, and functional impairment are present, but the specific type (e.g., Alzheimer's, vascular) cannot be determined. Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 2/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #20 was severely cognitively impaired. Review of Resident #20's Care Plan revealed, Focus: (Resident#20) has a behavior concern r/t (related to) dementia with behavioral disturbances. Date Initiated: 01/27/2026. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness, explain all procedures to the resident before starting and allow the resident time to adjust before proceeding. Date initiated: 1/27/26 .Review of Resident #20's Medication Administration Record (MAR) revealed, Order: Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Milligrams/Milliters) . Give 0.25 ml by mouth three times a day for chronic pain. Start date: 4/6/26.During a medication administration observation on 4/9/2026 at 8:14 AM, Licensed Practical Nurse (LPN) G prepared a syringe with 0.25 mL (milliliters) of Morphine for Resident #20 and then placed the syringe of morphine in an 8-ounce cup of cranberry juice. LPN G reported Resident #20 refused her medications, so the facility had obtained an order from her hospice (specialized, compassionate care for individuals with terminal illnesses, focusing on comfort, pain management, and quality of life rather than curing the disease) provider to administer her morphine in juice. LPN G then took the cup of cranberry juice and placed the cup on Resident #20's breakfast tray which was sitting on the cart of meal trays that were being passed out to residents on the unit. When this writer queried LPN G about why she was not taking Resident #20's medication to her room to administer to her, LPN G reported she could not give Resident #21 the juice, because Resident #20 would not take medications from her. When this writer queried LPN G how she was able to determine that Resident #20 had received all of her medication, and that the medication was not given to someone else, LPN G reported the CNA's on her unit knew that she put Resident #20's morphine in her juice, and that she stayed near her room when she had the medication. LPN G then marked the morphine as administered in Resident #20's MAR and began to prepare medications for another resident. This writer noted that LPN G left her medication cart which was parked outside of Resident #20's room to administer medications to another resident. It was noted that LPN G continued on with passing medications to several other residents as Certified Nursing Assistant (CNA) R delivered Resident #20's meal tray to her. During the time that Resident #20 was eating her breakfast and drinking her juice in her room, LPN G was out of view of Resident #20 as she entered five different resident rooms to administer medications to other residents. When this writer queried LPN G as to how she was able to ensure that Resident #20 was drinking her juice that had the narcotic in it as she continued to enter other resident rooms, LPN G reported she knew how to keep her eyes on Resident #20. LPN G then entered Resident #20's room with this writer, it was noted that CNA R had already removed Resident #20's breakfast tray and juice cup which had the morphine in it. LPN G told this writer, See, she already drank it all. When this writer queried as to where the order was that indicated that Resident #20 could have morphine administered in her juice, LPN G reported that she did not know where it was, but she knew it was an order. During an interview on 4/9/2026 at 10:15 AM, CNA R confirmed that she was aware that Resident #20 had been receiving some kind of medicine in her cranberry juice in the morning. CNA R confirmed that she saw Resident #20 drink all of the cranberry juice because she was in Resident #20's room assisting her roommate with eating. CNA R confirmed that she removed Resident #20's cup of cranberry juice before LPN G had come in to check on Resident #20. CNA R reported that she knew that if Resident #20 didn't drink all of her juice in the morning, she would leave it on her tray table to drink at lunch. (Noted that Resident #20's morphine order was scheduled for three times a day, and she was scheduled to receive her next dose of morphine at 1:00 PM). During an interview on 4/9/2026 at 10:24 AM, CNA NN reported that she was aware that Resident #20 was getting medication in her juice cup. CNA NN reported that sometimes nursing staff would put Resident #20's morphine in milk, which she didn't really like, so she would not usually drink all of the milk. During an interview on 4/9/2026 at 11:16 AM, CNA V reported that she often cared for Resident #20 and she had no clue that nurses were putting medications in her drinks, and that was not communicated to her from the nursing staff at the facility.During an interview on 4/9/2026 12:26 PM, Unit Manager (UM) I reported she was aware that LPN G had been placing Resident #20's morphine in juice, but she did not know what her process was for ensuring that Resident #20 was being supervised during medication administration. UM I reported that Resident #20 had not been assessed to self-administer medications, and that nurses were expected to follow the rights of medication administration. UM I reported nursing staff should were supposed to supervise residents as they were taking medications to ensure that they received the medications. During an interview on 4/9/2026 at 12:48 PM, Director of Nursing (DON) B reported she was not aware that nurses at the facility were administering Resident #20's morphine in cups of juice/milk. DON B reported that nurses were supposed to observe residents when they were administering their medications to ensure that they received the medication. Review of the facility's Standards of Practice policy dated 2/3/26 revealed, Policy Overview: Residents will receive services, treatments, and care in accordance with professional standards of practice . Review of the facility's Medication Administration policy dated 2/3/26 revealed, Policy Overview: To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs. General Instructions: Medications are administered in accordance with the following rights of medication administration: right resident, right medication, right dose, right route, right time and frequency, right documentation, right of resident to refuse, and right clinical indication .Administer medication: . remain with resident until administration of medication is complete .sign MAR after medication is administered .

Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care (provide showers and/or washing hair) for 2 (Residents #39 and Resident #21) of 4 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. 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 muscle weakness and chronic pain syndrome. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 3/10/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #39 was cognitively intact. Review of Resident #39's Care Plan revealed, Focus: (Resident #39) has ADL self-care deficit related to (r/t) impaired mobility . Date initiated: 1/11/26. Interventions: ADL (Activities of Daily Living) assist of 2 staff, assist to bath / shower as preferred per shower schedule and as needed, provide sponge bath when a full bath or shower cannot be tolerated. Dated initiated: 3/27/26 . During an interview on 4/8/2026 at 8:57 AM, Resident #39 reported she felt like some of the staff at the facility did not care for her or want to take care for her because she was high maintenance. This writer queried as to what Resident #39 about her definition of high maintenance, Resident #39 reported she required two staff members to assist her with ADL care, so she required more time from staff. Resident #39 reported she did not feel like she always received adequate ADL care, and she did miss showers/bed baths at times. Noted that Resident #39's hair was disheveled and greasy. During an interview on 4/9/2026 at 12:01 PM, Certified Nursing Assistant (CNA) D reported that when the facility had call ins, which happened often, CNAs could not provide care timely and adequate ADL care. CNA D reported residents who required longer times of assistance, did not get showers or bed baths when CNA staffing was less than 5 CNA on day and evening shift. CNA D confirmed that Resident #39 would be considered a resident that required a long shower and it would not be possible to complete a shower or bed bath for her if they facility had less than 5 CNAs on the floor. During an interview on 4/9/2026 at 10:24 AM, CNA NN reported that she frequently cared for Resident #39. CNA NN reported that this was difficult for staff to accommodate because Resident #39 required two-person assistance, so her care took more time for staff to complete. CNA NN reported that Resident #39's was missing showers regularly because they did not have the staff to take two staff members off the floor to assist her. Review of Resident #39's Bathing Task Documentation on 4/9/26 indicated that Resident #39 received one shower and one bed bath in April 2026. Resident #39 had one bed bath documented as completed in March 2026, and two refusals documented in March 2026. Resident #39 had one shower documented as completed in February 2026. Review of Resident #39's Shower Sheets revealed that Resident #39 received showers on 2/3/26 and 2/6/26, 2/20/26 and 4/3/26 and bed baths on 3/6/26, 3/29/26 and 4/7/26. During an interview on 4/9/2026 at 12:48 PM, Director of Nursing (DON) B reviewed Resident #39's bathing documentation and shower sheets with this writer and confirmed that the facility was missing documentation to verify that Resident #39 was receiving her scheduled twice weekly showers/baths or documentation of refusals. DON B reported CNA's were supposed to complete a shower sheet and document the shower/bath in the bathing tasks in the resident's electronic health record (EMR). DON B reported she was aware that the facility had issues ensuring all residents were receiving their scheduled showers/baths, and that the facility was working on it. Resident #21 Review of a Face Sheet revealed Resident #21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: adjustment disorder with depressed mood (stress related mental health condition characterized by significant sadness) and seborrheic dermatitis (chronic inflammatory condition causing itchy, greasy, red patches covered with white or yellow scales, often called dandruff on the scalp). Review of a Minimum Data Set (MDS) assessment for Resident #21 with a reference date of 3/1/26, 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 #21 with a reference date of 1/27/26 revealed the following focus/goal/interventions: Focus: ADL (Activities of Daily Living) self-care deficit related to physical limitations.Goal: Will receive assistance necessary to meet ADL needs. Interventions.Bathing/Showering as preferred per shower schedule.needs medicated shampoo. Review of a Physician's Order for Resident #21 with a reference date of 2/22/26 revealed Ketoconazole External Shampoo 2% (percent)(topical).Apply to scalp topically every day shift every Wed (Wednesday) , Fri (Friday) for scalp sensitivity. During an observation on 4/7/26 at 11:04am in Resident #21's room, Resident #21's hair appeared shiny and soiled with distinct comb lines from the hair sticking together after being combed. In an interview on 4/7/26 at 11:05am, Resident #21 reported she had not had her hair washed in 2 weeks and was bothered by the state of her hair. Resident #21 reported a staff member normally helped her wash her hair by backing her wheelchair up against the sink in her room and then washing her hair for her, but that staff member left a few weeks ago, so her hair had not been washed. Resident #21 described her hair as dirty and oily. Resident #21 reported due to her oily scalp, she used to wash her hair daily when she was at home and could still do it herself. Resident #21 confirmed she could no longer wash her hair on her own. During an observation on 4/8/26 at 12:34pm in Resident #21's room, Resident #21's hair was pulled back in a ponytail. The surface of her hair appeared shiny, deep comb marks were present and the hair in the ponytail appeared stuck together. In an interview on 4/8/26 at 12:36pm, Resident #21 reported she still had not had her hair washed and was increasingly frustrated. Resident #21 stated I've got enough oil in this hair; I think I'm going to bottle it!. In an interview on 4/9/26 at 12:07pm, Resident #21 reported her head was very itchy prior to having her hair washed the evening prior to this date. Resident #21 reported she needed to use medicated shampoo/have her hair washed on a regular basis to avoid having extremely itchy scalp. Review of a Shower Record for Resident #21 with a reference date of March 2026, revealed the resident received assistance with showering 4 times during the month. Review of an Activities of Daily Living policy with a reference date of 2/2/26 revealed Policy Overview: .Appropriate care and services will be provided for residents who are unable to carry out ADL independently.in accordance with the plan of care.

Based on observation, interview, and record review, the facility failed to ensure implementation of resident-specific comprehensive care plans for 2 residents (R13 and R52), and prevent the development of a pressure ulcer for 1 resident (R13) of 4 residents reviewed for pressure ulcers, resulting in the development of a pressure ulcer for R13 and the potential for skin breakdown for R52. Findings include: Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included limitations of activities due to disability. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 4/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. Review of Resident #13's ''Care Plan revealed, Focus: (Resident #13) has ADL (Activities of daily living) self-care deficit related to muscle weakness . Date initiated:1/13/26. Interventions: Bed Mobility: One person assist. Date Initiated: 01/20/2026. Focus: Actual pressure injury formation related to: Resident has pressure injury DTI (deep tissue injury) with risk for delayed wound healing secondary to progressing comorbidities such as . DTI left 5th metatarsal phalangeal joint (the knuckle of the little toe, connecting the long foot bone (metatarsal) to the base of the smallest toe): 2/4 intact blister. DTI right dorsal 5th metatarsal phalangeal joint (the joint located on the top (dorsal) side of the foot where the fifth metatarsal bone connects to the smallest toe, situated on the outer edge of the ball of the foot). - 2/4 intact blister. Date Initiated: 01/21/2026. Interventions: Frequent turning and repositioning .Date Initiated: 01/21/2026 Review of Resident #13's Orders revealed, Wound Care Order Site: R (right) & L (left)5th metatarsal intact blisters 1) Cleanse wound with NS (normal saline) 2) Pat Dry with Gauze 3) Paint with betadine (topical antiseptic) 4) Apply dry bordered gauze dressing to left and right foot. everyday shift for wound management. Start date: 3/26/26. Review of Resident #13's Wound Progress Note dated 4/8/26 revealed, . Skin Issues Note: L (left) 5th metatarsal deteriorating related to the superficial layer lifting. Treatment orders will change to xeroform (type of gauze dressing) cut to wound bed & covered with dry bordered gauze dressing . During an observation and interview on 4/07/2026 at 10:41 AM, Resident #13 was lying in her back on her back. Resident #13 was wearing prevalon boots (medical device designed to prevent and treat heel pressure injuries by completely elevating (floating) the heel off the mattress surface.) on both of her feet which were noted to be lying directly on the foot of her bed. Resident #13 reported that she had developed pressure ulcers on her feet at the facility because she was too tall for her bed so her feet would lie directly on the foot of her bed. Resident #13 reported that she had been told that the facility was not able to add a bed extender to her bed because her room was not big enough for a larger bed. During an observation on 4/07/2026 12:56 PM, Resident #13 was noted to be in the same position as previous observation, with her feet lying directly on the foot of her bed. During a wound care observation on 4/08/2026 at 8:17 AM, Wound Care Nurse Practitioner (WCNP) EE and Unit Manager I entered Resident #13's room and noted that her feet were lying directly on the foot of the bed, so they boosted(refers to the coordinated and assisted maneuver of moving a dependent patient up toward the head of the bed or repositioning them) Resident #13 up in her bed. As UM I was completing wound care on the wound on Resident #13's foot, she reported that the top layer of the skin on her foot was starting to become detached. WCNA EE assessed Resident #13's left foot wound and noted that she was going to update the treatment plan. In an interview on 4/08/2026 at 8:27 AM, WCNP EE reported that Resident #13 had developed both wounds on her feet at the facility, due to her bed being too small for her. WCNP EE reported that she thought that Resident #13 was in a long bed. WCNP EE confirmed that she needed to update Resident #13's treatment order for the wound on her left foot because the blister on top of the wound became detached, and that the wound was deteriorating. During an interview on 4/8/2026 at 2:08 PM, UM I reported that Resident #13 had developed pressure ulcers on her feet due to her feet touching the end of her bed. UM I reported that Resident #13 had been wearing prevalon boots before she obtained the pressure injuries, and she believed that staff had not been boosting resident up in her bed often enough, so her feet were lying on the foot of the bed frequently. UM I reported that the facility was not able to put a bed extender on Resident #13's bed because her room was too small for one. UM I reported that the facility had not considered or offered to move Resident #13 to a room that could accommodate a larger bed for her. During an observation on 4/09/2026 at 8:49 AM, Resident #13 was lying in bed on her back. Resident #13 was wearing her prevalon boots with her feet lying directly on the foot of her bed. During an observation on 4/09/2026 at 10:05 AM, Resident #13 was in the same position as previous observation at 8:49 AM. During an interview on 4/9/2026 at 10:15 AM, Certified Nursing Assistant (CNA) R reported that she cared for Resident #13 often, and that she rarely got out of bed. CNA R reported that she would typically boost Resident #13 in the morning when she would check on her, but she did not have a schedule for how often she checked on and boosted Resident #13 throughout the day. During an interview on 4/9/26 at 10:24 AM, CNA NN reported that the staff did not have any kind of schedule for when to boost Resident #13 to make sure her feet were not lying on the foot of her bed. During a follow up interview on 4/9/2026 at 12:38 PM, UM I reported that the facility had never considered offering Resident #13 to move to a room where she could have a longer bed. During an interview on 4/9/26 at 12:48 PM, Director of Nursing (DON) B reported that she felt that Resident #13's pressure ulcers were unavoidable due to her underlying medical conditions. DON B confirmed that she was aware that Resident #13 was tall enough that her feet would often lie directly on the foot of the bed. DON B reported that she thought that Resident #13 was now in a longer bed. R52 Observed on 4/07/2026 at 9:34 AM, R52 in his room sitting in a high-backed wheelchair (Broda). R52 was not wearing blue Prevalon heel boots on either foot. Both boots were in a chair in the corner of his room. According to the Minimum Data Set (MDS) dated [DATE], R52 scored 15/15 on his BIMS (Brief Interview Mental Status) signifying he was cognitively intact. His diagnoses included diabetes, traumatic brain dysfunction, arthritis, non-Alzheimer's dementia, and partial paralysis in right arm and leg. Section GG-indicated R52 was dependent on staff for his ADLs (activities of daily living). Section M-indicated R52 was at risk of developing pressure ulcers/injuries, had a pressure ulcer/injury, MASD (moisture associated skin damage), and received interventions/treatments that did not include a turning/repositioning program. Review of R52's Order Summary dated 8/30/2024, revealed, Skin prep to left toes-keep blankets off of toes as much as possible for resident allows at bedtime for left toe redness. Print date 4/9/25 at 1:41 PM. Review of R52's Order Summary, dated 9/5/24, revealed, Prevalon Boots (Prevalon boots (aka (also known as) heel boots or blue boots) a medical device designed to prevent and treat heel pressure injuries (bedsores) by completely elevating (floating) the heel off the mattress surface) on at all times. Every day and night shift for Wound care/ prevention. Check placement. Print date 4/7/26 at 2:38 PM. Review of R52's Medication/Treatment Administration Record (MAR/TAR) dated 4/1/26-4/30/26, revealed Prevalon boots on at all times. Every day and night shift for wound care/prevention. check placement. Start date: 9/5/2024 7:00 PM Discontinue date: 4/8/26 12:49 PM. It was noted, survey started on 4/7/26. Review of R52's Order Summary dated 4/8/26, revealed, Prevalon Boots on when in bed for pressure relief at bedtime for wound care/prevention check placement. Print dated 4/9/26 at 1:41 PM. Further review of R52's MAR/TAR dated 41/26-4/30/26 and Care Plan for Potential/Actual Impairment to Skin Integrity, did not include the resident-specific treatment of R52 to have the Prevalon Boots in bed for pressure relief at bedtime. Review of R52's Care Plan, dated 2/20/26, Potential/actual impairment to skin integrity related to contracture with use of orthotics (splints and braces), weakness/debility with impaired mobility.multiple comorbidities including Diabetes with neuropathy and Dementia.history of redness to left great toe. The goal for R52 was to heal within the limits of the disease process. Interventions included Elevate heels off bed surface . Prevalon boots on at all times. Further review of R52's Care Plan, dated 2/20/26, Potential/actual impairment to skin integrity related to contracture, did not have the newest 4/8/26 order for Prevalon boots on when in bed for pressure relief at bedtime for wound care/prevention check placement. The Braden Scale is used to assess the resident's level of risk for development of pressure ulcers. The evaluation is based on six indicators: sensory perception, moisture, activity, mobility, nutrition, and friction or sheer. Scoring includes: At Risk: 15-18, Moderate Risk: 13-14, High Risk: 10-12, and Very High Risk: 9 or below. Review of R52's Braden Score for Predicting Pressure Ulcer Risk Evaluation, dated 1/2/2026, indicated a score of 17.0 and on 1/10/26, a score of 16.0. The two assessments indicated R52 was at risk for developing a pressure ulcer/injury. During an observation on 4/8/26 at 9:15 AM, R52 was in bed with eyes closed without covers over his lower legs. R52 was not wearing blue Prevalon heel boots on either foot. Both residents knees were bent with both of his heels resting directly on the mattress. Observed two blue Prevalon boots on the closet floor with personal belongings lying on top of them. During an observation and interview on 4/8/26 at 12:30 PM, R52 was being pulled backwards in his high-backed wheelchair by Certified Occupational Therapy Assistant (COTA) KK down the hall towards therapy. R52 was not wearing blue Prevalon heel boots on either foot. COTA KK stated he did not need to wear the blue Prevalon heel boots. During an interview and record review on 4/9/26 at 1:30 PM, Unit Manager (UM) I stated, (R52) wore the Prevalon boots for pressure ulcer prevention. He does not have pressure ulcers on his heels. He does receive care on top of his toes for redness and prevent a pressure wound. UM I reviewed R52's medical records, specifically order summary and care plans. It was noted therapy discontinued the order for Prevalon boots but did not update the care plan. UM I stated, I'm new to Long Term Care, and don't know much about care plans. I will discuss with therapy to update care plans when they change orders, and I will have the DON educate me on care plans.

This citation pertains to intake #MI00151905 Based on interview, and record review, the facility failed to provide adequate supervision in 1 resident (Resident #101) of 3 residents, reviewed for elopement, when Resident #101, who was actively exit seeking and a high fall risk, exited the facility unattended on 3/27/25 and descended 16 concrete steps to a parking lot, resulting in the potential for serious injury and/or harm. Findings include: Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: repeated falls, delusional disorder, parkinson's disease, and alzheimer's disease. Review of Resident #101's Wandering risk scale assessment dated [DATE] indicated a high risk to wander. Review of Resident #101's Care Plan revealed, .elopement risk r/t (related to) delusion at times when resident is confused due to lewy bodies (a gradual decline in mental abilities). Created on 2/24/2023 .Interventions: May wander or attempt to leave facility unattended: triggers for wandering/eloping are thinking that people are trying to get her, or violence is occurring outside. De-escalated by redirection, speaking to her about things, active listening. Created on 8/30/2024, Distract resident when increased wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc. per resident preferences. Created on: 2/24/2023, Encourage rest periods as tolerated if fatigue or weakness observed with wander and/or exit seeking behavior. Created on: 2/24/2023, Provide structured activities; toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, etc. to identify personal space. Created on: 2/24/2023, Provide visual reminders and/or deterrents to high risk exit locations per facility protocol. Created on: 8/30/2024 . Review of the Facility Reported Incident (FRI) dated 3/27/25 revealed, .Resident (Resident #101) exited the facility unsupervised at 5:10 AM. She exited the building through the left exit doors in the main dining room .Interviews/Investigation Timeline: 2:30 AM Resident was wandering hallways looking for family. Resident had been testing doors in the front lobby but was able to be redirected. Resident awoke at 3:20 AM asking nursing staff to bring her to her sister's house and stating that she wants to go home. Gave PRN (as needed) pain medication for c/o (complaints of) leg pain and PRN Ativan for anxiousness and her urgent requests to leave. Resident drank 180 cc med pass (nutritional supplement). Ambulated thru-out facility and resident hallways. Roughly 5:00 AM resident was laid back in bed and appeared to be asleep. At roughly 5:10 AM the dining room exit door began alarming. Staff responded and observed (Resident #101) at the bottom of the stairs outside leading in to the parking lot. Upon further investigation and interviews it was determined that (Resident #101) had been having exit seeking behaviors since 2:30 AM. She had been noted to be pushing on doors in the front lobby and dining room .During the time when staff were doing rounds (Resident #101) had exited her room, walked down 200 hall and into the common area, proceeded to open the doors to the dining room and exited through the back left exit door .down 16 stairs to the parking lot .staff were able to get her while she was in the parking lot . During an observation on 6/17/25 at 9:50 AM of the facility floor plan. Observed 3 halls with resident rooms and 1 hall with offices that lead to the lobby and the dining room. At the far end of the dining room, observed a fire exit that lead to 5 steep concrete stairs, a platform, then a turn with 5 additional steep concrete stairs, then another platform and ended with 5 wide steps that led to a parking lot full of cars. In an interview on 6/17/25 at 11:24 AM, Certified Nursing Assistant (CNA) F reported that she was not assigned to Resident #101's hall but at approximately 4:00 AM on 3/27/25 she heard the main dining room door alarming CNA F reported that when she got to the door Resident #101 was observed in the parking lot. CNA F reported that she called for more help and headed out the door to get the resident. CNA F reported that it was very cold outside that night and Resident #101 did not have her walker. CNA F reported that Resident #101 had been ramping up and exit seeking more frequently but was not assigned to any increased supervision. In an interview on 6/17/25 at 2:03 PM, Registered Nurse (RN) C reported that Resident #101 was a high fall risk and had been agitated, wandering and exit seeking for 2 days prior to her elopement on 3/27/25. RN C reported that Resident #101 had been testing doors and more agitated than usual. RN C reported that the facility was short a nurse on 3/27/25 therefore RN C and Licensed Practical Nurse (LPN) C were sharing Resident #101's hall (200) but were both on other halls during the elopement. The CNA's had a similar assignment and were on other halls during the elopement. RN C reported that staff had closed the resident's room door and closed the double doors to the main lobby/dining room in an attempt to stop Resident #101 from leaving the unit unsupervised. RN C reported that she had heard the door alarm going off for a couple minutes between 4:30-5:30 AM but was in a room doing wound care; when she came out of the room she did not see any staff. RN C went to the nurse's station and the board was showing that the main dining room door was alarming. RN C made her way down the administration hall, and through the dining room where she saw CNA F trying to open the exit door. RN C reported that Resident #101 was already walking across the parking lot when they first saw her; she had made it down 3 flights of stairs. RN C reported that Resident #101 was unsteady on her feet and frequently fell. RN C reported that staff had not implemented an increased supervision intervention on 3/27/25 when the resident was exit seeking. Multiple attempts were made to contact LPN D, with no return phone call prior to survey exit. In an interview on 6/18/25 at 7:59 AM, RN K reported that on 3/26/25 (day before elopement) Resident #101 was constantly trying to exit the facility and the door alarms were going off. RN K reported that Resident #101 was observed exiting the door at the end of 200 hall on 3/26/25 at approximately 4:00 AM, but was immediately redirected back to her room on 200 hall. In an interview on 6/18/25 at 9:01 AM, CNA M reported that she was in a room on 300 hall with another CNA on 3/27/25 when Resident #101 eloped from the facility. CNA M reported that Resident #101 was wandering and exit seeking since about 10:00 PM that evening and constantly setting off the door alarm in the main lobby. CNA M reported that staff had closed the double doors to the lobby/main dining area in an attempt to stop the resident from exit seeking. CNA M did not hear a door alarm or know about the elopement until she came out of the room she was in with CNA G. In an interview on 6/18/25 at 1:17 AM, CNA L reported that she was not working on Resident #101's hall the night of her elopement but reported the resident was roaming the halls with her walker, talking about someone coming to pick her up and had extra clothes with her. CNA L reported that she was charting on 100 hall and remembered hearing a door alarm that morning. CNA L did not respond to the door alarm. In an interview on 6/18/25 at 11:30 AM, Director of Nursing (DON) B reported that Resident #101 had a history of exit seeking, requested help opening doors, pushed on doors, wandered, and would look for a train station. DON B reported that Resident #101 had been actively exit seeking, and had exited the 200 hall door the day before around the same time. DON B reported on 3/27/25 when the resident was exit seeking, staff responded by administering anti-anxiety and pain medication, and thought that the resident was resting in bed until the elopement occurred. DON B reported that he would have expected staff to increase supervision of Resident #101 and that did not happen. Additionally, DON B reported that Resident #101 was a very high fall risk, had most recently fallen on 3/24/25 and should have had increased supervision. In an interview on 6/18/25 at 1:30 PM, Director of Therapy (DOT) P reported that Resident #101 was not safe to ambulate unsupervised, was very unsteady, had a shuffled gait, and a history of falls. DOT P reported that Resident #101's last therapy recommendations were supervised to touching assistance for walking. Review of Resident #101's Physical Therapy Discharge Summary dated 10/23/2024 revealed, .Ambulation: Walk 10 feet .Walk 50 feet with two turns .Walking 10 feet on uneven surfaces-supervision or touching assistance . Review of Resident #101's Fall Reports indicated that she had 6 unwitnessed falls between 2/13/25 and 3/24/25. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education with all staff on increasing supervision for residents that are actively exit seeking, reviewing all residents at risk for elopement, and continued audits to ensure all residents were accurately assessed and monitoring was in place. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, at 9:25 AM on 2/24/25, it was observed that there was no available soap or paper towel at the only hand sink in the kitchen. When asked about the soap, Food Services Director (FSD) F stated that it ran out and he would have to get more from the basement. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision. Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A)Individual, disposable towels . According to the 2017 FDA Food Code section 6-301.11 Handwashing Cleanser, Availability. Each HANDWASHING SINK or group of 2 adjacent HANDWASHING SINKS shall be provided with a supply of hand cleaning liquid, powder, or bar soap. During the initial tour of the freezer, at 9:35 AM on 2/24/25, observation found that a box of raw burger patties was found open and exposed with the box and plastic covering left open. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: . (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings . During the initial tour of the kitchen, at 9:50 AM on 2/24/25, it was observed that the door gasket seals on the two door [NAME] unit was found to have an accumulation of black spotted debris. Observation of the dish machine area, at 9:55 AM on 2/24/25, found an increased accumulation of debris on the top surfaces of the dish machine as well as wet debris underneath the floor juncture area of the machine. Observation of the milk cooler, at 10:02 AM on 2/24/25, found that both door seals had an increased accumulation of black debris. Inside of the unit was found with the floor and walls of the unit with discolored build up from crates going in and out. During an observation of the clean utensils, hanging above the three compartment sink, at 10:06 AM on 2/24/25, one mechanical scoop was found with dried on food debris. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During an interview with FSD F, at 10:42 AM on 2/24/25, it was found that dietary staff pull outdated food in the pantry, but the food gets checked in up front before being put in the pantry when its brought in for a resident. Observation of the pantry, at 1:40 PM on 2/24/25. found the following items: two ramekins of salsa with no label or date, a manufacture mac and cheese product with a best by date of 2/17/25, a leftover container of pea soup dated 2/19/25, three unopened bottles of orange juice with best by dates of Jan302025 and Feb162025, a plastic grocery bag containing a leftover chicken dinner labeled and dated 2/9/25, a fast food salad labeled with no date, a grocery bag with small containers of mac and cheese and cooked vegetables with no date, two bologna sandwiches and one peanut butter and jelly sandwich dated with use by dates of 2/22. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During an observation of meal service, starting at 11:48 AM on 2/24/25, it was observed that [NAME] MM did not wash his hands after changing his gloves to start plating lunch service. It was noticed that a clean dry wiping cloth was on the steam table ledge in front of [NAME] MM and he was observed routinely wiping his gloves on the rag when they became dirty. Observation of cook MM at 12:04 PM on 2/24/25, found that he stepped off the serving line to take a drink out of his personal drink. After taking a drink, [NAME] MM stepped back on the serving line with no hand washing or glove changes. According to the 2017 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. According to the 2017 FDA Food Code section 3-304.15 Gloves, Use Limitation. If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

This deficient practice has two DPS's: DPS A Based on observation, interview, and record review, the facility failed to implement posted Enhanced Barrier Precautions (EBP) and don required Personal Protective Equipment (PPE) prior to providing direct resident care in 4 of 5 residents (Resident #9, #35, #24, & #10) reviewed for Enhanced Barrier Precautions, resulting in the potential for cross-contamination and the development and/or spread of infection to a vulnerable population. Findings include: Resident #9 Review of an Admission Record revealed Resident #9 was a female, with pertinent diagnoses which obstructive uropathy (a blockage that hinders flow through the urinary system), dysphagia (difficulty swallowing), neuromuscular dysfunction of the bladder (a condition where the nerves controlling the bladder are damaged or not functioning properly), muscle atrophy (loss of muscle), and weakness. Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 12/27/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. Review of an Order Summary Report for Resident #9 revealed the active physician order .Resident requires Enhanced Barrier Precautions related to Urinary Catheter & Tube Feeding . with a start date of 9/6/24. Review of a current Care Plan for Resident #9 revealed the focus .Resident requires Enhanced Barrier Precautions related to Urinary Catheter & Tube Feeding . with interventions which included .Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care) . and .Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray . all initiated 4/29/24. In an observation on 2/24/25 at 10:55 AM, Certified Nursing Assistant (CNA) EE and CNA V assisted Resident #9 with a transfer from her bed to her electric wheelchair in her room. Noted a sign on the wall outside Resident #9's room which indicated Enhanced Barrier Precautions were in place. Observed CNA EE and CNA V utilize a sit-to-stand lift to complete the transfer for Resident #9. Noted no gowns or gloves were worn by CNA EE and CNA V while transferring Resident #9. In an interview on 2/24/25 at 1:02 PM, Resident #9 reported staff don't typically wear gowns and gloves when assisting her with transferring. In an observation on 2/26/25 at 9:43 AM, CNA Q and CNA U assisted Resident #9 with a transfer from her bed to her electric wheelchair in her room. Noted a sign on the wall outside Resident #9's room which indicated Enhanced Barrier Precautions were in place. Observed CNA Q and CNA U utilize a sit-to-stand lift to complete the transfer for Resident #9. Noted no gowns or gloves were worn by CNA Q and CNA U while transferring Resident #9. In an interview on 2/26/25 at 11:01 AM, CNA U reported gowns and gloves should be worn when providing direct care for Resident #9, which included transfers. In an interview on 2/26/25 at 11:11 AM, CNA Q reported gowns and gloves are to be worn when providing catheter care for Resident #9. CNA Q reported gowns and gloves are not required for transfers for Resident #9. In an interview on 2/26/25 at 11:19 AM, CNA T reported for residents on Enhanced Barrier Precautions, gowns and gloves should be worn when providing catheter care or wound care. CNA T reported gowns and gloves would not be required for transferring. In an interview on 2/26/25 at 12:00 PM, Director of Nursing (DON) B reported for residents on Enhanced Barrier Precautions, gowns and gloves (PPE) should be worn when providing direct care, which included transfers. 41424 Resident #35: Review of an Admission Record revealed Resident #35 was a male with pertinent diagnoses which included colostomy, unhealed peg tube wound, and open tracheostomy wound. Review of Orders for Resident #35 revealed, .On Enhanced Barrier Precautions d/t (due to) unhealed surgical wounds, every shift for unhealed surgical wounds . During an observation on 02/24/25 10:12 AM, Certified Nursing Assistant (CNA) PP was standing at the side of the bed on the left side. The hoyer was placed on the right side of the bed. CNA PP did not have on a gown only gloves. CNA P entered the room, raised the head of the bed, and she removed Resident #35's nasal cannula. Resident #35 was observed to have an colostomy and an colostomy bag on his left side. Resident #35's bed was raised, each CNA attached their side of the beds sling loops to the hoyer. CNA P was talking with the resident and informing the resident what was happening next. She had Resident #35 place his hands across his chest while she was talking and provided reassurance to him. CNA PP guided the hoyer forks under the bed while CNAP guided his bottom to get him centered on the side of the bed. CNA PP lowered the bed from under Resident #35 and then she proceeded to move him towards the entrance door to straighten the hoyer out and moved towards his wheelchair. CNA P was behind his wheelchair and she guided the resident back to the seat of the wheelchair, she informed him she was going to position him so when he was lowered he would be seated correctly. CNA P touched his side and then she grabbed the back of the sling to pull him back in the chair while CNA PP slowly lowered him down into the chair. Both CNAs talked to the resident as he was gently lowered into the wheelchair seat. CNA PP' moved the hoyer away while CNA P was adjusting his clothing, making sure he was comfortable. CNA PP proceeded to wipe down the hoyer. Resident #35 asked to have his shirt changed due to some soiling on his shirt. CNA P proceeded to assist with removal his arm from the sleeve and then raised it over his head, and then took the shirt down to his left arm. CNA P placed the shirt over his head and he leaned forward to adjust it on the back after she placed his arms in the sleeves. CNA PP placed the dirty shirt in a plastic bag with other items and exited the room. CNA P had removed her gloves and performed hand hygiene when she left the room. Resident #24: Review of an Admission Record revealed Resident #24 was a female with pertinent diagnoses which included pressure ulcer of left buttock, osteomyelitis right ankle and foot, and chronic ulcer of right lower leg with fat layer exposed, and chronic ulcer of left foot with fat layer exposed, and urinary catheter. Review of Orders dated 2/6/25 revealed, .Enhanced Barrier precautions (EBP) for wound and presence of urostomy. every shift for patient monitoring. Initials indicate precautions maintained throughout shift . During an observation on 02/24/25 at 10:55 AM, Resident #24 was lying in bed. CNA T repositioned the resident in bed as she was leaning to her left side. Resident #24 reported she did not feel well, that her chest hurt. CNA T removed her gloves and exited the room. CNA T did not don a gown when she repositioned the resident. CNA T entered the room, had donned gloves, placed a paper towel on the floor and placed a graduated cylinder on top of it, she cleaned the port opening to the catheter bag with an alcohol wipe and drained the urine from the bag. CNA T did not don a gown prior to emptying the catheter bag. Resident #10: Review of an Admission Record revealed Resident #10 was a female with pertinent diagnoses which included a catheter, kidney disease, urinary tract infections, and need for assistance with personal care. Review of Orders dated 9/6/24, revealed, .Catheter care has been provided every day and night shift for management routine . Review of Orders dated 9/6/24, revealed, .Resident requires Enhanced Barrier Precautions related to presence of indwelling urinary catheter every day and night shift to neuromuscular dysfunction of bladder . During an observation 02/26/25 10:21 AM, CNA U exited Resident #10's room and proceeded to bring the hoyer into the room. CNA Q grabbed gloves from the bathroom. There was PPE noted in a container hung on the doorway to the bathroom. CNA U moved to the left side of Resident #10's bed and CNA Q moved to the right of bed, Resident #10 crossed her hands and a catheter bag was observed hanging on the right side of the bed. Both attached the loops to the hoyer sling, slowly lifted her up from the bed, slowly moved her over to her wheelchair. CNA U adjusted the height and positioning of the wheelchair to the position Resident #10 preferred. CNA U was in the back of the sling, and grabbed the back straps, CNA Q moved her legs over and she was slowly lowered into the wheelchair. Resident #10 feet were positioned in the foot rests, and she was adjusted back into the seat of the chair, as far back as she could go, like she liked as she had a table which crossed over her lap in the chair. Both CNAs provided adjustment to the resident in the wheelchair so she was comfortable. Both CNAs were observed with no gown on when Resident #10 was transferred. In an interview on 02/26/25 at 12:40 PM, Registered Nurse (RN) M reported with enhanced barrier precautions she should wear a gown and gloves when care was provided to the resident and then if there was a splash propensity, then she would wear eye protection. In an interview on 02/26/25 at 12:56 PM, Certified Nursing Assistant (CNA) Q reported she was under the impression that the only time the staff would wear personal protective equipment was when they were doing brief changes, and catheter bag emptying. CNA Q reported she wasn't aware that she was supposed to be wearing PPE during transfers of a resident under EBP. CNA Q reported that she was educated today that she has to wear personal protective equipment anytime she is to have hands-on care with the resident. In an interview on 02/26/25 at 09:11 AM, Infection Preventionist (IFP) OO reported during the last all staff meeting on 2/19/25, she provided enhanced barrier education on why and when staff were required to wear personal protective equipment (PPE) to the staff who attended. IFP OO reported she worked the floor third shift and she was able to provide surveillance of proper PPE use during third shift but was not able to monitor staff use during first and second shift. In an interview on 02/26/25 10:08 AM Director of Nursing (DON) B reported for residents with enhanced barrier precautions (EBP) the staff should follow the sign on the doorways. DON B reported the sign also indicated which bed number for EBP. DON B reported the staff recently received education and handouts for EBP. Review of the policy/procedure Enhanced Barrier Precautions, dated 3/27/24, revealed .It is the policy of this facility to use Enhanced Barrier Precautions (EBP) to expand the use of PPE and to refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to resident during these high-contact care activities .Even if the resident is not known to be infected or colonized with a MDRO, an order for enhanced barrier precautions will be obtained for residents with any of the following .Wounds .Indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy / ventilator tubes) .Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include .Bathing/Showering .Transferring .Providing personal hygiene .Changing linens .Changing briefs or assisting with toileting .Device care . 38905 DPS B Based on observation and interview the facility failed to maintain equipment and surfaces in a manner that would reduce the risk of bacterial harborage. This resulted in the increased likelihood of domestic water and clean and sanitary supplies becoming contaminated. FindingsiInclude: During a tour of the 100 hall soiled utility room, at 2:11 PM on 2/24/25, found the hopper sprayer atmospheric vacuum breaker did not have a top cap and was leaking heavily when turned on. No water was able to come out of the sprayer, indicating a stagnant line. During a tour of resident room [ROOM NUMBER]'s shared bathroom, at 2:13 PM on 2/24/25, it was observed the back of the toilet had a slow leak revealing a six by six inch puddle on the floor. This area on the floor behind the toilet was found to be discolored with black staining. When asked if she could see the leak, Housekeeping Manger (HKM) NN, nodded her head. During a tour of the central supply room, at 2:19 PM on 2/24/25, it was observed that eight racks of shelving were found to help stack and store supplies, including clean and sanitary items. Further review found that the eight racks used press board shelving, which is not smooth and easily cleanable. Shelving should be able to be wiped as a clean surface without absorbing moisture and possible contamination. When asked how long the shelves had been here, HKM NN stated that the facility just got them in awhile ago. During an observation of the 200 hall spa, at 2:35 PM on 2/24/25, it was observed that an approximate 12 x16 inch portion of the top back wall was found chipping and pealing. When asked about the patch, HKM NN stated that it was something that maintenance was working on.

Based on observation, interview, and record review, the facility failed to update and revise the person centered care plan in a timely manner with appropriate interventions for 2 (Resident #3 and Resident #25) of 2 residents reviewed for comprehensive care plans, resulting in inaccurate reflection of the resident's status. Findings include: According to Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, October 2018, Chapter 4.7 The RAI and Care Planning on page 4-8 indicated, .The care plan must be reviewed and revised periodically .The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving .Further review of the RAI Manual revealed under Chapter 4.8 CAA [Care Area Assessment] Tips and Clarifications on page 4-12, .The resident's care plan must be reviewed .and revised based on changing goals, preferences and needs of the resident and in response to current interventions . Resident #3: Review of Admission Record revealed Resident #3 was a male whose pertinent diagnosis which included chronic pain syndrome, muscle weakness, back pain, diabetes with neuropathy (weakness, numbness, and pain from nerve damage) and osteoporosis (bones became weak and brittle). Review of Care Plan for Resident #3, revealed no focus or intervention for a PRAFO (custom fitted ankle foot orthosis (AFO) fully adjustable, that helps manage foot and ankle conditions). Review of Resident #3's orders revealed no order for the device. Review of Therapy to Nursing Communication Sheet dated 11/26/24 revealed, .Splint/Orthotic .Other: B (bilateral) PRAFO . During an observation on 02/24/25 at 01:03 PM, Resident #3 reported she no longer received therapy and had the two braces on her feet because her foot drops. During an observation on 02/25/25 at 2:30 PM, Resident #3 was leaving the computer area, and she had her feet out in front of her with her PRAFO braces on bilaterally as she was unable to lift her legs and place her feet on the foot pedals of her wheelchair. Business office manager LL assisted her with placing her feet on the foot pedals. During multiple observations over the course of the survey, Resident #3 was always observed to be wearing her PRAFO devices. Resident #25: Review of Admission Record revealed Resident #25 was a male whose pertinent diagnosis which included paralysis left side, stroke, heart failure, muscle spasm, abnormalities of gait and mobility, lack of coordination, and muscle wasting & atrophy (wasting or thinning of muscle mass). Review of Resident #25's care plan revealed no focus or intervention for the use of the AFO (ankle foot orthosis). Review of Resident #25's orders revealed no order for the device. During an observation on 02/24/25 at 12:22 PM, Resident #25 was observed in his room seated in his wheelchair. Resident #25 was observed to have a hard AFO (ankle foot orthosis- a medical device used to support, protect, or correct body structures) on his left lower leg. During an observation on 02/26/25 at 02:20 PM, Resident #25 was observed seated in his wheelchair at the main entry with a hard AFO on his left lower leg. In an interview on 02/25/25 at 11:42 AM, Certified Nursing Assistant (CNA) V reviewed Resident #3's care guide for CNAs and reported she did not see the intervention of the bilateral use of the PFAROs. CNA V reviewed the resident's care plan and was unable to locate an intervention for the use of the bilateral PFAROs. CNA V reported for Resident #25 there was the leg strap for the left leg but nothing for the AFO in the care guide for CNAs or the care plan. CNA V reported there was a binder at the nurse's station staff could refer to for information of therapy recommendations. CNA V reported if not familiar with a resident and unable to review the binder with therapy recommendations she would not know if they required an assistive device like a brace. In an interview on 02/25/25 at 02:00 PM, Director of Physical Therapy (DPT) HH reported there was a binder at the nurse's station of every residents transfer status, orthotic or splints, special shoes, and/or assistive device the resident would use. DPT HH reported the therapist who conducted the evaluation would enter a treatment order in the record. DPT HH reported when the resident received the new device education was provided to the resident, educate the staff who were working on the floor on how to use it, apply it, and what they should be looking out for. DPT HH reported the interventions should be in the care plan, but the therapy staff were unable to access or edit the care plan. In an interview on 02/24/25 at 4:23 PM, Unit Manager (UM) BB reported the therapy communication forms should be given to her for review, so she would be able to ensure the interventions were added to the care plan and implemented. This writer and UM BB reviewed the care plans for Resident #3 and Resident #25 and neither had an intervention for the devices they were current used. Review of the Therapy Communication forms for Resident #3 and Resident #25 revealed no documentation the recommendations were reviewed or added to the care plan and care guides. In an interview 02/26/25 10:42 AM, Director of Nursing (DON) B reported Resident #25 had the brace from when he was admitted to another long term care facility, and it followed him to the current facility. DON B reported he was unaware Resident #25 did not have a care plan for the use of the brace. This writer and DON B reviewed the care plans for Resident #3 and Resident #25 and reported neither had interventions for the use of their current braces.

Based on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL), specifically personal hygiene (shaving) and changing resident clothes daily were provided for 2 of 4 residents (Resident #13 and Resident #54) reviewed for ADL care, resulting in unmet care needs and the potential for avoidable declines in overall health and wellness. Findings include: Resident #13 Review of Admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle wasting and atrophy (a condition that causes muscles to lose mass and strength). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 11/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #13 was moderately cognitively impaired. Review of Resident #13's Care Plan revealed, Resident has an ADL self-care performance deficit r/t (related to)muscle weakness .Date Initiated: 11/02/2023 . Interventions: Provide supportive care, assistance with daily care needs (ADLs) as needed. Document assistance as needed. Date Initiated: 11/02/202 . During an observation on 2/24/25 at 11:43 AM, Resident #13 was sitting up in bed. Resident #13 appeared disheveled. Resident #13's hair was noted to be messy and tangled, and it was noted that Resident #13 had several long hairs on her chin. During an observation on 2/25/25 at 12:29 PM, Resident #13 was sitting in her wheelchair in her room eating lunch. It was noted that Resident #13 was wearing the same clothes as the day before. During an observation and interview on 2/26/25 at 10:15 AM, Resident #13 was sitting in her bed. Resident #13 reported that she would like for facility staff to help her with shaving, and changing her clothes every day. Review of Resident #13's Shower Sheets from November 2024- February 2025 indicated that staff had not offered to shave Resident #13. It was noted that there were no documented refusals for shaving from Resident #13. During an interview on 2/26/25 at 11:19 AM, Unit Manager (UM) AA reported that staff were expected to change resident's clothes every day as they allow. 41424 Resident #54: Review of Admission Record revealed Resident #54 was a male with pertinent diagnoses which included limitation of activities due to disability, muscle wasting and atrophy in right hand, lack of coordination, and paralysis of his right arm. Review of Care Plan for Resident #54, revised on 4/30/24, revealed the focus, .Resident has an ADL self-care performance deficit r/t (related to) muscle weakness, impaired mobility, limited ROM (range of motion) on bilateral hands, dialysis, arthritis, polymyalgia (inflammatory disorder causing muscle pain and stiffness around the shoulders and hips), diabetes, chronic joint pain . with the intervention .Right hand splint to be on when awake . Note: Nothing in the care plan to address providing Resident #54 with assistance with shaving. In an interview on 02/24/25 at 10:48 AM , Resident #54 reported it had been two weeks since he had been shaved. Resident #54 reported the staff do not ask if he would like to be shave or offer to shave him when he takes a shower, or do not offer to shave him when he needs to be shaved. Resident #54 reported he has to tell them to shave the staff to shave him. Resident #54 reported he was given an shower on Saturday (2/22/25) but the staff did not shave his face. Resident #54 reported he was able to wash his face with a washcloth if the cloth was given to him but he was unable to get one himself. During an observation on 02/24/25 at 02:12, Resident #54 was seated in his wheelchair and was still unshaven. In an interview on 02/26/25 08:26 AM, Resident #54 was observed in his room eating his breakfast and he reported he had not received a shave. Observed a beard on his face. Review of Resident #54's shower task for February 2025, revealed, showers were given on 2/1/25 and 2/15/25. Resident #54's shower days were on Saturdays. Resident #54 needed extensive assist or was dependent for shaving. In an interview on 02/26/25 at 02:03 PM, Certified Nursing Assistant (CNA) R reported with each shower or bath for dependent residents she would offer to shave the resident. In an interview on 02/26/25 at 02:06 PM, Registered Nurse (RN) O reported she expected the CNAs to shave a resident on their shower days. In an interview on 02/26/25 02:17 PM Director of Nursing (DON) B reported shaving should be offered and completed during the shower days for residents and that staff were expected to complete shaving when residents received their showers if residents wanted to be shaved.

This citation pertains to Intake # MI00146840. Based on observation, interview, and record review, the facility failed to implement consistent venous ulcer interventions, monitoring, and treatments consistent with physician orders for 1 of 5 residents (Resident #34) reviewed for wounds, resulting in the potential for worsening of wounds and further skin breakdown. Findings include: Review of Admission Record revealed Resident #34 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care. Review of Resident #34's Care Plan revealed, The resident has potential for impairment skin integrity r/t (related to) stump appliance, Fragile/Thin skin and edema to left leg,refusing to elevate lower extremities, DM (diabetes mellitus) CKD (chronic kidney disease), decrease mobility, incontinence, noncompliant with treatment and cares. Date Initiated: 10/15/2019. Interventions: .Follow physician orders for treatment of skin impairments. Refer to eTAR (Treatment administration record) for specifics. Provide pain management with treatments as needed. Date Initiated: 11/11/2023 . Resident has potential/actual impairment to skin integrity r/t PVD (peripheral vascular disease), left outer calf. Date Initiated: 02/16/2025. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 02/20/2025. HEEL PROTECTORS: left foot on at all times except for cares. Date Initiated: 02/19/2025 . Review of Resident #34's Wound Note dated 2/19/25 and documented by Nurse Practitioner/Wound Provider (NP-WP) C, revealed, . (Resident #34) . presents with evidence of skin breakdown to left lower leg and ankle noticed by nursing staff. Wound specialist was consulted for evaluation and treatment of wounds .Wound: 2 Location: Left Lateral Ankle. Primary Etiology: Venous Stage/Severity: Full Thickness. (sore that develops due to poor circulation in the veins) Wound Status: Initial Odor Post Cleansing: None. Size: 1 cm x 1.7 cm x 0.1 cm. Calculated area is 1.7 sq cm. Wound Base: 50% epithelial.(approximately half the wound area is covered by newly formed epithelial tissue) Exposed Tissues: Scab, 50% .Periwound: Intact. Exudate: Light amount of Serous.(clear watery fluid that leaks from wounds or inflamed areas)Wound Pain at Rest: 2. Wound goals. Healing. Plan: Wound #2 Left Lateral Ankle Venous. Treatment Recommendations: 1. Cleanse with normal saline or wound cleanser .2. Apply Betadine .3. Secure with Leave open to air . 4. Change Daily, and PRN (as needed) . Review of Resident #34's Wound Note dated 2/26/25 and documented by NP-WP C revealed, .(Resident #34) .presents with evidence of skin breakdown to left lower leg and ankle noticed by nursing staff. Wound specialist was consulted for evaluation and treatment of wounds .Wound: 2 Location: Left Lateral Ankle. Primary Etiology: Venous. Stage/Severity: Full Thickness. Wound Status: Improving without complications. Odor Post Cleansing: None Size: 2 cm x 1.6 cm x 0.1 cm. Calculated area is 3.2 sq cm. Wound Base: , 100% granulation. Periwound: Intact Exudate: Moderate amount of Serosanguineous. (a fluid that contains both serum and blood cells) Wound Pain at Rest: 1. Improved due to: Pain. Wound goals: Healing .PLAN: Wound # 2 Left Lateral Ankle Venous. Treatment Recommendations: 1. Cleanse with normal saline or wound cleanser . 2. Apply Xeroform (type of dressing used to treat wounds) . 3. Secure with Bordered gauze (type of dressing used to treat wounds).4. Change Daily, and PRN . Noted that the wound size had increased from 2/19/25 to 2/26/25. During an interview on 2/25/25 at 1:11 PM, Former Unit Manager (FMU) CC reported that she was responsible for overseeing the wound care program at the facility. FMU CC reported that Resident #34 would allow staff to complete treatments on his wounds. FMU CC reported that she had experienced issues and voiced concerns with nurses not completing wound treatments. During an interview on 2/25/25 at 1:48 PM, Registered Nurse (RN) N reported that Resident #34 did not currently have any wounds. RN N reported that Resident #34 would allow staff to complete treatments on him. During an interview on 2/26/25 at 8:09 AM, Unit Manager (UM) BB reported that she monitored the wounds at the facility. UM BB reported that Resident #34 had two wounds that were just discovered. UM BB reported that Resident #34 had wound care orders in place to be completed every other day. UM BB reported that Resident #34 did allow for staff to complete wound care treatments on him. During a wound care observation on 2/26/25 at 8:42 AM, UM BB removed the dressing from Resident #34's left outer calf. It was noted that the dressing was dated 2/23/25. NP-WP C assessed Resident #34's wound and noted that the surface area of the wound had increased, but since the tissue looked healthy, she would note the wound as improved. Review of Resident #34's Treatment Administration Record revealed, Treatment to left outer calf; Xeroform cut to size, cover with small white bordered gauze dressing. Vascular ulcer. every day shift every other day for vascular ulcer It was noted that the treatment was due on 2/25/25, and documented as missed by RN N due to Resident #34 sleeping. On 2/26/25 at 8:50 AM, UM BB reviewed and confirmed that Resident #34 was supposed to have wound care treatment completed on 2/25/25, and this was missed. UM BB reviewed Resident #34's treatment administration record with this writer and confirmed that RN N had documented the treatment as missed due to Resident #34 sleeping. UM BB confirmed that nurses were responsible for completing all treatments on their shift, or communicating that a treatment was not completed so the oncoming shift could complete the treatment. On 2/26/25 at 8:57 AM, This writer attempted to contact RN N. RN N was unable to be reached prior to survey exit. On 2/26/25 at 10:36 AM, RN O reported that nurses were supposed to complete all treatments for residents within their 12 hour shift. RN O reported that nurses were expected to let management know if they were unable to complete resident treatments, and if a resident was sleeping, they should return later or wake the resident up if needed. RN O reported that RN N would frequently skip treatments and document the treatment as missed due to resident sleeping. During an interview on 2/26/25 at 11:19 AM, Unit Manager (UM) AA reported that nurses were expected to reapproach a resident is they were sleeping and a treatment needed to be completed. UM AA reported that if the nurse did not have time, they should wake the resident to complete the treatment, and that skipping a treatment due to a resident sleeping was unacceptable. UM AA reported that nurses were responsible for communicating missed treatments so that they could be completed on the next shift. UM AA confirmed that she had not been made aware of Resident #34 missing a wound care treatment on 2/25/25. During an interview on 2/26/25 at 1:06 PM, Director of Nursing (DON) B reported that nurses were expected to complete all treatments on their shift, and communicate to staff if they needed assistance with completing treatments. DON B confirmed that the nurses had manageable work loads, and should not have any issues completing all treatments on their units in their 12 hour shift. DON B reported that it was completely unacceptable for a nurse to document a treatment as missed due to a resident sleeping. DON B confirmed that there were plenty of extra staff on 2/25/25 to assist RN N to complete Resident #34's wound care treatment if she had communicated that she had missed it. DON B confirmed that he was unaware that Resident #34 has missed a wound care treatment on 2/25/25.

Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent worsening of contractures for 1 (Resident #13) of 2 residents reviewed for range of motion resulting in the potential for worsening of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints). Findings include: Resident #13 Review of Admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle wasting and atrophy (a condition that causes muscles to lose mass and strength). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 11/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #13 was moderately cognitively impaired. During an observation and interview on 2/24/25 at 11:43 AM, Resident #13 was lying in bed. It was noted that Resident #13's left hand was contracted. Resident #13 reported that she used to wear a splint on her hand and arm, but staff had not put them on her lately. Resident #13 reported that she liked wearing the splint, and would prefer that staff put it on her. It was noted that there were two pictures of a splint in Resident #13's room with instructions for staff on how to apply the splint. Review of Resident #13's Care Plan and Orders did not include any orders for splints or braces for Resident #13's left hand. During an interview on 2/26/25 at 9:56 AM, Director of Rehab (DOR) HH reported that Resident #13 was seen by Occupational Therapy in May 2024 for contracture management. DOR HH reported that Resident #13 did have a modified splint for her arm and hand that she was supposed to wear for 2-4 hours every day. When queried about Resident #13 not having orders for the splint, DOR HH reported that therapy was unable to place orders in resident's charts, and they relied on nursing staff to enter them. DOR HH reported that the staff followed the therapy communication book at the nurses' station to know which residents had splints to wear. DOR HH showed this writer the therapy communication book and Resident #13 was listed as a resident that had two splints to wear daily. During an interview on 2/26/25 at 9:44 AM, Certified Nursing Assistant (CNA) EE reported that she did not think that Resident #13 had any splints. During an interview on 2/26/25 at 10:20 AM, Unit Manager (UM) BB reported that she did not know if Resident #13 had a splint to wear. UM BB went to Resident #13's room with this writer and asked Resident #13 if she had a splint to wear. Resident #13 confirmed that she had a splint, but she did not know where it was. Resident #13 informed UM BB that she had not worn the splint in some time. UM BB looked around Resident #13's room and found both splints. It was noted that one of the splints was missing a piece, and Resident #13 was unable to wear it. DON BB reported that she would have the facility's Occupational Therapist look at Resident #13's splint. During an interview on 2/26/25 at 12:35 PM, Occupational Therapist (OT) II reported that he assessed Resident #13's splint and noted that the hand splint was missing a piece of the splint and he was going to try to fix it for her to wear. OT II reviewed Resident #13's occupational therapy notes and confirmed that Resident #13 was supposed to wear the splints 2-4 hours a day to prevent the worsening of hand contractures. OT II reported that he did not know how long Resident #13's hand splint was broken. During an interview on 2/26/25 at 1:04 PM, Director of Nursing (DON) B reported that he had just discovered that Therapy staff were not putting in their own orders or care plans, and this was how nursing staff had missed ensuring that Resident #13 was wearing her splints every day.

Based on observation, interview, and record review, the facility failed to adequate respiratory care in 1 (Resident #35) of 1 resident reviewed for tracheostomy (surgical opening in the neck to help with air passage) care, resulting in breathing complications and risk for infection. Findings include: Review of an Admission Record revealed Resident #35 was a male with pertinent diagnoses which included stroke, traumatic brain injury, GERD ( gastroesophageal reflux disease), chronic respiratory failure, dysphagia (swallowing disorder in the throat that impairs the ability to swallow), and history of pneumonia. Review of Care Plan for Resident #35, revised on 12/26/24, revealed the focus, .Resident has a old tracheostomy r/t (related to) respiratory failure prior to admission . with the intervention .Resident has a tracheostomy r/t surgery .The resident will have no s/sx (signs or symptoms) of infection through the review date .suction at bed side external trach site from increase secretions from trach site. resident is able to preform as needed and staff .Reassure resident to decrease anxiety .Provide good oral care daily and PRN (as needed) . During an observation on 02/25/25 at 12:23 PM, Resident #35 was observed in his room seated in his wheelchair with his tray table and lunch tray in front of him. Resident #35 coughed multiple times appeared to be unable to clear the phlegm from his throat. Resident #35 sounded very wet and congested. Resident #35 continued to cough and started to try to use his left hand to move his wheelchair wheel but was unable to grasp the wheel fully as he was continuing to cough. This writer observed resident's roommate look over at resident with a concerned look. At 12:24 PM, Licensed Pratical Nurse (LPN) J proceeded to walk right in front of Resident #35's doorway while he was coughing and continued down the hallway to take a break. Resident #35 continued to cough unable to clear his throat. This writed observed no staff in the hallway. Resident #35 was observed to have his nasal cannula on and an oxygen tank on the back of his wheelchair. This writer observed Resident #35's oxygen tank and it was empty. Resident #35 continued to cough unable to clear the phlegm from his throat. This writer asked Resident #35 if he needed assistance and he was barely able to tell this writer, Yes as he continued to cough. Resident #35's facial expression was one of a person who was anxious and scared with his eyes expressing fear as he was unable to stop coughing and clear out the phlegm from his throat. This writed stepped out of the room to alert a staff member and saw Social worker (SW) Y who was alerted to find LPN J or another nurse to assist Resident #35. At 12:26 PM, LPN J came to Resident #35's room, with her coffee cup in her hand, and informed him she had to place her coffee cup down and she would return to assist Resident #35. Resident #35 continued to cough and sounded wet and had phlegm sound still but his coughing was not continuous at this time. At 12:27 PM, LPN J returned with a pulse oximetry device and placed it on his right hand finger. LPN J reported his oxygen was 97 percent. Observed his oxygen tank and indicated it was empty, removed the nasal cannula from Resident #35, placed the tubing and nasal cannula in a plastic bag hanging from the his wheelchair. LPN J did not replace the empty oxygen tank with a full one. At this time Resident #35 was not coughing continously, but was not able to express verbally answers to LPN J. LPN J indicated to Resident #35 she was going to go and finish her break and she would change the dressing covering the trach opening when she returned and left the room. In an interview on 02/25/25 at 12:29 PM, LPN J reported Resident #35 had an old trach opening and it was not closed. LPN J reported when Resident #35 eats, he does get a lot of phlegm in his trach, he gets phlegm and usually does pretty fine. LPN J reported he did have a speech evaluation and was ordered to have a pureed diet for meals. LPN J reported he usually ate in the dining room when queried if Resident #35 needed to be monitored when he was eating. LPN J reported Resident #35 was not known for concern with aspiration, he usually coughed due to phlegm but was able to usually clear it out. LPN J reported the dressing would be changed on his trach opening as needed and she would return to change it when she was finished with her break. This writer observed a suction machine on Resident #35's night stand next to the head of his bed. LPN J did not suction Resident #35 prior to leaving the room. Resident #35 was still coughing sporatically and sounded very wet and had phlegm he was unable to clear. Reveiw of Resident #35's medical record revealed no documentation of this event in his medical record. In an interview on 02/26/25 01:56 PM, Registered Nurse (RN) M reported she would ensure the resident was sitting up right, stay with them, check vitals and make sure they were getting oxygen. RN M reported she would suction him due to his phylem, difficulty to speak, and coughing, RN M reported she would do that as there could be a bollus in there. RN M reported she would document the event in a progress note, complete a skilled nursing assessment and respirtaty symptom evaluation. In an interview on 02/26/25 at 02:06 PM, Registered Nurse (RN) O reported she would check the saturation and suction as needed for Resident #35. RN O reported she would monitor the resident to ensure they were not having a significant change. RN O reported the resident would be suctioned to ensure the Resident #35's airway was clear. In an interview on 02/26/25 at 09:08 AM, Resident #35 reported yesterday when he was coughing and could not get the phlegm cleared he was scared. Resident #35 reported that happened a lot to him. In an interview on 02/25/25 at 4:35 PM, Unit Manager (UM) BB reported the nurse should have suctioned Resident #35 when he was coughing so much and sounded like he had an unproductive wet phlegm sounding cough as he was considered an aspiration risk. UM BB' indicated the nurse would have monitored him closely because of the extended coughing and his history of aspiration pneumonia. UM BB reported LPN J should have replaced the oxygen tank at that time. In an interview on 02/26/25 02:17 PM Director of Nursing (DON) B reported LPN J should have replaced the dressing at that time as it was soiled, provide Resident #35 with the [NAME] to self suction as he typically was able to complete the suctioning himself and not go to lunch. DON B reported the nurse should have monitored the resident closely due to the continous coughing and increased sputum and due to his medical history. DON B reported the event should have been documented in the medical record so the information was available to the other staff who would be providing care for the resident. Review of Orders dated 02/12/25, revealed, .O2 @ 3 liters per minute via NC (nasal cannula) every 24 hours as needed for SOB (shortness of breath), wheezing give if O2 is <90% . Review of Orders dated 02/21/25, revealed, .Suction via trach site per yanker every 4 hours as needed for maintenance of patient airway . Review of Medication Administration Record (MAR) for February 2025, revealed, Resident #35 had not been suctioned after order was written or during this survey. Resident was hospitalized on [DATE] - 10/30/24 due to pneumonia; and 12/19/24 - 12/25/24 due to pnuemonia. hospitalized on [DATE] - 2/7/25 due to altered mental status due to severe sepsis. Review of Resident #35's medical records from his hospitalization in December 2024 revealed, he had .sepsis due to pnuemonia, bilateral .thick and copious yellow sputum from trach site .accuentuated lucency (the blood vessels and airways of the lungs appear more prominent or visible than usual, potentially indicating underlying respiratory or cardiac conditions) in the left upper lobe potentially bolus formation .recent history of pseudomonas (bacteria that can be challenging to get rid of and certain antibiotics that would typcially treat the condition no longer work) cultured from drainage of tracheostomy site .history of reflux aspiration .CT (scan) on 12/19 showed small airways thickening, mucous plugging (a condition where the thick mucous builds up and partially or completely blocks the airways in the lungs, causing breathing difficulties due to reduced airflow), subsegmental atelectasis (a partial collapse of a small section of lung tissue), infectious/inflammatory ground-glass (hazy appearance in the lungs) and tree-in-bud opacieities (small, clustered, branching, resembling branches of a tree, typically indicating inflammation or infection within the small airways of the lungs), mild to moderate pulmonary emphysema (lung diseases that permanently damages the lungs air sacs making it difficult to breathe) .

Based on observation, interview, and record review the facility failed to provide or use adaptive feeding equipment correctly for 1 residents (Resident #25) of 1 residents reviewed for adaptive equipment needs, resulting in the potential for decreased independence of consuming food and fluids and weight loss. Findings include: Review of Admission Record revealed Resident #25 was a male whose pertinent diagnosis included dysphagia oropharyngeal phase (swallowing disorder in the throat that impairs the ability to swallow). Review of Care Plan revised on 1/31/25 revealed, .(Resident #25) has a swallowing problem r/t (related to) complaints of difficulty or pain with swallowing medication and dysphagia . with the intervention .Alternate small bites and sips .Encourage resident to be up in his chair for all meals . Instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly .ASPIRATION PRECAUTIONS (FYI) . Review of Care Plan revised on 1/30/25, revealed, .(Resident #25) has nutritional problem or potential nutritional problem r/t (related to) hemiplegia/hemiparesis, dysphagia, GERD, and Depression/Anxiety . with the intervention .MEAL/INTAKE ASSISTIVE DEVICE: 5cc Provale cup (a cup that provides only a fixed amount of liquids with every normal drinking motion) only, many not use regular cup or straw . Review of Orders dated 1/30/25, revealed, .Regular diet Dysphagia Mech Soft/NDD3 texture (Level 3 dysphagia diet which allows for moist, bite-sized pieces of foot that are relatively easy to chew and swallow), Regular fluid, thin consistency, 5cc Provale cup only, may not use regular cup or straw . Review of Therapy to Nursing Communication Sheet dated 2/12/25 revealed, .Adaptive Equipment: Other .Provale Cups .Instructions: No straws, Provale cup only . Review of Resident #25's Dietary meal slips for breakfast, lunch, and dinner revealed, Adaptive cup: Provale cup 5cc (blue lid) . Note: No alerts for no straws there. During an observation on 02/24/25 at 12:22 PM, Resident #25 was observed in his room seated in his wheelchair. Resident #25 was observed to have two Provale cups on his lunch tray as well as a sytrofoam cup with straw, and a small 2 oz cup with water on his tray table. Resident #25 reported he gets a Styrofoam cup with water at every meal. During an observation on 02/25/25 at 01:53 PM, Resident #25 had a small 4oz cup of water with a straw, he had a cup with water he took a sip from. Observed a Styrofoam cup with a lid and straw on his tray table as well. On his lunch tray, there were two Provale cups. During an observation on 02/26/25 at 10:17 AM, observed Resident #25 was observed in his room he had a small plastic cup with a straw, and a water cup with a straw. In an interview on 02/26/25 at 10:35 AM, Certified Nursing Assistant (CNA) T reported Resident #25 had a special cup he received on his meal tray, believed it was so he was able to hold it due to Resident #25 shaking. CNA T reported with the Provale cup he was using it because he could choke and aspirate. CNA T reported Resident #25 should have the Provale cup with the ice water the CNAs brought to the resident's room each shift. In an interview on 02/26/25 at 11:52 AM, Speech Language Pathologist (SLP) JJ reported Resident #25 was in the hospital he had a video swallow study done, recommendations for the study were if he maintained intaking thin liquids, it would be either by teaspoon, safe straw (the facility does not have those available) or Provale cup. SLP JJ reported Resident #25 was not complaint with the teaspoon, so the facility implemented the provable cup as it released no more than 5 cc at a time to control the bolus size. SLP JJ reported Resident #25 was at an increased risk of aspiration and anytime he drank fluids the provable cup should be used. SLP JJ reported she educated the staff, Resident #25, and his wife on the use of the Provale cup.

This citation pertains to MI00133137 and MI00131737. Based on observation, interview, and record review the facility failed to consistently implement pressure ulcer prevention and treatment interventions and ensure complete and accurate skin assessments were performed to monitor, identify and treat skin alterations for 5 residents (Resident #11, #48, #7, #317, and #65) out of 7 residents reviewed for pressure ulcer care, resulting in the formation of new facility acquired pressure ulcers for Resident #11 and Resident #48, a delay in the treatment of a DTI (deep tissue injury) to the right foot and a stage 2 pressure injury to the left foot of Resident #65, and the potential for further clinical compromise for Resident #7 and #317. Findings include: Resident #11 Review of an Admission Record revealed Resident #11 admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia and Multiple Sclerosis. Review of a Minimum Data Set (MDS) assessment for Resident #11, 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 #11 was cognitively intact. Further review of the same MDS assessment revealed Resident #11 required assistance with bed mobility, toileting, and personal hygiene. Review of a current ADL (activities of daily living) Care Plan intervention for Resident #11, initiated [DATE], directed staff that Resident #11 could be up in her powered wheelchair daily for four hours at a time and was then required to lay down for one hour before getting back up for offloading of pressure. Review of a current physical mobility Care Plan intervention for Resident #11, initiated [DATE], directed staff that Resident #11 was totally dependent on staff for repositioning and turning in bed frequently as necessary. In an interview on [DATE] at 11:34 AM, Family Member of Resident #11 KK reported recently only 2 nursing aides showed up for the entire facility, 1 aide for 28 residents. In an interview on [DATE] at 3:19 PM, Family Member of Resident #11 KK reported staff are not turning Resident #11 every two hours and Resident #11's wound recently reopened because there was not enough staff to get her out of her powered wheelchair. In an interview on [DATE] at 9:35 AM, Resident #11 reported she had a wound on her bottom that was healed and then opened back up because she was left up in her powered wheelchair for 9 hours. Resident #11 reported that she was only allowed to be up for 4 hours at a time in her powered wheelchair to relieve pressure on her bottom. Resident #11 reported that 3rd shift was good about turning her every 2 hours, but 1st and 2nd shift were not as good. Resident #11 reported that she is unable to turn herself. Resident #11 reported that she was last turned at 6:45 AM, 3 hours ago. Resident #11 reported that 3rd shift checks on her automatically, but on 1st and 2nd shift she has to request turning. Resident #11 reported that it can take a long time for her call light to be answered, sometimes up to 2 hours. Resident #11 reported that call light response time depends on the staffing that day. In an interview on [DATE] at 10:25 AM, Resident #11 reported that it was a couple months ago that her wound broke back open, after being up in her powered chair for 9 hours. Resident #11 reported that there was a music activity and many residents needed assistance after the activity. Resident #11 reported that there was only 1 aide working on the hall that night and she seemed overwhelmed. In an observation on [DATE] at 11:58 AM in Resident #11's room, Wound Care Provider DD evaluated Resident #11's pressure ulcer on her right medial buttock to be 0.1 by 0.4 centimeters. Review of Resident #11's Wound Care Provider Progress Note dated [DATE] revealed .(Resident #11) is seen today because staff state she has an ulcer on her bottom again. Resident has a history of pressure injuries to her sacrum and right medial buttock . Resident with an ulcer on the right upper medial buttock measuring 0.2by1.1by0.2cm . Pressure injury of right buttock, stage 3 . Resident with a pressure injury to the right upper medial buttock again . Resident #48 Review of an Admission Record revealed Resident #48 admitted to the facility on [DATE] with pertinent diagnoses which included spinal stenosis and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #48, 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 #48 was cognitively intact. Further review of same MDS assessment revealed Resident #48 required assistance with bed mobility, toileting, and personal hygiene. Review of a current Kardex for Resident #48 directed staff that Resident #48 needed extensive assistance of 1 staff with bed mobility. In an interview on [DATE] at 10:05 AM, Resident #48 reported she needs help turning in bed and stated, they keep turning the call light off, don't come right away. In an observation and interview on [DATE] at 12:19 PM in Resident #11's room, Unit Manager E reported that a new wound was found over the weekend on Resident #11's left heel. Wound Care Provider DD evaluated the wound to be a 3.5 by 6.6-centimeter unstageable deep tissue injury. Observed left heel wound to be a large, blood-filled blister. In an interview on [DATE] at 8:54 AM, Resident #48 reported staffing was short over the weekend when her new left heel wound was found. Resident #48 reported when staffing is short they do not come in to assist her with repositioning in bed. Resident #48 reported when staffing is short it takes a long time for her call light to be answered. Review of the facility worked schedule on Saturday, [DATE] revealed there were only 3 nursing assistants working in the entire building from 11:00 AM until 11:00 PM. In an interview on [DATE] at 10:42 AM, LPN AA reported staffing has been challenging for months. LPN AA reported there were only 3 aides in the facility that morning and only 1 aide working with her on the 100 hall with 23 residents to care for. LPN AA reported when there is only 1 aide on the hall, there is not enough time to give residents showers and it is not possible to check, change, and turn residents every two hours. LPN AA reported when staffing is short, the aides work methodically through the unit to get to everyone as quickly as possible. In an interview on [DATE] at 10:06 AM, Certified Nursing Assistant (CNA) S reported that she was the only CNA on 100 hall the previous day. CNA S reported that happens at least once a week. CNA S reported there is no time for resident showers when she is the only CNA on the hall and it is not possible to perform check and changes and turns every two hours. In an interview on [DATE] at 2:55 PM, CNA U reported the facility needs a minimum of 5 CNA's to perform adequate resident care. CNA U reported that a couple times a month she works as the only CNA on a hall. CNA U reported when she is the only CNA working on a hall resident showers cannot be completed, waters might not get passed, and it is not possible to perform two hour resident checks and changes and turns. CNA U reported it takes closer to 4 hours to perform check and changes and turns when she is working alone on a hall. For patients at risk for skin breakdown who are able to sit in a chair, limit the amount of time they sit to 2 hours or less at any given time. In the sitting position the pressure on the ischial tuberosities is greater than in the supine position . Support surfaces are specialized devices for pressure redistribution designed for management of tissue loads, microclimate, and/ or other therapeutic functions (i.e., any mattress, integrated bed system, mattress replacement, overlay, seat cushion, or seat cushion overlay) (NPUAP, EUPAP, PPPIA, 2014). Support surfaces reduce the hazards of immobility to the skin and musculoskeletal system. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations ,d+[DATE]). Elsevier Health Sciences. Kindle Edition. Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (NPUPA, EUPAP, PPPIA, 2014). A standard turning interval of to 2 hours does not always prevent pressure ulcer development. Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition. When repositioning, use positioning devices to protect bony prominences (WOCN, 2010). The WOCN guidelines (2010) recommend a 30-degree lateral position (Figure ,d+[DATE]), which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions (see Chapter 39). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations ,d+[DATE]). Elsevier Health Sciences. Kindle Edition. Review of facility policy/procedure Skin Monitoring and Management- Pressure Ulcer, dated [DATE], revealed .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 . Prevention . Reposition the resident .Treatment . Continue preventative measures as appropriate, including but not limited to : pressure reduction, continence care, mobility, nutrition management, hydration management . 27445 Resident #7 Review of the face sheet revealed Resident #7 orginally admitted to the facility on [DATE] and discharged on [DATE] and readmitted on [DATE] with diagnosis that included multiple sclerosis, paraplegia, pressure ulcers, and urostomy (opening in the abdomen that connects to the urinary tract to allow urine to drain). Review of the Physician order dated [DATE] at 1:59 pm revealed Resident #7 was to have Wound Care for Stage 4 pressure ulcer to right ischium : Cleanse with NS; Apply thick layer of zinc barrier cream to peri wound. Pack wound with thin strip of Aquacel AG (about 2 cm deep). Cover with Mepilex. Change daily. In an observation on [DATE] at 12:58 PM, Physician Assistant/Wound Care Provider (PA/WCD) DD and Licensed Practical Nurse/Unit Manager (LPN/UM) E were preparing to change Resident # 7 pressure ulcer dressing on her right ischium. PA/WCD DD retrieved zinc oxide and placed it into a cup. LPN/UM E reported the wound is to be dressed using aqua cell AG and PA/WCD DD and LPN/UM E began looking for it. LPN/UM E stated I don't think we carry that. PA/WCD DD reported that the facility doesn't have it, and only the wound clinic has it. PA/WCD DD removed Resident #7's brief and there was a bandage on right lower ischium that was undated and unsigned. PA/WCD DD removed calcium Alginate packing (note, dressing material was not what was ordered)Resident #7's wound edges were clean, dry and intact. PA/WCD DD measured the wound depth to be 1.0. The wound was circular and approximately ,d+[DATE] cm. PA/WCD DD decided to use iodoform instead of Aquacel AG since they did not have any and stated the order is for aqua cell but can't follow the order because we don't have the material. PA/WCD DD packed iodoform in the wound, placed gauze into hole and covered with a bandage. Resident #7 then received a new brief, was boosted back up in bed by PA/WCD DD and LPN/UM E. Resident #7 voiced no complaints for procedure. Note that the ordered aqua cell was not used and zinc oxide was not placed in peri wound area. In an interview on [DATE] at 3:14 PM, LPN/UM E reported the Aqua Cell should have arrived by pharmacy if done by physician orders and it should have been delivered the next day the 29th. LPN/UM E reported the order was not entered correctly by the LPN who put the order in as other category instead of pharmacy. 47659 Resident #317 Review of Admission Record revealed Resident #317 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region. Review of a Minimum Data Set (MDS) assessment for Resident #317, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #317 was moderately cognitively impaired. Review of Skin Conditions revealed that Resident #317 was at risk for developing pressure ulcers. Review of Resident #317's Care Plan revealed, .has potential/actual skin impairment to skin integrity r/t (related to) stage IV pressure injury to sacrum (tailbone), impaired mobility. Date initiated [DATE]. Goal: Resident's skin integrity breaks will exhibit healing by next review date. Interventions: Elevate heels off bed surface while at rest in bed .Keep skin clean and dry .Follow physician orders for treatment of skin impairments .Provide pain management for treatments as needed .Date initiated [DATE] . There were no interventions related to Resident #317's pressure injury on the sacrum. During an interview on [DATE] at 08:29 AM, Resident #317 reported concern that call lights did not get answered quickly enough,which led to several occasions where Resident #317 had incontinence while waiting for assistance to use the restroom and was left wet. During an observation on [DATE] at 03:30 PM, Resident #317 was observed in her room sitting in her wheelchair. There were no pillows underneath Resident #317 hips or bottom to offload the sacral pressure ulcer. During an observation on [DATE] at 7:55 AM, Resident #317 was in her bed, lying on her back with the head of bed elevated at approximately 45 degrees. There were no pillows were observed underneath Resident #317 hips or bottom to offload the sacral pressure ulcer. Resident #17's feet were observed lying directly on the surface of the bed. During an interview and observation on [DATE] at 09:14 AM, Resident # 317 was observed lying in her bed in the same position as previous observation. Resident #317 reported that the wound on her butt was painful and facial grimacing was noted throughout interview. Resident #317 reported that she felt the staff were unreliable and inconsistent, and she was not getting repositioned every two hours. During an interview on [DATE] 09:20 AM, Registered Nurse (RN) X reported that she was aware that Resident #317 was in pain and that had already given her Tylenol and oxycodone (pain medication) for this, and that Resident #317 needed a better mattress. RN X also reported that she had been in Resident #317's room every 35 seconds this morning. Review of Medication Administration Record indicated Resident #317 received Acetaminophen (Tylenol) 500 mg at 08:00 AM, and Oxycodone 5 mg at 07:09 AM. RN X documented Resident #317 pain level at 0 under pain evaluation, and 1 under pain level for administration of Oxycodone. During an observation on [DATE] at 10:22 AM, Resident# 317 was observed sitting in her wheelchair without any pillows for offloading or positioning, and sitting directly on her pressure wound. During an observation on [DATE] at 11:16 AM, Resident #317 was observed on her back with the head of the bed elevated to approximately 45 degrees. There were no pillows observed for offloading the wound of Resident #317's sacral area. Resident #317 was positioned on her pressure wound and her feet were directly on the surface of the bed (not elevated). During an wound care observation on [DATE] at 11:24 AM, Resident #317 was lying in bed on her right side. Physician Assistant-Wound Care (PA-WC) DD removed Resident #317's incontinence brief which revealed a large gaping wound approximately fist size, with slough and eschar (dead tissue) in the wound bed, and reddened skin surrounding the wound. Resident #317 was positioned on her back following wound care and stated Ouch it hurts. PA-WC DD reported that Resident #317 should have an alternating pressure air mattress due to her sacral wound, and LPN UM D reported that she would get it ordered. During an interview on [DATE] at 12:47 PM, PA-WC DD reported that her clinical recommendations for Resident #317's wound care would include an alternating air pressure mattress, repositioning at least every two hours, and she would not want to see Resident #317 in a position where she is sitting directly on the wound. PA-WC DD reported that offloading with pillows would help decrease the pain from the wound. During an observation on [DATE] at 01:32 PM, Resident #317 was observed sitting up in bed in the same position as previous observation on [DATE] at 11:24 AM. Resident #317 had been in the same position for greater than 2 hours. Resident #17's feet were observed lying directly on the surface of the bed. During an interview on [DATE] at 02:05 PM, Certified Nursing Assistant (CNA) O reported that she goes from room to room to check on residents, and she determines which residents need to be repositioned every two hours by just asking the residents. CNA O did not identify that Resident #317 required every 2 hour repositioning. During an observation on [DATE] at 08:29 AM, Resident #317 was observed lying in bed with the HOB approximately 45 degrees, and there were no pillows to offload Resident #317's sacral pressure ulcer. Resident #317's bed did not have an alternating air pressure mattress. Review of Resident #317's Order summary report did not include orders for frequency of repositioning or alternating air pressure mattress. Review of Resident #317's Kardex (CNA care guide) revealed, elevate heels off bed surface while at rest in bed, keep skin clean and dry . There were no interventions related to repositioning. 41027 Resident #65 Review of an Admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness and severe protein/calorie deficiency. Review of a Minimum Data Set (MDS) assessment for Resident #65, 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 #15 was cognitively intact. Review of the Functional Status revealed that Resident #15 required extensive assistance of one person to reposition in bed, and extensive assistance of two people for toileting needs. Review of Skin Conditions revealed that Resident #65 was at risk for pressure ulcers and did not have any pressure ulcers or other skin conditions. In an interview on [DATE] at 12:43 PM, Family Member (FM) LL reported that Resident #65 was sent to the hospital on [DATE] and died a few weeks later. FM LL reported that Resident #65 had uncontrolled pain, was dehydrated, and had wounds on both feet, that the facility had not identified during their skin observations. FM LL reported that Resident #65 was too tall for his bed and his feet pressed against the foot board. Review of Resident #65 Hospital Records indicated admission via emergency roiagnom on [DATE], wound consult on [DATE], transition to palliative care on [DATE], and death in the hospital on [DATE]. Images from [DATE] reviewed and indicate wounds on the bottom of both feet. Wound Care Services on [DATE] at 5:30 AM .The Wound Healing Program is consulted for bilateral black wounds on 5th toes. He is a poor historian and does not know how long the wounds have been present or how he got them. He states he does not ambulate .Pressure injury of deep tissue of right foot, Assessment & Plan: Plantar surface (bottom of foot) over right 5th MT (metatarsal: bone on outside on foot) Dark tissue from evolving DTI (deep tissue injury) likely from pressure, 1.4 x 1.5 x 0.1 cm .Pressure injury of left foot, stage 2. Assessment & Plan: Appears to be recovering DTI, Wound is located over the 5th MT, 0.6 x 0.5 x 0.1 cm, Partial thickness likely from pressure . In an interview on [DATE] at 10:49 A.M., DON reported that Resident #65's record did not indicate that Resident #65 had any wounds, and that DON had evaluated Resident #65's skin at the request of FM LL, and the only finding was dry skin. Review of Resident #65's Nursing Admission assessment dated [DATE] indicated that Resident #65 did not admit to the facility with wounds. Review of Resident #65's Weekly Skin Observations from admission through to the last one complete on [DATE] all indicated that Resident #65 had No New Skin Conditions. Review of Resident #65's Physician Admission assessment dated [DATE] did not include Skin in the examination and did not indicate Resident #65 had skin wounds under History or Assessment and Plan. Review of Resident #65's Physician Orders revealed no orders related to dry skin or wounds. Review of Resident #65's Braden Scale for Predicting Pressure Ulcers dated [DATE] indicated that Resident #65 was at moderate risk for developing pressure ulcers. Review of Resident #65's Skin Care Plan revealed, .has potential/actual skin impairment to skin integrity r/t (related to) decreased mobility, decreased awareness of needs, incontinence. Date initiated [DATE] .Goal: Resident will maintain intact skin through the next review. Interventions: Educate resident/family/caregivers .Encourage good nutrition and hydration .Follow physician orders for treatment of skin impairments. Refer to eTAR (electronic treatment administration record) for specifics .Observe skin daily .Weekly treatment documentation to include measurement of each area of skin breakdowns . The care plan was created and initiated on [DATE] and did not have any revisions. Review of Resident #65's Skilled Nursing Note dated [DATE] at 09:25 AM revealed, Resident's guardian came to facility to speak with med staff about resident's pain control. MD (Medical Director), NP (Nurse Practitioner), DON and UM (unit manager) met with guardian .Guardian expressed interest in having resident examined, as he appeared to have continued dryness to his skin. Med staff to see today . Review of Resident #65's Progress Note dated [DATE] at 6:45 PM revealed, Acute Care Transfer .Resident c/o (complains of) significant pain with sudden onset of worsening pain .Order to send to ER .

Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 of 4 residents (Resident #14) reviewed for accidents/hazards, resulting in the potential for residents to sustain a fall injury which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #14 was a female with pertinent diagnoses which included heart failure, diabetes, GI bleed, muscle weakness, cervical disc degeneration (compression on the vertebrae in the neck causing pain), colon cancer, diverticulosis (pockets or small pouches in the intestine which can become inflamed), kidney disease, anxiety, bursitis (inflammation in the cushions of the joint) of the left hip, chronic pain, spinal stenosis, anemia, shortness of breath, respiratory failure, and abnormalities of gait. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 3/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #14 was cognitively intact. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 11/01/2022, revealed, .Extensive Assistance .Two+ persons physical assist .Upper extremity .Impairment on one side . Review of current Care Plan for Resident #14, revised on 3/14/2021, revealed the focus, .Resident has an ADL (activities of daily living) self-care performance deficit r/t (relate to) impaired mobility (cervical disc degeneration, bursitis left hip, sciatic RIGHT LE (lower extremity) . with the intervention .Encourage and/or assist resident to meet toileting needs either with utilization of bathroom, bedpan, commode, urinal per resident request, preference, and as needed . In an interview on 05/01/23 at 08:04 AM, Resident #14 reported she fell and broke her leg last December 2022. Resident #14 reported the aide didn't' know how to get me up as she utilized a sit to stand for transfers. Resident #14 stated, .I was slipping out of the sling, she didn't buckle the two buckles, it was a smaller of the vest and I couldn't breathe .I think that I fainted .I guess I let go of the handle bars, slid out and flat on my back .I twisted my leg somehow and broke my femur .I was in terrible pain, screaming and the ambulance came and took me to the hospital . Review of Event Note dated 12/19/2022 at 10:50 PM, revealed, .During transfer resident slid out of [NAME] pad and onto the floor. CNA witnessed this event and state resident did not hit her head. Resident immediately stated pain in her right knee. Right knee appears swollen. On call provider notified and order to send resident to the emergency room obtained. Resident transferred via (ambulance service) to (Local Hospital). Review of Incident Report dated 12/19/22 at 21:30 PM, revealed, .Resident slid to the floor during a transfer with the [NAME] lift .Patient Description: I don't know, I think I passed out.Resident stabilized on the floor, physician and EMS notified. Assisted off the floor by EMS and sent to (Local Hospital) .Pain .Right Knee (front) .Predisposing Physiological Factors: Incontinent, Weakness/Fainted .Other Info .Resident states her pad for the lift wasn't positioned properly . Review of Witness Statement by Agency CNA NN included in the Incident Report revealed, .Her butt was on the edge of the bed, I said to (Resident #14), hold on to the handles I need to push her more and the bed, but she took her hands off the handles, and she slide down to the floor . Review of Statement dated 12/19/22, signed by LPN SS revealed, .During examination by nurse of (Resident #14) it was noted that (Resident #14)'s right knee had swelling .Resident expressed extreme pain in the right knee and was not able to extend leg out .Nurse was supporting (Resident #14) by sitting behind her and holding her so that she was not resting her head and back on the [NAME] stand legs .Three CNAs and two nurses came to assist nurse with resident. Resident was assisted to the floor and [NAME] stand moved from under her safely . Review of Post Fall assessment dated [DATE], revealed, .Previous history of fall .Yes .Injuries related to his fall .Yes .Any pain during ROM (range of motion) or ambulation .Yes .Previous Interventions: Call light within reach, medications as ordered, bed in lowest position .New Interventions: Educate all staff that transfers with mechanical lifts must have 2 people Review of (Local Hospital) Emergency Department Note dated 12/19/22 revealed, .Patient presents emerged department for right knee pain. Patient currently lives in a skilled nursing center. Patient was brought to the emergency department via EMS. According to paramedics, the patient was transferring from wheelchair to bed with assistance. Patient's legs gave out. Patient slid to the floor. Injuring her right knee .Patient is now complaining of right lower extremity pain. She states that she cannot put any weight on her right lower extremity. Patient informs me that she does have a surgery scheduled for tomorrow. She believes it has something to do with her Foley catheter. Patient's prearrival form states that the patient had a bowel prep done today for colonoscopy tomorrow . Musculoskeletal: Right lower extremity: There is obvious deformity over the knee joint. There is gross soft tissue swelling. There is mild shortening or rotation of the right lower extremity when compared to the left. Patient is not able to move the right lower extremity secondary to pain. She has significant tenderness over the generalized femur area . Review of Orthopedic Trauma Consult dated 12/20/22 at 7:22 AM, revealed, .Patient is a 78 y.o. female with a right periprosthetic Distal Femur Fracture s/p twisting injury during transfer at care facility .Clinical impressions: Closed bicondylar fracture of distal femur, right .Closed fracture of distal end of right femur, unspecified fracture morphology . Review of Admit/Readmit Note dated 12/22/2022 at 3:12 PM, revealed, .Resident arrived at facility approximately 1:40 pm accompanied by two paramedics transferred by stretcher from (Local Hospital). Residents admitting Diagnosis to (Local Hospital) Right Femur Fracture. Paramedics transferred resident from the stretcher to bed Resident c/o some discomfort during transfer and repositioning. Assessment completed by writer .Wound Treatments Primapore to Right Femur. (Primapore: a post operative wound dressing .aids in the prevention of bacterial contamination .water resistant dressing). Review of General Progress Note dated 12/28/2022 at 1:35 PM, revealed, .Resident c/o (complaint of) mild pain to leg area .accepted prescribed pain medications, Gabapentin and PRN Tramadol. Also allowed writer to administer Lidocaine patch to upper right thigh prior to scheduled therapy. Resident relaxed calm, with no complaints thereafter administration of pain medication. Residents dressing to right thigh intact without drainage. Will continue to monitor resident . In an interview on 05/03/23 at 10:10 AM, Resident #14 reported she was concerned because she was not being taken to the bathroom. Resident #14 stated, People are not wanting to take me to the bathroom .Telling me they don't have time to take me to the bathroom .Supposed to be two people to get me up and take me to the bathroom but there was only one aide on the hallway, and they have to always look for help to take me to the bathroom . Review of General Progress Note dated 4/4/2023 at 4:32 PM, revealed, .Late entry for 4/3/23 Quarterly MDS w/ ard 3/20. Patient interviewed and confirmed total assist mechanical lift with two assist used for all transfers . In an interview on 05/03/23 at 11:21 AM, Registered Nurse (RN) I reported she was the manager on duty and it was a significant event. RN I reported the CNA was assisting Resident #14 was transfer to her bed, not quite on the bed and she slid out of the sit to stand. RN I stated, When I got down there, she was on the floor, the nurse was with her .She was in a lot of pain and I could tell something was wrong, told staff not to move her, and call EMS to have the come and evaluate her .They started her IV and gave her fentanyl because she was in so much pain .The resident told me she thought she fainted .It was horrible .Education was immediately provided to staff members .She was a two person sit to stand . RN I reported if they were a lift, they were a two person for transfers. In an interview on 05/03/23 at 11:42 AM, Agency CNA NN reported the facility was giving the resident prep for a colonoscopy the next day. CNA NN reported staff were telling me the resident did not need two persons for assist with the [NAME] stand lift. CNA NN stated, .I kept telling people I needed help and she needed two people to transfer .What was I supposed to do? I was the only CNA assigned to that hall and she needed to get to the bathroom because she was drinking stuff for the colonoscopy .I set her down on the toilet and raised her up, cleaned her bottom .She was getting weak, pulled the light .I really needed help and yelled out the door but no one would answer me .She was feeling lightheaded and she had diarrhea continuously and she was not strong enough to hold on .I had to get her off the toilet, I couldn't get help and I couldn't let her sit there for hours (in the bathroom) .It was in the best interest of the resident .I got her up and got her over to the edge of the bed and asked her to let me get her steady and everything was intact, the sling goes all around behind her, and raised her up and she let go of everything and slid from underneath the [NAME] lift . I felt the best of my knowledge not to leave her in that, as that is not right either, and not getting help from the other staff . In an interview on 05/03/23 at 02:18 PM, DON B reported the resident let go of the handles during the transfer and does not participate very well with being transferred with the lift. DON B stated, .With the [NAME] lift we would have to do some of the work for her . DON B reported Resident #14 was to have been a two person assist with transfers.

This citation pertains to intake #MI00127894 Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being in 5 of 60 sampled residents (Resident #31, #14, #42, #11, & #48) reviewed for staffing, resulting in unmet care needs , reopening of a pressure ulcer for Resident #11, a fall with fracture for Resident #14, and the potential for physical and psychosocial harm for all residents in the facility. Findings include: Review of Resident Census and Conditions of Residents (CMS Form 672) submitted for review on 5/1/2023 indicated a census of 60 residents, and that there were 60 residents were either an Assist of One or Two Staff or Dependent on staff for bathing; 59 residents were either an Assist of One or Two Staff or Dependent on staff for dressing; 54 residents were either an Assist of One or Two Staff or Dependent on staff for transferring; and 60 residents were an Assist of One or Two Staff for toilet use . In a confidential group interview on 05/03/23 at 10:29 AM, 7 out of 9 residents reported the staff were coming in the resident's rooms and were turning off the call lights when the need was not met. Residents reported concerns with second shift and third shift. Residents reported it was really hard to get their needs met when there was only one aide on each hallway. Review of the Master Schedule for Nurse Supervisor First Shift 6:45 AM to 3:15 PM had an open position for part time nurse and a full-time nurse; Second shift 2:45 PM to 11:15 PM, had an open position for a part time nurse for coverage on Saturday and Sunday on the first week of the rotation. Nurse Supervisor Third Shirt 10:45 PM to 7:15 AM, had an open full time position . Review of the Master Schedule for Nurse Aide First Shift 7a - 3p had one full time opening, and two part time openings; Nurse Aide Second Shift 3pm-11pm had three full time openings and one part time opening; Nurse Aide Third Shift 11pm - 7am had a part time opening . In an interview on 05/03/23 at 12:24 PM, Scheduler CC reported the facility had a master schedule with the same rotation every two weeks. The staff process to request personal time off should be submitted at least 30 days prior typically, lesser if they need it off for an emergent situation. Scheduler CC reported she would post all open shifts in the schedule book and would send out mass messages to staff informing them of the openings. If not all the shifts were covered, then there would be a meeting held with the unit managers to recruit staff. Scheduler CC reported the facility does utilize an staffing agency to assist with staffing. Scheduler CC reported for aide staffing had been 3 aides for 100 hallway, 3 aides on 300 hallway, and 1 aide on the 200 hallway with a split person. The split person would cover the hallway with the heavier load based on the acuity level. Scheduler CC reported on the weekends staff don't want to work and would call in. Scheduler CC reported the facility does not do mandations but have offered extra pick up pay per hour. Resident #31: Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 3/15/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #31 was cognitively intact .B. Transfer: Total Dependence with Two+ persons physical assist. In an interview on 05/03/23 at 10:42 AM, Resident #31 reported he really had a hard time getting to activities because there were not enough CNAs to get him up for the activities. Resident #31 stated, .Sometimes I get to go and sometimes I don't . Resident #14: Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 3/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #14 was cognitively intact. In an interview on 05/01/23 at 08:04 AM, Resident #14 reported she fell and broke her leg last December 2022. Resident #14 reported the aide didn't' know how to get me up as she utilized a sit to stand for transfers. Resident #14 stated, .I was slipping out of the sling, she didn't buckle the two buckles, it was a smaller of the vest and I couldn't breathe .I think that I fainted .I guess I let go of the handle bars, slid out and flat on my back .I twisted my leg somehow and broke my femur .I was in terrible pain, screaming and the ambulance came and took me to the hospital . Review of Orthopedic Trauma Consult dated 12/20/22 at 7:22 AM, revealed, .Patient is a 78 y.o. female with a right periprosthetic Distal Femur Fracture s/p twisting injury during transfer at care facility .Clinical impressions: Closed bicondylar fracture of distal femur, right .Closed fracture of distal end of right femur, unspecified fracture morphology . Review of General Progress Note dated 4/4/2023 at 4:32 PM, revealed, .Late entry for 4/3/23 Quarterly MDS w/ ard 3/20. Patient interviewed and confirmed total assist mechanical lift with two assist used for all transfers . In an interview on 05/03/23 at 11:21 AM, Registered Nurse (RN) I reported she was the manager on duty at the time of the fall and it was a significant event. RN I reported the CNA was assisting Resident #14 was transfer to her bed. RN I stated, When I got down there, she was on the floor, the nurse was with her .She was in a lot of pain and I could tell something was wrong, told staff not to move her, and call EMS to have the come and evaluate her .They started her IV and gave her fentanyl because she was in so much pain .The resident told me she thought she fainted .It was horrible .She was supposed to be a two person sit to stand . RN I reported if they were a lift, they were a two person for transfers. In an interview on 05/03/23 at 11:42 AM, Agency CNA NN reported the facility was giving the resident prep for a colonoscopy the next day. CNA NN stated, .I kept telling people I needed help and she needed two people to transfer .What was I supposed to do? I was the only CNA assigned to that hall and she needed to get to the bathroom because she was drinking stuff for the colonoscopy .I set her down on the toilet and raised her up, cleaned her bottom .She was getting weak, pulled the light .I really needed help and yelled out the door but no one would answer me .She was feeling lightheaded and she had diarrhea continuously and she was not strong enough to hold on .I had to get her off the toilet, I couldn't get help and I couldn't let her sit there for hours (in the bathroom) .I got her up and got her over to the edge of the bed and asked her to let me get her steady and everything was intact, the sling goes all around behind her, and raised her up and she let go of everything and slid from underneath the [NAME] lift . I felt the best of my knowledge not to leave her in that, as that is not right either, and not getting help from the other staff . In an interview on 05/03/23 at 10:10 AM, Resident #14 reported she was concerned because she was not being taken to the bathroom. Resident #14 stated, People are not wanting to take me to the bathroom .Telling me they don't have time to take me to the bathroom .Supposed to be two people to get me up and take me to the bathroom but there was only one aide on the hallway and they have to always look for help to take me to the bathroom . Resident #42: Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 1/9/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #42 was cognitively intact. In an interview on 05/01/23 at 11:30 AM, Resident #42 reported the staff have taken a long time to respond to call lights. Resident #42 reported the staff would come in, say they would get someone to come help me and then they never come back. Resident #42 stated, .I feel sometimes they ignore me . Resident #42 stated, .One day what day I called because I needed my pants changed, they were poopy .They (staff) never came and I was in poopy pants practically all day I was getting a sore in my butt crack and right there (Resident #42 pointed to her vaginal area) .Poopy pants are not good . Resident #42 reported she was not getting her showers or baths as well as the facility was really short on staffing with only one aide on the hallway. In an interview on 05/03/23 at 12:40 PM, CNA Y reported on Monday 05/01/23 reported was super busy and I had no partner to help me. CNA Y reported management was coming out and helping when they could. CNA Y stated, .This does happen a couple times a month .When I have a partner we can usually get things done but when I don't I just try to keep up with the basic stuff, check and changes, and try to touch everybody .Sometimes the resident gets a bed bath instead of a shower .And when the resident was a two person assist there was extra long waiting to get someone else to help me .I really try to communicate with my residents to let them now when I can get to them .It is hard though when they have to go to the bathroom . In an interview on 05/03/23 at 01:58 PM, Director of Nursing (DON) reported the facility maintains a certain level for staffing. The NHA will send out a broadcast if we get to the critical level of staffing. We don't want to go above the number of residents to every one staff. DON B reported it would be 1 staff member for every 8 residents for 1st shift, 1 staff member for every 12 residents for 2nd shift, and 1 staff member for every 15 residents for 3rd shfit. DON B reported we have a staffing meeting and discuss what is happening with staffing for the next few days. 45410 Resident #11 Review of an Admission Record revealed Resident #11 admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia and Multiple Sclerosis. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 4/1/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #11 was cognitively intact. Further review of the same MDS assessment revealed Resident #11 required assistance with bed mobility, toileting, personal hygiene, and bathing. Review of a current ADL (activities of daily living) Care Plan intervention for Resident #11, initiated 12/7/2021, directed staff that Resident #11 could be up in her powered wheelchair daily for four hours at a time and was then required to lay down for one hour before getting back up for offloading of pressure. Review of a current physical mobility Care Plan intervention for Resident #11, initiated 8/7/2021, directed staff that Resident #11 was totally dependent on staff for repositioning and turning in bed frequently as necessary. Review of a current ADL (activities of daily living) Care Plan intervention for Resident #11, initiated 8/7/2021, directed staff that Resident #11 should be showered according to the shower schedule. In an interview on 4/27/2023 at 11:34 AM, Family Member of Resident #11 KK reported recently only 2 nursing aides showed up for the entire facility, 1 aide for 28 residents. In an interview on 4/27/2023 at 3:19 PM, Family Member of Resident #11 KK reported staff are not turning Resident #11 every two hours and Resident #11's wound recently reopened because there was not enough staff to get her out of her powered wheelchair. In an interview on 5/1/2023 at 9:35 AM, Resident #11 reported she had a wound on her bottom that was healed and then opened back up because she was left up in her powered wheelchair for 9 hours. Resident #11 reported that she was only allowed to be up for 4 hours at a time in her powered wheelchair to relieve pressure on her bottom. Resident #11 reported that 3rd shift was good about turning her every 2 hours, but 1st and 2nd shift were not as good. Resident #11 reported that she is unable to turn herself. Resident #11 reported that she was last turned at 6:45 AM, 3 hours ago. Resident #11 reported that 3rd shift checks on her automatically, but on 1st and 2nd shift she has to request turning. Resident #11 reported that it can take a long time for her call light to be answered, sometimes up to 2 hours. Resident #11 reported that call light response time depends on the staffing that day. Resident #11 reported staff are not able to shower her when there are staffing problems. In an interview on 5/2/2023 at 10:25 AM, Resident #11 reported that it was a couple months ago that her wound broke back open, after being up in her powered chair for 9 hours. Resident #11 reported that there was a music activity and many residents needed assistance after the activity. Resident #11 reported that there was only 1 aide working on the hall that night and she seemed overwhelmed. In an observation on 5/2/2023 at 11:58 AM in Resident #11's room, Wound Care Provider DD evaluated Resident #11's pressure ulcer on her right medial buttock to be 0.1 by 0.4 centimeters. Review of Resident #11's Wound Care Provider Progress Note dated 3/7/2023 revealed .(Resident #11) is seen today because staff state she has an ulcer on her bottom again. Resident has a history of pressure injuries to her sacrum and right medial buttock . Resident with an ulcer on the right upper medial buttock measuring 0.2by1.1by0.2cm . Pressure injury of right buttock, stage 3 . Resident with a pressure injury to the right upper medial buttock again . Review of the facility Daily Shower Assignment revealed Resident #11 was scheduled to receive showers on day shift on Mondays and Thursdays. Review of Resident #11's Skin Observation Shower sheets provided by the facility revealed that from February 2023 until 5/3/2023, Resident #11 received a shower on 2/2/2023, 2/27/2023, 3/16/2023, 3/20/2023, 3/23/2023, 3/30/2023, 4/17/2023, 4/21/2023, and 4/27/2023. Resident #48 Review of an Admission Record revealed Resident #48 admitted to the facility on [DATE] with pertinent diagnoses which included spinal stenosis and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 4/3/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #48 was cognitively intact. Further review of same MDS assessment revealed Resident #48 required assistance with bed mobility, toileting, personal hygiene, and bathing. In an observation and interview on 5/2/2023 at 12:19 PM in Resident #11's room, Unit Manager E reported that a new wound was found over the weekend on Resident #11's left heel. Wound Care Provider DD evaluated the wound to be a 3.5 by 6.6-centimeter unstageable deep tissue injury. Observed left heel wound to be a large, blood-filled blister. In an interview on 5/3/2023 at 8:54 AM, Resident #48 reported staffing was short over the weekend when her new left heel wound was found. Resident #48 reported when staffing is short they do not come in to assist her with repositioning in bed. Resident #48 reported when staffing is short it takes a long time for her call light to be answered. Review of the facility worked schedule on Saturday, 4/29/2023 revealed there were only 3 nursing assistants working in the entire building from 11:00 AM until 11:00 PM. Review of the facility Daily Shower Assignment revealed Resident #48 was scheduled to receive showers on day shift on Wednesdays and Saturdays. In an interview on 5/1/2023 at 10:05 AM, Resident #48 reported she has been missing many showers. Resident #48 reported missing showers makes her feel dirty and grubby. Review of Resident #48's Skin Observation Shower sheets provided by the facility revealed that from February 2023 until 5/3/2023, Resident #48 received a shower on 2/1/2023, 2/27/2023, 3/23/2023, 3/27/2023, 4/6/2023, 4/24/2023, and 4/27/2023. In an interview on 5/1/2023 at 10:42 AM, LPN AA reported staffing has been challenging for months. LPN AA reported there were only 3 aides in the facility that morning and only 1 aide working with her on the 100 hall with 23 residents to care for. LPN AA reported when there is only 1 aide on the hall, there is not enough time to give residents showers and it is not possible to check, change, and turn residents every two hours. LPN AA reported when staffing is short, the aides work methodically through the unit to get to everyone as quickly as possible. In an interview on 5/2/2023 at 10:06 AM, Certified Nursing Assistant (CNA) S reported that she was the only CNA on 100 hall the previous day. CNA S reported that happens at least once a week. CNA S reported there is no time for resident showers when she is the only CNA on the hall and it is not possible to perform check and changes and turns every two hours. In an interview on 5/3/2023 at 2:55 PM, CNA U reported the facility needs a minimum of 5 CNA's to perform adequate resident care. CNA U reported that a couple times a month she works as the only CNA on a hall. CNA U reported when she is the only CNA working on a hall resident showers cannot be completed, waters might not get passed, and it is not possible to perform two hour resident checks and changes and turns. CNA U reported it takes closer to 4 hours to perform check and changes and turns when she is working alone on a hall. .There is a positive correlation between direct patient care provided by an RN (Registered Nurse) and positive patient outcomes, reduced complication rates, and a more rapid return of the patient to an optimal functional status .Research also correlates poor staffing with missed nursing assessments and missed nursing care . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 1265 of 76897). Elsevier Health Sciences.

This citation pertains to intake number MI 290. Based on interview and record review, the facility failed to provide adequate supervision to prevent elopement in 1 of 3 sampled residents (Resident #101) reviewed for supervision, resulting in an immediate jeopardy when Resident #101, who was an elopement and fall risk and had a BIMS of 1, eloped from the facility unbeknownst to facility staff and was last seen on 8/13/21 at approximately 6:00 A.M. and found on 8/13/21 at 2:30 P.M. by his son in front of a local church 1.4 miles from the facility and located on a four-lane, 35 mph road in an [NAME] business district. Resident #101 stated he had a fall and had a reddened arm when found. This deficient practice placed 13 additional residents identified as at risk for elopement at risk for serious harm, injury, and/or death. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was a male, with pertinent diagnoses which included: [CONDITION(S)], [CONDITION(S)], seizures, and history of falling. Review of Resident #101's Wandering Risk Scale assessment dated [DATE] revealed a Category of At Risk To Wander and a Score of 9.0 indicating resident was At Risk to Wander. Review of a facility incident report received by the state agency on 8/13/21 at 1:05 P.M and investigation report received by the state agency on 8/20/21 at 4:45 P.M. revealed, the incident occurred on 8/13/21 at 8:00 A.M. Incident Summary At 8 AM CNA was bringing (Resident #101) his breakfast tray, and found that he was not in his room. Code called and staff confirmed that resident was not in the building. Investigation Summary of the Event: At 8:00 AM Director of Nursing (DON B) had been called when (Resident #101) was found not to be in his room when CNA delivered his breakfast tray. Nurse (Licensed Practical Nurse (LPN) CC) had not yet interacted with (Resident #101) during her shift, but had learned in report from Nurse (Licensed Practical Nurse: (LPN) AA) that he had been up during the night walking in the hallways and refused his morning medications at 6:00 AM .8/12/2021 o 10:00 PM: CNA (Certified Nurse Aide (CNA) H) noticed that (Resident #101) was up pacing the hallways. The typical time he goes to bed is 10:30 PM and this was not typical behavior for him during that time of day. 8/13/2021 o 1:00 AM - 2:00 AM: CNAs (H and I) interacted with (Resident #101) as he walked down the hallway to the nurses' station. (Resident #101) is not typically up during the night. Both CNAs discussed how unusual this was with him and that he told them he napped during the day, so he was unable to sleep .6:00 AM: Nurse (Licensed Practical Nurse: (LPN) AA) went to (Resident #101)'s room. He was asleep in his bed facing the window with his back to her. She tried to wake him to take his pills but he didn't move. She knew it was him in his bed because she could see his hair. o 8:00 AM: CNA came to (Resident #101)'s room to deliver his breakfast tray and found him not in his room. She found his blankets and pillows arranged under his blanket to look like there was a body under the blanket .2:00 PM: Son (name omitted) found (Resident #101) outside of the (business name and address omitted) .2:15 PM .(Resident #101) presents slightly tense but conversational. He had some belongings with him on a hand truck. (Resident #101) was willing to discuss why/how he left the building, and willing to accept bottle of water. He had informed his son that he fell earlier in the day and it was evidenced by redness to his right arm .2:40 PM: Ambulance arrives and (Resident #101) is willing to go to the hospital, and sits down on stretcher. EMT takes report from Son and Administrator and leaves for (hospital name omitted) for evaluation of right arm and psychiatric evaluation . In an interview on 9/7/21 at 2:50 P.M., Family Member (FM) M reported Resident #101 had had a wander guard when he was first admitted to the facility years ago but that had been removed because the facility had decided he was no longer a wander risk. FM M reported Resident #101 was therefore not wearing a wander guard when eloped. FM M stated, I did call the Social Worker at one time and told her to keep an extra eye on him. FM M reported the call was made to the Social Worker a few months ago because Resident #101 had been collecting money to run away. FM M stated, They probably told you he wasn't taking his medications. When my son found him, he had big bags of pills with him. So now they have started watching him swallow the pills. In an interview on 9/7/21 at 3:02 P.M. Certified Nurse Aide (CNA) F reported had worked on Resident #101's hall the morning of 8/13/21. CNA F reported had received report that morning from CNA H who had mentioned that Resident #101 had been up pacing the halls until 2:00 A.M. CNA F reported when went into Resident #101's room to give him is breakfast around 8:00 A.M. on 8/13/21, he was not there. CNA F reported when did rounds at the beginning of the shift, Resident #101's door was closed and We didn't think anything of it. He is independent so we don't go in there unless we have to. In an interview on 9/7/21 at 3:33 P.M., Activities Director (AD) D stated, Resident #101 did not have a wander guard at the time that he left because we felt no need. In an interview on 9/7/21 at 4:23 P.M., CNA H reported had worked 2nd and 3rd shift on 8/12/21 - 8/13/21. CNA H reported the staff had noticed Resident #101 was walking the halls in the early morning of 8/13/21 (12:00 A.M. or 1:00 A.M.) and had asked Resident #101 what was wrong and was he okay. CNA H reported Resident #101 had said he had taken a nap during the day and couldn't sleep. CNA H reported not being aware that Resident #101 was an elopement risk at the time that he eloped. CNA H stated, he didn't have a wander guard before. It wasn't like a known thing that we had to watch out for him eloping but now it is. CNA H reported the only thing that was out of the ordinary that shift was that Resident #101 was up late but staff just thought he couldn't sleep because he had taken a nap earlier that day. In an interview on 9/7/21 at 5:16 P.M., CNA I reported had worked third shift the night of 8/12/21 into the morning of 8/13/21 on 200 hall where Resident #101 resided. CNA I reported Resident #101 was not considered an elopement risk when he eloped. CNA I reported was unaware if the facility had an Elopement Book and was unaware of any other residents at the facility who were at risk for elopement. CNA I indicated if staff noticed a resident was acting out of the ordinary for their normal routine, they were supposed to tell the nurse. CNA I reported Resident #101's being up later than usual and walking the halls in the early morning of 8/13/21 was not considered out of the ordinary because he had said he had taken a nap earlier that day. In an interview on 9/8/21 at 9:53 A.M., Licensed Practical Nurse (LPN) AA indicated had worked the night shift on 8/12/21 into the morning of 8/13/21 and was Resident #101's nurse. LPN AA indicated normally Resident #101 would be asleep but had been up that night walking and saying hi to everyone. LPN AA reported had asked Resident #101 if he needed anything and he had said no, he just couldn't sleep. LPN AA reported Resident #101 had not been assessed as an elopement risk at that point. LPN AA indicated had gone to Resident #101's room to administer medications at approximately 6:10 A.M. (morning of 8/13/21) but that he had not taken his medications. LPN AA reported Resident #101 had been asleep in his bed with his earbuds in, which he wore because he didn't like the noise in the hallway. LPN AA reported had said Resident #101's name 3 times and he had not rolled over for his medications but that it was not of concern since he had been up throughout the night. LPN AA reported had told the morning nurse that Resident #101 had not taken his medications. In an interview on 9/8/21 at 11:12 A.M., CNA T reported the only way to know if a resident was considered an elopement risk was if they had a wander guard bracelet on their ankle. In an interview on 9/8/21 at 1:32 P.M., Registered Nurse (RN) W reported any resident who was considered an elopement risk would have a wander guard placed on them. RN W reported did not know of anyone who was an elopement risk who did not have a wander guard and would have to check with the Unit Manager to see if there were any. RN W reported being new to the facility (had started last month) but that after the incident when Resident #101 got out and was found to have not taken his medications, nursing had to start doing an oral check for medication administration - especially for him. In an interview on 9/8/21 at 2:51 P.M. Social Worker (SW) S reported Resident #101 had a wander risk assessment completed on 7/27/21 which showed a score of 9 which indicated wander risk. SW W reported there was no elopement risk care plan in place for Resident #101 prior to the elopement on 8/13/21. SW W reported a when a resident scored at risk to wander or higher, they were added to the elopement book. In an interview on 9/8/21 at 4:02 P.M., RN Y reported was an agency nurse. RN Y reported had Resident #101 as a patient the day before he eloped and that he had been trying to go outside. RN Y reported had passed that information on in report to the next shift. RN Y reported staff would know if someone was an elopement risk because they would have a band on their ankle. RN Y stated, There is no other way to know if someone is an elopement risk except the band on their ankle. If someone is at risk and does not have an ankle band, I wouldn't even know. In an interview on 9/8/21 at 4:17 P.M, LPN CC reported was Resident #101's nurse the morning he eloped. LPN CC reported that it had been shared by the previous shift that Resident #101 had been up throughout the night into the morning, so staff left him alone in his room to sleep. LPN CC reported when the CNA went to deliver Resident #101's breakfast tray to him 8:00 A.M., he was not in his room, but his bed was made up as if he was in it. LPN CC reported the door alarm had not gone off at all during the shift. LPN CC reported Resident #101 had not had a wander guard and he never struck me as someone who would exit seek. LPN CC reported that if a resident was at risk for elopement, then they would have to have a wander guard on. LPN CC stated, I am sure all the residents who are elopement risks have the wander guard on. Review of a Progress Note for Resident #101, dated 6/9/21 at 11:11 A.M. revealed, Note Text: SW received a call from resident's wife/DPOA. She is concerned resident is collecting money to try to run away. SW discussed options of wander guard or frequent checks or both. DPOA does not think resident will respond well with the wander guard. SW implemented frequent checks for resident for the next 4 days. Nurse .indicated resident has not shown signs of wanting to leave the facility. Resident was just outside and did not try to leave. He came back into the facility after enjoying time outside without any concern. On 9/8/21 at 2:18 P.M., NHA A was requested to provide a copy of Resident #101's Wander Risk/Elopement Care Plan in place at the time that he eloped on 8/13/21. On 9/8/21 at 5:31 P.M., the following electronic correspondence was received from NHA A, .(Resident #101) did not have an elopement risk care plan in place until 8/13/21. Review of a facility policy, Elopement last revised 2/5/20 revealed, POLICY: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care .Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: 1. All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition and as needed. 2. Residents identified as high risk for elopement/wandering and exhibit exit seeking behaviors will have a plan of care implemented to address their elopement/wandering behaviors . Review of a facility-provided list of residents assessed as being at risk to Wander revealed 13 residents (which included Resident #101) labeled as Resident's at risk to wander (and have wander guards) and 1 resident labeled as At risk to wander w/o (without) wander guard for a total of 14 residents residing at the facility as being assessed as at risk to Wander. On 9/8/21 at 11:13 A.M., Nursing Home Administrator (NHA) A was verbally notified and received written notification of the Immediate Jeopardy that began on 8/13/21 and was identified on 9/8/21 due to the facility's failure to prevent the elopement of Resident #101. A written plan for removal for the Immediate Jeopardy was received on 9/9/21 and the following was verified on 9/9/21. 1. On 8/13/21 at approximately 8:00 AM the facility identified that resident #101 was missing. 2. On 8/13/21 a Code Yellow for missing person was appropriately called and executed. 3. On 8/13/21 the facility immediately completed a head count to ensure all residents were in the facility. 4. On 8/13/21 at 2:30 PM, Resident #101 was found, and the resident was sent to the hospital to ensure no ill effects and it was noted he did not have any injuries. 5. On 8/13/21 resident #101's care plan was reviewed and updated with wander/elopement interventions. 6. On 8/13/21 at 8:30 PM resident #101 returned to the facility from the hospital and a wander/elopement device was placed. 7. Facility initiated frequent monitoring on 8/13/21 through 8/31/21. 8. On 8/13/21 the code to the exit doors were changed. The codes are changed monthly and as necessary as a practice. The code is changed by the Maintenance Supervisor, and the change starts by the IDT/Administrator/DON/any team member who notifies him they've observed a reason to make a change. In response to the elopement the code was changed 8/13/2021. The new codes used are not the same as other doors in the facility. 9. On 8/13/21 a review was completed on the alarm system to ensure all doors were functioning and residents were not able to unsafely leave the facility. 10. All residents were reviewed to ensure a wander risk assessment were completed and residents at risk for elopement were reviewed to ensure resident safety and proper plan of care were in place. This task was completed for 13/13 on 8/16/21. 1 additional resident scores At Risk to Wander, but this resident was assessed on 6/17/21 by IDT and again on 8/16/21 determining that she requires an assist of 1 for ambulation and cannot move about the building independently to wander or elope. Resident thus does not require a Wandergard for safety or other care planned safety interventions. 11. All staff were educated on protecting the code to the alarm on the exit doors from resident's view. This occurred during education provided: 8/16/21 for 50/63 staff members were educated 8/20/21 for 2/63 staff members received first education (the rest of the attendees were receiving the education for an additional time) 8/25/21 for 8/63 staff members received first education (the rest of the attendees were receiving the education for an additional time) Total educated staff 60/63. 3/63 have not worked since education has been provided and will be educated prior to working. 8/8 staff are new, and have received elopement education during General Orientation. September 8/9th additional education was completed by 38 staff members in person reviewing elopement policy procedure, including safe use of door codes. All staff will receive this re-education prior to their next worked shift. 12. Nursing and SW staff have been educated on care planning/addressing residents at risk for wandering. This was completed on 8/16/21. Nurses and Social Worker are responsible for completing elopement care plans. 15/15 that we educated. 13. The Maintenance director/designee will complete random audits on the alarm system to ensure the alarm code is entered into the pad and protected from the view of residents weekly for 4 weeks then monthly thereafter. The code change was 8/13/2021. These audits began 8/16/21 and the code is protected by staff entering it in the code using themselves as a barrier the resident's view, i.e. their body or hand between the key pad and the resident's view. Although the Immediate Jeopardy was removed on 9/9/21, the facility remained out of compliance at a scope of isolated and severity of no actual harm due the fact that not all facility staff have received all education and sustained compliance has not been verified by the State Agency.

This citation pertains to Intake MI 446 and MI 519. Based on interview and record review the facility failed to (1) implement sufficient safety measures and adequate staff and (2) follow care planned interventions to prevent falls for 2 of 5 residents (Resident #104 and Resident #109) reviewed for falls, resulting in a preventable fall (for Resident #109), multiple falls (for Resident #104), and pain/injury and hospitalization . Findings include: Review of the Fall Policy/Procedure dated 10/22/2020, 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's will be evaluated after a fall . 6. Evaluate for cause of fall and attempt to place an intervention in place to prevent further falls. 9. Document all appropriate information in the medical record. Review of the Fall Management Program (Post-Falls Huddle) (no date), revealed A post-fall huddle (PFH) is a team approach to critically evaluate the circumstances surrounding a resident's fall. Led by a facilitator who uses a standardized tool, it is a positive and safe learning environment to best understand why the fall occurred. The primary goal of the huddle is to determine the root cause of the fall and intervene appropriately to prevent a reoccurrence; if the resident was injured in the fall, it provides the opportunity to determine the immediate source of the injury. Since most repeat falls occur under similar circumstances as the first fall, elimination of those circumstances is instrumental in preventing further falls When does a post-fall huddle take place? The PFH convenes as soon as the resident's needs have been addressed, with the goal to be within 15 minutes but no later than 24 hours of the fall event while it is fresh in everyone's mind and the environment has not been significantly changed. Where does a post-fall huddle take place? The PFH takes place in the environment where the resident fell . If this is not possible, choose a location that is similar to the environment such as an empty resident room. Ensure the location allows for the group to speak freely about the event Resident #104 Review of an Admission Record revealed Resident #104 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] (progressive nervous system disorder), unsteadiness on feet, [CONDITION(S)], dizziness, and visual hallucinations. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 10/22/20 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #104 was cognitively impaired. Review of a Patient Admission Information document dated 10/8/2020, revealed . Occupational Therapy Inpatient Evaluation (in red typing) Precaution: Fall (use alarms) history of [CONDITION(S)], medical staff made aware: Yes - . Occupational Therapy (OT) Discharge Recommendations: (10/8) (in red typing) BARRIERS TO DISCHARGE HOME: SUPPORT SYSTEM: lack of adequate family/caregiver support: Patient lives alone. PHYSICAL ASSIST: needs Minimum assist to transfer or ambulate with walker. With cane, which was what patient uses at home, patient very unsteady. High risk for falls. SAFETY CONCERNS: Patient is a high risk for falls. Patient appears to lack insight into safe judgement, slower processing. ACTIVITY TOLERANCE: poor/limited activity tolerance: Patient appears fatigued with activity. Patient would benefit from ongoing skilled therapy to address safety/functional deficits. Review of an Emergency Department (ED) Physician assessment dated [DATE] at 1:18 PM, revealed a [AGE] year old male with [CONDITION(S)] who presented to the Emergency Department (ED) following a fall. He had become dizzy, fall backwards, and hit his head. No loss of consciousness. He had also been experiencing recurrent falls at home over the past several months. He had a work-up in the ED, which was negative for acute injury, PT/OT evaluated him and recommended skilled rehab. He discharged to skilled rehab on 10/8/2020. Comments- Fall. No acute injury or process identified in ED; weakness, deconditioning with recurrent falls. PT/OT to evaluate and treat .[CONDITION(S)]. Continue [MEDICATION(S)]. Depression with visual hallucinations. Continue [MEDICATION(S)], [MEDICATION(S)].Hypertension Blood pressure elevated, not on anti-hypertensives. Monitor BP and adjust medications as needed. Review of the Activity of Daily Living (ADL) care plan dated 10/11/2020, revealed Interventions: *Transfers: Limited assist x 1 Date Initiated 10/8/2020, Toilet Use: The resident requires limited assistance by (1) staff for toileting. Date Initiated 10/9/2020. Review of the Fall Care Plan dated 10/9/2020, revealed Resident #104 was at risk for falls related to unsteady due to [CONDITION(S)], history of fall, and poor safety awareness. Interventions: * Follow facility fall protocol. Date Initiated 10/9/2020, *Anticipate and meet resident's needs. Date Initiated 10/15/2020, *Assist Devices Wheelchair, Walker or cane Date Initiated 10/9/2020, *Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition. Date Initiated 10/9/2020, *ensure resident has grippy socks on at all times. Date Initiated 12/8/2020, *labs as order. *MD to obtain referral for neurology follow up. *Med review for more effective bowel regimen. *Medication review r/t [CONDITION(S)] and wandering at night. *Minimize risk factors in environment .*Standby assist on ambulation. *Touch Pad call light. Review of a Fall assessment dated [DATE] at 10:35 PM, revealed Resident #104 had a history of falls (yes), scoring 40 for a Moderate fall risk (25-44). Fall 1 (10/15/2020) Review of an Incident Report dated 10/15/2020 documented at 5:28 PM, revealed Incident Description: Staff was alerted to the fall by the resident's roommate, who had heard the fall but not seen it. The resident was lying on the floor facing the doorway of room . with the remains of his breakfast strewn around him. VS 127/100 97.3 84 18 97% Room Air (RA). Blood glucose (Bg) was 98. The resident replied that he did not hit his head. He denied pain or discomfort. Assessment revealed no apparent injuries. Patient Description: I was here with speech therapy and then I fell . Immediate Action Taken: Resident reminded to use call light and get assistance with ambulation. No witnesses found. In an interview on 2/16/21 at 10:51 AM, Licensed Practical Nurse (LPN) E reported that Resident #104 was ambulatory, non-directable, impulsive, and did not request help for anything. LPN E reported that the interventions that were in place were the standard instructions on use of call light and to ask for help when he wanted to get up. LPN E reported that he did not recall what new interventions were put in place when he knew that Resident #104 was impulsive, LPN E reported that Resident #104 did not request help for anything. LPN E reported that Resident #104 would toilet himself without assistant, was able to dress himself without assistant, was very ambulatory, and very fast and determined to elope. LPN E reported that we had to watch him for elopement, and he was also very delusion, we were on the lookout for his movements if he was on the move, we were watching for him, in his room aside for 1:1 it is impossible to keep an eye on someone. In an interview on 2/11/2021 at 2:45 PM, Physical Therapist (PT) JJ reported that (Resident #104) started on therapy on 10/9/20, went to the hospital on 10/15/20 due to a fall, returned to the facility on [DATE], and continued therapy until he was eventually discharged . PT JJ reported that (Resident #104) had a real unsteady gait, at home, so therapy had been trying to figure out what mobility device he should use. PT JJ reported they tried him with a cane at 150 feet with a contact guard (meaning he walked with a cane for 150 feet with someone standing next to him) from the 10/9/20 admission until just prior to his fall when he declined this intervention. PT JJ reported the following therapy transfer interventions for (Resident #104): contact guard assist when ambulating, contact guard when moving from a sitting to standing by bedside, and assistance to get into a chair and in and out of the bed. PT JJ reported that at times (Resident #104) was confused and he had a history of hallucinations, so his cognition varied. PT JJ reported that the facility did not use alarms, however in place of alarms residents were checked and their environments were accommodated as needed, in general we gave the resident a call light, staff checked on him, a contact guard was used when he was up and walking, and he was independent with bed mobility (when moving in bed). PT JJ reported that Resident #104 really did need someone with him when he was up and moving. In an interview on 2/16/2021 at 11:06 AM, Certified Nursing Assistant (CNA) S reported that Resident #104 was a wanderer, and we could put clothes on him, and he would take them off, he would dress if we asked him. CNA S reported that Resident #104 was confused but easy going and depending on the day he ate at least 50%. CNA S reported that Resident #104 used to walk up and down the hallways all the time, if he came out of his room, he would sometimes have his walker and sometimes he would not and if he did have his walker, we would walk with him, when he had his walker, we let him walk alone. CNA S reported that Resident #104 was supposed to have someone with him when he was walking and if I knew he was up I would get his walker and stay with him until he sat down, but he did not have an alarm so I did not know when he was up and I would check on him all the time. CNA S reported that Resident #104 did take himself to the bathroom if I walked by his room and saw he was not in his bed or in the chair right outside his door I would go and check the bath room and if he was in the bathroom and then I would stay right outside the bathroom door to make sure he did not need any help then make sure he got back to where he wanted to go. CNA S reported that Resident #104 kept staff very busy. In an interview on 2/16/2021 at 11:30 AM, Confidential Informant (CI) X reported that Resident #104 was a wanderer, he was someone I would have to keep an eye on, he could do some of his Activities of Daily Living (ADL) on his own, but we tried to keep in our sight, if we did not keep in sight he would fall. CI X reported that I would check on him every time I went by his room, if I noticed anything out of the ordinary, I would step in and help him. On our shift we had 2 Certified Nursing Assistants (CNA's) most of the time) and 1 (nurse), sometimes I would observe the resident walk backwards and if a chair at (bedside) were not lined up right next to his legs he would lower himself to the floor, CI X reported that 'if Resident #104 was observed walking backwards and there was time the chair would be repositioned CI X reported each time Resident #104 lowered himself to the floor it was reported to the nurse, If they try to sit on the floor I think that counts as a witnessed fall, but I am not sure all of them got turned in. In an interview on 2/16/2021 at 4:12 PM, LPN Unit Manager (UM) T reported that when Resident #104 first came to us he was a transfer limited assist x one on 10/11/2020, in the Activity of Daily Living (ADL) Care Plan- which means tons of queuing and staff need to be next to him when up he was up a walker, Resident #104 was not supposed to walk to the rest room by himself, however he still tried to get up, so we kept the walker near him because he still tried to get up and staff were aware that he got up and went to the bathroom by himself. The care plan at that time had that staff were going to anticipate Resident #104's needs, cueing and reminder, grippy socks at all times. UM T reported that she felt there was enough staff to monitor Resident #104 and take care of all the other residents, that he started taking naps and sat in the hall like a gentleman, however he was impulsive a 1:1 was not ordered since he was docile, and impulsivity was sporadic. UM T reported that the facility had specialist coming to look at him, because the orientation of the behavior was not happening just at night for sundowning it was very hit or miss. UM T reported that the staff are pretty open to telling us about issues if they had a hard time, we would have heard about it, I think 9 falls is pretty impulsive, but we had to get to know him, and we were in works with trying to get him in a memory unit. UM T reported that after the fall on 10/15/20- when Resident #104 was eating and was drinking, they put him on sodium supplement. Review of a Fall assessment dated [DATE] at 5:28 PM, revealed Resident #104 had a history of falls (yes), - overestimates or forgets limits, and was a score or 65 High fall risk (45 and higher). Review of a Progress Note dated 10/16/2020 at 3:28 PM, revealed Resident #104's Sodium level is critical at 119 (normal 130-143 MEQ/L). The previous day Sodium was 127 They gave orders to send to ER for further evaluation. Review of a Progress Note dated 10/17/2020 at 6:47 PM, revealed IDT (Interdisciplinary Team) met to discuss occurrence that happened on 10/15/2020 at 1728 (5:28 PM). Resident was observed on his floor by staff member. It was noted that resident had just finished meal with speech therapy. His bedside table was askew, food on floor, drinks on floor. When asked, he stated that he was trying to get up. He could not explain why he was getting up. Resident is here for new onset confusion and falls. He has past history of [CONDITION(S)]. [CONDITION(S)] has been noted, as of late. MD (Medical Doctor) has examined him multiple times for this issue. As his stay continues, he has shown increased confusion and decreased self-safety awareness. Resident was examined following falls. Labs were ordered to ascertain reason for continued increased confusion. It was noted that sodium level was depleted. MD was notified of result of this lab and resident was sent to ER (emergency room ) for evaluation and treatment. He remains there, at this time. Will re-assess his fall risks upon return from hospital. Review of the Hospital Occupational/Physical Therapy Inpatient Evaluation dated 10/19/20 at 8:52 AM, revealed precautions, fall (use alarms), at risk for falls due to generalized weakness and impaired balance, He demonstrates posterior displacement of his balance during transfers and when standing statically. During ambulation, his steps are short and shuffled with minimal assist needed to complete. He has difficulty with balance in sitting as well, though he does well with verbal and tactile cues to facilitate improve agonist/antagonist coordination and lower extremity tone. Review of the Hospital Admission Report dated 10/16/2020, revealed Resident #104 remains on a 2 gram salt tab 3 times daily and 1500 mL fluid restriction diet. Patients sodium levels continue to slowly improve - now 131 this AM. Fall 2 (10/29/2020) Review of an Incident Report dated 10/29/2020 at 02:00 AM, revealed Incident Description: Resident was observed sitting in an upright position on his floor next to his bed. Patient Description: Patient unable to give description. Immediate Action Taken: Assessed Resident head to toe, no injuries observed, able to move all extremities without resistance, asked Resident if he was in pain and stated no, Resident pulling himself up unable to settle Resident down long enough to get hoyer to hoyer Resident back up to bed, x2 assist up to his bed, and Resident now resting comfortably. Neuro checks and VS started on Resident. No injuries noted at time of incident, no witnesses found. In an interview on 2/16/2021 at 2:19 PM CNA Y reported that Resident #104 was very forgetful walking around a lot, very pleasant, he was always in his room, he had a cell phone in his room he would roam around in the back hall by himself without a walker and I remember he fell and then when he came back from the hospital and he was supposed to walk with a walker, before that I do not recall that he was not a standby assist when he was in a room. CNA Y reported that when you would see him try and get up, you always had to check on him and even if you sat him in the chair in the hall outside his door, if you looked back and he was gone, you had better stop and go find him. You could not get your other jobs done timely and keep track of him safely. If you did not see him, had to look for his shoes, he would take his clothes off and strip naked in the hallway and wait for the bus in the hallway you had to help get him dressed, there was a lady in the room across the hall they had to put a STOP sign up for him so he would not go in her room. CNA Y reported that a 1:1 for Resident #104 would have helped, she did not tell any of the nurses, the management does not listen to us the nurses were on the hall with us they could see how things were. In an interview on 2/16/2021 at 4:12 PM, LPN Unit Manager (UM) T reported 10/29/20- that when Resident #104 was observed on floor next to bed; interventions were to monitor labs 2 x week x 6 weeks - IDT felt that would help monitor his confusion since his sodium (NA) had recently dropped. Review of a Progress Note dated 10/30/2020 at 8:05 PM, revealed late entry to follow up 10/29/20 at 2:33 AM event note IDT reviewed incident of fall; root cause analysis was due to weakness from low sodium. Resident is alert, with confusion. BIMS is 9/15 in most recent MDS. He is ambulatory with use of walker, independent to supervision with bed mobility and transfers. Risk factor for fall include, but not limited to, unsteady gait due to [CONDITION(S)], hx of falls and [CONDITION(S)] secondary to Syndrome of inappropriate antidiuretic hormone (SIADH). Intervention was to monitor labs (BMP) 2x a week x 6 weeks. Other fall precautions in place which IDT reviews and updates, as necessary. Review of a Progress Note dated 10/31/2020 at 7:43 AM, revealed Patient has been up throughout the night. Patient has been wandering the halls with and without his walker. When asked where is he going patient states he is trying to find the store or go back home. Patient is easily directed back to his room but comes right back out and repeat the same things. Patient was offered toileting fluids and snacks and was pleasantly confused. Fall 3 (10/31/2020) Review of an Incident Report dated 10/31/2020 at 7:45 PM, revealed Incident Description: Roommate alerted staff that he witnessed resident slowly lowering self to floor. He was able to stand up and get to sit back in his bedside chair. Patient Description: Unable to describe. Immediate Action Taken: Head to toe assessment, vital signs taken, pain evaluation done, Neuro checks ongoing from previous fall, Touch pad call light in place, no injuries observed at time of incident, no witness documented. In an interview on 2/16/2021 at 12:41 PM, LPN M reported Resident #104 required assistance with transfers, but he tried to self-transfer a lot, he was alert and oriented but got more confused as the evening progressed and would wander more come evening. LPN M reported that on 11/2/2020 it looked like he had crawled out of bed, she had seen him lying on his stomach on the bed at an angle (unable to state time), so that his feet were lying off the bed, then later I was going down the hall with medication pass and he appeared to have slid down to the floor on his knees, because of the way he had been positioned in the bed prior. LPN M could not say why she did not reposition him when she saw him lying at the awkward angle. In an interview on 2/16/2021 at 3:59 PM, CNA L reported Resident #104 wandered a lot and stayed in the room every so often, staff had to keep reminding him to keep his walker with him, he was up and walking and we just had to make sure he had his walker with him. CNA L reported that there was updates on the kardex (visual/bedside report) and I do not recall if he needed someone up when he was walking I just had to make sure he had his walker. CNA L reported we did not have enough staff to make him a 1:1 we were supposed to go by his room often and make sure he was in his room sitting down and dressed and redirect him back to his room, take out clothes so he could get redressed (he liked to take his clothes off), we had to get his walker so he could have it hand, try and Keep him in his room and if he wanted to walk the hall, we just had to make sure he had the walker with him. In an interview on 2/16/2021 at 4:12 PM, LPN Unit Manager (UM) T reported that on the fall on 10/31/20- Resident #104 lowered himself to floor; a touch pad call light was put in place since Resident #104 was not alert enough to use a call light, we felt if he moved in the bed he would bump the touch pad and the staff would be alerted that he needed something. Review of a Progress Note dated 11/2/2020 at 11:29 AM, revealed Resident continues to wander out of room and throughout the hall. Resident is confused at baseline unable to be re-directed at times. Resident does not use the call light appropriate. Continuing to educate resident. Fall 4 (11/2/2020) Review of an Incident Report dated 11/2/2020 at 7:15 PM, revealed Incident Description: as this nurse was walking past resident room he was observed on his knees next to his bed assisting himself back in bed. Just prior to this resident was observed laying on his stomach on his bed. Patient Description: Resident unable to explain what happened. Immediate Action Taken: Resident assessed for injury. He assisted himself back to bed, one witness documented. Review of a Post Fall assessment dated [DATE] at 7:15 PM, revealed Resident #104 previous interventions (check labs and have MD evaluate resident for low sodium) new interventions (request evaluation for possible urinary tract infection due to increased confusion). In an interview on 2/16/2021 at 4:12 PM, LPN Unit Manager (UM) T reported 11/2/20- Resident #104 slid out of bed onto knees; IDT determined neurology follow up, the doctor did felt that the confusion was his baseline and he lived by himself and wanted neuropsychologists to follow up. Review of a Progress Note dated 11/4/2020 at 10:13 AM. Revealed IDT met to discuss occurrence that happened on 11/02/2020 at 1915 (7:15). Resident was noted on the floor, attempting to climb onto his bed. Nursing assessed him for injury and found none. Neuro assessments initiated, per protocol. Resident was able to place own self back into his bed. He displayed full range of motion, as is normal for him. Resident was last seen just minutes prior by Certified Nursing Assistant (CNA), lying on bed sleeping. When asked, he was unable to explain why he was on the floor. He has been observed placing own self on floor to sit, as of late. He was unable to confirm a fall, or sitting self on floor. Resident has shown a significant decline in cognition since admission. He has had increased confusion and increased behaviors that lead to falls. He has been observed sitting on floor at times. His sodium remains low at 119 and he continues with sodium supplements. MD to examine resident this shift for possible medical reason for decline. Neuro to be contacted for a referral. IDT feels that his increase in confusion, decrease in cognition and overall weakness led to his being on the floor. Due to the lack of physical harm, IDT feels that it is probable that he placed own self on floor, as he has been doing, of late. He will be examined today, as stated. Care plan updated. He does remain at risk for falls. See care plan for complete update. Review of a Progress Note dated 11/19/2020 at 7:14 PM, revealed Patient have been wondering the halls throughout the shift and exit seeking. Patient has been asking if someone was coming to pick him up. Patient grew agitated around 2 am and stated that he was upset because he does not know what time he is getting picked up. Patient was offered fluids and a snack and sat by nurses' station for a few minutes and then continued to wonder again throughout the halls. Review of a Nurse Practitioner Progress Note dated 11/20/2020 revealed Sodium 135. Review of a Progress Note dated 11/20/2020 at 7:17 PM, revealed Patient continued to wonder and exit seek throughout the night. Patient was not able to be directed. Patient was adamant about leaving and going home. Patient also grew agitated stating that he was waiting for his ride and why they have not picked him up. Patient was offered toileting snacks and fluids but refused. Patient was in and out his room and throughout the halls until 630 am. Patient has not slept all night. Message sent to provider to further advise. Review of a Nurse Practitioner Progress Note dated 11/23/2020 at 12:58 PM, revealed confusion waxes and wanes resident appears less confused today, urinalysis pending, labs pending, neuropsych evaluation pending. Previous sodium 135. No change in medication noted. No advise noted. Review of a Progress Note dated 11/25/2020 at 7:41 PM, revealed Patient has been exit seeking throughout the night. Patient has been wondering in and out of other patients' room. Patient is not easily directed and becomes agitated when approached and redirected. Patient was offered fluids and snacks and refused. Patient was toileted throughout the night as well. Patient is currently sitting in the hallway in his room door. Review of a Nurse Practitioner Progress Note dated 11/30/2020 at 2:18 PM, revealed Fall. Had witnessed fall onto back on 11/29. Did not hit head. No apparent injury. Medications reviewed. Confusion waxes and wanes Nursing reports resident exit seeking, increased agitation at times. Labs stable, neuropsych evaluation pending. No change in medication noted. No advise noted. Review of a Progress Note dated 11/26/2020 at 6:42 PM, Patient has been awake throughout the night exit seeking and going in and out of rooms. When redirected patient has an increase in agitation and continues to do what he was doing. Patient was offered fluids snacks and toileting. Patient has increased confusion and does not follow commands. Patient is currently sitting at the nurse station with no other concerns at this time. Fall 5 (11/29/2020) Review of an Incident Report dated 11/29/2020 at 11:40 PM, revealed Incident Description: Patient was walking with walker through the hallway doors and started to walk backwards and backing up down the hall and lost balance and fell directly on his back. Patient Description: Nursing assessment completed, range of motion (ROM) vital signs within normal limits, no injuries observed at time of incident, nurse observed incident. In an interview on 2/16/21 at 12:14 PM, Confidential Informant (CI) F reported that on 11/29/20 Resident #104 was walking backwards down the hall, the nurse was at the nursing station and he acted like he saw a ghost and he got wide eyed and fell backwards he did not hit his head, I had just come out of a room. Resident #104 was not grabbing at that moment, but he had let go of the walker. CI F reported that Resident #104 had been walking in the hallway without a standby prior to his fall. CI F reported that Resident #104 was an extremely high fall risk no matter what the circumstance even with his walker, he was in a state of dementia, hallucination, and CI F questions his eye sight, he was not oriented, with him and the other residents generally I am not able to meet all the needs and keep watching him if he was not sleeping, When am I supposed to be checking and changing and assisted other residents on the hall? CI F reported that the nurse generally did one and a half halls, when other staff called in, they would do their best to get someone in, but it was not helpful if it was management and they stayed in the office and did paperwork, they needed to be on the floor helping with the check and changes. CI F reported that CNA staff suggested to the LPN M and all the nurses that take care of Resident #104 that due to his dementia an extra set of eyes and a 1:1 would be super helpful and they agreed. In an interview on 2/16/2021 at 4:12 PM, LPN Unit Manager (UM) T reported that on 11/29/20- when Resident #104 fell backwards when backing up in hall; interventions put in place was a stand by assist with ambulation. Review of a Progress Note dated 11/30/2020 at 3:58 PM, revealed IDT reviewed incident of fall: root cause analysis was resident was walking backwards while ambulating in the hallway with use of walker. He is alert with confusion; BIMS is 9/15. He is ambulatory using a walker. Resident continues to be at risk for falls related to unsteady gait due to [CONDITION(S)], weakness from recent hospital stay, hx of falls. No discomfort of pain verbalized. Intervention would be for staff to provide stand by assist when seen ambulating in hallway. He is on therapy services to increase strength and mobility; plans to go back to prior living setting once practical level of function is achieved. Other fall precautions in place which IDT reviews and update as necessary. Fall 6 (12/6/2020) Review of an Incident Report dated 12/6/2020 at 1:45 AM, revealed Incident Description: Resident was observed sitting on his butt in the hallway with legs out in front of him. He had proper shoes on at the time. His walker was in front of him, glasses and hat on floor beside him. Patient Description: Resident states I fell . He states he hit his head on the floor, indicating the back of his head when asked where. He also states his left hip hurts. Immediate Action Taken: Resident assessed, no bumps, bruising noted on back of head. He was initially given a pillow to rest his head on while waiting instructions from on call physician and he fell asleep. He woke easily and stood on his own with 2 assist, he was assisted with his walker back to his room, he was able to transfer himself into bed with no s/s of pain/discomfort and easily fell back to sleep, nurse witnessed. Review of a Post Fall assessment dated [DATE] at 01:45 AM, revealed Resident #104, previous interventions (standby assist when up in hall) new interventions (requesting medication evaluation related to [CONDITION(S)] causing increased night-time wandering). In an interview on 2/16/2021 at 4:12 PM, LPN Unit Manager (UM) T reported that the on 12/6/20- Resident #104 was sitting on his butt in hall; interventions put in place were medication review [CONDITION(S)] and wandering, we wanted to know if some of his medications were causing impulsive behavior and to see if we could improve sleep at night, he had just been put to bed and he got right back up. UM T reported that this was not a new behavior for him after reviewing the progress notes. Review of a Progress Note dated 12/6/2020 at 5:24 PM revealed Resident showing signs and symptoms of low back/left hip pain as well as verbalizing. On call notified and order obtained: STAT 2 view Lumbar Spine, 2 view Pelvis - r/o fracture related (r/t) fall ordered with MobilX. Review of a Progress Note dated 12/7/2020 at 00:27 AM, revealed X-ray results show no fractures or dislocations. In an interview on 2/16/2021 at 12:41 PM, LPN M reported that she had stayed over on 12/6/20 and the door to the hall was shut, between the nursing station and the hall with the residents, when Covid initially hit the facility all the doors on all the facility were closed, this hall (where Resident #104 was located) did not have Covid but we were using caution, Resident #104 was self-ambulating in the hall alone (without a staff member) but he did have his walker, it was sitting upright in front of him (he was not supposed to be alone he was a stand by assist). LPN M reported that I was at the nursing station and my aid was in another room with a resident so he was walking without anyone out in the hall with him, I [TRUNCATED]

Based on observation, interview and record review the facility failed to keep Foley catheter tubing off of the floor for 1 resident (Resident #1) out of 2 residents reviewed for Foley catheters and failed to provide peri care to keep 1 resident from sitting in feces for extended periods of time and used expired medication to flush the Foley catheter for 1 resident (Resident #10) out of 2 residents reviewed for Foley catheters from a total sample of 15 residents, resulting in urinary tract infections. Findings include: Review of Resident #1's face sheet dated [DATE] revealed she was a [AGE] year old female admitted to the facility on [DATE]. Resident #1's Brief Interview of Mental Status (BIMS) score dated [DATE] was ,[DATE], normal cognition. Resident #1 was observed in her room on [DATE] at 9:00 am. Resident #1 was sitting in her wheel chair and her catheter bag was in the privacy bag. The catheter tubing and clip to secure the tubing where lying on the floor under her wheel chair (tubing is not to touch the floor as it increases the risk of infection). Review of the facility policy for Catheter Care: Indwelling Catheter revealed under item #14. Check that tubing is not looped, kinked, clamped or positioned above the level of the bladder and off the floor-place bag in the catheter bag holder if appropriate. Review of Resident #1's laboratory results for the last year revealed she had she had 5 positive urinary tract infections that required medical treatment. Three of the five urinary tract infections required Intravenous (IV) antibiotics due antibiotic resistant infections. (positive urinalysis result dates [DATE], [DATE], [DATE], [DATE] and [DATE]). Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #10 was cognitively intact and required extensive assistance for activities of daily life (ADLs). An interview was completed with Resident #10 on [DATE] at 12:40 AM. Resident #10 advised that she had a catheter and got frequent urinary tract infections. Resident #10 stated she is incontinent of bowel and wears a brief, she stated often waits ,[DATE] minutes and sometimes about 30 minutes to be cleaned by staff when she has a bowel movement and it can go everywhere including around her catheter. Resident #10 also stated that her catheter bag is often not emptied by first shift. Resident #10 stated it bothers her and it is not my responsibility to remind them to do it. Resident #10 stated it can be embarrassing to go out of her room when the bag is full because she feels like it can smell. Resident #10 stated her catheter bag being frequently emptied was an ongoing issue and she has brought it up at resident council and had told Director of Nursing (DON) B about it as well as the former Nursing Home Administrator. Resident #10 stated that her catheter tubing is generally flushed with an acetic acid solution twice daily and she feels this has decreased her incidences of urinary tract infections. An observation was made on [DATE] at approximately 1:10 PM of Resident #10's bathroom. A prescription bottle for Resident #10 containing Acetic Acid solution was observed. The bottle read good for 24 hours on the label. A label with the open date of ,[DATE] was observed. A review of Resident #10's medical record revealed that she had multiple urinary tract infections with noted culture collection dates of [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The urinary tract infections were noted to be caused by escherichia coli on [DATE] and [DATE]. A urinary tract infection caused by escherichia coli is caused by contamination from fecal matter. A review of Resident #10's physician's orders dated [DATE] which noted acetic acid 0.25% Irrig soln (irrigation solution) and flush suprapubic catheter with 50 ML every 12 hours *discard bottle 24 hours after opening* During the general tour of the facility at 10:15 AM on [DATE] it was observed that a bottle of Acetic Acid was stored on top of the paper towel holder in the bathroom of room [ROOM NUMBER]. The open date at the top of the Acetic Acid was ,[DATE]. It was noted that the sticker on the side of the bottle stated Do Not Use Beyond 24 Hours.

Based on observation, interview and record review, the facility failed to dispense of needles and blood contaminated glucose strips into the sharps container for one resident (Resident #18) and in one room (Room 205), out of a total of 15 resident's rooms observed for safety, from a total sample of 15 residents, resulting in the potential for puncture wounds and contamination from blood borne pathogens. The facility also failed to supervise to prevent falls for two residents (Resident #9 and 11), out of 3 residents reviewed for falls, from a total sample of 15 residents, resulting in ongoing falls and the potential for injury. Findings include: According to a facility face sheet dated printed on 6/19/17 at 9:40 a.m., Resident #9 was [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. According to a Minimum Data Set (MDS) quarterly assessment dated [DATE], Resident #9's Brief Interview for Mental Status (BIMS) Score was 3 out of 15 indicating Resident #9 mental status was severely impaired. According to a court document dated 6/29/16, Resident #9 had a court appointed guardian to make medical and financial decisions for her. According to a MDS quarterly annual assessment on 11/2/16, Resident #9 was assessed to be at risk for falls According to facility incident/accident reports reviewed from 10/15/16 to 8/6/17, Resident #9 had 12 falls: According to a facility incident/accident report dated 10/5/16 at 3:30 p.m., Resident #9 fell in her room while attempting to self transfer from the wheel chair to the bed. No injury was noted. The intervention placed on the care plan to prevent further falls was to have Physical Therapy evaluate and treat. There was no immediate intervention based on a root cause analysis of the fall to prevent another fall. According to a facility incident/accident report dated 10/6/16 at 1:00 p.m., Resident #9 fell in her room, Resident #9 was observed sitting on the floor next to her bed. No injury was noted. The intervention placed on the care plan to prevent further falls was to have Occupational Therapy treat for deconditioning. There was no immediate intervention based on a root cause analysis of the fall to prevent another fall. According to a facility incident/accident report dated 11/28/16 at 12:30 a.m., Resident #9 fell in her room. Resident #9 was found on the floor on her right side in a pool of blood. Resident #9 required emergency medical attention and 911 was called. According to a facility document for Resident #9 titled, Routine physician's orders [REDACTED].#9 was prescribed, Clopidogrel 75 mg (milligrams) by mouth once daily. Clopidogrel is an anticoagulant and inhibits the coagulation or clotting of the blood. According to a facility incident/accident report dated 3/9/17 at 4:30 p.m., Resident #9 fell in her room. Resident #9 had a fall with a bump to the back of her head. Resident #9 was observed to be laying on her back behind the room door but in front of her wheelchair. Resident #9 was able to state she was reaching for tissues. The intervention placed on the care plan to prevent further falls was to obtain an ammonia level (a lab test). There was no immediate intervention based on a root cause analysis of the fall to prevent another fall. According to a facility incident/accident report dated 4/7/17 at 9:45 p.m., Resident #9 fell in her room attempting to transfer self to the wheelchair. Resident #9 had a seizure 20 minutes after the fall. The intervention placed on the care plan to prevent further falls was to obtain a Keppra (seizure medication) level (a lab test). There was no immediate intervention based on a root cause analysis of the fall to prevent another fall. According to a facility incident/accident report dated 5/6/17 at 7:30 p.m., Resident #9 fell in her room. Resident #9 stated she was trying to reach for popcorn on the floor. The intervention placed on the care plan to prevent further falls was to have Resident #9 call for assist. Resident #9's mental status is severely impaired. According to Geriatric Nursing Protocols for Best Practice, Second Edition. (2003) Springer Series on Geriatric Nursing, The majority of all falls that occur in the acute care setting involve individuals over the age of 65 .The increased risk of falling in older adults may be due to a number of age-related changes, such as altered visual acuity, decreased reaction time, decreased balance and muscle strength .Nurses in the acute care setting have the most contact with patients and are in key positions to evaluate these individuals and implement interventions to decrease falls .A prior history of falls is frequently cited in the literature as a risk factor contributing to falls. Once an older adult has fallen, there is a significant increased risk that he or she will fall again under similar circumstances .a major concern with a fall is the subsequent fear of falling that can occur. Fear of falling has been cited as one of the most serious and debilitating psychological consequences of a fall .The intention of a fall prevention program in acute care is not only to prevent falls, but also to provide patients with nursing care that focuses on improving and maintaining the functional ability of older patients. A facility practice guide titled, Falls Practice Guide dated 12/2011 reflected, The Quality of Life Falls Practice Guide is an approach that uses the nursing process frame work: assess, plan, implement and evaluate. This document also reflected, The approaches for fall interventions are clear, specific and individualized for the patient's needs. managing falls can be complex as many falls do not have a single cause but include a combination of risk factors and causes. Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patients's condition and needs change the center may designate members from the interdisciplinary team to participate in a post fall patient evaluation activities .the bedside evaluation may include, but is not limited to the following: review of the circumstances surrounding a patient's fall, evaluation of the patient's room and other areas to identify environmental risk factors, interview of the patient or other witnessing the fall, if possible, identification in any changes in the patient's risk factors, condition and functional status, review of the patient's current plan of care, revision of the care plan to address the patient's current risk factors and needs. During medication pass on 3/9/17 at 7:55 am, Registered Nurse (RN) I gave Resident #18 a Enoxparin (medication) injection and placed the used syringe in the sharps container in Resident #18's bathroom. After Registered Nurse (RN) I walked out of the bathroom it was observed that the syringe was not dispensed into the box, but was sitting on the clear plastic drop down mechanism where it could easily come in contact with residents or staff and injure by puncturing the skin. RN I went back into the bathroom when she was told the syringe did not go into the box and proceeded to push down on the clear plastic mechanism and the syringe dropped into the sharps container. During the general tour of the facility starting at 9:00 AM on 8/9/17 it was observed that the sharps container in the bathroom of 201 (Room of Resident #18) had a syringe that was not dispensed into the box, but was sitting on the clear plastic drop down mechanism where it could easily come in contact with residents or staff. There was also what looked to be a used glucose strip stuck to the opening of the sharps container of room 205, in nearly the same position as the syringe in 201 (Resident #18). According to a facility face sheet dated printed on 8/10/17 at 7:50 AM, Resident #11 was [AGE] year old male readmitted into the facility on [DATE] with the Diagnoses: [REDACTED]. According to a Minimum Data Set (MDS) 5 day assessment dated [DATE], Resident #11's Brief Interview for Mental Status (BIMS) Score was 9 out of 15 indicating Resident #11 mental status was moderately impaired. On 6/7/17 Resident #11 was care planned for falls. According to facility incident/accident reports reviewed from 06/07/17 to 8/10/17, Resident #11 had 6 falls: According to a facility incident/accident report dated 6/9/17 at 6:50 AM, Resident #11, was observed kneeling on the floor beside his bed. Resident states that he was trying to get up for breakfast. No injury was noted. The intervention placed on the care plan to prevent further falls was to reinforce need to call for assist. There was no immediate intervention based on a root cause analysis of the fall to prevent another fall. According to a facility incident/accident report dated 6/12/17 at 12:31 AM, Resident #11 fell in his room, Resident #11 was observed lying on the floor on his right side. Resident was trying to get up when he rolled out of bed. No injury was noted. Call light was on, placed by roommate after Resident#11 fell . The intervention placed on the care plan to prevent further falls was updated to include initiation of a sleep log x 72 hours to identify sleeping patterns. There was no immediate intervention based on a root cause analysis of the fall to prevent another fall. According to a facility incident/accident report dated 6/16/17 at 12:30 AM, Resident #11 had a unwitnessed fall in his room, Resident #11 wanted to go to the bathroom. No injury was noted. No call light on. The intervention placed on the care plan to prevent further falls was updated to include initiation of offering toileting at midnight and PRN if resident is awake. Offer Early rise in the AM if Resident is awake. According to a facility incident/accident report dated 6/20/17 at 6:00 AM, Resident #11 had a unwitnessed fall by the nursing desk. Resident #11 was observed on the floor on his right side against the wall by the nursing desk, Resident stated he was lying down taking a siesta. Resident stated hi head hurt just a little and pointed to right forehead. No redness or bruising seen, neuros unchanged. Resident was assisted back into wheelchair, toileted. The intervention placed on the care plan to prevent further falls was updated to include initiation of comprehensive medication review to evaluate any needed changes to promote stabilization of sleep-wake cycle. According to a facility incident/accident report dated 6/22/17 at 6:30 PM, Resident #11 fell in his room, Resident #11 was observed sitting on the floor next to his bed. Resident was trying to get in bed. Report revealed, Resident was sitting next to his bed which was elevated off the floor making it difficult to get into it. No injury was noted. Resident was assisted off the floor and brought to the nurses station for observation. The intervention placed on the care plan to prevent further falls was updated to include initiation,Resident bed to remain in lowest position this is the same as the Care Plan intervention 'Bed In Low Position which had implemented on date of 6/8/17. According to a facility incident/accident report dated 7/30/17 at 7:30 PM, Resident #11 had an unwitnessed fall in his room. Resident #11 was in bed reached for his urinal when he rolled to the floor. Resident had an abrasion to his right forehead. The intervention placed on the care plan to prevent further falls was updated to include initiation, Urinal on order with urinal holder. According to a Minimum Data Set (MDS) 30 day assessment dated [DATE], Resident #11's Brief Interview for Mental Status (BIMS) Score was 6 out of 15 indicating Resident #11 mental status was severely impaired. A review of patient safety note date 7/31/17 at 5:42 PM revealed that, Resident #11 requires 1 person assistance with transfers, toileting, and personal care. His gait is impaired, .Patient can bear weight and stand from his w/c independently; however continues to require assist related to poor safety awareness and decreased strength. Impulsive behavior continues to be present throughout the day. patient has a tendency to stand up from his chair and sit or lay himself on the floor to rest, sleep, or lay down.

This citation pertains to MI 701. Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview, and record review, the facility failed to prevent an elopement for 1 of 1 residents reviewed for elopement (Resident #6) who had been recognized as demonstrating exit seeking behavior, from a total of 11 sampled residents, resulting in Resident #6 leaving the building unattended on 3/17/16 sometime between 4:30 PM and 5:18 PM, (for up to 45 minutes) in below freezing weather, and found to have fallen next to a hazardous road and sustaining a broken finger; placing Resident #6 and 11 other residents, who were identified by the facility as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed that Resident #6 was a [AGE] year-old female, who was admitted to the facility on [DATE], who had severe cognitive deficits, and [DIAGNOSES REDACTED]. The MDS revealed Resident #6 ambulated independently. According to an Ambulance report, dated 3/17/16, they received a call at 5:18 PM and arrived at the Resident #6 ' s side at 5:33 PM. Per the report, .pt (Resident #6) stated .ground level fall .weight 140 lbs; .Pt escaped from the nursing home and wanted to go for a walk. Pt triped (sic) on the curb and feel (sic) onto her knees according to bystanders. Fire (Department) helped pt up and back to the nursing home . According to a Witness Statement about the elopement of Resident #6, dated 3/18/16, LPN/Licensed Practical Nurse P reported, I responded to the request of (Administrator A) who said (Resident #6) was down by (Street name) We observed her to be standing, communicating and exhibited no pain. She had a coat on . On 4/13/16 at 8:00 AM, this Surveyor observed the distance between the front door of the facility and the road in front of the dentist's office (around a corner and out of sight of the facility) to be approximately 350 yards away; adjacent to a very high traffic, 4 lane, inner city road. The temperature on 3/17/16 at 5:30 PM (according to wunderground.com) was approximately 30 degrees Fahrenheit. According to the 5 Day Investigation, not dated, . On 3/17/16 at approximately 5:30 PM, (Resident #6) was located at the end of the facility ' s driveway. She was assessed at the scene with no life threatening injuries; the only abnormal finding was a superficial scratch to the knee .At approximately 5:30 PM on 3/17/16, the facility was notified by a dental office at the end of the driveway that a resident had tripped and fallen by the road. A passerby called 911 .returned to the facility .A wander guard (also known as Secure Care bracelet or alert bracelet) was placed on her ankle .After its investigation, the facility determined that (Resident #6) followed a visitor out of the front door of the facility after the visitor had put the code into the door . (Resident #6) .reported breaking her fall with her hand and during the evening of 3/17/16, her pinky began to swell. An x-ray was taken and she was noted to have a broken finger . Initial review of Resident #6's Care Plans revealed an elopement Care Plan was initiated on 11/06/15. The Focus of the Care Plan was Wants to go Home/elopement risk related to: missing her daughter, potential infection, statement of wanting to go home; Interventions included Check alert bracelet placement Q (every) Shift and Functioning Q Day. According to a second elopement Care Plan for Resident #6, initiated 12/04/16, Wants to go Home/elopement risk related to: mental illness (dementia) .Often speaks about leaving here and has pushed on exit doors; Interventions included Check alert bracelet placement Q (every) Shift and Functioning Q Day. On 4/14/16, Administrator A reviewed the elopement Care Plans with the Discontinue dates printed which revealed Resident #'s alert bracelet was discontinued on 2/23/16. The Nurse Aide assigned to Resident #6 (Nurse Aide CC) no longer worked at the facility at the time of the investigation and attempts to reach her via phone were unsuccessful. However, review of the facility's staff interviews, conducted post Resident #6's elopement (3/17/16 - 3/21/16) revealed 27 staff members (9 Licensed Nurses (D, F, I, J, P, Q, V, AA, and BB), 13 Nurse Aides (C, G, H, L, M, N, O, R, S, T, U, W, and X), Receptionists E and Z , a Housekeeper Y and Activities K, and the Administrator A reported they had seen Resident #6 engaging in exit seeking activities such as talking about leaving, packing her bags, or exit seeking. According to the Administrator's Witness Statement, dated 3/17/16, To your knowledge, had (Resident #6) every (sic) talked about wanting to leave the building? Yes - about 1 mo. (month) ago. She was talking . the Wander Guard feeling like a prison, why would she leave, its good here. She was assessed by IDT (Interdisciplinary Team) and it was determined she was no longer at risk. According to Nurse Aide G's Witness Statement, dated 3/17/16 at 6:30 PM, .Over last week, she (Resident #6) has been looking for daughter .She (Resident #6) talks about going home. According to Nurse Aide H's Witness Statement, dated 3/17/17, A couple of weeks she (Resident #6) talking about husband and how she was gonna leave and go home .I told nurse DD. According to LPN F's Witness Statement, dated 3/17/16, The other night she (Resident #6) tried to get out front door . According to LPN D's Witness Statement, dated 3/17/16, 2 weekends ago she (Resident #6) was standing by basement door .she was looking for her husband . During an interview, on 4/13/16 at 8:00 AM, Resident #6 was sitting on her bed and reported, I don't live here. I'm visiting. Resident #6 had no recollection of being outside, falling and fracturing her finger recently. In an interview, on 4/13/16 at 8:45 AM, Administrator A spoke about Resident #6's elopement on 2/17/16; she said, (Resident #6's husband passed away here. We initiated the Wander Guard because she was seeking to leave .a huge period of time. We normalized her behavior. We missed the opportunity to monitor (after we removed the Secure Care bracelet). We found that to be the root cause. In a telephone interview, on 4/13/16 at 10:25 AM, Resident #6's son/Medical Power of Attorney EE spoke about the facility having removed Resident #6's alert bracelet. Son EE said, I think they were a little lax because she's been like this (exit seeking) for 2 years. On 4/13/16 at 10:40 AM, this Surveyor observed Resident #6 wearing a heavy sweater jacket, walking spryly to the lobby of the facility; she picked up a newspaper and sat on a couch next to the front door, out of sight of Receptionist E. The Administrator A was notified, on 4/14/16 at 9:45 AM of Immediate Jeopardy is due to the facility's failure to prevent an elopement for Resident #6, who had been recognized as demonstrating exit seeking behavior and left the building unattended (for up to 45 minutes) in below freezing weather, and found to have fallen next to a hazardous road on 3/17/16, sometime between 4:30 PM and 5:18 PM, sustaining a broken finger. This deficient practice places 12 residents, who were identified by the facility as at risk for elopement, at risk for serious harm, injury, and/or death. Immediacy was removed on 3/21/16 when the facility had the following in place: · On 3/17/16 by 5:35 PM, a facility licensed nurse arrived at the end of the driveway and had completed an assessment on Resident #6 and found no obvious injuries. · On 3/17/16 at 5:45 PM, Door System function was checked on 100% of doors which exited to the outside with no functional concerns identified. · On 3/17/16 at 5:50 PM, Resident #6 returned to the facility and was placed on one to one supervision. · On 3/17/16 at 6:00 PM, education for staff was initiated with emphasis on door code procedure (in relation to visitors), what constitutes an elopement, identify a potential elopement, identify when a security bracelet should be placed, the process to put a security bracelet on and what is needed to complete appropriate documentation for an exit seeking resident. As of 4/21/16 the majority (over 50 %) of staff had received the above education and the remaining staff will not work until they have completed the required education. · On 3/17/16 at 6:05 PM, a Secure Care bracelet was placed on Resident #6's wrist and checked for functionality. · On 3/17/16 at 6:15 PM, an audit of the 55 residents in-house to determine elopement/wandering risk was initiated. The audit, completed at 8:00 PM, showed 19 like residents had the potential to be at risk for elopement, but only 6 of those residents were identified at risk for elopement/wandering and required Secure Care bracelet placement, (3 of those 6 residents were newly identified and a Secure Care bracelet was placed on them). The 7 residents with Secure Care bracelet were validated for placement and function with no concerns noted. · On 3/17/16 at approximately 8:00 PM, the 19 like residents at risk for elopement were reviewed for appropriate orders, assessment, documentation and appropriate plans of care/task lists. · On 3/17/16 at approximately 8:00 PM, the 3 newly identified elopement risk residents were added to the Center Watch book (picture binder). · On 3/17/16 at 10:00 PM, Administrator A changed the front door entry code and placed a sign indicating that the entry/exit code will not be given out, and staff will assist with visitors coming and going from facility. On 4/15/16 the facility submitted the following past non-compliance packet which was accepted. Element #1: Resident #6 was assessed after the incident with no abnormal findings. A secure device was immediately applied to Resident's right ankle and she was placed on immediate 1:1 supervision. Element #2: All residents identified with signs of exit seeking were evaluated and residents with actual risk for elopement had behavioral assessments completed, physician orders [REDACTED]. Element #3: A review of wandering/exit seeking policy and procedures was completed which included review of door alarm security and alarm buddies (1:1) initiation and monitoring. Documentation reviewed included behavior evaluations, care plan updates, progress notes, TARs for placement and function of secure care device and physician orders. Education was completed on all staff for resident exit seeking behaviors, use of secure care device and every shift check on TAR, use of alarm buddies, wander book use and location, door code alert and security, care plans/task Kardex. Newly admitted resident continue to be evaluated for elopement risk during the admission evaluation, with change of condition, and quarterly; and identified risk reducing interventions are put into place upon admission. All exit doors will continue to be locked 24 hours a day. Code Green Drills will be conducted at increased frequencies. Door alarm checks will be completed at increased frequencies. Element #4: Quality improvement measures for sustained compliance will include daily behavior monitoring, elopement drills, daily door function for security wander book use and location, and monitoring of secure care devices to ensure placement and function. The facility administrator/designee will audit system effectiveness weekly times 4 and findings will be addressed immediately and then forwarded to the QAPI committee for further recommendations. Date of compliance is 3/21/16. ( )

This citation pertains to intake numbers MI 282 and MI 284 Based on observation, interview and record review, the facility failed to reassess, monitor, implement interventions, conduct a root cause analysis and adequately supervise 3 of 4 residents reviewed for falls and safety (Residents #1, #2 and #3) out of a total sample of 4 residents resulting in a fractured tailbone for Resident #1's fall ; repeated falls and a fall with lacerations and bruising around the right side of the forehead and right eye for Resident #2; and a preventable fall without injury for Resident #3. 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 #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #1 had memory impairment, spoke only Spanish, and required staff assistance with all activities of daily living which included ambulation and transfers. Review of the Incident Report dated 11/6/14 at 1:30 AM, reflected that Resident #1 had an unwitnessed fall in the bathroom. Resident #1 complained of right hip pain and an xray was ordered. The conclusion of the incident reflected that the resident attempted to self transfer to the bathroom without staff assistance and the call light was not used. In an interview on 11/19/14 at 12:45 PM, Certified Nurse Assistant (CNA) #2 stated that before Resident #1's fall on 11/6/14, Resident #1 was extensive assist of one staff to ambulate and was continent of bladder. CNA #2 stated that Resident #1 did everything for herself and would go to the bathroom by herself and did not use the call light for assistance. CNA #2 stated that she could tell that Resident #1 had used the bathroom because Resident #1 would use a large amount of paper to wipe and would leave the bathroom a mess. In an interview on 11/20/14 at 10:20 AM, CNA #3 stated that it was difficult to care for Resident #1 because Resident #1 spoke only Spanish and did not understand English. CNA #3 stated she worked the midnight shift and would often have to call Resident #1's daughter to translate over the phone. CNA #3 stated Resident #1 needed staff assistance to ambulate but would routinely self transfer (without staff assistance) to the bathroom. CNA #3 stated she knew when Resident #1 used the bathroom because Resident #1 would leave lots of toilet paper in the bathroom waste can after she used the bathroom. In a interview on 11/19/14 at 3:15 PM, Registered Nurse (RN) #1 stated that Resident #1 did not use the call light to ask for help. RN #1 reported that Resident #1 was confused and thought it (the call light) controlled the over the bed light. RN #1 stated that Resident #1 was aware that Resident #1 would self transfer to the bathroom because staff saw her do it. Interviews from CNAs #2 and 3 and RN#1 confirmed Resident #1 would independently go to the bathroom in spite of being a 1 person assist. There was no intervention to address this pattern of high risk behavior which the nursing staff was aware and Resident #1 fell on [DATE]. Review of the Interdisciplinary Team note dated 11/6/14, reflected that Resident #1 ambulated to the bathroom without staff assistance and fell . The call light was changed to a flat (soft touch) call light and was to be placed on the resident's right side and to be kept in reach at all times. The note indicated that the care plan and Kardex were updated. Review of the nursing notes dated 11/10/14 through 11/14/14 reflected that Resident #1 had unrelieved lower back pain (as a result of the fall on 11/6/14) and was sent to the hospital on [DATE] and returned to the facility on [DATE]. Review of the Investigation Report dated 11/18/14 signed by the Nursing Home Administrator (NHA) reflected, "On 11/11/14. the resident (#1) was seen for a follow up by the facility's Physician Assistant (PA). The resident (#1) continued focus on her pain lead the PA to order another set of xrays and a medication adjustment. The xrays were again negative; however the resident (#1) went to the ER for intractable back pain. The ER performed several CAT scans, with results showing bilateral fractures of the sacral ala (broken tailbone). The resident (#1) was readmitted to the facility with non-surgical, pain management orders." During an interview on 11/20/14 at 1:00 PM, the Director of Nursing (DON) stated that Resident #1 was an extensive assist of one staff member with a gait belt to ambulated before the fall and now (post fall) required 2 staff members and the use of a mechanical lift. The DON stated that Resident #1 remained continent of bladder and the staff now transfers Resident #1 to the bathroom via the mechanical lift. The DON also demonstrated the transfer with the mechanical lift (by using an unoccupied lift with no resident in it). The DON stated that Resident #1' did not have restrictions regarding ambulation. The DON agreed due to Resident #1's legal blindness, and memory impairment may not be able to see or use the call light next to her. The DON further agreed that Resident #1 could attempt to self transfer to the bathroom without staff assist now that her pain is controlled. The DON also agreed that this was not clear on the care plan or the Kardex what assistance and frequency Resident #1 required to use the bathroom safely. In an interview on 11/19/14 at 3:15 PM, Register Nurse (RN) #1 stated that since the fall and readmission to the facility, Resident #1 used a bed pan to void but after a search of the room, RN #1 was not able to find a bed pan and then stated, "I'd have to ask the CNA's how she voids". In an interview on 11/20/14 at 1:10 PM, CNA # 7 stated that she had been assigned to care for Resident #1 for the day. CNA #7 stated that Resident #1 had been incontinent since her return from the hospital on [DATE] and she did not offer Resident #1 assistance to use the bathroom. Resident #2 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #1 had cognitive impairment and required staff assistance with her activities of daily living which included ambulation and transfers. In an observation and interview on 11/19/14 at 10:05 AM, Resident #2 was resting on the bed and had laceration to the right forehead, with bruising to right side of the forehead and bruising that surrounded the right eye. Resident #2 was not able to answer specific questions related to the falls. Review of the Incident Report dated 11/13/13 at 6:00 AM, reflected that Resident #2 fell in the bathroom. The nursing note dated 11/13/14 at 17:13 reflected that Resident #2 suffered the following injuries during the fall; two bruises to the head 3 x 3 cm and 3 x 2.3 cm, bruise to the right shoulder 4 x 3 cm, lacerations (no measurement listed) on the head tender to touch. Resident #2 was sent to the hospital emergency room for further evaluation and treatment. The nursing note dated 11/13/14 at 19:02 reflected that Resident #2 was returned to the facility and had received a CAT Scan of the head and sutures to the lacerations. In a phone interview on 11/19/14 at 3:10 PM, CNA #4 stated that she was assigned to Resident #2 on 11/13/14 and assisted her to the bathroom. CNA #4 stated that she stood outside of the bathroom (out of direct supervision) while Resident #2 used the bathroom. CNA #4 stated she did not see Resident #4 fall and felt terrible about the incident. CNA #4 stated that the facility did not train her how to care for Resident #2. When asked about the orientation CNA #4 received, CNA #4 stated that she started at the facility about 6 weeks ago and did not complete an orientation competency and was not aware that Resident #2 was not to be left alone in the bathroom. In an interview and record review on 11/19/14 at 4:15 PM, the NHA stated no orientation competency could be located within CNA #4's personnel record. On 11/20/14 at 1:40 PM, when asked to review additional CNA orientation competency for CNA #2, CNAs #8 and CNA #9 who were hired between 9/18/14 and 10/6/14 the NHA stated that the orientation competency could not be located. The NHA stated that CNAs #2, #8 and #9 were working independently and she (the NHA) was unaware that the orientation competency was not completed. In an interview and record review on 11/20/14 at 10:10 AM, the DON stated that Resident #2 was an extensive assistance of 1 with transfers and ambulation. The DON reviewed Resident #2's fall reports with the Surveyor. The reports reflected that Resident had 7 falls (9/20/14 at 1:44 AM, 10/1/14 at 11:30 AM, 10/1/14 at 1:00 PM, 10/30/14 at 11:00 PM, 11/3/14 at 8:00 PM, 11/9/14 at 5:00 AM, and 11/13/14 at 6:00 AM) in 54 days, which all had the same root cause of Resident #2 not using the call light for assistance, and self transferring with out staff assistance. 5 of the 7 falls took place in the bathroom or attempting to get to the bathroom. The DON stated that on 11/11/14 a bladder diary (log of data related to Resident #2's need and bathroom usage) was started for 7 days and Resident was offered the bathroom every 2 hours. The Surveyor requested to review the 7 days of bladder diary data and DON stated that the last 2 days 11/16/14 and 11/17/14 could not be located. The DON stated that Resident #2 remained continent if assisted with toileting every 2 hours. When asked if that intervention was added to Resident #2's care plan or Kardex, the DON stated, "No it wasn't I already looked." Review of the falls care plan reflected a "stop sign" was initiated on 11/17/14 and when asked about the intervention, the DON stated, "To remind her (Resident #2) not to self transfer." The DON stated that the intervention of assisting Resident #2 to the bathroom every 2 hours would be added to the care plan and Kardex so the staff will know. Resident #3 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #1 had memory impairment, had difficulties making his needs known, and required staff assistance with his activities of daily living which included transfers. In an interview and record review on 11/19/14 AT 3:05 PM, RN #1 reviewed Resident #3's falls on 9/24/14 at 12:05 PM, 10/7/14 at 2:15 PM and 10/29/14 at 1:00 PM. All 3 falls had the same root cause of Resident #3 attempting to self transfer from the wheel chair to the bed. RN #1 stated after Resident #3's fall on 10/7/14 the intervention to lay him down after meals was added to his falls care plan. When asked about the intervention identified after the fall on 10/30/14 to assist Resident to lay down immediately after meals, at the time of meal tray pick up, RN #1 stated the that the care plan nor the Kardex reflected the new intervention. (# )

Based on observation, interview, and record review, the facility failed to assess, monitor, and prevent pressure ulcers for 2 out of 10 residents reviewed for pressure ulcers, from a total of 15 sampled residents, resulting in skin breakdown including unstageable pressure ulcers for Resident #6 and Resident #8. Findings include: Resident #6 According to Resident #6's MDS/Minimum Data Set, dated dated [DATE], he needed extensive assistance for bed mobility, had functional impairment in both lower extremities, had no cognitive impairment and did not resist care, had an indwelling urinary catheter, and was frequently incontinent of stool. The MDS also revealed Resident #6 had [DIAGNOSES REDACTED]. In an interview, on 6/16/14 at 3:10 PM, the DON/Director of Nursing reported that Resident #6 wore Prevalon Boots (padded footwear) and that Resident #6 acquired heel ulcers while residing at the facility. Review of Resident #6's medical records, revealed Resident #6 was originally admitted to the facility on [DATE] and had a total of 7 discharges and re-entries. In 2013, Resident #6 was discharged on [DATE] and returned on 3/28/13, but then remained at the facility until 4/05/14 (approximately 1 year). Resident #6's Pressure Ulcer Healing Charts revealed he had no open pressure ulcers upon reentry on 3/28/13, but had open pressure ulcers during that 1 year: R (right) heel deep tissue - Stage 2: 8/22/13 - 11/21/13 L (left) heel deep tissue - (not staged): 8/22/13 - 10/03/14 Left coccyx - Stage 2: 1/14/14 - 2/13/14 Right coccyx - Stage 2: 1/16/14 - 2/13/14 Right outer buttock - not staged: 3/10/14 - 3/13/14 Right inner buttock - not staged: 3/10/14 - 3/13/14 Right lower buttock - not staged: 3/10/13 - 3/13/14 Upper coccyx - not staged: 3/10/14 - 4/03/14, and Lower coccyx - not staged: 3/28/14 - 4/03/14 Resident #6 was discharged to the hospital on [DATE] with a coccyx pressure ulcer that measured 4.0 cm length x 3 cm width x 1.0 cm depth. In an interview, on 6/17/14 at 10:00 AM, Resident #6 reported the wounds on his heels were, "All dried up", and said, "My coccyx has a sore that's being taken care of by the wound doctor. I went yesterday and go back in 1 month". When asked how he acquired the sore on his coccyx, Resident #6 stated, "Laying on my back too much. Sitting in a wheelchair. I have no padding like you women...I get on them for it. I tell them to move me and shift me. I can't turn myself". When asked if he was on a turning schedule, Resident #6 replied, "Turning schedule? They should, but they don't". Resident #6 also stated, "Lately, I lost 10 pounds or so. Before that, I kept my weight steady. I don't drink that much...I'm supposed to have a special mattress, but I don't. This one is the same one I've had. It's hard". Resident #6 reported he thought it was the facility's fault that he got the pressure ulcers because, "I was laying on my back...they should have pushed me (to turn). I never turned them down....a long time ago I did, but not lately...after they educated me I haven't. I'm more aware of what's going on now. The doctor took a chip of my bone, trying to keep away from infection in my bone...I'd be good with a 2 hour turn schedule". Review of Resident #6's medical records since August 1, 2013 revealed he did not have a a turning schedule in place on his care plans, he did not have a care plan regarding refusing care, and he had no behavior charting regarding refusal of care. In an interview, on 6/17/14 at 11:13 AM, the DON stated, "We document if (Resident #6) refuses, but we don't have a schedule to turn him. He calls to tell you if he needs to be turned". When asked if Resident #6 had been provided a schedule to remind himself to call to be turned, the DON stated the facility had not provided him with a turning schedule for him to look at. The DON stated, "He's up after breakfast and down after lunch..." The DON reported they were not limiting the amount of time Resident #6 was to be sitting on his coccyx wound but stated, "the Kardex says he's to be turned frequently. That means every 2 hours". When asked why Resident #6 acquired pressure ulcers while residing at the facility, the DON replied, "He's his own person. I think his air mattress is effective to prevent his pressure ulcers...He gets them because of his co-morbidities (existing medical conditions)...he could use a Clinitron (air flow bed designed to accelerate healing) because he has a Stage 4 pressure ulcer. He's up after breakfast and down after lunch... but then you can't get out of a Clinitron...I can't make the judgement on what will work. All you can do is reposition and watch his skin". In an interview and observation in Resident #6's room, on 6/18/14 at 9:15 AM, this Surveyor asked Resident #6 when he was last turned, and he replied, "They should do it right now. I had a shower at 7:00 AM and I've been laying on a wet dressing. I don't think its good to lay on a wet bandage". When asked if he had been turned during the previous night, Resident #6 said, "It's hard to enforce those rules". This Surveyor observed there was an alternating pressure air mattress on Resident #6's bed, but it was not functioning; it was on "standby" mode. There was a Roho (designed for therapeutic treatment and prevention of pressure ulcers) cushion in Resident #6's wheelchair. An observation by the Surveyor was made in Resident #6's room on 6/18/14 at 10:45 AM, as the DON performed a dressing change on Resident #6's coccyx wound. The wound appeared as a crater with slough tissue and pink tissue with bluish skin surrounding it. The DON described the wound: "5.5 cm x 5.0 cm.... 1.0 cm deep. Undermining of 0.5 cm between 12:00 and 6:00 (depth and undermining areas were not measured with a cotton swab), edges approximated, some slough and granulation tissue. Stage 4. Maceration at noon. Surrounding discoloration area 15 cm x 16.5 cm. Tissue purple and dark pink with scar tissue". When asked if Physician "N" had ever seen this wound, the DON replied, "I don't know. I don't recall". The DON packed the crater wound with 3 - 4 x 4 medication soaked gauzes and covered it with a dressing. Review of Resident #6 Braden Scale/skin assessments revealed he scored as Low Risk for skin breakdown on 2/18/14, 4/04/13, 4/11/13, 5/13/13, 6/05/13, 7/15/13, 8/19/13, 9/04/13, 1/01/14, and 6/16/14. In an interview, on 6/18/14 at 1:35 PM, Physician "N" was asked why Resident #6 had pressure ulcers and he replied, "He refuses to be turned. He's a paraplegic. He is at high risk for skin breakdown". Review of Resident #6's Nursing Progress Notes, dated 6/04/14, revealed, "...Pain is present in coccyx wound..." Review of Resident #6's Nursing Progress Notes, dated 6/17/14, "late entry 6/13/14...APM/alternating pressure mattress given to resident, Roho cushion to wheelchair... On 6/18/14 at at 2:35 PM Resident #6 was observed laying on his back in bed in his room. The air mattress alternating pressure device was still not functioning; it was in the "standby" mode. Resident #8 According to Resident #8's MDS/Minimum Data Set, dated dated [DATE], she was admitted to the facility on [DATE], needed extensive assistance with transfers, had functional impairment in both lower extremities, had no cognitive impairment and did not resist care, was in continent of bowel and bladder and was not on a toileting program. The MDS also revealed Resident #8 had [DIAGNOSES REDACTED]. According to the current nurse aide care guide (Kardex), Resident #8 needed to be encouraged and assisted to reposition and "Transfers with one person extensive assist with gait belt". In an interview, on 6/17/14 at 10:30 AM, Resident #8 stated, "I think I got the sore on my bottom from laying on my back. I got it here (while at the facility)...No, they don't turn me. I don't remember to remind them. I don't remember them turning me in the night". Resident #8 reported she sat in the wheelchair "...most of the day...I don't walk at all and the staff don't walk me. I'd have to use the walker. I haven't' been using the walker...Yes, I can turn myself but I can't position the pillows underneath myself...I have a little pain from the sore on my bottom". Resident #8 stated that the 4 wheeled walker against the wall near her bed was hers and did not know why staff was not walking her. According to Resident #8's Physical Therapy Discharge Summary, dated 3/21/14, she was walking 120 feet with her four wheeled walker and contact guard assistance. In an interview in the presence of Surveyor , on 6/17/18 at 3:17 PM, PA/Physician Assistant "A" reported the ulcer on Resident #8's right buttock was not due to a pressure ulcer. PA "A" stated, "I clearly recognized it was a hematoma (a collection of blood under the skin)". When asked how she determined the area was not a deep tissue injury pressure ulcer, PA "A" said, "Do you mean with an x-ray or ultrasound?" When asked if she had ever seen a deep tissue injury pressure ulcer, PA "A" stated she had not. PA "A" said, "I asked (the DON) about what to do. They put ice on it the first day...No, I did not discuss it with (Resident #8's Physician/Medical Director "N"). One week later, the skin was broken. I consulted with (the DON). (The DON) doesn't write orders, but I consult with her....It's a hole (Resident #8's wound); bigger than a quarter and deep. It is a crater right now. I don't know about the pressure kinds of deep tissue injuries". PA "A" reported she had no special training in wound care and said, "It would be nice to know where we get information on wound care and treatments". In an interview, on 3/17/14 at 3:00 PM, Nurse Aide "B" reported she was Resident #8's assigned nurse aide that day. Nurse Aide "B" stated Resident #8 had been up in her wheelchair "about 4 hours today (so far)". When asked how long Resident #8 would be up in her wheelchair, Nurse Aide "B" said, "The Kardex did not say how long she should be up...(Resident #8) is still in Bingo now. Second shift will take over". Nurse Aide "B" reported the Kardex did not specify how often Resident #8 was to be turned while she was in bed. Nurse Aide "B" said, "There is a little blue cushion in her wheelchair. I just asked her how her bottom feels once and awhile. I don't stand her. I put the gait belt on her and pull her to reposition her in her wheelchair, if she wants to". In an interview, on 6/17/14 at 4:09 PM, the DON was asked why there was no Pressure Ulcer Healing Charts (records) for Resident #8's coccyx wound and she replied, "It's not a pressure ulcer. She has a [DIAGNOSES REDACTED]. The DON reported she had not discussed the "hematoma" with physician "N" and when asked, reported she neither possessed a certification in wound care nor did she know if the facility had wound care protocols. The DON stated, "I assume (Physician "N") is aware because his PA diagnosed it". The DON stated Resident #8 was not going to the wound clinic, "because its (the buttock wound) getting smaller...We (she and PA "A") opened it up...it was debrided. We cleansed the area, injected it with [MEDICATION NAME] (pain killer), cut around it with a scalpel." In an interview, on 6/17/14 at 4:22 PM, Nurse Aide "K" reported she worked full time on second shift and was assigned to Resident #8 3-4 days/weeks "ever since she's been here". Nurse Aide "K" stated, "Usually, (Resident #8) is up when we get here and is up until 8:00 - 9:00 PM...the sore on her bottom is nasty. When I first saw it, it looked like the start of a bed sore. It was nickle size, and red, like you've been laying on it too long. It was pinkish red on her cheek. Yes, she sits on that area. I have seen these sores before. Yes, it was a pressure ulcer". Nurse Aide "K" also reported there was "nothing on the care guide (Kardex) to stand or reposition (Resident #8)". Nurse Aide "K" stated she reported the nickle sized area to the nurse but could not remember who the nurse was or when she reported it. On 6/18/14 at 9:18 AM in Resident #8's room, this Surveyor observed Resident #8 had a standard issued mattress on her bed and a standard foam cushion in her wheelchair (confirmed in an interview with Central Supply Clerk "O" on 6/18/14 at 3:00 PM). At this time, Resident #8 reported that other than bruising on her hands and skin, she had no unusual bleeding; her gums did not bleed and she had no nosebleeds. According to Resident #8's MAR/Medication Administration Record, [REDACTED]". Review of Resident #8's physician progress notes [REDACTED]. Not infected but given location, susceptible to becoming infected... Impression/treatment plan: [REDACTED]. There were no measurements documented. The first documentation of the wound on Resident #8's Skin Alteration Records appeared on 4/30/14: "Length: 8 cm. Width: 5 cm; Depth 0 cm. Pale, pink tissue, Edges approximated, Dark pink/red tissue. Drainage: Serosanguineous (sic) - thin red. Skin Surrounding Alteration: Normal Appearance". On 5/07/14, Resident #8's Skin Alteration Record read exactly as it did on 4/30/14: "Length: 8 cm. Width: 5 cm; Depth 0 cm. Pale, pink tissue, Edges approximated, Dark pink/red tissue. Drainage: Serosanguineous (sic) - thin red. Skin Surrounding Alteration: Normal Appearance". Documentation on the Skin Alteration Record showed the wound had no depth until 5/27/14 (Depth 0.5 cm). By 6/10/14, Resident #8's Skin Alteration Record revealed: "Length 4 cm. width: 5 cm. Depth: 4 cm. Tunneling: 3.0 cm at 7:00. Dark pink/red tissue. Drainage: Serosanguineous (sic)- thin, red. Skin Surrounding: Reddened, Firm/hard". The first documentation of the wound in Resident #8's Nursing Progress Notes appeared on 4/26/14: "Pt (Resident #8) left buttocks is broken not, trx (treatment) performed as ordered. Scant serous drainage to dressing. No odor noted..." There were no measurements documented. According to Resident #8's MAR/Medication Administration Record, [REDACTED]" on 5/27/14. According to Nursing Progress Notes, dated 6/03/14, "...The wound has a very fowel (foul) strong order (odor). The base of the wound is black and what looks like black string. There was a large amount of drainage". There were no measurements documented. Review of Resident #8's care plans since admission on 3/03/14 revealed no turning schedules or ambulation interventions. Review of Resident #8's medical record on 6/18/14, revealed the last documented measurements of the wound on Resident #8's left buttock was on a Skin Alteration Record dated 6/10/14: "Length:4 cm. Width: 5 cm. Depth: 4 cm. Dark pink/red tissue. Drainage: Serosanguineous (sic) - thin, red. Skin Surrounding Alteration: Reddened, Firm/hard". Resident #8 had no Pressure Ulcer Healing Charts. On 6/18/14 at 11:15, this Surveyor observed the DON perform a dressing change on Resident #8's left buttock wound in Resident #8's room. Resident #8 was sitting at a 40 degree angle in bed and reported she had been lying on her back "all day so far" since before breakfast. Resident #8 reported no one asked to turn her during the night and the DON said to Resident #8, "Are you sure you don't remember?" Resident #8 adult brief had a large amount of non-formed brown stool in it. After cleaning Resident #8 of stool and opening the dressing, this Surveyor observed an open crater wound in the middle of Resident #8's left buttock; it had a dark purple bed and was weeping a dark purple fluid. The DON described the wound: "Its a hematoma. 4.9 cm x 5.5 cm. with a depth of 1.2 cm. The DON stated that the wound was "getting better". The DON packed the crater wound with 3 - 4 x 4 medication soaked gauzes and covered it with a dressing. This Surveyor then asked to observe the tissue under Resident #8's gluteal folds. There was an open area weeping sero-sanginous fluid present there. This Surveyor asked the DON "What is that? " and the DON said, "I'm not sure, I'll have to check...It's over scar tissue...0.5 cm x 1.0 cm. red area with serosanguinous drainage. If it is a pressure ulcer, it would be a Stage 2". After the DON left the room, Resident #8 was again asked if staff had turned her during the night, and she emphatically said "No, I usually lay on my back...I like to lay on my side." When the DON returned to the room, this Surveyor asked, "Do you limit the time she can be up in a chair?" and the DON replied, "No, she likes to be in her chairs (wheelchair and recliner)". When asked if staff ever walked Resident #8, the DON stated, "They walk her to the bathroom". When the DON was out of earshot, this Surveyor asked Resident #8 how often staff walk her in the hall or to the bathroom, and she replied emphatically, "Never!" In the hallway, following the dressing change, the DON reported she had a certificate in wound care and would bring it "tomorrow". On 6/19/14 at 12:40 PM, the DON reported she did not have a certificate in wound care. In the presence of the Human Resources Director "M", on 6/18/14 at 11:45 AM, review the DON's employment resume and cover letter revealed no evidence that she had special training in wound care. The DON had been employed by the facility since 2/2014. Review of Resident #8's Braden Scale/skin assessments revealed she scored at Low Risk for skin breakdown on 3/11/14, 3/20/14, 3/27/14, and 3/31/14. In an interview, on 6/18/14 at 1:35 PM, Physician "N" reported Resident #8 was at risk for skin issues due to her "fragile [MEDICATION NAME] tissue (skin)", and her [DIAGNOSES REDACTED].#8's buttock wound and had not been notified about it prior to this Surveyor's request that he come to the facility that day to assess and discuss it. Physician "N" stated, "All documentation says it started as a hematoma...A pressure ulcer starts out as an open area. A deep tissue injury...has eschar...would be a Stage 4; down to the bone/with muscle injury...". Physician "N" stated he was not aware that Resident #8 did not have a turning schedule and was allowed to be up in her wheelchair all day. Physician "N" stated, "The key to preventing pressure ulcers is turning every 2 hours." Physician "N" stated he could not stage the wound on Resident #8's buttock because, "It is a hematoma that's been evacuated", but also said, "The new area (in Resident #8's right gluteal fold) is a Stage 2 pressure ulcer". Physician "N" did not write a progress note on Resident #8 before he left the building. In an interview, on 6/19/14 at 11:05 AM, PT/Physical Therapist "R" reported Therapy's goal with Resident #8 was "to have her start walking more with new shoes that fit...(Resident #8) did get shoes that fit after she was discharged from Therapy...Yes, she could have walked with gripper/no-slip socks on". PT "R" reported she did not know why staff was not walking Resident #8 and said the Therapy Department had not been asked to reassess Resident #8 for a decline in ADLs (Activities of Daily Living). PT "R" stated, "for a couple of days, (Resident #8) was not weight bearing; resting her arms because of a fistula problem". PT "R" continued, "The only referral we got for (Resident #8) was for a hematoma. We gave her diathermy treatments. The machine gives deep heat and increases circulation. It is a 30 minute program. We put the machine over the affected area. We tried a couple of sessions. After 3 sessions there was no improvement..." In an interview, on 6/19/14 at 2:30 PM, Nurse Aide "S" reported she had worked at the facility full time for the past 4 years on the unit that Resident #8 resided. Nurse Aide "S" stated, "Last month I first saw the sore (on Resident #8's buttock). At first it was just red and about 1/2 dollar size. Then, it became black. They cleaned it out and now it's a hole. When it was red, it looked like a pressure ulcer. It was pinkish...Yes, she sits on that area...(Resident #8) is mobile and can stay up as long as she wants". Nurse Aide "S" stated she thought Resident #8 was no longer walking and getting weaker "from her [MEDICAL TREATMENT]". In a telephone interview, on 6/19/14 at 2:45 PM, LPN/Licensed Practical Nurse "T" stated "The first time I saw it (the wound on Resident #8's left buttock) it was a little bigger than a 1/2 dollar and it was red and hard...dark pink. (Resident #8) complained about it itching. It was not open initially. I went and got someone...I believe it was (PA "A"). She's new and has blond hair. They said it was [MEDICAL CONDITION] (inflammation)...I can't remember if I charted". When asked if she updated Resident #8's care plan at that time, LPN "T" said, "I don't think so because I didn't get an order for [REDACTED]. According to the National Pressure Ulcer Advisory Panel: "Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown...eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined... Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue...Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment". (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/)

This citation pertains to MI 272 Based on observation, interview, and record review the facility failed to follow their policy and procedure for medication administration for 16 of 22 sampled residents (Resident #101, Resident #102, Resident #104, Resident #105, Resident #106, Resident #107, Resident #108, Resident #109, Resident #110, Resident #111, Resident #112, Resident #115, Resident #116, Resident #119, Resident #121, and Resident #122), from a total sample of 22 residents, resulting in an Immediate Jeopardy when, on 12/13/12 on the 3rd shift, Licensed Practical Nurse (LPN) #5 preset medications that were due to be administered between 4:00 a.m.-7:00 a.m. for 16 residents and then documented that the medications as being given on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. These deficient practices placed all 64 residents, residing in the facility, at risk for serious harm, injury and/or death. Findings include: In an interview on 12/13/12 at 2:50 AM, Licensed Practical Nurse (LPN) #5 stated, "I don't usually preset" the medications and chart the medications as given. LPN #5 stated she preset medications because, "I have treatments that take a long time." Review of Facility Policy and Procedure Medication Administration: Medication Pass, dated 3/2010, revealed under "9., Administer medication", that the procedure was to "administer medication in accordance with frequency prescribed by physician- within 60 minutes before or after prescribed dosing time" and "document initials on MAR for each medication administered." In an interview on 12/13/12 at 4:35 a.m., Director of Nursing (DON) #2 stated, "the expectation is that they (staff) pass their med's (medications) on time and not preset (the medications)" and "give them (medications) and sign off on time (in the Medication Administration Record)." "After administering a medication, the nurse records it immediately on the appropriate record form. Recording immediately after administration prevents errors." (Potter, P.A. & Perry, A.G. (2005) Fundamentals of Nursing (6th edition). St. Louis: Mosby). Resident #101: Review of the Face Sheet revealed Resident #101 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was cognitively intact. An observation on 12/13/12 at 4:27 a.m., of the medication cart revealed an unlabeled medication cup which contained 1 pill. Review of the physician's orders [REDACTED]."6P 6:00 p.m.)." Resident #102: Review of the Face Sheet revealed Resident #102 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #102 had moderate cognitive impairment. An observation, on 12/13/12 at 4:25 a.m., of the medication cart revealed an unlabeled medication cup which contained 2 pills and 2 packaged pills. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]#5 for 6:00 a.m. on 12/13/12. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]. tablet" once a day at "6 AM (6:00 a.m.)" and "Pantoprazole SOD 40 mg Tab... by mouth daily" at "6 AM." Resident #104: Review of the Face Sheet revealed Resident #104 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #104 was cognitively intact. An observation on 12/13/12 at 4:15 a.m. of the medication cart revealed an unlabeled medication cup which contained white powder. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]#5 for 6:00 a.m. on 12/13/12. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]."6 pm (6:00 p.m.)", "[MEDICATION NAME] 20 mg" once a day at "6 AM." and "[MEDICATION NAME] 0.1 mg tab" once a day at "6 AM." Resident #105: Review of the Face Sheet revealed Resident #105 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #105 had severe cognitive impairment. An observation on 12/13/12 at 4:13 a.m. of the medication cart revealed an unlabeled medication cup which contained 1 pill. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]..by mouth daily" at "6A." Resident #106: Review of the Face Sheet revealed Resident #106 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #106 had moderate cognitive impairment. An observation on 12/13/12 at 4:11 a.m. of the medication cart revealed an unlabeled medication cup which contained 1 pill. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]." Resident #107: Review of the Face Sheet revealed Resident #107 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #107 had moderate cognitive impairment. An observation on 12/13/12 at 4:10 a.m. of the medication cart revealed an unlabeled medication cup which contained 2 1/2 pills. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]#5 for 7:00 a.m. on 12/13/12 and [MEDICATION NAME] 20 mg was initialed as given for 6:00 a.m. on 12/13/12. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]..once daily" at "7A (7:00 a.m.), "[MEDICATION NAME] 25 mg...daily" at 7AM (7:00 a.m.), "[MEDICATION NAME] 20 mg...once daily" at "6AM". Resident #108: Review of the Face Sheet revealed Resident #108 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #108 was severely cognitively impaired. An observation on 12/13/12 at 4:05 a.m. of the medication cart revealed an unlabeled medication cup which contained 2 pills. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the 12/2012 MAR indicated [REDACTED]#5 stated, "no" when asked by surveyor if the medication had [MEDICATION NAME] had been given and stated, "yes" when asked if she initialed the MAR indicated [REDACTED] Review of the physician's orders [REDACTED].:00 a.m.)" and "12A." Resident #109: Review of the Face Sheet revealed Resident #109 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #109 was cognitively intact. An observation on 12/13/12 at 4:02 a.m. of the medication cart revealed an unlabeled medication cup which contained 3 pills. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]..2 tabs" 3 times per day at"6A, 2P (2:00 p.m.), and "10P" (10:00 p.m.) and "[MEDICATION NAME] 88 mcg..once daily." Resident #110: Review of the Face Sheet revealed Resident #110 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #110 was severely cognitively impaired. An observation on 12/13/12 at 4:00 a.m. of the medication cart revealed an unlabeled medication cup which contained white powder. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated uh huh (indicated yes)" when asked by surveyor if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]. Resident #111: Review of the Face Sheet revealed Resident #111 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #111 was cognitively intact. An observation on 12/13/12 at 3:56 a.m. of the medication cart revealed an unlabeled medication cup which contained 2 pills. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]#5 for 6:00 a.m. on 12/13/12. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]." and "[MEDICATION NAME] 7.5/325...twice daily" at "6A" and "5P (5:00 p.m.)." Resident #112: Review of the Face Sheet revealed Resident #112 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #112 was moderately cognitively impaired . An observation on 12/13/12 at 3:54 a.m. of the medication cart revealed an unlabeled medication cup which contained powder. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]." Resident #115: Review of the Face Sheet revealed Resident #115 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #115 was severely cognitively impaired. An observation on 12/13/12 at 3:45 a.m. of the medication cart revealed an unlabeled medication cup which contained 2 pills. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]."[MEDICATION NAME] 20 mg...once daily" at "6A." Resident #116: Review of the Face Sheet revealed Resident #116 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #116 was cognitively intact. An observation on 12/13/12 at 3:40 a.m. of the medication cart revealed an unlabeled medication cup which contained 1 pill. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. While reviewing the MAR indicated Yes" when asked if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]." Resident #119: Review of the Face Sheet revealed Resident #119 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #119 had moderate cognitive impairment. An observation on 12/13/12 at 3:15 a.m. of the medication cart revealed an unlabeled syringe with clear fluid. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]#5 at 6:00 a.m. on 12/13/12. LPN #5 stated, "no" when asked by surveyor if she had given the [MEDICATION NAME]because "I haven't checked his sugar (blood glucose) yet". LPN #5 stated, "Yes" when asked by surveyor if she initialed the MAR before giving both medication. Review of the physician's orders [REDACTED]...6 units...every morning" at "6A." Resident #121: Review of the Face Sheet revealed Resident #121 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #121 was moderately cognitively impaired. An observation on 12/13/12 at 2:52 a.m. of the medication cart revealed an unlabeled medication cup which contained crushed powder. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. LPN #5 stated, "these are for 6am" medication pass and said, "yes" when asked by surveyor if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]."6PM (6:00 p.m.)." Resident #122: Review of the Face Sheet revealed Resident #122 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS, dated [DATE], revealed Resident #122 was severely cognitively impaired. An observation on 12/13/12 at 2:54 a.m. of the medication cart revealed an unlabeled medication cup which contained white powder. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. LPN #5 stated, "Yes" when asked by surveyor if she initialed the MAR before giving the medication. An interview with LPN #5 and a record review of the 12/2012 MAR indicated [REDACTED]. LPN #5 stated, "Yes" when asked by surveyor if she initialed the MAR before giving the medication. Review of the physician's orders [REDACTED]...3 times daily" at "6A, 12P" and "6P", "[MEDICATION NAME] 20 mg..every morning" at "6AM" and "[MEDICATION NAME] 10-325...every 4 hours" at "4A, 8A (8:00 a.m.), 12P, 4P (4:00 p.m.), 8P (8:00 p.m.)" and "12A." On 12/14/12, Administrator #1 was notified of the Immediate Jeopardy that was identified on 12/13/12 and began on 12/13/12 when, on 12/13/12 on the 3rd shift, LPN #5 preset medications that were due to be administered between 4:00 a.m.-7:00 a.m. for 16 residents and then documented that the medications were given on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/17/12, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 12/13/12, LPN #5 was immediately suspended and will receive disciplinary action according to facility policy. 2. On 12/13/12, the Medical Director/Attending physician was notified of the event. No further instructions were given. 3. On 12/13/12, a Quality Assurance meeting was held and an investigation was initiated. 4. On 12/13/12, the facility policy and procedure regarding medication pass/administration was reviewed and deemed appropriate. 5. On 12/13/12, the medications preset by LPN #5 were discarded per policy and a scheduled administration pass under the supervision of the Assistant Director of Nursing Services (ADNS) was completed with no concerns were noted. 6. On 12/14/12, all 16 residents, who potentially could have been affected, were assessed with [REDACTED]. It was determined that no adverse reactions were present. 7. On 12/13/12, a complete medication audit was done by the ADNS. There were no additional preset medications found. 8. On 12/13/12, the education of nursing staff was initiated. 24 of 24 nursed were educated regarding medication administration including not pre-setting of medications and to not pre-chart medications prior to administration. 9. As of 12/13/12, the Director of Nursing or designee will conduct medication pass audit checks on 100% of nursing. 10. As of 12/13/12, the Director of Nursing or designee will do random monitoring of the medication carts and medication pass practices at least 3 times per week for the next 4 weeks to monitor for nurses' compliance with the medication administration policy. Although the Immediate Jeopardy was removed on 12/14/12, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not yet been verified by the State Agency. ( )

This citation pertains to intake #MI 972 Based on interview and record review the facility failed to provide services to maintain the highest practicable physical well-being in 1 of 3 sampled Residents (Resident #102) in a total of 6 sampled Residents, resulting in Immediate Jeopardy (IJ) when Resident #102, who was a full code, was found unresponsive on [DATE] at approximately 6:00 a.m. and facility staff did not immediately assess Resident #102, immediately initiate Cardiopulmonary Resuscitation (CPR), or notify Emergency Medical Services (EMS) until 42 minutes after Resident #102 was first found unresponsive. These deficient practices placed all Residents, who may experience a life threatening injury or event and require emergent care, at risk for serious harm, injury and/or death. Findings include: Resident #102 was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] and [DATE]. Resident #102 had a history of [REDACTED]. According to the Physician Admission order dated [DATE], Resident #102 was a full code. Review of the Minimum Data Set ((MDS) dated [DATE], Resident #102's Brief Interview for Mental Status Score (BIMS) was 8 (indicating moderate cognitive impairment) and Resident #102 required extensive assistance for most of her activities of daily living. During an interview with Certified Nursing Assistant (CNA) #1, on [DATE], at 6:40 AM, CNA #1 said, "I was on my last rounds on [DATE] at about 6 AM and I noticed (Resident #102) was not moving/chest not moving. I went to get Licensed Practical Nurse (LPN) #1 and (LPN #1) did not come. I took CNA #2 and #3 to see (Resident #102) was not breathing. CNA #2 went to get (LPN #1) to tell her (Resident #102) was not breathing and this time (LPN #1) came and took Resident #102's pulse and oxygen level. (LPN #1) then put her face up to Resident #102's face and said she is not breathing." CNA #1 was asked by the surveyor if Resident #102 was cold to the touch when she first found her. CNA #1 said, "no, I shook her hand and it was warm." During an interview on [DATE] at 9:15 AM, LPN #1 was asked by the surveyor when she became aware that Resident #102 was not breathing on [DATE]. LPN #1 said she became aware between 6:,[DATE]:15 AM. LPN #1 said, "(CNA #2) said she could not wake up (Resident #102) and I told her ok. Five minutes later (CNA#2) said you need to look at (Resident #102). I went right away and attempted to get vital signs. Resident #102 had no response and was cool to touch. I went to grab another nurse, (LPN #2), and she said we do not do CPR when the body is cold. Then (LPN #3) said to start CPR and call Emergency Medical Services." LPN #1 reported that was around 6:20 AM. During an interview on [DATE] at 7:20 AM, LPN #2 was asked by the surveyor if LPN #1 asked her look at Resident #102 on [DATE] when she was found without vital signs. LPN #2 said LPN #1 wanted to know what to do. LPN #1 said, "When I touched the body and it was cold, I told her I do not think we do CPR when the body is cold." LPN #2 said, "Then the day shift (LPN #3) came in and said we do CPR." During an interview on [DATE] at 7:05 AM, CNA #4 said, (LPN #1 and LPN #2) were at the nursing desk and LPN #1 and LPN #2 checked Resident #102's code status as first shift was coming in and a first shift nurse (LPN #3) said Resident #102 was a full code. CNA #4 said when she heard Resident #102 was a full code she grabbed the crash cart and took it to Resident #102's room According to the EMS run sheet for Resident #102 dated [DATE], EMS was called at 6:42 AM, approximately 42 minutes after CNA #1 first notified LPN #1 of Resident #102's acute change of condition. EMS arrived at Resident #102's bedside at 7 AM and found Resident #102 unresponsive, cold, pale in color, with vital signs absent. EMS contacted the hospital and the hospital physician pronounced Resident #102's time of death as 7:02 AM. Review of the Physician order [REDACTED]." According to the Release of Remains form dated [DATE] Resident #102's body was released to the Medical Examiner (ME) on [DATE] at 7:50 AM. During an interview with a clerk at the Medical Examiners (ME) office on [DATE] at 2:30 PM, Clerk #1 reported that the ME completed an autopsy on Resident #102 and her death was ruled as "natural cause". On [DATE] at 2:50 PM the Administrator was notified of the Immediate Jeopardy that began on [DATE] when the facility failed to provide services to maintain the highest practicable physical well-being in 1 of 3 sampled Residents (Resident #102) in a total of 6 sampled Residents, resulting in Immediate Jeopardy (IJ) when Resident #102, who was a full code, was found unresponsive on [DATE] at approximately 6:00 a.m. and facility staff did not immediately assess Resident #102, immediately initiate Cardiopulmonary Resuscitation (CPR), or notify Emergency Medical Services (EMS) until 42 minutes after Resident #102 was first found unresponsive. These deficient practices placed all Residents, who may experience a life threatening injury or event and require emergent care, at risk for serious harm, injury and/or death. On [DATE] this surveyor confirmed that the facility staff implemented the following to remove the immediate jeopardy. 1. On [DATE], the two licensed nurses and the CNA's involved in incident of [DATE], were suspended pending further investigation. 2. On [DATE] at approximately 1:45 PM, the Administrator reviewed current residents with full code status and verified that appropriate code identification was present. 3. On [DATE] at approximately 2:00 PM the Administrator and Administrative Director of Nursing developed a Nurse and CNA education plan for Emergency Management and Change of Condition. 4. On [DATE] at approximately 2:45 PM, CNA in-services were initiated for the following procedures. As of [DATE], 14 of 30 CNA's were in-serviced. The remaining CNA's, including "as needed" staff, have been notified of the required education. They will not be allowed to work until they participate in the education. - The Change in Status Report, 24 Hour Report. 5. On [DATE] at approximately 2:45 PM, Nursing in-services were initiated for the following procedures. As of [DATE], 8 of 14 licensed nurses were in serviced. The remaining licensed nurses, including 'as needed" staff, have been notified of the required education. They will not be allowed to work until they participate in the education. - The Change in Status Report, 24 Hour Report. - The Cardio-Pulmonary Resuscitation-Adult guidelines - The Emergency Management: Identification of Patient Do Not Resuscitate: or "Code" Status - The Automatic External Defibrillation Nursing Procedure - The Emergency Management: Documentation Checklist - The Emergency Management: Mock Drill and QA&A Adult tool. 6. On [DATE] at 8:20 PM nurses and CNA's were notified by phone of the mandatory scheduled education sessions (see #4 and #5 above) on [DATE] at 9:00 AM and 12:30 PM 7. On [DATE] at 3:50 PM, 4:30 PM, and 10:45 PM, mock code drills were conducted. 8. On [DATE], at approximately 6:30 PM the Medical Director was contacted and a QA (Quality Assurance) meeting was scheduled. 9. On [DATE], at approximately 6:45 PM, Emergency Management Rounds were conducted by the Director of Nursing which included an audit of emergency management equipment (AED (defibrillator), emergency carts , Oxygen, suction machine) 10. On [DATE], at 7:00 PM a staff in-service matrix for tracking of nurse and CNA mandatory in-service attendance was developed. 11. On [DATE] at approximately 7:30 PM, a QA meeting was held with the Medical Director, Director of Nursing, and Nursing Home Administrator. The Administrator will be responsible for maintaining compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm but potential for more than minimal harm that is not an Immediate Jeopardy due to all education had not yet been completed and sustained compliance has not been verified by the State Agency ( )

Complaint Intake Number: MI- 259 Based on observations, interviews, and records review the Facility failed to ensure adequate and appropriate use of assistance devices to prevent accidents (wheelchair foot rests) for 1 of 5 residents in the sample (#104) resulting in actual harm lacerations, bruises and abrasions to the head, face and shoulder. Findings include: Per the Investigation File dated 12/6/10 and the Incident Report dated 12/6/10 on 12/6/10 Nurse Aide #18 "attempted to transport (Resident #104) in her wheelchair without foot pedals" and Resident #104 "popped out" of the wheelchair and landed on her left side and sustained a laceration to the left side of the forehead, a laceration above her left eye, a laceration to the left temporal area, and a scrape below the left eye. Per the Hospital Emergency Triage assessment dated [DATE] Resident #104 sustained "large bruising to face, surrounding abrasion that extends to mid scalp and left temple, periorbital swelling, and ecchymosis to left side" of face and a "left shoulder abrasion." Per the statement dated 12/6/10 signed by Nurse Aide #18, Resident #104 "wasn't wearing her foot pedals. It was completely my fault." In a telephone interview on 12/10/10 at 11:20 a.m. Nurse Aide #18 stated on 12/6/10 at 7:45 a.m. she was pushing Resident #104 in her wheelchair in the corridor when Resident #104 "fell forward" onto the floor. Nurse Aide #18 said she was "unable to say what part of her body hit the floor first. I didn't know she hit her head until I saw the bump." In a telephone interview on 12/10/10 at 12:42 p.m. Nurse Aide #18 said when she came on duty on 12/6/10 she found Resident #104 sitting in her wheelchair minus its' foot pedals at the Nurses' Station. Nurse Aide #18 stated it was unlikely that Resident #104 had self-propelled her wheelchair to the Nurses' Station as although Resident #104 was able to push forward with her feet, she "rolled back" when she stopped and she self-propelled only short distances. She doesn't tend to get very far." Nurse Aide #104 stated she knew foot rests should be used when transporting residents however it was common practice for staff to transport residents without footrests. Nurse Aide #104 said she had seen the "Director of Nursing, therapists, and lots of staff" transporting residents in wheelchairs without footrests. Per the "Things You Need to Know for Great Patient Care and Safety" signed by Nurse Aide #18 on 1/19/09, "Foot pedals must be used when transporting residents. Self-ambulatory patients do not need them on unless staff is going to move them. Any patient who is being wheeled by a staff member must have foot pedals on the wheelchair, feet must be on the foot pedals if in motion-no matter how small or great the distance being moved." In an observation on 12/9/10 at 12:45 p.m. Resident #104 was noted to have purple and green colored bruises to her forehead, temple and under both eyes (raccoon eyes) with healing abrasions and lacerations to the forehead and left temple and multiple raised areas on her balding scalp. In an observation on 12/10/10 at 11:00 a.m. Resident #104 was noted to have a 3.0 cm x 2.5 cm healing abrasion on her left shoulder. In an interview on 12/9/10 at 12:45 p.m. Resident #104 said she fell out of her wheelchair and hit her head. Resident #104 stated, "That woman was going too darn fast. I told her to slow down...Both my eyes were swollen shut...I want her fired." Resident #104 said, "I have cancer" and brushed her hand across her balding scalp. Per the Nurses' Notes dated 10/26/10 Resident #104 was diagnosed with [REDACTED]. Per the Nurses' Notes dated 11/26/10 Resident #104 went out for a radiation treatment. Per the Nurses' Notes dated 11/29/10 and 12/1/10 Resident #104 went off-campus to medical appointments for "treatment" to her scalp. Per the Minimum (MDS) data set [DATE] Resident #104 was diagnosed with [REDACTED]. ( )