Every finding on record at Optalis Health & Rehabilitation of Bloomfield Hill

This citation pertains to intake 3137447.Based on interviews and record reviews the facility failed to ensure timely implementation of preventative wound interventions, failed to accurately implement wound treatment orders as noted by the Wound practitioner for one (R300) of three residents reviewed for wounds, resulting in a change in condition from a wound infection that required a transfer to a higher level of care and admission into the Intensive Care Unit (ICU) requiring multiple intravenous antibiotics and surgical wound debridement.Findings include:A review of a complaint submitted to the State Agency (SA) reported neglect regarding the care provided to R300.A review of the medical record revealed R300 admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke) due to thrombosis (blood clot), hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction, chronic kidney disease, tracheostomy (surgical opening to the neck to provide an alternative airway) and gastrostomy (surgical opening through the abdominal wall to insert a feeding tube) status. R300 was dependent on staff for all activities of daily living.A review of a Nursing admission Evaluation dated 3/13/26 at 7:28 PM, documented in part . Clinical Evaluation Integumentary (Skin). Coccyx - redness.A review of the medical record revealed no preventative treatment implemented for the coccyx redness.A review of the admission Braden assessment noted a score of 9.0 Very High Risk.A review of a care plans revealed the following:3/13/26 - A care plan titled Resident has pressure ulcer noted one intervention Administer analgesics as needed.3/13/26 - At risk for alteration in skin integrity related to: cognitive status and decreased mobility noted one intervention Barrier cream to per area/buttocks as needed.A review of the progress notes revealed the following:On 3/13/26 at 1:20 PM, a Nursing note documented in part, . Skin assessed by wound care nurse no open area noted.On 3/13/26 at 3:21 PM, a skin wound note documented upon second skin observation upon admission, there are no skin concerns at this current time. MD (medical doctor) and (R300's daughter name) aware, skin is clean dry and intact.On 3/19/26 at 1:20 AM, a Nursing note documented in part . reported skin tear during care. Writer assesses site and notes small skin tear to resident's left buttock. Wound care consult and treatment order in place.On 3/19/26 at 1:36 AM, a change in condition note documented in part . The Change in Condition/s reported on this CIC (change in condition) Evaluation are/were: Skin wound or ulcer.On 3/19/26 at 2:19 PM, a skin/wound note documented in part . writer seen resident for wound consult, resident has abrasion to sacrum area from friction and shear. TX (treatment order in place).Further review of the care plans revealed additional wound interventions implemented on 3/20/26.A review of the Physician orders revealed calmoseptine ointment was implemented to be applied to the buttocks every shift for Skin tear on 3/19/26. This order stayed effective for the whole duration of R300 stay at the facility, being applied concurrently with other treatments to the same area.A review of a skin/wound note dated 3/24/26 at 1:07 PM, documented in part . nurse evaluated abrasion on sacrum, wound looks more deteriorating, bigger and more excoriated measuring 2.0x2.0x0.1 wound np (nurse practitioner) consult for further evaluation.Review of a Wound Consult dated 3/25/26, documented in part . Chief Complaint: Wound care consulted for stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) to the sacrum. 3/25/26: Wound care consulted for stage III pressure ulcer to the sacrum, new treatment plan implemented. Continue pressure offloading interventions. Stage III pressure ulcer to the sacrum, current measurements 2.26 cm (centimeters) x 4.18 cm . 0.3 cm, surrounding tissue with some dark discoloration and is fragile, no odor, no signs or symptoms of infection or cellulitis (skin infection), base with granular tissue (healthy new tissue), some prior epithelial scarring, and yellow necrotic slough (non-viable yellow, tan, gray, green or brown tissue), minimal serosanguineous drainage (thin watery pink/red fluid). Wound care recommendations for sacrum: Clean wound with wound cleaner/normal saline, pat dry with gauze, apply Medihoney, apply a thin layer of Triad, apply superabsorbent dressing, change daily and as needed.A review of the Physician orders documented the following:Cleanse sacrum with wound cleanser and normal saline apply medi honey to wound bed and cover with border gauze dressing every shift for Stage 3 wound.A review of the medical record revealed no documentation on why the order was not implemented as ordered by the Wound practitioner.A review of the Physician orders noted the following:3/31/26 - Cleanse sacrum with wound cleanser and normal saline apply Medi honey if Santyl not available to wound bed and cover with border gauze dressing every shift for Stage 3 wound.3/31/26 - Wound Gel apply to sacrum topically every shift for wound care. The order did not specify what gel to use.A wound consult dated 4/1/26, documented in part . Re evaluation for stage III pressure ulcer to the sacrum. Stage III pressure ulcer to the sacrum, current measurements 4.27 cm x 4.03 cm x 0.3 cm, surround tissue with some dark discoloration and is fragile, no odor, no signs or symptoms of infection or cellulitis, base with granular tissue, some prior epithelial scarring, and yellow necrotic slough, minimal serosanguineous drainage- stalled. Wound care recommendations for sacrum: Clean wound with wound cleaner/normal saline, pat dry with gauze, apply Santyl, apply superabsorbent dressing, change daily and as needed. This order was not implemented as directed by the Wound practitioner.A wound consult dated 4/8/26, documented in part . Re evaluation for stage III pressure ulcer to the sacrum. current measurements 4.62 cm x 5.18 cm x 0.3 cm, surrounding tissue with some dark discoloration and is fragile, no odor, no signs or symptoms of infection or cellulitis, base with granular tissue, some prior epithelial scarring, and yellow necrotic slough, minimal to moderate serosanguineous drainage- stable. Wound care recommendations for sacrum: Clean wound with 1/4 th dakins solution, pat dry with gauze, apply Santyl, apply superabsorbent dressing, change bid (twice a day) and as needed.The above order was not implemented as directed by the Wound Clinician. A review of the medical record revealed no documentation on why the wound orders were not implemented as directed by the Wound practitioner.On 4/13/26 at 11:50 AM, a skin/wound note documented Upon dressing change writer noted foul odor and increased drainage coming from sacral wound, delayed healing, Extensive slough and necrotic tissue (dead tissue) covering wound bed with yellow, brown and black areas, periwound erythema and discoloration, no warmth, no signs of pain noted. MD (medical doctor) notified and instructed writer to start resident on Bactrim (antibiotic) 800-160mg (milligram) BID (twice a day) x10 days.On 4/13/26 at 12:06 PM, a Nursing note documented in part . Writer notified wound care nurse that foul smell odor, excess drainage with slough noted during dressing change. Wound nurse and writer assessed resident. ordered Bactrim 800-160 mg BID.On 4/14/26 at 4:25 PM, a Nursing note documented in part . patient had a blood sugar of 501, BP (blood pressure) was 104/78, temp (temperature) was 100.4. patient is diaphoretic (heavy sweating). notified on-call doctor, order was given to send patient to hospital.A review of the hospital medical record revealed the following:An Emergency Medicine consult dated 4/14/26 at 4:20 PM, . presents with, hypoxia, SOB (shortness of breath). sent from a skilled nursing facility for concern for infection related to a sacral pressure ulcer. acute hypoxia (low levels of oxygen) and increased work of breathing. arrival Sp02 was -69% on room air with shallow respirations (-30/min), improving to -90% after tracheostomy suctioning and oxygen at 15 L (liters). SNF (skilled nursing facility) noted thick green respiratory secretions. arrival vitals included hypotension (BP -blood pressure- 87/38) with HR (heart rate) -70. glucose was -505 mg/dl. she is ill-appearing and diaphoretic. Breath sounds: Rales (abnormal popping/bubbling breath sounds) present. Capillary refill takes 2 to 3 seconds. GCS (Glasgow coma scale) eye subscore is 3. verbal subscore is 1. motor subscore is 1. Lactic Acid 3.6. [NAME] Blood Cell 23.8. MICU (medical intensive care unit) was contacted for evaluation of the patient. They evaluated the patient at bedside and were agreeable with admission. Diagnoses - Hypoxia, Fever, unspecified fever cause, Sepsis, due to unspecified organism. ED (emergency department) Disposition: hospitalized .A skin evaluation documented the following wound-Right ear - deep tissue injury (non-blanchable deep red, maroon or purple discoloration) 3.5 x 1.2 cm.Left ear - unstageable pressure injury (Full thickness skin and tissue loss which the extent of the damage cannot be confirmed) 1.4 x 0.6 cm.Right back - deep tissue injury 1.4 x 0.6 cm.Sacrum to bilateral buttock - unstageable pressure injury 9 x 11.5 cm. Full thickness loss with unknown depth of injury due to tan necrotic tissue obscuring the base. Moderate amount of purulent drainage. Wound odor noted.Left lateral leg (superior) - deep tissue injury, suspected 3 x 2 cm. Purple intact blister.Left lateral leg (inferior) - deep tissue injury, suspected 9 x 2.5 cm .Right plantar foot - deep tissue injury 1.6 x 2.8 cm.Left heel - deep tissue injury.Right medial heel - deep tissue injury, suspected 2 x 2.5 cm.On 4/16/26 at 1:13 PM, a debridement procedure was completed of the sacrum revealing a stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound).An Infectious Disease consult dated 4/18/26 at 8:43 AM, documented in part . Reason for Consult - Sepsis. admitted from a skilled nursing facility with fever, acute hypoxic respiratory failure, and decreased responsiveness. Initial labs notable for leukocytosis (high white blood cell count), lactic acidosis (dangerous build up of lactic acid in the blood), severe hypernatremia, hyperglycemia, and acute kidney injury. Blood cultures have grown gram-positive cocci in clusters (bacteria) in one set, and respiratory cultures showed mixed flora (bacteria). She was started on broad-spectrum antibiotics including vancomycin, cefepime, and metronidazole (antibiotics), and underwent bedside debridement (surgical procedure to remove devitalized/necrotic tissue) of the sacral wound with cultures growing E coli and proteus mirabilis. WBC (white blood cell) initially trending up to 25.5 but now trending down to 17.9. Been on Vancomycin, cefepime and flagyl (antibiotics). Impressions: 1. Sepsis likely 2/2 (secondary) to infected decubitus ulcer.On 8/24/26 at 1:17 PM, Wound Nurse (WN) A (Director of Nursing - DON in attendance) was interviewed and asked their responsibilities as the facility's wound nurse. WN A explained they completed wound rounds with the Wound practitioner every Wednesday. WN A explained after the wound rounds the Wound practitioner provides them with documentation of new or modified wound orders. WN A reported they compared those orders to the Wound practitioner consult in the electronic medical record and implement the orders as recommended by the Wound practitioner. WN A reported they were recently hired at the facility as the wound nurse.On 8/24/26 at 1:29 PM, the DON was interviewed and asked about the previous Wound Nurse (the wound nurse employed at the facility during R300 stay at the facility) and the DON reported the previous Wound Nurse was no longer employed at the facility. The DON was asked about the inaccurate assessments of R300's sacrum/buttock wound, why the treatments that were recommended by the Wound practitioner not implemented and applied as ordered. The DON was asked about the lack of preventative interventions initially placed to prevent wound development including initial treatment when the redness was identified to the coccyx area upon admission. The DON was also asked if a wound culture was completed for R300 and why multiple wound treatments were being applied concurrently for the sacrum area. The order that noted to apply Medihoney if Santyl was not available was discussed and asked how that order was effective when they are two different wound care treatments, with different active ingredients and intended uses. The DON acknowledged the concerns and stated they would look into it and follow back up. At 3:27 PM, the DON returned and reported a wound culture was not completed although starting the resident on an antibiotic. The DON confirmed the orders, treatments and accurate wound assessments were a problem and one of the main reason why the prior Wound Nurse is no longer employed at the facility.No other explanation or documentation was provided for review before the end of the survey.

This citation pertains to intake 3137447.Based on interviews and record reviews the facility failed to provide sufficient fluids to maintain proper hydration for a resident receiving fluids via Percutaneous Endoscopic Gastrostomy (PEG) for one (R300) of four residents reviewed for hydration, resulting in dehydration, acute kidney injury (aki), the need for intravenous fluid replacement and contributing to the resident's transfer to a higher level of care.Findings include:A review of a complaint submitted to the State Agency (SA) reported neglect regarding the care provided to R300.A review of the medical record revealed R300 admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke) due to thrombosis (blood clot), hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction, chronic kidney disease, tracheostomy (surgical opening to the neck to provide an alternative airway) and gastrostomy (surgical opening through the abdominal wall to insert a feeding tube) status. R300 was dependent on staff for all activities of daily living.A review of the admission nutrition Full Assessment dated 3/16/26 at 10:29 AM, documented in part . Fluid needs: 1920. Diet Order- NPO (nothing by mouth). Is the resident receiving enteral feedings- Yes. (enteral formula name) 1.5 x 50 ml/Hr (milliters an hour) x 24 hours. Free H20 (water): 910 ml (TF- tube feeding) with Auto Flush of 30 ml/hr adds an additional 720 ml = total free H20: 1630. receives Enteral TF. Plan/Intervention: 1. Continue with NPO diet, 2. Continue with TF of (formula name) 1.5 x 24 hours, 3. Increase Autoflush to 30 mL/hr x 24 hours. This assessment was completed by Registered Dietician (RD) B.A review of the Physician orders revealed on 3/13/26 at 2:46 PM, RD B implemented the following order Flush with 20 cc of H20 Every Hour, via Autoflush, while pump is running.On 4/14/26 at 4:25 PM, a Nursing note documented in part . patient had a blood sugar of 501, BP (blood pressure) was 104/78, temp (temperature) was 100.4. patient is diaphoretic (heavy sweating). notified on-call doctor, order was given to send patient to hospital.Further review of the Physician orders revealed on 4/14/26 at 11:18 AM, RD B implemented the following order Flush with 50 cc of H20 Every Hour, via Autoflush, while pump is running. Every shift for feeding tube maintenance/Hydration. A review of the medical record revealed no documentation of why RD B implemented the order on 4/14/26 and revealed no further nutritional assessments or notes in the medical record.A review of the hospital medical record revealed the following:On 4/14/26 at 4:20 PM, an Emergency Medicine consult documented in part . presents with fever, hypoxia (low levels of oxygen), SOB (shortness of breath). she was less responsive than usual with reported GCS (Glasgow coma scale) -5. She also had acute hypoxia and increased work of breathing. On arrival Sp02 was -69% on room air with shallow respirations (-30/min), improving to -90% after tracheostomy suctioning and oxygen at 15 L (liters). noted thick green respiratory secretions. ill-appearing and diaphoretic. Mucous membranes are dry. Sodium 167. Blood Urea Nitrogen (BUN) 119. Creatinine 1.75.The consult noted R300 was admitted to the Intensive Care Unit (ICU).On 4/15/26 at 11:03 AM, a Pulmonary & Critical Care Medicine consult noted in part, . Hypernatremia (high blood sodium concentration), likely in the setting of dehydration (the loss of more fluid than the body takes in) -Corrected sodium 172 on admission -Free water deficit 4.6 L (liters) -FWF (free water flush) per PEG 200 cc (cubic centimeter) q2h (every two hours) for 5 doses total followed by q6h -Serum osmolality is 399 -Nephro (nephrologist) following. Acute Kidney Injury, likely pre-renal in the setting of dehydration -Cr (Creatinine) on admission 1.76 - Likely pre-renal.On 4/15/26 at 2:29 PM, a Nephrology consult documented in part . Reason for consult: Aki (acute kidney injury) and severe Hypernatremia. Severe hypernatremia with sodium 167 due to dehydration and osmotic diuresis (increased urination due to the presence of certain substances in the fluid filtered by the kidneys) from hyperglycemia (high blood sugar) along with sepsis (a life threatening medical emergency, extreme response to an infection) induces losses. Recommendations/plan- Continue IVF (intravenous fluids) D5LR (5% dextrose in lactated ringer's intravenous fluid) @ 75cc/hr (cubic centimeters per hour), Continue FFW 250 q2h. Aki improving with fluids. Strict input and output monitoring.On 8/24/26 at 2:31 PM, RD B was interviewed and was asked about their initial nutritional assessment and asked about their plan to implement 30 ml/hr of H20 for R300 fluid needs, however implementing an order for only 20 ml/hr. RD B was also asked why they implemented an order on 4/14/26 the day R300 was transferred to the hospital for 50 ml/hr of H20. RD B stated they would review their notes and the medical record and follow back up. At 2:49 PM, RD B returned and stated they must have been notified verbally by someone that (R300) was dehydrated and that is likely the reason for the increased H20 order on 4/14/26. RD B was asked why their plan to implement 30 ml/hr of H20 was not implemented initially to ensure proper hydration to R300 and RD B replied they were unable to review (R300) old orders and offered no further explanation or documentation for review.A review of a facility policy titled Nutritional Management dated 10.2022 documented in part, . The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A comprehensive nutritional assessment will be completed by a dietitian within 5-7 days after admission. Components of the assessment may include. Food and fluid intake. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's. fluid needs. Current standards of practice /formulas are used in calculating these estimates.

This citation pertains to intake: 3137447.Based on interviews and record reviews the facility failed to obtain laboratory services as ordered by the Physician for one R300 of two residents reviewed for hospitalization. Findings include:A review of a complaint submitted to the State Agency (SA) reported neglect regarding the care provided to R300.A review of the medical record revealed R300 admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke) due to thrombosis (blood clot), hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction, chronic kidney disease, tracheostomy (surgical opening to the neck to provide an alternative airway) and gastrostomy (surgical opening through the abdominal wall to insert a feeding tube) status. R300 was dependent on staff for all activities of daily living.A review of the Physician orders revealed the following:4/8/26 - CBC (complete blood count)/CMP (comprehensive metabolic panel)/A1C (blood sugar levels measured over a 2-3 month period).Review of the medical record revealed no results of the labs ordered on 4/8/26 and no documentation on why the labs were not completed.On 8/24/26 at 1:29 PM, the Director of Nursing (DON) was asked if the labs ordered on 4/8/26 were completed and if they could provide a copy of the results for review. The DON stated they would check into it and follow back up. At 3:27 PM, the DON returned and stated the labs were not done and they were currently trying to find out why they were not completed.No further explanation or documentation was provided by the end of the survey.

This citation relates to Intake 3054948. Based on observation, interview, and record review, the facility failed to ensure the proper preparation of purred food related to the kitchen tray prep line for one Resident (R701) of one resident reviewed resulting in a choking incident. Findings include: Review of a complaint received by the State Agency on 6/25/26 revealed Certified Nurse Aide (CNA O ) was feeding resident R701 and was not familiar with their care needs. The report showed R701 was supposed to have a pureed diet but was given regular food and R701 began choking and had to call for help. The complainant reported this had happened more than once. The report alleged inadequate training for agency staff as well. On 7/20/26 at 11:00 a.m., R701 was observed in their room in their hospital bed with the covers over them. On 7/20/26 at 11:27 a.m., R701 agreed to be interviewed, and confirmed there was an incident recently when they choked on food. R701 said she was supposed to be on a pureed diet and staff hit them on the back which resolved the choking. R701 was unable to answer further questions as appeared fatigued. R701 was oriented to themselves, their surroundings, and situation. Review of R701's nursing progress note, dated 6/17/26 at 17:40 (5:40 p.m.) showed, Writer was notified by CNA (unnamed) that resident (R701) appeared to be choking while being fed meal tray. Writer immediately arrived to assess resident. Resident (R701) coughed and expelled the piece of food from throat without further intervention. No vomiting, respiratory distress, or signs of aspiration noted at this time. The note showed physician and family notification. On 7/20/26 at 3:49 p.m., LPN I was asked about R701's choking incident. LPN I described a new agency CNA (unnamed) not familiar with R701 came out of R701's room and said it looked like R701 was choking. LPN I said they observed R701 choking and coughing, and Registered Nurse (RN) H arrived patted R701 on the back and said the chicken came out of her airway. LPN I said R701's food looked like regular food, a chicken breast, and was not cut up or pureed. LPN I explained R701 was able to talk after the incident. LPN I said RN H told them this was not the first time this had occurred and said they had addressed with the dietary department prior to this incident. LPN I said they notified the physician and put in an order for speech therapy to see the resident. LPN I confirmed they were R701's nurse assigned when the incident occurred. On 7/20/26 at 4:13 p.m., RN H reported during a phone interview an aide (unnamed) came out of R701's room and they saw R701 was coughing and gave them a couple back blows, and the food came out, and then their airway was cleared. RN H said R701 was supposed to be on a pureed diet, and what they coughed up was dime sized meat chunks which appeared to be chicken. RN H said R701 was fine after the incident, and they came to assist with the incident however they were not R701's nurse. RN H said they could not recall R701's meal ticket or what it showed. On 7/20/26 at 4:56 p.m., Speech Language Pathologist (SLP) J was asked about R701, the choking incident and their follow-up. SLP J was accompanied by the Director of Therapy (DOT) K. SLP K reported R701 was on their caseload when the choking incident occurred, and R701 was on a pureed diet. SLP K said they left R701 on a pureed diet after the incident. SLP K said they were on the unit when the incident occurred, and it looked like the aide was feeding the resident a mechanical soft diet, not a pureed diet as ordered. SLP K said they were in R701's room with RN H after the incident occurred, and their tray ticket said a pureed diet. On 7/20/26 at 5:05 p.m., SLP K confirmed the diet was the wrong texture. SLP K clarified R701 needed a pureed diet due to dysphagia (difficulty swallowing). SLP K said this was a significant concern because R701 was on the lowest diet (consistency) already and she was a 1:1 (one person assist) feeding assistance because she was legally blind. SLP K described R701 seemed ok after the incident, caught her breath and was talking afterwards. SLP K said they acknowledged mistakes happened intermittently related to residents' food textures or liquid consistencies. SLP K said they followed up with the dietary department after the incident in person and the supervisor what happened via email. SLP K reported they educated the CNA involved when the incident occurred and educated staff on the spot when they found errors with consistencies and had not done an overall education for all staff. Review of SLP K's witness statement about the incident, dated 6/17/26, revealed they heard staff say someone was choking, and saw the nurse patting the resident on the back. The statement further showed SLP K observed the tray looked like mechanical soft in texture. On 7/20/26 at 5:52 p.m., Registered Dietician (RD) L was interviewed. RD L acknowledged they were made aware of R701's choking incident the following day and made sure the tray tickets were updated to the pureed texture as appropriate. RD L reported they believed R701's diet was changed and R701 was downgraded to pureed the next day and believed R701 was on a minced or mechanical soft diet per their recall without reviewing the record. R701's physician order was reviewed with RD L, which showed they could have a regular or mechanical soft cookie, with their pureed diet. RD L said that was sometimes ordered, and R701 was on a pureed diet after the incident. RD L reported their food services director completed the education after the incident. The Nursing Home Administrator (NHA) arrived during the interview. Review of R701's physician orders showed R701 was on a pureed diet on 6/16/26, and from 6/16/26 to present. It was noted soft or regular cookies had been removed from the orders on 6/16/26, with a new order written the same day for a pureed diet texture for all foods. On 7/20/26 at approximately 5:58 p.m., the NHA confirmed the Dietary manager completed education with staff, which included reading the tickets correctly, ensuring the correct diet was designated, the food on the ticket was correct, and the food that went out of the kitchen was correct. The NHA was made aware of the concerns related to SLP J reporting the discrepancies between the tray tickets and observed consistencies on the trays. The NHA said their expectation would have been they would have earlier been made aware of any concerns related to food consistencies. On 7/21/26 at 9:40 a.m., the Certified Dietary Manager (CDM) M confirmed the kitchen made a mistake, as a resident on a pureed diet (R701) was fed a mechanical diet. CDM M acknowledged the concern, as a resident (R701) choked, when dietary staff gave R701 the wrong diet texture on their dinner tray. CDM M explained Staff Q, and Staff R were educated the next day. CDM M clarified the staff who call the ticket was responsible as well as the last staff on the tray line to verify the correct diet texture was on the tray and all kitchen staff were trained in each position on the tray line. CDM M explained the process was to verify the tray (meal) with the ticket (a resident's meal ticket). CDM M said the ADON (Assistant Director of Nursing) also provided staff education. CDM M confirmed Staff M and Staff Q did not complete witness statements, as none by them were found in the investigation file provided electronically. Review of the facility investigation confirmed kitchen staff were educated regarding, Allergies /Meal Tickets on 6/17/26, without further clarification. A document was attached which showed staff education likely included on the policy, Mechanically Altered Diets. This document (reviewed 8/16/25) revealed, The facility will offer foods in a form that the resident is able to eat, such as a mechanically altered diet. The need for altered diet is determined by the SLP and or physician, ordered in the EMR. The diet change will automatically change the diet in the dietary software system. The SLP will notify the department of the diet texture change between meals.The dietary department will mechanically alter the food according to the guidelines within the IDDSI diet framework.Puree diets will receive all foods in smooth puree form. This education also showed Dietary Staff Q and Dietary Staff R received 1:1 education related to following dietary orders and ensuring the proper food consistency. The attachments included dietary staff education and review of residents to ensure pureed diets were being given appropriately. There was no nursing staff education included. On 7/21/26 at 10:03 a.m., Staff Q was interviewed about R701's tray via phone. Staff Q said they were not sure what happened and said they were at the end of the tray line and had not been made aware R701 choked. Staff Q clarified they had been made aware R701 was sent a mechanical tray when they were supposed to be sent a pureed tray. Staff Q said they called the ticket and were at the end of the tray line and had been educated about the incident. Staff Q denied completing a witness statement describing what had occurred. Staff Q acknowledged they should have double checked R701's ticket. An attempt was made to reach Staff R on 7/21/26, with no call returned. On 7/21/26 at 10:18 a.m., CNA O reported during a phone interview R701 was chewing their food for a minute and appeared uncomfortable. CNA O said they gave R701 some water, and was feeding them, and R701 began choking, patted their back, and described R701 started choking again. CNA O reported a male nurse arrived, smacked R701 on her back and said this was not the first time this had happened, and this time it was more severe. CNA O reported the diet was a normal consistency and was solid. CNA O said they were not sure what type of food but it was not bite sized and said they did not double check the meal check to the food. Review of R701's meal tickets, received on 7/21/26 at 18:51 p.m. (6:51 p.m.) revealed R701 was on a regular pureed diet with thin liquids on 6/16/26, and on 6/17/26. R701's meal ticket on 6/16/26 at dinner was shown and roasted pork pureed, mashed potatoes, a pureed salad, and a pureed crisp as well as thin liquids and a nutritional supplement. On 7/21/26 at 5:21 p.m., the NHA, with Regional Clinical Services Director P, confirmed their root cause of the incident was with the tray line process, and ensuring the proper process on the tray line, with staff ensuring the meal served had the right food (diet, texture, etc) with the right ticket. The NHA indicated they understood the concern with R701 being served the wrong food texture and said they had not received a pureed diet as prescribed when the incident occurred (6/16/26). The NHA explained education and audits were done with dietary staff. When asked about any concerns with tray delivery, the NHA then said education was done with their nursing staff as well. The NHA reported the cause of the incident was the kitchen error and did not speak to the concern regarding the resident being delivered the wrong tray on the unit as well. Survey team reviewed with the NHA and Regional Clinical Services Director P there were also concerns the nursing staff not matching the tray ticket to the meal upon delivery by the involved CNA as well, and there was no education received. This was also not included in a Past Non-Compliance (PNC) provided by the facility. The NHA reported they understood the concerns and then provided additional documentation of nursing staff education. Review of the facility investigation included a Past Non-Compliance Document, which read as follows: It is the content (sic) of (facility) to follow state and federal regulations. Deficiency Practice: 1. Staff failed to follow diet order and served a resident incorrect diet consistency. a. (R701) was supposed to be on a puree diet and believe (sic) it was mech (mechanical) soft. b. On 6/16/26, (R701) was served the incorrect diet and consistency which caused (R701) to have a choking/coughing incident. c. Kitchen staff served the incorrect diet receive (sic) a 1:1 education with emphasis on ensuring the diet is correct including consistency. d. Kitchen staff will be 100% educated by 6/17/26 to ensure that diets are served according to diet, including consistency. The document showed the NHA was responsible, audits were completed, and there was no reference to nursing staff education, which was deemed part of the root cause of the incident. Review of IDDSI guidelines, utilized by the faciltiy, described mechanical soft textured foods as moist, soft, tender, bite-sized food requiring minimal chewing; fork tender, solid pieces. Review of the policy, Food Preparation of Mechanically Altered Food, reviewed 7/14/26, revealed, .The facility will prepare mechanically altered foods per guidance according to IDDSI (food texture guidelines).The facility uses a food processor to break down food according to ground, minced and moist, pulsed, and smooth puree. Foods that are naturally pureed will be served according to manufacturer's directions, example instant pudding, mashed potato, gelatins, custard, souffles. The cook shall use nutrient dense liquids as a medium for puree, per faciltiy recipe and guidance.Examples include olive oil, whole milk, cream, margarine, broth, and base. Review of the policy, Tray Accuracy Policy, reviewed 7/01/26, revealed, All residents shall receive diets that are exactly matched to physician-ordered medical needs, individualized care plans, and the updated federal dietary guidelines.Dietary staff will check each tray against the meal ticket prior to loading the cart. Dietary staff will be trained on the importance of tray accuracy upon hire. The nursing staff will take the meal into patient/ residents' rooms, using the name, room number, and picture if printed on the ticket as the tray identifier. The facility will do routine audits on tray accuracy. Review of the document, 4 (texture) Pureed Food, IDDSI, International Dysphagia Diet Standardization Initiative, was provided by the facility in the electronic data share document as their pureed texture guidance. The guidelines noted, Level 4 Pureed Food for Adults. What is this food texture? Level 4 - Pureed Foods: Are usually eaten with a spoon, do not require chewing, have a smooth texture with no lumps, hold shape of a spoon, fall off a spoon in a single spoonful when tilted, are not sticky, liquid (like sauces) must not separate from solids.Why is this food texture level used in adults? Level 4: Pureed food may be used if you are not able to bite or chew food or if your tongue control is reduced. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing.

This citation relates to Intake 3065617. Based on observation, interview, and record review, the facility failed to provide dignified care and privacy for one Resident (R704) of four residents reviewed for dignity. Findings include: On 7/20/26 at 10:51 a.m., R704 was observed in their hospital bed wearing a gown, undraped, with their brief and legs exposed. There was no sheet or blanket to cover them, and only a fitted sheet on their bed. Their call light was observed clipped over their dresser on their left side, out of reach. On 7/20/26 at 10:51 a.m., R704 reported they were cold and needed a blanket or covering, and said they were upset they had no blanket over them. On 7/20/26 at 10:53 a.m., floor staff were notified R704 needed a blanket, per their request. On 7/20/26 at 10:59 a.m., R704 remained uncovered. R704 said, I need a blanket and I am still uncovered here.Please put it on me; I am freezing to death. R704 appeared cold by shivering and grimacing, appearing uncomfortable. On 7/20/26 at 11:00 a.m., R704 received a blanket from staff, nine minutes after they were found exposed. On 7/20/26 at 11:03 a.m., Licensed Practical Nurse (LPN) C was asked if R704 was able to use their call light, to notify staff they needed their call light. LPN C reported R704 sometimes used their call light. LPN C said Certified Nurse Aide (CNA) D had been in R704's room and left to provide care for another resident and had planned to return to put a blanket on R704. LPN C confirmed R704's call light should have been in place. On 7/20/26 at 11:29 a.m., CNA D was asked about R704's care this morning. CNA D said, I am not sure what happened. Normally, I cover my residents. I had to hurry up and lay another resident down. CNA D acknowledged R704's call light should have been in place and said they were an agency nurse newer to these residents. CNA D was asked if there was any reason R704's call light was not in place. CNA D said they had 10 residents and it was difficult to get their care needs met timely, and said they might miss something, such as what occurred. Review of R704's Care Plan, accessed 7/21/26, revealed, (R704) has a ADL (activities of daily living) self-care deficit related to disease process, muscle wasting and atrophy, physical limitation. Date initiated; 8/15/2025.Bed mobility: 1 person assistance.Call light within reach. Review of the policy, Dignity, dated 9/21/23, revealed, It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with us, feeling of self-worth, and self-esteem. General Guidelines: Residents will be treated with dignity and respect. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's stay at the facility.Resident's private space and property are always respected.Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

This citation relates to Intake 3065617. Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for two Residents (R701, R704) of four residents reviewed for accommodation of needs. Findings include: On 7/20/26 at 10:51 a.m., R704 was observed in their hospital bed wearing a gown, undraped, with their brief and legs exposed. There was no sheet or blanket to cover them, and only a fitted sheet on their bed. Their call light was observed clipped over their dresser on their left side, out of reach. It was noted that the light itself was a light with a grey plastic base and a red call button. On 7/20/26 at 10:51 a.m., R704 reported they were cold and needed a blanket or covering and said they were upset they had no blanket over them. R704 was alert and interviewable and was oriented to themselves and their surroundings. On 7/20/26 at 10:51 a.m., R704's roommate, R701, was observed laying in their bed with their covers over them. R701's call light was observed over their head on their right side, above the top of their pillow, out of reach. R701 attempted to reach their call light and said they could not reach it. R701 was aware of their name, situation, and surroundings. It was noted their call light was a grey soft touch pad. On 7/20/26 at 10:53 a.m., Licensed Practical Nurse (LPN) B was notified that R704 needed a blanket. On 7/20/26 at 10:59 a.m., R704 remained uncovered. R704 said, I need a blanket and I am still uncovered here.Please put it on me; I am freezing to death. R704 appeared cold by shivering and grimacing, appearing uncomfortable. On 7/29/26 at 11:00 a.m., R704 received a blanket from staff, nine minutes after they were found exposed and their call light was placed on them after Surveyors reported it was not accessible. Surveyors noted R701 and R704's call lights were out of reach. Staff placed R701's and R704's call lights in reach with a clip. It was noted the R704's call light was slipping from R704's hands, and they could only access it with extra effort and time. On 7/20/26 at 11:03 a.m., Licensed Practical Nurse (LPN) C was asked if R704 was able to use their call light, to notify staff they needed their call light. LPN C reported R704 sometimes used their call light. LPN C said Certified Nurse Aide (CNA) D had been in R704's room and left to provide care for another resident and had planned to return to put a blanket on R704. LPN C confirmed R704's call light should have been in place. On 7/20/26 at 11:29 a.m., CNA D was asked about R704's care this morning, as they were their assigned aide. CNA D said, I am not sure what happened. Normally, I cover my residents. I had to hurry up and lay another resident down. CNA D acknowledged R704's call light should have been in place and said they were an agency nurse newer to these residents. CNA D was asked if there was any reason R704's call light was not in place. CNA D said they had 10 residents and it was difficult to get their care needs met timely, and said they might miss something, such as what occurred. It was confirmed R701 used their call light most of the time as they were able to let staff know what they needed. On 7/21/26 at 11:43 a.m., R704 was observed in their bed, in their gown, with a blanket over them. Their call light was clipped to the left side of their sheet however the call light itself was hanging to the left almost touching the floor, out of reach. On 7/21/26 at 11:46 a.m, Registered Nurse (RN) G was asked to observe R704's call light. RN G concurred R704 could not reach their call light and placed their call light in reach. RN G said the call light needed to be in a reachable position on the middle of the bed. RN G reported R704 used their call light at times to call for assistance. Review of R704's Care Plan, accessed 7/21/26, revealed, (R704) has a ADL (activities of daily living) self-care deficit related to disease process, muscle wasting and atrophy, physical limitation. Date initiated; 8/15/2025.Bed mobility: 1 person assistance.Call light within reach. Review of R701's Care Plan, accessed 7/21/26, revealed (R701) is at risk for falls, decreased mobility, medication side effects, requires assist with adls. Date initiated: 11/19/2025.Call light in reach. Date initiated: 11/19/2025. Review of the policy, Call light Accessibility and Timely Response, issued 8/16/23, revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside and bathing facility (area) to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Each resident will be reviewed for unique needs and preferences to determine any special accommodation that may be needed for the resident to utilize the call system. Special accommodation will be identified on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.). Staff will ensure the call light is plugged in, functioning, within reach of residents, and secured, as needed. The call system will be accessible to residents while in their room at bedside as well as in the bathroom and shower room.

This citation relates to Intake 3065617. Based on observation, interview, and record review, the facility failed to ensure documentation of a physician order for wound treatment for one Resident (R703) of three residents reviewed for skin and wound care, resulting in the delayed documentation of a physician order for an unstageable pressure injury and the potential for missed treatments. Findings include: Review of the clinical record including wound care documentation showed R703 was readmitted to the facility after a hospital stay on 7/16/26, with a right heel pressure injury, which they had prior to their admission. Review of R703's census showed they were hospitalized [DATE] and readmitted to the facility on [DATE]. Review of R703's TAR (Treatment Administration Record) on 7/20/26 showed no right heel pressure injury treatment orders. On 7/20/26 at 11:56 a.m., R703 was observed in their room laying in their bed. R703 agreed to be interviewed initially, then declined to answer questions about wound treatment or for surveyors to observe their right heel pressure injury, with Licensed Practical Nurse (LPN) B. R703 was alert and oriented to themselves, time, situation, and surroundings. On 7/20/26 at 12:04 p.m., LPN B was asked about R703's right heel pressure injury, as no treatment orders were not found in the Electronic Medical Record (EMR). LPN B noted R703 had just returned from the hospital a few days prior, with the right heel pressure injury from prior admissions. LPN B confirmed R703 had the pressure ulcer prior to their hospitalization. LPN B said they used (Name brand) two wound care products to treat R703's right heel pressure injury on 7/17/26, despite no physician order in place, which would have been entered by them. LPN B reported they treated facility wounds about four times a week, and the nursing staff completed facility wound care about three times a week. LPN B confirmed R703 was designated to receive daily treatment for their right heel pressure injury. Review of R703's readmission wound care note, dated 7/17/26, showed R703 had an unstageable right heel pressure injury, which measured 2.25 (length) by 1.0 (width) by 0.2 (depth) by 1.78 (area) (centimeters squared). Review of R703's EMR on 7/20/26 with LPN B revealed R703 had no admission orders, and no way to determine if they received wound treatments on 7/18/26 or 7/19/26. LPN B said R703 refused wound care over the weekend, however this was not documented. R703 reported they completed R703's wound treatment on 7/17/26 and said they missed writing the order for R703's pressure injury, not the completion of the treatment. LPN B said they would add the wound care treatment order after the interview and ensure the physician was made aware. LPN B confirmed they were the wound care coordinator, and putting the wound in the EMR was typically their responsibility. LPN B reported they understood the concern. On 7/21/26 at 11:11 a.m., LPN B was about to complete R703's wound care. R703 was observed in their bed and declined the wound care and for their right heel to be observed at that time. It was noted they had a Kerlix wrap from their foot / heel and up to their knee. There was a tape securing the Kerlix at the top over their knee, with a date of 7/20/26. Review of the EMR showed R703 had a history of declining some wound care or other treatments. On 7/21/26 at 11:15 a.m., the Assistant Director of Nursing (ADON) was interviewed with LPN B present. The ADON acknowledged the concerns and reported they had been addressed. On 7/21/26 at 11:26 a.m., LPN B was asked for follow-up regarding R703's wound dressings and treatment. LPN B reported they had received a 1:1 education regarding the missing wound orders, and they were ensuring this did not happen again going forward. LPN B said they understood the concern treatment could not have been provided without orders for R703's right heel pressure injury, and the other nurses would not have had a treatment designated. LPN B confirmed they provided the treatments to R703's right heel pressure injury on 7/17/26 and 7/20/26. LPN B noted they could not clarify whether R703's pressure injury wound treatments on 7/18/26 and 7/19/26 were missed or refused from R703's TAR, as there was no physician order, and they had not made those attempts. Review of R703's TAR, showed they had a right heel pressure injury treatment for their right heel, dated 7/20/26, which was blank, to be provided once daily. Review of the policy, Physician and Practitioner Orders, revised 11/09/23, reviewed 2/03/26, revealed, The purpose of this policy is to provide guidelines for the proper and consistent provision of physician ordered services according to professional standards of quality.admission orders will be obtained for the residents' immediate care and needs. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission.For consulting physician / practitioner orders received in writing, verbally (including via telephone), or via fax, the nurse will: Contact the attending physician to verify the order. Transcribe the order into the EMR (Electronic Medical Record) in accordance with attending physician approval. Review of the policy, Skin and Wound Guidelines, revised 3/20/24, revealed, To describe the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations.Treatment options are based on the type of wound, the need for protection of the wound bed, the goal of treatment, and manufacturer's recommendation for product utilization. Treatments ordered by the medical practitioner. A complete treatment order consists of the following: Site of application, type of skin altercation or treatment needed, cleansing agent, if indicated, frequency, including end date orders if applicable, directions for use, if applicable, primary and secondary dressing, if applicable, type of securement, if applicable.

This citation relates to Intake 3054948. Based on observation, interview, and record review, the facility failed to prevent an avoidable choking incident for one Resident (R701) of four residents reviewed for accidents and incidents. Findings include: Review of a complaint received by the State Agency on 6/25/26 revealed Certified Nurse Aide (CNA O ) was feeding resident R701 and was not familiar with their care needs. The report showed R701 was supposed to have a pureed diet but was given regular food and R701 began choking and had to call for help. The complainant reported this had happened more than once. The report alleged inadequate training of agency staff as well. On 7/20/26 at 11:00 a.m., R701 was observed in their room in their hospital bed with the covers over them. On 7/20/26 at 11:27 a.m., R701 agreed to be interviewed, and confirmed there was an incident recently when they choked on food. R701 said she was supposed to be on a pureed diet and staff hit them on the back which resolved the choking. R701 was unable to answer further questions due to being sleepy. R701 was oriented to themselves, their surroundings, and situation. Review of R701's Care Plan, accessed 7/20/26, revealed an admission date of 5/11/18, and showed R701 was legally blind, and had diagnoses including stroke, heart failure, contractures, and were bed bound (bed dependent). The Care Plan showed R701 received total assistance for care including feeding. Their nutritional care plan further revealed R701 was at risk for aspiration and needed 1:1 assistance for feeding due to dysphagia (swallowing impairment) and to monitor for signs of choking or coughing with a puree diet and thin liquids, with the interventions dated 6/03/26. An updated intervention dated 6/16/26 designated R701 sit upright 30 to 60 minutes after meals. On 7/20/26 at 1:24 p.m., nursing staff were observed leaving R701's room and heard to say R701 choked; R701 was asked by staff if it was hard for them to swallow. Licensed Practical Nurse (LPN) C was outside R701's room and said R701 began coughing while eating their pureed lunch with staff assistance, and they were getting speech therapy to see R701. LPN C said R701's head was upright and she was eating in bed, and CNA D was the aide working with R701 when the incident occurred. On 7/20/26 at 1:26 p.m., R701's lunch tray was observed, which showed their ticket designated pureed food including baked chicken puree, mashed potatoes, and pureed sweet potatoes, which was observed. On 7/20/26 at approximately 1:27 p.m., R701 was briefly asked how they were doing. R701 said they were ok, and said, Sometimes I get like that. R701 did not elaborate further. On 7/20/26 at 1:34 p.m., CNA D was asked what happened. CNA D said they had to stop feeding R701 when they started coughing during the lunch meal and denied choking. CNA D confirmed R701 received a pureed diet and said R701 was fine afterwards. Review of R701's physician provider note, dated 6/22/26, revealed R701 was seen for an episode of choking on 6/16/26, with no signs or symptoms of distress or discomfort, with chest x-ray completed and no respiratory symptoms, and not convincing for aspiration. Aspiration precautions were continued and speech therapy was ordered. Review of R701's nursing progress note, dated 6/17/26 at 17:40 (5:40 p.m.), showed, Writer was notified by CNA that resident (R701) appeared to be choking while being fed meal tray. Writer immediately arrived to assess resident. Resident (R701) coughed and expelled the piece of food from throat without further intervention. No vomiting, respiratory distress, or signs of aspiration noted at this time. The note showed physician and family notification. On 7/20/26 at 3:49 p.m., LPN I was asked about R701's choking incident. LPN I described a new agency CNA (unnamed) who was not familiar with R701 came out of R701's room and said it looked like R701 was choking. LPN I said they observed R701 choking and coughing, and Registered Nurse (RN) H arrived patted R701 on the back and said the chicken came out of their airway. LPN I said R701's food looked like regular food, a chicken breast, and was not cut up or pureed. LPN I explained R701 was able to talk after the incident. LPN I said RN H told them this was not the first time this had occurred and said they had addressed with the dietary department prior to this incident. LPN I said they notified the physician and put in an order for speech therapy to see the resident. LPN I confirmed they were R701's nurse assigned when the incident occurred. On 7/20/26 at 4:13 p.m., RN H reported during a phone interview an aide (unnamed) came out of R701's room and they saw R701 was coughing and gave them a couple back blows, and the food came out, and then their airway was cleared. RN H said R701 was supposed to be on a pureed diet, and what they coughed up was dime sized meat chunks which appeared to be chicken. RN H said R701 was fine after the incident, and they came to assist with the incident however they were not R701's nurse. RN H said they could not recall R701's meal ticket or what it showed. On 7/20/26 at 4:56 p.m., Speech Language Pathologist (SLP) J was asked about R701, the choking incident and their follow-up. SLP J was accompanied by the Director of Therapy (DOT) K. SLP K reported R701 was on their caseload when the choking incident occurred, and R701 was on a pureed diet, and said they left them on a pureed diet after the incident. SLP K said they were on the hallway when the incident occurred, and it looked like the aide was feeding the resident a mechanical soft diet, not a pureed diet as ordered. SLP K said they were in R701's room with RN H after the incident occurred, and their tray ticket said a pureed diet. On 7/20/26 at 5:05 p.m. SLP K confirmed the diet was the wrong texture and said little mistakes happened sometimes. SLP K clarified R701 needed a pureed diet due to dysphagia (difficulty swallowing). SLP K said this was a significant concern because R701 was on the lowest diet (consistency) already and she was a 1:1 (one person assist) feeding assistance because she was legally blind. SLP K described R701 seemed ok after the incident, caught her breath and was talking afterwards. SLP K said they acknowledged mistakes happened intermittently related to residents' food textures or liquid consistencies. SLP K said they followed up with the dietary department after the incident in person and informed the dietary department what happened via email. SLP K reported they educated the CNA involved when the incident occurred and educated staff on the spot when they found errors with consistencies and had not done an overall education for all staff. SLP K had been made aware of the other choking incident on this date and planned to follow up but said they had not seen R701 yet on this date (7/20/26) to reassess them, as they were not currently on their caseload. Review of SLP K's witness statement about the incident, dated 6/17/26, revealed they heard staff say someone was choking, and saw the nurse patting the resident on the back. The statement further showed SLP K observed the tray looked like mechanical soft in texture. On 7/20/26 at 5:52 p.m., Registered Dietician (RD) L was interviewed. RD L acknowledged they were made aware of R701's choking incident the following day and made sure the tray tickets were updated to the pureed texture. RD L reported they believed R701's diet was changed and R701 was downgraded to pureed the next day and believed R701 was on a minced or mechanical soft diet per their recall without reviewing the record. R701's physician order was reviewed with RD L, which showed they could have a regular or mechanical soft cookie, with the puree diet. RD L said that was sometimes ordered, and R701 was on a puree diet after the incident. RD L reported their food services director completed the education after the incident. The Nursing Home Administrator (NHA) arrived during the interview. Review of R701's physician orders showed R701 was pureed diet on 6/16/26. On 7/20/26 at approximately 5:58 p.m., the NHA confirmed the Dietary manager completed education with staff, which included reading the tickets correctly, ensuring the correct diet was designated, the food on the ticket was correct, and the food that went out of the kitchen was correct. The NHA was made aware of the concerns related to SLP J reporting the discrepancies between the tray tickets and observed consistencies on the trays. The NHA was aware of the incident on this date at lunch with R701 choking / coughing. The NHA said their expectation would have been they would have earlier been made aware of any concerns related to food consistencies.On 7/21/26 at 9:40 a.m., the Certified Dietary Manager (CDM) M confirmed the kitchen made a mistake, as a resident on a pureed diet (R701) was fed a mechanical diet. CDM M acknowledged the concern, as a resident (R701) choked, when dietary staff gave R701 the wrong diet texture on their dinner tray. CDM M explained the process was to verify the tray (meal) with the ticket (a resident's meal ticket). CDM M said the ADON (Assistant Director of Nursing) also provided education. Review of the facility investigation confirmed kitchen staff were educated regarding, Allergies /Meal Tickets on 6/17/26, without further clarification. A document was attached which showed staff education likely included on the policy, Mechanically Altered Diets. This document reviewed 8/16/25 revealed, The facility will offer foods in a form that the resident is able to eat, such as a mechanically altered diet. The need for altered diet is determined by the SLP and or physician, ordered in the EMR. The diet change will automatically change the diet in the dietary software system. The SLP will notify the department of the diet texture change between meals.The dietary department will mechanically alter the food according to the guidelines within the IDDSI diet framework.Puree diets will receive all foods in smooth puree form. This education also showed Dietary Staff Q and Dietary Staff R received 1:1 education related to following dietary orders and ensuring the proper food consistency. This included dietary staff education and review of residents to ensure pureed diets were being given appropriately. The document did not show nursing staff including aides were educated. On 7/21/26 at 10:03 a.m., Staff Q was interviewed about R701's tray via phone. Staff Q said they were not sure what happened and said they were at the end of the tray line and had not been made aware R701 choked. Staff Q clarified they had been made aware R701 was sent a mechanical tray when they were supposed to be sent a pureed tray. Staff Q said they called the ticket and were at the end of the tray line and had been educated about the incident. Staff Q denied completing a witness statement describing what had occurred. Staff Q acknowledged they should have double checked R701's ticket. On 7/21/26 at 10:18 a.m., CNA O reported during a phone interview R701 was chewing their food for a minute and appeared uncomfortable. CNA O said they gave R701 some water, and was feeding them, and R701 began choking. CNA O stated they patted their back and described R701 started choking again. CNA O reported a male nurse arrived, smacked R701 on her back and said this was not the first time this had happened, and this time it was more severe. CNA O reported the diet was a normal consistency and was solid. CNA O said they were not sure what type of food but it was not bite sized and said they did not double check the ticket to the food. CNA O said they were an agency nurse aide and said denied receiving education, then said, No, not really. CNA O said they came from agency and assumed the nurses were checking the trays. CNA O reported they saw no other concerns for R701 during their shift. CNA O stated there were not enough nursing (CNA) staff to fully meet the care needs of the residents, however it was unclear whether this impacted what occurred. On 7/21/26 at 12:05 p.m., RN H was asked to clarify the tray delivery and ticket review process on the units at mealtimes. RN H reported it was the CNA's responsibility, not the nurses, to match the tray ticket to the diet, and ensure they matched. RN H explained they had not worked with R701 in a few months, since they relocated halls where they were typically assigned. RN H explained the CNA working with R701 when they choked should have ensured the tray ticket matched R701's meal on the tray. RN H acknowledged sometimes residents had been served with the wrong dietary texture prior, however denied this being R701, or other choking incidents or any outcomes when this had occurred. On 7/21/26 at 12:47 p.m., SLP J followed up with the survey team, with DOT K present. SLP J indicated they followed up with R701, and they had no concerns with pureed texture samples, said they made recommendations for oral motor exercises, completed resident and caregiver training, including safe swallowing strategies and recommended two outpatient swallow studies. SLP J denied receiving an all-staff education regarding the tray meal delivery or tray ticket process. On 7/21/26 at 4:32 p.m., LPN I confirmed during a phone interview they had received no staff education after R701's choking incident. LPN I confirmed the nursing aides were responsible for checking the trays and ensuring the tray tickets match the meals (diets, textures, etc.) on the residents' tray tickets. Review of R701's meal tickets, received on 7/21/26 at 18:51 p.m. (6:51 p.m.) revealed R701 was on a regular pureed diet with thin liquids on 6/16/26, and on 6/17/26. R701's meal ticket on 6/16/26 at dinner was shown and roasted pork pureed, mashed potatoes, a pureed salad, and a pureed crisp as well as thin liquids and a nutritional supplement. On 7/21/26 at 5:21 p.m., the NHA, with Regional Clinical Services Director P, confirmed their root cause of the incident was with the tray line process, and ensuring the proper process on the tray line, with staff ensuring the meal served had the right food (diet, texture, etc) with the right ticket. The NHA indicated they understood the concern with R701 being served the wrong food texture and said they had not received a pureed diet as prescribed when the incident occurred (6/16/26). The NHA explained education and audits were done with dietary staff. When asked about any concerns with tray delivery, the NHA then said education was done with their nursing staff as well. The NHA reported the cause of the incident was the kitchen error and did not speak to the concern regarding the resident being delivered the wrong tray on the unit as well. Survey team reviewed with the NHA and Regional Clinical Services Director P there were also concerns the nursing staff not matching the tray ticket to the meal upon delivery by the involved CNA as well, and there was no education received. This was also not included in a Past Non-Compliance (PNC) provided by the facility which could not be accepted. The NHA reported they understood the concerns and then provided additional documentation of nursing staff. Review of a record provided after this interview in the electronic data share file system at 7/21/26 at 18:28 (6:28 p.m.) revealed a CNA education by the ADON respective to understanding diet types and dietary restrictions, which was completed on 6/17/26. It was unclear why this was not provided earlier in the survey. Review of the facility investigation included a Past Non-Compliance Document, which read as follows: It is the content (sic) of (facility) to follow state and federal regulations. Deficiency Practice: 1. Staff failed to follow diet order and served a resident incorrect diet consistency. a. (R701) was supposed to be on a puree diet and believe (sic) it was mech (mechanical) soft. b. On 6/16/26, (R701) was served the incorrect diet and consistency which caused (R701) to have a choking/coughing incident. c. Kitchen staff served the incorrect diet receive (sic) a 1:1 education with emphasis on ensuring the diet is correct including consistency. d. Kitchen staff will be 100% educated by 6/17/26 to ensure that diets are served according to diet, including consistency. The document showed the NHA was responsible, audits were completed, and there was no reference to nursing staff education. Review of IDDSI guidelines, utilized by the facility, described mechanical soft textured foods as moist, soft, tender, bite-sized food requiring minimal chewing; fork tender, solid pieces. Review of the policy, Food Preparation of Mechanically Altered Food, reviewed 7/14/26, revealed, .The facility will prepare mechanically altered foods per guidance according to IDDSI (food texture guidelines).The facility uses a food processor to break down food according to ground, minced and moist, pulsed, and smooth puree. Foods that are naturally pureed will be served according to manufacturer's directions, example instant pudding, mashed potato, gelatins, custard, souffles. The cook shall use nutrient dense liquids as a medium for puree, per faciltiy recipe and guidance.Examples include olive oil, whole milk, cream, margarine, broth, and base. Review of the policy, Tray Accuracy Policy, reviewed 7/01/26, revealed, All residents shall receive diets that are exactly matched to physician-ordered medical needs, individualized care plans, and the updated federal dietary guidelines.Dietary staff will check each tray against the meal ticket prior to loading the cart. Dietary staff will be trained on the importance of tray accuracy upon hire. The nursing staff will take the meal into patient/ residents' rooms, using the name, room number, and picture if printed on the ticket as the tray identifier. The facility will do routine audits on tray accuracy. Review of the policy, Accidents and Incidents, reviewed 2/02/26, revealed, It is the policy of this facility for staff to utilized (EMR) risk management to report, investigate, and review any accidents or incidents that may involve or allegedly involve a resident.Types of incidents:.Choking. Review of the document, 4 (texture) Pureed Food, IDDSI, International Dysphagia Diet Standardization Initiative, was provided by the facility in the electronic data share document as their pureed texture guidance. The guidelines noted, Level 4 Pureed Food for Adults. What is this food texture? Level 4 - Pureed Foods: Are usually eaten with a spoon, do not require chewing, have a smooth texture with no lumps, hold shape of a spoon, fall off a spoon in a single spoonful when tilted, are not sticky, liquid (like sauces) must not separate from solids.Why is this food texture level used in adults? Level 4: Pureed food may be used if you are not able to bite or chew food or if your tongue control is reduced. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing.

This citation pertains to Intake Number(s): 2786159 and 2732494. Based on interview and record review, the facility failed to allow readmission into the facility after hospitalization and failed to document the reason for discharge in the medical record for one (R904) of three residents reviewed for inappropriate discharge, resulting in the resident remaining in the hospital for 45 days after they were determined to be stable for discharge. Findings include:A review of two complaints submitted to the State Agency revealed allegations that the facility refused to allow R904 to return to the facility after hospitalization. On 5/27/26 at 11:07 AM, an interview was conducted with long term care (LTC) Ombudsman 'B' via the telephone. When queried about R904's discharge to the hospital, Ombudsman 'B' reported R904 went to the hospital with suicidal ideations, and the facility would not allow her to return. R904 was in the hospital for a very long time. Ombudsman 'B' reported R904 was very easily triggered due to her developmental and behavioral diagnoses, and the facility placed a roommate with R904 and it went horribly. On 5/27/26 at 12:12 PM, an interview was conducted with one of R904's legal guardians who reported the facility would not take R904 back after a hospitalization. The guardian explained R904's room was changed to the second floor and said she would not have a roommate due to her mental and physical conditions, but a roommate was placed in R904's room. R904 became very vocal about not wanting to live after a roommate was moved in and she was sent to the hospital with suicidal ideations. The guardian said when R904 was ready to be discharged from the hospital, the facility would not allow her to return, and she stayed in the hospital for approximately six more weeks. The family and the hospital had to coordinate a discharge plan. A review of R904's clinical record revealed R904 was admitted into the facility on 3/26/24, readmitted on [DATE], and discharged on 1/7/26 with diagnoses that included: autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), generalized anxiety disorder, gastroparesis, seizures, and postural orthostatic tachycardia syndrome (POTS). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R904 had intact cognition and no behaviors. A review of R904's progress notes revealed the following documentation: On 1/6/26, a Social Work progress note documented, Resident called SW (social work) and spoke about how resident is upset that she is getting a roommate. Resident reported that she will leave and go to the hospital if she has to have a roommate. SW attempted to redirect resident and calm her down. Resident was still upset and not easily redirectable . On 1/7/26, a PROGRESS NOTE documented, Administrator spoke to resident with Social work Director and DON (Director of Nursing) present. Resident says she said she did not want a roommate. Resident was informed by Administrator that she was not promised a private room when she agreed to move upstairs .Resident attempted to remove her roommate's items and was immediately redirected. Resident says she would be calling her mom and sending herself to the hospital due to not wanting a roommate. On 1/7/26, a Nursing-Progress Note documented, Resident returned from appointment. While writer was in room, resident was on the phone with a 911 operator stating she wanted to leave and that she did not feel safe due to having a new roommate .resident was taken to (hospital) . On 1/7/26, a Social Work progress note documented, Resident came back from appt (appointment) and was upset about getting a roommate .Resident reported that she was going to go to the hospital and wanted to die due to hating her life. Resident reported 'I wish they just pulled the plug when I had sepsis. I do not want to be here and I do not want to live anymore. Social work had directive to petition for resident to be sent out for psych eval. However, resident called 911 on her own and willingly wanted to go to the hospital .Resident reported she does not like that idea of having a roommate and said she would go to the hospital if she got a roommate . On 5/27/26 at 1:03 PM, an interview was conducted with the Administrator and Regional Clinical Service Director (RCSD 'A') . When queried about why R904 was not allowed to return to the facility after the last hospital stay, the Administrator reported because R904 went to the hospital with suicidal ideations and while in the hospital she reported she overdosed on pills without the nursing home staff's knowledge in the past and that she would attempt to kill herself if she was sent back to the nursing home. RCSD 'A' reported R904's room was changed from the first floor where she had a private room to the second floor after the facility had to make some room changes to accommodate staffing needs. The room on the second floor was not a private room, but the Administrator and RCSD 'A' reported R904 was notified that she could get a roommate at any time. The Administrator reported R904 was fine with having a roommate. A review of R904's hospital records revealed the following: An ED (emergency department) Provider Note dated 1/7/26 documented, .history of autism spectrum disorder .functional paraplegia presenting for suicidal ideations .She does not believe that they (the nursing home) are flushing her ports correctly. States that this is causing her stress and that she 'no longer wants to be here'. States that she 'wishes she has [sic] never taken off the ventilator' and has been asking staff if they have against [sic] that they can 'shoot her' .Suicidal ideation without active plan .The mental health team did evaluate the patient and given her multiple medical conditions they do recommended [sic] Medicine admission with the psych on consult while they try and arrange additional treatment and placement . An H&P (History and Physical) dated 1/8/26 documented, .Patient stated that she did not like the facility she was staying at, hence she called EMS (Emergency Medical Services) and was transported to the ER (Emergency Room), patient refusing to go back to the same facility, stating that if she is sent back to same facility she will kill herself .case manager consulted for finding placement at new nursing/psychiatric facility .We will need inpatient psychiatry . A review of a Discharge Summary from the hospital revealed R904 remained inpatient in the hospital from [DATE] until 3/24/26 with a primary diagnosis of suicidal ideation. A Psychiatry Consult dated 1/8/26 documented, .On my evaluation today the patient reports she came to the hospital to get help as she does not like she current nursing home and if we release her back to that nursing home she is going to kill herself. Patient reports suicidal ideations but does not disclose a plan to me though she reports having a plan .She should be transferred to an inpatient psych unit once cleared medically . A Psychiatry Progress Note dated 1/20/26 documented, .Writer discusses with patient that noinpatient psychiatric facility can accept her due to medical admission criteria. Patient understandably is frustrated.When writer asks what accommodations can be made for her to feel more safe at nursing home, she begins yelling atwriter and telling him that nothing will make her feel safe. She continues to report suicidal ideation with plan tooverdose on medication if she does return to nursing home, however, denies any suicidal ideation or plan while in thisfacility .Recommendations .Per virtual social work, all inpatient psych options have been exhausted by the placement team, and no facility options remain. At this point, will need to coordinate safe discharge plan back to nursing home. Social work at our facility has been in contact with social work at (facility) in helping to coordinate increased frequency of psychiatric services for patient once she returns to nursing home. Importantly, our social work team did speak with administrator at (facility) who reported that they can accommodate 1:1 safety sitter for suicide, however they do not want to force a resident where they do not want to be and with her SI (suicidal ideations), 'it is a liability'. Appears administrator asked social work if our social work team can find alternative LTC placement for patient, but our social worker explained to them that they cannot find alternative LTC placement since she already has LTC and the SW at (facility) would have to work on alternative placement . A Psychiatry Progress Note dated 1/28/26 documented, .Patient more understanding of the reality of having to return to nursing home with (disability and mental health agency) working on finding patient alternative placement. She reports she would feel much more comfortable if she could have a private room at her nursing facility .she continues to deny suicidal ideation or plan while here in the hospital. She reports that in the case she returns to nursing home and has suicidal ideation with plan, she will call 911 for her safety .Meeting completed 01/28/2026 between 3 p.m. to 4 p.m. with our social work team, patient's mother (guardian), patient's grandmother, (disability and mental health agency) staff, myself, supervising psychiatrist and primary attending to discuss next steps. At this point, we clinically recommend increased frequency of psychiatric services. Specifically, patient would significantly benefit intensive dialectical behavioral therapy in the outpatient setting. It would help her symptoms improve, if patient did have a private room at her nursing home as she reports that having a roommate is one of the largest stressors for her. She reports that in the case she returns to nursing home and has suicidal ideation with plan, she will call 911 for her safety as she had prior to this admission. She was also made aware that (disability and mental health agency) will continue helping to assist with eventual transition to a semi-private residence although this will take time. She remains hopeful for this .When asked about thinking of hurting herself in the nursing home the patient reports she would not hurt herself as she feels now she is being heard by the team's and people are trying to help her. She tells me that she was talking about wanting to kill herself in the nursing home because she felt nobody was listening to her. Now she feels hurt [sic] and would not attempt to hurt herself. Patient does request however her needs and some accommodations be made known to the nursing home. Patient tells me that because of being on the spectrum she gets very stimulated and overwhelmed inthe presence of a roommate and is therefore requesting to be in a private room. I support and also recommend that patient be accommodated in the nursing home to a private room as the environment would be less stimulating for her that way with better chances of successfully working towards the goal of eventual independent living. When asked if the patient is willing to return to her nursing home she replied she is ready with the support that she has been requesting for. When asked about the possibility of recurrence of suicidal thoughts once the patient is at the nursing home she replied she would not hurt herself but would instead ask for help. She tells me that she is the 1 who called 911 last time from the nursing home and if she gets to a point that she has those thoughts of wanting to hurt herself she will once again seek help and call 911 or make sure she comes back to the hospital. Patient is very pleasant today, very motivated and looking forward to work with the team to be able to eventually live independently with support and is willing to work closely with the staff at the nursing home as well in order to achieve her goal. However the patient continues to request a private room at the nursing home which I strongly support . On 5/27/26 at approximately 2:30 PM, the Administrator and RCSD 'A' reported the [NAME] President (VP) of Clinical Services (VPCS) 'C' was the person who made the final decision not to allow R904 to readmit into the facility. On 5/27/26 at 2:57 PM, an interview was conducted with VPCS 'C' via the telephone. When queried about why the facility did not accept R904 back into the facility after the hospital developed a safe discharge plan for the resident, VPCS 'C' reported he talked with the hospital physician and asked if he could give a 100 percent guarantee that R904 would not kill herself if she came back to the facility and the physician said he could not guarantee it. When queried about what interventions could have been put in place by the facility, including a private room and the resources set up by the hospital, to ensure R904's safety to the best of their ability, VPCS 'C' reported they could not accept the resident back due to the suicidal ideations she expressed related to the facility. VPCS 'C' said R905 was alert and oriented and said she would kill herself so that was a risk. When queried about the safety plan coordinated by the hospital and the documentation of R904 no longer being suicidal and willing to work with the staff at the nursing home to achieve her discharge goal, VPCS 'C' said R904 was 'manipulative' and therefore they could not take a chance that she was just saying that to get back into the facility. Further review of R904's clinical record revealed no documentation of why R904's needs could no longer be met at the facility and the basis of the discharge. A review of a facility policy titled, Transfers and Discharges, revised 4/18/26, revealed, in part, the following, .Transfer to Acute Care Facility .Transfers to an acute care facility such as a hospital are initiated for medical reasons for the immediate safety and welfare of a resident .The resident will be assessed at the time of the proposed return to the facility and permitted to return as long as the facility can meet the resident's needs and that the safety or health the resident and individuals at the facility would not be endangered. The ability of the facility to meet the resident's needs and the risk of endangerment to the health and safety of individuals at the facility will not be based on the resident's status/condition at the time of transfer to the acute care facility .

This citation pertains to intake #2983214 Based on interview and record review the facility failed to issue a notice of discharge and discharge summary for one resident (R901) of two residents reviewed for discharges. Findings include:On 5/27/26 a concern submitted to the State Agency was reviewed which alleged the facility did not let R901 come back to the facility after they were transferred to the hospital. On 5/27/26 at approximately 9:55 a.m., R901 was contacted via phone to discuss their hospital transfer. R901 reported the facility did not allow him to return to their room after they were stabilized at the hospital. R901 indicated they had no chance of stating their case to return and indicated they felt the facility was not allowing them to return due to making previous complaints to the State Agency. R901 was queried if the facility had provided them or their responsible party with a notification of discharge and their discharge summary when they did not allow them to return and they indicated the facility did not send anything to them and their new facility does not have any records from them. On 5/27/26 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted on [DATE] and discharged on 5/3/26 with diagnoses including Schizoaffective disorder and Chronic obstructive pulmonary disease and was not readmitted . A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 4/7/26 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition.A progress note dated 5/3/2026 at 11:42 revealed the following: Nursing - Progress Note-Note Text: Ems (Emergency Medical System) arrived at 11:35. Resident left facility via stretcher at 11:40 he is being transported to [Name of local hospital]. Bed hold policy given.Further review of the medical record did not reveal any documentation that R901 or their responsible party had been provided a notice of transfer/discharge or a discharge summary when the facility made the decision not to permit R901's readmission to the facility. On 5/27/26 a review of the facility's communication with the local hospital regarding R901's readmission revealed the following: Facility message at 5/8/26 at 3:47 p.m.,-Facility says they can not accept back with cecostomy tube, it would need to be dc'd (discontinued) prior to return .Hospital message at 5/11/26 at 11:06 a.m.,-Good morning, GI (gastroenterologist) is stating that cecostomy tube is need to be in long term, is there reasoning as to why they are unable to accommodate? .Hospital message on 5/11/26 at 1:39 p.m.,-Okay, patient is medically cleared. Trying to find out if I need to start looking for alternative placement for him .Hospital message on 5/11/26 at 2:49 p.m.,-Sending over GI note from Friday that explains the plan of care regarding cecostomy .Hospital message at 5/12/26 at 1:34 p.m.,-Here are the instructions given to Nursing from GI specialist .Hospital message on 5/12/26 at 4:07 p.m.,-Please let me know if this is something that can be taught/educated to staff members or if I need to work with family to find different placement. The patient would prefer to return to you ASAP (as soon as possible) .Hospital message on 5/13/26 at 10:53 a.m.,-Physican is wanting to discharge, wanting to know if you can take him .Facility message to hospital on 5/13/26 at 10:56 a.m.,-Ok i'm sorry we cannot .On 5/27/26 at approximately 2:27 p.m., during an interview with Regional Clinical Service Director A (RCSD A), RCSD A was queried regarding the information that the hospital sent over instructions on how to care for R901's cecostomy tube. RCSD A indicated that the facility does not have a policy on that particular tube and would not be able to accommodate the return of the resident. RCSD A was queried regarding the information provided by the hospital in the readmission referral on how to care for the cecostomy tube and they indicated that the decision not to permit readmission was made by the [NAME] President of Clinical Services C (VPCS C).On 5/27/26 at approximately 2:30 p.m., during a conversation with the facility Administrator, the Administrator was queried for documentation that R901 was provided a notice of transfer/discharge from the facility indicating their appeal rights and the reasons why they were being discharged and not permitted to return. On 5/27/26 at approximately 2:56 p.m., during a conversation with VPCS C, VPCS C reported that the facility could not accommodate the new device/tube that R901 had which was a cecostomy tube. VPCS D reported the facility has no plan of care for that specific device and does not have a policy /procedure to care for that device so as long a R901 had the tube they would not be permitted to return to the facility and would need to be discharged . On 5/27/26 at approximately 4:07 p.m., during a follow up conversation with the facility Administrator, the Administrator was queried if they were able to provide any documentation that R901 or their responsible party was provided a notice of transfer/discharge, and they indicated they did not. On 5/27/26 a facility document pertaining to the policies and procedures of notifications of discharge was reviewed and revealed the following: Policy Title: Transfers and Discharges-The purpose of this policy is to provide guidelines for the safe transfer and discharge of a resident across the continuums of care Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for their stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for their stay. The facility ceases to operate. When a resident exercises their right to appeal a transfer or discharge, the facility will not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include the following at the time it is provided: The specific reason and basis for transfer or discharge. o The effective date of transfer or discharge. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . An explanation of the right to appeal the transfer or discharge to the State.The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.Information on how to obtain an appeal form. information on obtaining assistance in completing and submitting the appeal hearing request.The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident. The resident's health improves sufficiently to allow a more immediate transfer or discharge, o An immediate transfer or discharge is required by the resident's urgent medical needs, or o A resident has not resided in the facility for 30 days. The facility will maintain evidence that the notice was sent to the Ombudsman.If the information in the notice changes prior to affecting the transfer or discharge, the Social Services Director or designee must update the recipients of the notice as soon as practicable once the updated information becomes available. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification. For circumstances where the discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs or the resident's health has improved sufficiently so that the resident no longer needs the care of the facility, the resident's physician must document information about the basis for the transfer or discharge. Additionally, if the facility determines it cannot meet the resident's needs the documentation made by the resident's physician (or nurse practitioner or physician's assistant) will include: o The specific resident needs the facility could not meet o The facility efforts to meet those needs and o The specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for transfer or discharge will be provided by a physician, nurse practitioner, or physician assistant. For residents who are transferred to an acute care facility or psychiatric facility for the health and safety of others at the facility, those residents will be assessed at the time of the proposed return to the facility and permitted to return as long as the facility can meet the resident's needs and that the safety or health of individuals at the facility would not be endangered. The ability of the facility to meet the resident's needs and the risk of endangerment to the health or safety of individuals at the facility will not be based on the resident's status/condition at the time of transfer or discharge to the acute care facility. If the facility determines that they are unable to meet the needs of the resident at the facility at the proposed time of return, the facility will follow the steps outlined under the above section Discharge When Needs Cannot Be Met or When Safety and Health of Individuals is Endangered .

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled, dated, and stored. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/12/26, during an initial tour of the kitchen with Dietary Manager (Staff 'T') between 8:48 AM - 9:05 AM, the following was observed: In the standard refrigerator an open box of thickened water with a use by date of 1/7/26 was observed. In the walk-in freezer, there were four large ground beef rolls that were not labeled and dated. As well as a cake and two packages of what appeared to be waffles. In the walk-in cooler there were two defrosted large ground beef rolls that were not labeled and/or dated. A loosely wrapped open pound of butter that appeared to be one quarter used was also observed. When asked who was responsible for monitoring the food items for proper storage, labeling, and discarding, Staff 'T' stated that items should be labeled with open and expired dates. They noted that they had been out of the facility for over a week and would address the concern. According to the 2017 FDA (Food and Drug Administration) Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observations, interviews and record reviews the facility failed to maintain an ongoing Infection Control Surveillance system and ensure the consistent implementation of the facility's policies and procedures for the Infection Prevention and Control program. This deficient practice had the potential to affect all residents that resided in the facility, including R's 65, 57, 121, 48, 70, 113, 64, 106, 74, 5, 4, 99, and 62 of 13 residents reviewed for Infection Control. Findings include:On 1/12/26 at 9:48 AM, a signage for contact precautions was observed on the door of R65. It alerted staff and providers to don on gown and gloves upon entering the room. An observation of the Personal Protective Equipment (PPE) cart next to R65's door was conducted and revealed no gloves inside the cart for staff and providers to utilize. Another PPE cart across the hall was observed and again contained no hand gloves for staff and providers to utilize. At 9:51 AM, Unit Manager (UM) HH was asked to look into the PPE carts located outside the contact and enhanced barrier precaution rooms on the first floor. UM HH confirmed there were no gloves located in the carts for staff and providers. UM HH directed an aide to obtain boxes of gloves for the carts. On 1/12/26 at 9:59 AM, an interview with R57 conducted inside their room had started when UM HH was observed to have placed a signage on the resident's door. At that time the interview with R57 was paused and UM HH was asked what signage they were putting up. UM HH stated they were placing an enhanced barrier precaution sign. UM HH was asked why they had not had the signage up prior to the surveyor entering into the room and UM HH did not have a response. After completion of the interview, UM HH was observed at the nurses station at 10:38 AM. UM HH stated they were not sure what happened and stated R57 was readmitted from the hospital over the weekend and they were now ensuring all of their orders were put into the system correctly. When asked whose responsibility it was to ensure that this was done upon readmission, UM HH stated the nurses. INFECTION SURVEILLANCE PROGRAM A review of a facility policy titled Covid-19 revised 10/26/23, documented in part . Policy Overview: To establish a facility-wide system for the prevention, identification, reporting, investigation, and control practices designed to minimize transmission of Covid-19. Such as proper use of personal protective equipment (PPE), transmission precautions which reflect current standards of practice, and/or other relevant infection prevention and control practices are in place. Testing Trigger. Symptomatic individual identified. Residents, regardless of vaccination status, with signs and symptoms must be tested. A review of the Centers for Disease Control and Prevention (CDC) titled . Testing for SARS-CoV-2 for Health Care Providers, dated 8/29/24, documented in part . Testing individuals with signs or symptoms consistent with COVID-19. Additionally, consider other illnesses with similar symptoms that may require testing. For many diseases, including flu, early diagnosis and prompt treatment can be important for preventing severe illness. Overview of Testing for SARS-CoV-2 | COVID-19 | CDC A review of the CDC guidance titled Infection Control Guidance: SARS-CoV-2 dated 6/24/24, documented in part . This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes. The recommendation in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection. Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: -A positive viral test for SARS-CoV-2, -Symptoms of COVID-19 or Close contact with someone with SARS-CoV-2 infection. Infection Control Guidance: SARS-CoV-2 | Covid | CDC A review of the CDC guidance titled Symptoms of COVID-19, dated 3/10/25, documented in part . Possible symptoms include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Sore throat, Congestion or runny nose, New loss of taste or smell, Fatigue, Muscle or body aches, Headache, Nausea or vomiting, Diarrhea. Symptoms of COVID-19 | COVID-19 | CDC A review of the Infection Surveillance Program revealed the following: R106- Review of an Infection Report Form onset date 12/30/25, documented cough and congestion. A Nurse Practitioner (NP) progress note dated 12/30/25 at 8:10 AM, documented in part . slightly wheezing left anterior and posterior lung. R74- Review of an Infection Report Form onset 12/30/25, documented in part . cough. A NP progress note dated 1/6/26 at 8:00 AM, documented in part . occasional productive cough. continues to have congestion and stuffy nose, occasionally patient reports of headache. R5- Review of Social Services note dated 11/28/25 at 10:36 AM, documented in part . feeling ill. A Nursing note dated 11/28/25 at 12:45 PM, documented in part . Fever. 101.5. R4- Review of an Infection Report Form onset 11/26/25, documented in part . elevated labs, leukocytosis (high white blood cell count), SOB (shortness of breath), cough, temp (temperature). A Medical Doctor (MD) note dated 11/25/25 at 12:12 PM, documented in part . reports nausea and vomiting which began yesterday. reports looser stools. She has an associated persistent cough and us unable to participate in therapy due to feeling unwell. R99- Review of an Infection Report Form onset 12/10/25, documented in part . lethargic, cough. A Nursing note dated 12/10/25 at 11:43 PM, documented in part . Resident is hard to arouse. A MD (Medical Doctor) note dated 12/11/25 at 11:10 AM, documented in part . has a cough. arousable but has difficulty with arousal. Review of the medical records for R's 106, 74, 5, 4, and 99 revealed no documentation of the residents to have been tested per the facility policy and CDC guidance. On 1/14/26 at approximately 9:04 AM, the Infection Control Preventionist (ICP) W was interviewed and asked the facility protocol and practices for testing residents who are symptomatic for respiratory infections and/or COVID-19. ICP W stated they would notify the doctor and follow the physicians orders. ICP W was asked if they adhered to the Centers for Disease Control and Prevention guidance for testing of symptomatic residents for COVID-19 and their facility policy regarding COVID-19 and Influenza testing of symptomatic and ICP W responded they follow CDC guidance and their policy for the surveillance of the facility's infections. ICP W was then asked why R's 106, 74, 5, 4 and 99 were not tested for COVID-19 despite documentation from their surveillance program and the residents medical records to have contained documentation revealing that all were symptomatic and ICP W stated they were unsure on why these residents were not tested and would have to follow up and get back to the surveyor. At 12:44 PM, ICP W returned and stated residents who are symptomatic are now being tested moving forward. No further explanation or documentation was provided by the end of the survey. On 1/12/26 at 10:34 AM, a Contact Precautions sign was taped on R121's door. Licensed Practical Nurse [LPN] 'AA' was asked why R121 was in Contact Precautions. LPN 'AA' explained R121 had wounds and anyone with wounds was put on Contact Precautions. Observation of the isolation cart in the hall outside R121's room revealed no gloves in the cart. Review of the clinical record revealed R121 was in Contact Precautions for CRE [Carbapenem-resistant Enterobacterales] in the urine. On 1/12/26 at 11:45 AM, a Contact Precaution sign was observed on R48's door. R48 was observed lying in bed. R48 was asked if staff was wearing isolation gown and gloves when they were in the room. R48 explained they were not. After removing gown and gloves to exit the room, no garbage can could be found in R48's room or bathroom. On 1/13/26 at 8:42 AM, LPN 'H' was observed as part of the medication administration task. One of R70's medications was not in the medication cart. LPN 'H' walked to a different Unit, used a computer at the nurse station, retrieved the medication from the backup, walked back to R70's room, placed the medication in a medication cup and gave it to R70 with no hand hygiene performed. On 1/13/26 at 9:10 AM, LPN 'G' was observed as part of the medication administration task. As R113 was tipping the medicine cup filled with seven pills to her mouth, one pill fell out and landed on her lap. LPN 'G' grabbed the pill with her ungloved hand and placed it back into the medication cup and R113 then took the pill. One medication was not in the cart, LPN 'G' went to the nurse station and obtained a stock bottle of medication, returned to the medication cart, removed the safety top on the bottle, then shook one pill into the palm of her ungloved hand and put the pill in a medicine cup and gave it to R113. On 1/13/26 at 10:44 AM, observation of R64's wound care with LPN 'N', who served at the Wound Treatment Nurse, revealed LPN 'N' flicking her unrestrained long hair that was falling in front of her face then continuing treatment on R64's wounds with the same gloves. On 1/13/26 at 11:12 AM, observation of R121's wound care with LPN 'N' revealed no gloves in the isolation cart outside of R121's room. LPN 'N' was asked about the gloves. LPN 'N' explained since R121 was in Contact Precautions, the gloves were inside the room. Observation of the Contact Precaution sign read gloves were required before entering the room. LPN 'N' prepared the supplies needed for the wound treatment, placed them on foam trays and took the trays into the room and placed the supplies on a dresser inside of the room without wearing any PPE. LPN 'N' then exited the room and put on a gown and mask, entered the room and put on gloves and moved the supplies to a tray table. While performing wound care, LPN 'N' needed more supplies, she walked to the doorway, removed her gown and gloves, then without performing hand hygiene opened the treatment cart and removed additional supplies. On 1/14/26 at 8:40 AM, the Director of Nursing [DON] was asked if nurses were allowed to touch pills with their bare hands. The DON explained pills should not be touched with bare hands. The DON was asked when hand hygiene should be done. The DON explained if hands were visibly dirty, they should be washed with soap and water, but there was alcohol based cleanser stationed all over the facility and on the medication carts to clean hands. The DON was asked if gloves should be kept in an isolation cart, or inside a Contact Precaution room. The DON explained gloves should be in the isolation cart. On 1/12/26 at 10:06 AM, during an observation of the 2 East Unit, a bin that contained Personal Protective Equipment (PPE) was observed to have a heavily soiled mask with dried brown and orange stains stored inside the top drawer with the clean masks. A second PPE bin located on the same hallway was observed to have dried brown substance all over the outside of the bin. In order to open the drawers, the dried brown substance would have to be touched. On 1/12/26 at 10:29 AM, R62's door was observed with no signage that indicated the resident was on any type of preventative or isolation precautions. At that time, during an interview with R62, Certified Nursing Assistants (CNA) 'D' and 'C' entered R62's room with a mechanical lift and began to provide care to the resident. Upon exiting R62's room there was a sign hung on the door (that was not there prior to entering) that indicated R62 was on Enhanced Barrier Precautions (EBP - a protective measure to prevent transmission of multi-drug resistant organisms) and all staff that provided care were required to don a gown, gloves, and mask prior to entrance into the room. On 1/12/26 at 10:48 AM, CNA 'C' exited R62's room and an interview was conducted. When queried about why they did not don PPE prior to entering R62's room and providing care as the sign indicated, CNA 'C' reported they worked for a staffing agency, it was their first day back, and that the sign was not hung on the door prior to them entering the room. On 1/12/26 at 10:50 AM, CNA 'X' opened the drawer of the PPE bin that contained the soiled mask and closed the drawer without removing the mask or disposing of the clean masks stored with the dirty ones. On 1/12/26 at 11:16 AM, CNA 'D' opened the top drawer of the PPE bin that contained the soiled mask and closed the drawer without removing the mask or disposing of the clean masks stored with the dirty ones. At that time, Licensed Practical Nurse (LPN) 'Y' opened the drawer and removed the soiled mask and threw it out in the medication cart trash compartment and closed the drawer. At that time, Central Supply Staff (CS) 'Z' was on the unit stocking the PPE bins with equipment. LPN 'Y' was interviewed about the soiled mask and she acknowledged it was not supposed to be in there. At that time CS 'Z' said all the clean masks had to be disposed off and the bin had to be sanitized. At that time, the other bin with the dried brown substance on it was pointed out to CS 'Z' who said it would need to be sanitized and stated, It has an odor. On 1/14/26 at 8:44 AM, an interview was conducted with the Director of Nursing (DON). The above observations were shared with the DON. The DON reported he understood the concerns.

This citation pertains to Intakes 2711600 and 2703853. Based on interview and record review, the facility failed to ensure sufficient nursing staff on the 2 [NAME] Unit for three (R4, R9, R11) residents reviewed, resulting in resident's not receiving their medications according to physician's orders. This had the potential to affect all residents who resided on the 2 [NAME] Unit. Findings include:A review of a complaint submitted to the State Agency revealed an allegation that on 12/25/25, the facility was short staffed from 7:00 PM until 11:00 PM on the 2 [NAME] Unit. The complaint alleged there was no nurse during those times and therefore the residents did not get their medications timely. The complaint noted staff said they were going to send help, but they did not send anyone until 11:20 PM. On 1/14/26 at approximately 4:00 PM, an interview was conducted with Staffing Coordinator (SC) 'E'. When queried about any staffing challenges on second shift on 12/25/25, SC 'E' reported two night nurses called in. When queried about what was done to fill those spots, SC 'E' reported she was not the person on call that day, but she thought nurse managers came in. SC 'E' said Unit Manager, Licensed Practical Nurse (LPN) 'L' came in, but she was not required to punch in because she was a manager and was salary. On 1/14/26 at approximately 5:00 PM, an interview was conducted with the Administrator and SC 'E'. A request for the names of the nurses who were assigned to the 2 [NAME] Unit on 12/25/25 between 7:00 AM and 11:00 PM were requested. Evidence that those nurses actually worked was also requested. At that time, the Administrator reviewed the time punches along with SC 'E' and they reported there were two nurses assigned to the 2 East Unit, one nurse for 1 West, and one nurse for 1 East. They said they were still trying to get the assignment sheet for 2 [NAME] and would follow up. On 1/14/26 at 5:31 PM, the assignment sheet for the 2 [NAME] and 2 East Units on 12/25/25 was provided by the facility. The assignment sheet was reviewed at that time and revealed the following: Unit Manager, Licensed Practical Nurse (LPN) 'L' was assigned to the 2 [NAME] Unit from 7:00 PM until 11:00 PM along with LPN 'U'. Unit Manager, Registered Nurse (RN) 'V' was assigned to the 2 [NAME] Unit from 11:00 PM until 7:00 AM along with RN 'Q'. RN 'Q' was also documented as assigned to the 2 East Unit during the same time frame. A review of time punches of all nursing staff who worked on 12/25/25 was reviewed and the following was revealed: LPN 'U' punched in at 7:00 AM and punched out at 8:59 PM. However, they were listed as a nurse assigned from 7:00 PM until 11:00 PM on the 2 [NAME] unit. LPN 'L' did not have a time punch due to being salary and not required to punch in. RN 'V' punched in at 11:15 PM and punched out at 8:15 AM. RN 'Q' punched in at 7:00 AM and punched out at 11:45 PM. No missed punches were provided by the facility with the time punches. A review of residents who resided on the 2 [NAME] Unit on 12/25/25 was conducted. A review of R4's Medication Administration Record (MAR) for December 2025 revealed they had orders for the following medications scheduled for administration at 9:00 PM on 12/25/25: Atorvastatin 80 milligrams (MG) at bedtime (9:00 PM)Colace 100 MG every 12 hours for constipation (9:00 AM and 9:00 PM)Eliquis (a medication used to prevent blood clots) 5 MG every 12 hours (9:00 AM and 9:00 PM)Metoprolol Tartrate (a medication used to treat high blood pressure) 25 MG two times a day (9:00 AM and 9:00 PM)Tizanidine HCl (a medication to treat muscle spasms) 4 MG three times a day (9:00 AM, 1:00 PM, 9:00 PM) All of the above medications were signed off as given by RN 'V' who did not punch in for their shift until 11:15 PM. Over two hours after the medications were due. A review of R9's Medication Administration Record (MAR) for December 2025 revealed they had orders for the following medications scheduled for administration at 9:00 PM on 12/25/25: Divalproex Sodium (a medication used to treat bipolar disorder and/or seizure disorder) 125 MG two times a day (9:00 AM and 9:00 PM)Voltaren External Gel (a topical medication used to treat pain from arthritis) in the morning and at bedtime (9:00 AM and 9:00 PM) All of the above medications were signed off as given by RN 'V' who did not punch in for their shift until 11:15 PM. Over two hours after the medications were due. A review of R11's Medication Administration Record (MAR) for December 2025 revealed they had orders for the following medications scheduled for administration at 9:00 PM on 12/25/25: Atorvastatin Calcium 40 MG at bedtime (9:00 PM)Lantus (insulin) Inject 12 units at bedtime (9:00 PM)Gabapentin (medication used to treat nerve pain) 300 MG four times a day (9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM) All of the above medications were signed off as given by RN 'V' who did not punch in for their shift until 11:15 PM. Over two hours after the medications were due. On 1/14/26 at approximately 5:45 PM, an interview was conducted with the Director of Nursing (DON) in the presence of Assistant Director of Nursing (ADON) 'W'. When queried about whether they were aware of any staffing challenges on 12/25/25, the DON reported he was not aware. The ADON reported the nurse managers came in. At that time, evidence of when they came and left was requested. The DON was further interviewed about how RN 'V' signed out medications due at 9:00 PM but did not punch in until 11:15 PM and acknowledged the concern and said he would look into it. On 1/14/26 at approximately 6:00 PM, the DON followed up with RN 'V'. RN 'V' reported she came in early but didn't punch in until 11:15 PM. RN 'V' reported she did not request a missed punch from Human Resources because she was also a manager. At that time RN 'V' was asked if she could provide evidence of when she arrived and left on 12/25/25 and she said she could not. The DON asked what he could provide to show evidence of the hours worked by RN 'V'. At that time the audit report of medication administration times was requested for the resident's medications above. The DON reported corporate staff said they were unable to access that report. No further information was provided prior to the end of the survey.

Based on observation, interviews and record reviews the facility failed to ensure medications were properly stored and ensure proper disposal of loose medications for three (1 East cart-2, 2 East high hall cart, and 2 East center cart) of four medication carts and for R120, all reviewed for medication storage. Findings include: R120 On 1/12/26 at 11:05 AM, R120 was observed in their room sitting in their wheelchair. During the interview R120 recalled an incident of a nurse instructing the resident to administer their own medications that were located in the drawer of their bedside table. Observed in the drawer of their bedside table were: Eliquis 5 mg (milligram), Atorvastatin calcium 80 mg, Midodrine HCL 10 mg, and Gabapentin 100 mg. Pills were identified in all of the medication bottles. A review of the medical record revealed no self-administration assessment completed for R120 to be able to take their own medications. A review of the medical record revealed R120 was admitted on [DATE], with diagnoses that included: end stage renal disease, moderate protein-calorie malnutrition and dependence on dialysis. On 1/13/26 at 10:05 AM, Unit Manager (UM) HH was asked to accompany the surveyor to R120's room. Inside R120's bag was identified to contain all of the above medications noted. UM HH reviewed the medications and stated the medications should not be in the room and should have been stored away by the staff. UM HH explained to R120 that they would have to take their medications from their room and will return them when R120 discharges from the facility. A review of a facility policy titled Medication & Treatment Cart Storage dated 5/4/22, documented in part . It is the policy of this facility to ensure all. medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. No further explanation or documentation was provided by the end of the survey. On 1/13/2025 at 9:30 AM, an observation of the medication cart on unit one East-floor cart number two was conducted with Licensed Practical Nurse (LPN) G. Inspection of the second drawer revealed three loose pills. Inspection of the third drawer revealed one loose pill. LPN G could not identify the loose pills. LPN G said the loose pills should have been discarded and that the nurses were responsible to clean and organize the medication carts and that the medication carts were cleaned on 1/12/2025. On 1/13/2025 at approximately 9:45 AM, an observation of the medication cart on unit 2 East high was conducted with Registered Nurse (RN) Q. Upon inspection of the medication cart one loose pill was observed in the bottom of the second drawer. When RN Q was queried who was responsible for cleaning the carts RN Q said all the nurses were responsible. On 1/13/2025 at approximately 9:50 AM, an observation of the mediation cart on unit 2 East center cart was conducted with LPN R. Upon inspection of the medication cart one loose pill was found in the second drawer and one loose pill was found in the third drawer. When LPN R was asked who was responsible to clean the medication carts, LPN R said the loose pills should be properly disposed of and that the nurses were responsible to clean the medication carts. On 1/14/2025 AM, the Director of Nursing (DON) was interviewed and said the medication carts were cleaned and organized on 1/12/2025. The DON further said that each nurse was responsible for their own cart, and the expectation was for the medication carts to be clean and not to have loose pills. Review of the facility policy titled Medication Administration issued date: 8/7/2023 revealed in part.Keep medication cart clean, organized, and stocked with adequate supplies. Dispose of medication per policy or state specific guidance. Review of the facility policy titled Medication and Treatment Cart Storage date approved 5/4/2022 revealed in part.C. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on interview and record review the facility failed to maintain an effective antibiotic stewardship program to monitor the appropriateness of antibiotic use for two (R's 3 and 104) of two residents reviewed for the antibiotic stewardship. Findings include:R3A review of the medical record revealed R3 was initially admitted to the facility on [DATE], with a readmission date of 12/18/25 and diagnoses that included: anxiety disorder, bipolar disorder, and adjustment disorder.A review of an Infection Report Form Onset Date: 12/16. documented in part . mental status change, lethargic, fever. Cephalexin 500mg (milligrams)/3xday/oral. Total Days of Therapy: 10.A review of the McGeer Criteria Worksheet attached to the Infection Report Form was blank.A review of the medical record for R3, revealed no documentation of the identified mental status change, lethargic, fever.A review of a Nursing note dated 12/16/25 at 2:23 AM, documented in part . Pt (patient) requested to see the nurse. pt requested to see the nurse. pt stated that she could see mold on the floors and having a hard time breathing. Writer raised HOB (head of bed), auscultated lung sounds and assessed vital signs. No abnormalities noted, pt disagreed. Writer examined the room for hazardous conditions, none found. Writer offered for floors to be swept and mopped, pt declined, asking to speak with a supervisor on duty. After writer notified the supervisor on site, Pt made the decision to contact EMS (emergency medical services) to transport her . to the hospital.Further review of the record revealed multiple documentation of episodes of disruptive behaviors, yelling, refusals of care, irritability, agitation and frustration, which appeared to be the resident's baseline.A Nursing note dated 12/18/25 at 5:22 PM, documented in part . resident had called 911 to come take her to the hospital due to canker sores in her mouth.A nursing note dated 12/18/25 at 11:47 PM, noted the resident arrived back at the facility.A nursing note dated 12/19/25 at 1:28 PM, documented in part . found foaming at the mouth, cyanotic, shaky, and unresponsive. 911 called. Pt regained conscious, and was alert. with confusion. pt transferred back to the hospital.A nursing note dated 12/19/25 at 6:10 PM, documented in part, . Pt arrived from (hospital name). New orders received; Cephalexin 500mg tid (three times a day) for 10 days for a mild UTI (urinary tract infection).A review of the medical record revealed no documentation of the reviewal of the appropriateness of the antibiotic or labs or culture reports from the hospital. R104A review of the medical record revealed R104 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included: paranoid schizophrenia, psychotic disorder with hallucinations and adjustment disorder.A review of an Infection Report Form Onset Date 12/11/25, documented in part . Signs and Symptoms (blank). Augmentin 500-125mg/Q12h (every 12 hours)/oral. Date 12/11/25. Treatment #1 Augmentin 500-125mg/Q12h/oral. Start Date: 12/24/25. Stop Date 12/31/23. Treatment #2 Augmentin 500-125 mg/Q12h/oral. Start Date 12/15/25. Stop Date: 12/16/25.Review of a blank McGeer Criteria Worksheet was attached to the Infection Report Form. A urinalysis and culture report was attached to the Infection Report Form that noted Escherichia coli, > (more than) 100,000 found in the resident urine and reported to the facility on [DATE].A review of a NP note dated 12/11/25 at 9:00 AM, documented in part . Following after report from staff that patient was physically aggressive to facility staff. Patient in bed, she is somewhat irate, does not want to be bothered, she states she wants to go home. She has no complaints, no respiratory distress and discomfort no pain. A recent verbal and physical aggression with nursing staff. CBC (complete blood count), CMP (comprehensive metabolic profile), UA (urinalysis), CS (culture report), psych eval (evaluation). Vascular dementia, moderate with behavioral disturbance. Psychiatric illness/MDD (major depressive disorder) with history of suicidal ideation.Further review of the record revealed prior incidents of use of inappropriate language towards staff, attempting to hit staff, refusals of medications/care, frustration, irritability, and verbal aggression.A review of the December 2025 Medication Administration Record (MAR) revealed the following:Start Date 12/15/25 Augmentin 500-125 mg every 12 hours for a UTI, for seven days. This order stopped on 12/16/25, with a total of one dose administered.Start Date 12/23/25 Augmentin 500-125 mg every 12 hour or a UTI, this order stopped on 12/24/25 with a total of two doses administered.Start Date 12/24/25 Augmentin 500-125 mg every 12 hours for UTI for 7 days. This order stopped on 12/31/25, completing the full regime ordered.Review of the medical record revealed no documentation of the appropriateness of the antibiotic or documentation of the resident to have met the criteria of an infection.On 1/14/26 at approximately 9:07 AM, the Infection Control Preventionist (ICP) W was interviewed and asked how they review and ensure the appropriateness of the antibiotics prescribed to the facility residents and ICP W explained they run a report every morning to see who is on antibiotics. ICP W stated they would get in touch with the doctor and go over the antibiotics. ICP W was asked where they document their conversation with the Physician regarding reviewing the appropriateness of the antibiotics and ICP W stated they . just realized that it should be documented in the record. ICP W was asked to provide all documentation they had regarding the reviewal of appropriateness for R's 3 and 104 antibiotics for review. ICP W stated they would look into it and follow back up.No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake 2711600 Based on observation, interview, and record review, the facility failed to ensure one (R5) of one resident reviewed for accommodation of needs had an appropriate call light that they were able to use. Findings include. A review of a complaint submitted to the State Agency revealed an allegation that R5, a resident who was bed bound did not have a proper call light. The complaint further noted R5 was unable to utilize her hands to activate the call light and it was difficult for staff to know when she needed assistance. On 1/12/26 at 10:20 AM, R5 was observed lying in bed with their head leaned over to the left side. A standard push button call light was observed clipped to R5's blanket. At that time, R5's family member was present and was asked if R5 was able to use the call light and they were not sure. On 1/14/26 at 10:00 AM, R5 was observed lying in bed with their head leaned over to the left side. A standard call light was observed clipped to R5's blanket. At that time R5 was asked if they were able to press the call light button and they slightly shook their head to indicate they could not. On 1/14/26 at 10:12 AM, an interview was conducted with Unit Manager, Registered Nurse (RN) 'B'. When queried about whether R5 was able to use a standard push button call light, RN 'B' reported she could. At that time, an observation of R5 was made with RN 'B'. RN 'B' asked R5 if they could hold the call light and R5 said she could not. RN 'B' attempted to put the call light into R5's hand and was unable to. RN 'B' said R5 could not hold the call light and said she would need to be assessed for a different type of call light. On 1/14/25 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). The DON reported if staff noticed a resident was unable to use a standard call light, they should be assessed for an appropriate call light. A review of R5's clinical record revealed R5 was admitted into the facility on 9/10/25 with diagnoses that included: contractures, functional quadriplegia, and muscle wasting and atrophy. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R5 had unclear speech, severely impaired cognition, and was dependent on staff for all activities of daily living. A review of a facility policy titled, Call Light Accessibility and Timely Response dated 8/16/23 revealed, in part, the following, .Each resident will be reviewed for unique needs and preferences to determine any special accommodation that may be needed for the resident to utilize the call light system .

Based on observation, interview, and record review, the facility failed to ensure end of life wishes were accurately and clearly reflected in the medical record for one resident (R4) out one resident reviewed for advanced directives. Findings include: On [DATE] at approximately 3:03 PM, a review of R4's clinical record was reviewed and revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: coronary heart disease, paranoid schizophrenia, type II diabetes and psychotic disorder. The face sheet noted that R4's code status was: Adv (advanced) Directive: Full Cardiopulmonary Resuscitation (CPR).Continued review of R4's clinical record revealed an Advanced Directive form dated [DATE] and signed by R4 that noted the resident had chosen DNR (do-not-resuscitate). On [DATE] at approximately 8:45 AM, R4 was observed lying in bed. They were alert but confused at times. When asked as to their end-of-life wishes, they noted that only their family can do CPR not anyone else. *It should be noted that R4 had a court appointed guardian via a company and there were no family members that acted as their legal guardian. On [DATE] at approximately 12:08 PM, two Certified Nursing Assistances (CNA CC and CNA DD) were queried as to how they determine a resident's code status. Both CNAs noted that they were not directly employed by the facility and worked via an agency. However, they indicated they were instructed to read from the face sheet. Both CNA CC and CNA DD reviewed R4's record and stated that R4 was FULL CODE. On [DATE] at approximately 12:30 PM, Registered Nurse EE was interviewed and asked if they were aware of R4's code status. Nurse EE reviewed the resident's record and reported that R4 was FULL CODE. On [DATE] at approximately 12:56 PM, an interview and record review was conducted with Social Work Director (SWD) FF. SWD FF was asked about R4's code status and noted the resident was a DNR.

This citation pertains to Intake 2711600. Based on observation, interview and record review, the facility failed to maintain a homelike environment for three residents (R5, R9 and R85) of three reviewed for environment. Findings include:On 1/12/26 at approximately 11:03 AM, during an initial tour of the facility, R9 was observed lying in bed. There were several items of garbage all of the floor and the wall across from their bed was splattered with a brown substance. A second observation was made on 1/12/26 at approximately 2:10 PM and the room remained the same. On 1/12/26 at 10:20 PM, an observation of R5 and R85's room was conducted. The floor on both side of the room were littered with trash and debris and appeared as if it had not been mopped. R5's over bed table appeared dirty and discolored. R5's nightstand was observed with multiple dried spots of tube feeding formula on the top and dried formula that had dripped down the front of the nightstand. R85's overbed table appeared dirty and sticky. R5's family member was asked about whether the room was typically cleaned and R5's family member pointed to the trash on the floor and shrugged. On 1/13/26 at 11:15 AM, an observation of R5 and R85's room was conducted with Maintenance Director 'F'. At that time, the floor, nightstand, and over bed tables remained in the same condition as mentioned about. Maintenance Director 'F' acknowledged the condition of the room and said it needed to be cleaned and R5's overbed table needed to be replaced. A review of a facility policy titled, Homelike Environment, dated 9/21/23, revealed, in part, the following, .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment .

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the Administrator in a timely manner for one (R80) of five residents reviewed for abuse. Findings include: On 1/12/25 at 11:48AM, R80 was observed lying in bed. A dark purple bruise that appeared to be squarish, approximately 1 inch x 1 inch was observed on the outside of R80's left upper arm. R80 was asked how she got the bruise. R80 explained an aid was rough with her care a couple days ago. When asked if she had told anyone about the rough care, R80 explained she had told the nurse.Review of the clinical record revealed R80 had been admitted into the facility on 3/30/23 and readmitted [DATE] with diagnoses that included: rheumatoid arthritis, ankylosing spondylitis [type of arthritis that fuses the spine] and muscle weakness. According to the Minimum Data Set [MDS] assessment dated [DATE], R80 was cognitively intact and required the assistance of staff for all activities of daily living [ADL's].Review of R80's progress notes revealed a General Note dated 1/12/26 at 4:54 PM by Licensed Practical Nurse [LPN] 'P' that read in part, writer made another attempt to do ADL care on resident resident accepted care resident [sic] writer gave full bed bath and bed change resident resting in bed w/ [with] call light and bedside table within reach resident is stable in good condition. Continued review of R80's progress notes revealed no documentation of the bruise on R80's left upper arm.Review of R80's assessments revealed the most recent skin assessment had been completed on 1/7/26 with no mention of bruising.Review of facility provided Incident & Accident [I&A] reports revealed the most current I&A report was dated 1/5/26, and was not regarding bruising.On 1/13/26 at 2:40 PM, the Administrator, who was the Abuse Coordinator, was asked if any staff had notified her of the bruise to R80's upper arm. The Administrator explained she had not been notified by anyone of R80 having a bruise. The Administrator was told R80 had a dark purple bruise on her left upper arm, said an aide was rough with care and that she had told a nurse about it. The Administrator explained no one had informed her. The Administrator was asked if staff should report a dark purple, oddly shaped bruise on a resident that required complete ADL assistance. The Administrator made no reply.Review of a facility policy titled, Abuse updated 5/24/23 read in part, .The facility will educate the staff in identifying abuse (mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services), neglect, exploitation, mistreatment, and misappropriation of resident property. Possible indicators of abuse include, but are not limited to: .Suspicious or unexplained injuries such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body.

There are two deficient practice statements. Deficient Practice Statement (DPS) #1. This citation pertains to Intake 2703853.Based on interviews and record reviews the facility failed to complete accurate assessments, document accurate vitals in the medical charts, complete labs as ordered, administer medications/intravenous fluids as ordered, and report accurate assessments to the Physician for timely treatment, care and/or transfer to a higher level of care, for three (R's 122, 99 and 4) of four residents reviewed for a change in condition.Findings include: R122 A review of a complaint submitted to the State Agency (SA) documented a concern of the facility's negligence that resulted in the death of R122. A review of the hospital record Discharge Summary dated 12/5/25 at 8:55 PM, noted in part . presented for a few days of decreased oral intake, fatigue, lethargy. having poor oral intake and coughing when attempting to eat. Per wife, he was prescribed diltiazem on 11/29 for documented tachycardia. Per EMS (emergency medical services) note, patient was hypotensive 97/67, HR (heart rate) 140s. On admission, he was hypotensive 79/56, HR 138. T 40.3 C (104.54 degrees Fahrenheit), Sp02 99% on 6L (liters) NC (nasal cannula). He was given sepsis bolus LR (lactated ringers) 2.1 L, vanc (vancomycin) and Zosyn (intravenous antibiotics) were started and pt (patient) was admitted for further workup. WBC (white blood cell) 14.6. Comfort care measures after talking to family. Pt expired at 20:55 (8:55 PM). Family notified at bedside. A review of the medical record revealed R122 was initially admitted to the facility on [DATE] with a readmission date of 7/29/25 with diagnoses that included: dementia, seizures and dependence on wheelchair. A Minimum Data Set (MDS) assessment dated [DATE], noted that R122 was . rarely/never understood). R122 was dependent on staff for all Activities of Daily Living (ADLs). A review of the progress notes documented in part: On 11/29/25 at 3:27 PM, a Nursing note documented in part . Nurse was checking resident's vitals as per ordered, noticed elevated HR (heart rate), nursed notified that to doctor and received verbal order for medication, ordered followed. On 12/1/25 at 8:28 PM, a Nursing note documented in part . Resident wife wants provider to notify her. Wife also had c/o (complaint of) nail bed being discoloration. Writer did assessment. Resident fingers were cold. Resident fingers didn't appear to have discoloration. Writer informed unit manager of wife concerns. Resident appetite poor today. Fluids encouraged. A review of a Nurse Practitioner (NP) consultation dated 12/2/25, documented in part . Temp (temperature) 97.7, BP (blood pressure) 168/89, heart rate 77, SpO2 96% . Family at the nurses station requesting appetite stimulant. Reports patient is having a decreased appetite. Nursing reports patient is pocketing food in his cheeks and not swallowing. Respiratory: Clear to auscultation, symmetric, No respiratory distress. A Nursing note dated 12/2/25 at 6:50 PM, documented in part . vitals are taken after wife/guardian alerted on shift nurse, vitals SPO2 saturation was declining from 94% go 91%, nurse also heard on lower lobe, resident was having SOB (shortness of breath), on shift nurse notified doctor and DON (Director of Nursing) changing condition, as per guardian wife request, nurse received order to send resident to the hospital from doctor. A review of the vitals for 12/1/25 at 8:36 AM, recorded the following: Temp 97.7, BP 168/89, Pulse 77, and SpO2 96% on room air. These are the same values noted in the NP consultation on 12/2/25. An interview conducted with the complainant on 1/13/26 at 3:20 PM, revealed in part . The nurse came back running and called the doctor and the doctor said that no one is leaving my facility and the wife called 911. An interview was conducted with R122's wife on 1/13/26 at 5:45 PM. R122's wife was asked if they could recall the incident that led to their husband being transferred to the hospital on [DATE]. R122's wife stated they arrived at the facility around 5:45 PM that evening and noticed that R122 did not look well and they wanted R122 transferred to the hospital. R122's wife stated they notified the nurse who replied they would call the Physician. R122's wife stated the doctor was yelling at the nurse and was threatening their job is they sent the resident out to the hospital. The wife stated they demanded as R122's guardian to send the resident to the hospital and the resident was then transferred. R122's wife stated prior to being transferred the nurses were attempting to obtain vitals and the blood pressure machines were not working properly. The wife stated they had taken pictures that was verified by the date and time that staff had obtained the vitals. A picture of the facility's blood pressure machine was reviewed. The photo had the properties of 12/2/25 at 6:17 PM, that showed a BP of 215/160. The wife admitted it took a while for the staff to send the resident out to the hospital due to the staff waiting for the approval to transfer the resident from the Physician. On 1/13/26 at 4:30 PM, a telephone interview was attempted with Registered Nurse (RN) S (the nurse assigned to R122 the shift they were transferred to the hospital) and was unsuccessful. A message was left for RN S to return the call. On 1/14/26 at 9:39 AM, RN S returned the call for an interview. When asked about the change in condition with R122 on 12/2/25 that required a transfer to the hospital, RN S stated they along with the unit manager took the resident vitals, notified the doctor and sent the resident out to the hospital. When asked how they became aware of the change in condition for R122, they stated R122's wife had informed the unit manager. RN S stated they were on the second floor helping another nurse with something. RN S stated when they came back down to the floor, they along with the unit manager obtained R122's vitals. RN S was asked about the picture provided by R122's wife that noted the resident BP to be 215/160 and RN S confirmed they had received that reading, however stated they obtained two of the facility's blood pressure machines and both were given two different readings. When asked why the 215/160 was not documented in the residents chart, RN S stated they thought it was an unbelievable reading and felt that the reading wasn't accurate due to R122's contracted body. When asked if either of the nurses had taken R122's vitals manually to confirm the abnormal value, RN S stated they did not. The vitals documented in the medical record was reviewed with RN S at the time of the change of condition that noted no temperature to have been obtained, a blood pressure of 100/61 (manual), a pulse of 79 (manual), respiration of 22 breath/min and pulse oxygen saturation of 91% on room air all at 6:31 PM. RN S was asked why they did not obtain a full set of vitals that included a temperature and RN S did not have a response. RN S then stated that R122 was declining and their oxygen saturation had dropped down to 89, heart rate and blood pressure was abnormal. When asked why the medical record did not reflect the true values of the decline, RN S replied . I wasn't sure if I should document it, if they weren't true values. RN S was then asked what the Physician directive was when they notified them of R122's condition. RN S stated the Physician told them they were not sending the resident out with a 94% oxygen saturation. When asked what exactly it was that they reported to the Physician, RN S stated they informed the Physician that R122's . heart rate is all over the place, 02 stat (oxygen saturation) was 94% and he looks very distress and blood pressure is high. RN S stated they were unsure if they called the Physician back to inform them of their declining oxygen saturation but was told by the Physician that if R122 declines, to send the resident out. RN S stated the Physician verbalized that if they (RN S) were the one to send R122 out without the family to have requested it, they (RN S) would be in big trouble. A review of the recorded vitals from 11/29/25 to 12/2/25 documented the only abnormal reading of a blood pressure of 168/89 on 12/1/25 at 8:36 AM. A review of a EMS Ambulance Form dated 12/2/25, documented the following in part . Primary impression Sepsis/Septicemia. Signs & Symptoms- Fever, Hypotension, Tachycardia. responded emergency. of difficulty breathing. pts (patient) oxygen level was low and had an elevated heart rate. family sts (states) he is more lethargic than normal. initial assessment of lung sounds found rhonchi in all fields. Initial 02 saturation was 80% on room air. found sinus tachycardia at 140 bpm (beats per minute). found respirations 35-40. fluid bolus given for hypotension. transported priority 1. Oral temperature was assessed and found 101.4. The facility nurses failed to obtain, document and report to the Physician accurate assessments of R122's change in condition. A review of the hospital records revealed the following: A Emergency Medicine consult dated 12/2/25 at 7:31 PM, . Triage Complaint: Shortness of Breath. presenting to the emergency department over concerns. profoundly tachycardic in the 140s pre-hospital, and relatively hypotensive with systolic pressures in the 90s. He was started on IV (intravenous) fluids and transported to the ER (emergency room) for further evaluation. Tachycardia present. Review of the medical records revealed R122 was admitted to the Medical Intensive Care Unit at the hospital. R4 On 1/12/26 at approximately 3:03 PM, a review of R4's clinical record was reviewed and revealed the resident was initially admitted to the facility on [DATE]. Their last readmission to the facility was 1/9/2026 following a hospital stay from 12/30/25 through 1/9/26. R4 had diagnoses that included: coronary heart disease, paranoid schizophrenia, type II diabetes and psychotic disorder. A review of the resident's Minimum Data Set (MDS) noted a Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition). Continued review of R4's clinical record revealed the following: 12/26/25: Nursing Notes: .writer was notified by CNA (Certified Nurse Assistant) that resident had vomited her am Medications, writer assessed resident and resident c/o (complains of) upset stomach and not feeling well. Resident did not eat breakfast, nor lunch, resident had nausea and vomiting 2x today . 12/26/25: SBAR (Situation, Background, Assessment, Recommendation): .Change in Condition: .Nausea and vomiting .Recommendations: New Testing Orders .Blood Tests . 12/27/25: Lab Results: CBC/Diff (Blood test that provides a detailed breakdown of blood cells): .Collection date: 12/26/25 Reported date: 12/27/25 (7:07 AM) .Results: WBC (white blood count) 15.4 (high) .RBC (red blood count) 3.88 (low) HGB (hemoglobin) 11.4 (low) . 12/27/25: SBAR (late entry): .Change in Condition: Bleeding other that GI (gastrointestinal) .Recommendations: New Testing Orders: blood test . *Blood Test had already been collected on 12/26/25 see above. 12/27/25: Laboratory: Lab results placed in Dr.(Doctor) log and faxed to Dr. NN. Further review of the medical record revealed no documents that indicated the lab results were read by Dr. NN. 12/28/25 (12:03 PM): Nursing Note: .Resident nose was bleeding .Ordered a BCB for Monday . 12/30/25: Physician Team Progress Notes: .Following to review repeat venous Doppler . 12/30/25: SBAR Notes: .Change in Condition: Altered mental status Functional decline .At the time of evaluation resident/patient vital signs .Blood Pressure 104/66 .altered level of consciousness .Recommendation: send resident hospital .New Testing . 12/30/25 (11:09 AM): Nurse-Transfer to Hospital Summary: Resident being sent to hospital .experiencing changes . (Authored by Nurse P). 12/30/25: Blood Pressure Summary: The last Blood Pressure (BP) record noted R4's BP at 104/66. There were no additional BP notes recorded on 12/30/25. (recorded by Nurse P) EMS (emergency medical services): .Pt (Patient) transferred 12/30/25 .11:34 AM .the patient has is experiencing hypotension, which has persisted for 3 hours . presents with generalized weakness and hypotension . PT nurse states she had a pressure of 80/59 prior to arrival and states she was throwing up last night . Hospital Records (12/30/25-1/9/26): .History of Present Illness: .presents with dehydration and low blood pressure. She was sent from her extended care facility due to not eating or drinking for the past week, resulting in dehydration and low blood pressure. Her initial blood pressure was recorded in the fifties, and upon arrival, it was seventy-six over forty-six .She experienced vomiting and was unable to keep food down .her potassium level was noted to be three .Assessment and plan: Dehydration and hypotension . On 1/14/26 at approximately 2:39 PM, an interview was conducted with Nurse P. Nurse P reported that they are an Agency nurse and work in different areas in the building approximately three times per week. Nurse P was asked if they were familiar with R4 and their change in condition on 12/20/25. Nurse P reported that R4 was in activities and a staff person came to tell her that R4 did not seem herself. Nurse P recalled trying to take R4's BP with two different machines and recalled that one BP read low. Nurse P could not recall the BP level. When asked if they had been informed that R4 had experienced vomiting and bleeding the past few days, Nurse P reported that they were not aware and noted as an agency nurse not all information is provided. On 1/14/26 at approximately 2:47 PM, an interview and record review were conducted with the DON and ADON W and Corporate Clinical Support BB. All were asked about R4 and queried as to whether the 12/26/25 lab results were read and any further documentation related to R4's vitals. It was reported that it appeared the 12/26/25 labs were provided to Physician NN. On 1/14/26 at approximately 3:58 PM, a phone interview was conducted with Dr. NN. Dr. NN was asked if they had reviewed the labs obtained on 12/26/25 and if so, would they have made any additional orders based on the results. Dr. NN reported that they did not recall viewing the lab results and indicated that if they had, notes would have been placed in the resident's record. R99 A review of a hospital Discharge Summary dated 1/6/26, documented in part . Principle problem: Respiratory Failure. Procedures performed: Intubation, Arterial Line, Central Line. He was found unresponsive and required airway protection. On arrival, his Glasgow Coma Scale (GCS) was 3. He then developed VT (ventricular tachycardia) arrest, then shock requiring pressors. MICU (medical intensive care unit) was consulted for respiratory failure and shock. he was started on Zosyn after blood cultures were collected. He then experienced a ventricular tachycardia (VT) arrest lasting approximately 15-20 minutes, during which he was defibrillated seven times and received amiodarone and lidocaine. He had another episode of loss of pulse and was persistently hypoxic, requiring bagging. He was eventually started on levophed (intravenous vasopressure- used to treat severe hypotension), vasopressin (vasopressor used to treat severe hypotension), amiodarone infusion (intravenous treatment for severe, life threatening heart rhythm problems) and transferred to ICU (Intensive Care Unit). On further discussion. family decided on pursing a comfort care approach. Gift of life approached family regarding organ donation and family agreed. He was continued on pressor and ventilator support till the organ donation surgery, where his support stopped. and pronounced at 9:43 AM on 01/06/26. A review of the medical record revealed R99 was initially admitted to the facility on [DATE], with diagnoses that included: cerebral infarction, acute respiratory failure with hypoxia and hemiplegia and hemiparesis affecting the left side. A MDS assessment dated [DATE], documented Moderately impaired cognitive skills for daily decision making and was dependent on staff for all activities of daily living. Review of the progress notes revealed the following: On 12/28/25 at 12:11 PM, a Nursing note documented in part . Resident has change in condition audible fluid on lungs accompanied by cough. Residents bp (blood pressure) is elevated and has a low grade fever of 99.1. Tylenol administered per order along with 40mg (milligram) Lasix IM (intramuscular). Physician aware and family. On 12/29/25 at 7:26 AM, a Nursing note documented in part . BP 155/81, Pulse 101. On 12/30/25 at 7:27 AM, a Nursing note documented in part . Change In Condition. Shortness of breath. the resident started to present sob (shortness of breath), tachycardia, which may be caused by his poor healthy-medical history/conditions. Primary Care Provider responded with the following feedback. log into the dr. book, Dr. (doctor)/NP will come today to see the resident. On 12/30/25 at 10:08 AM, a NP note documented in part . Chief Complaint: Acute respiratory failure multiple wounds, pneumonia. decreased responsiveness no verbal response. Makes eye contact slight left facial droop noted. diminished breath sounds bilaterally. Monitor 02 sat. Monitor vital signs. Monitor for signs of infection. On 12/30/25 at 2:18 PM, a Nursing note documented . tachypneic and tachycardic, NP notified, CBC and CMP (Comprehensive Metabolic Panel) was ordered, morning BP meds were held r/t (related to) vitals being outside of parameters. Review of the medical record revealed no results of the ordered CBC and CMP to have been completed. Review of the December 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR), noted the 12/30/25- 9 AM Lisinopril 40 mg (milligram) and the 9 AM Metoprolol 25 mg to be held. The parameters on the Metoprolol noted SBP (systolic blood pressure) < (less than) 100 or HR (heart rate) <60. A review of R99's blood pressure and heart rate that morning was documented the SBP (systolic or top number of blood pressure) to be 101 and the HR to be 67, which indicated they were not out of parameters as noted by the nurse. On 12/31/25 at 2:21 PM, a NP note documented in part . Chief Complaint: Tachycardia, tachypnea. diminished breath sounds. Temp 99.6. heart rate 114. sp02 98% on 3 L. Monitor 02 sat. Tachycardia 1 L normal saline IV fluid bolus. Labs pending. Monitor. Review of the December 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR), revealed no documentation of the IV fluid bolus to have been administered. On 1/2/26 at 3:55 PM, a Nursing note documented in part . observed the resident was lethargic and had a pulse of 129. MD (medical doctor), NP. notified. medication given as ordered. New order to increase metoprolol to 50mg. On 1/2/26 at 8:01 PM, a MD (Medical Doctor) note documented in part . Heart Rate: 125. Tachycardia- 1 L normal saline IV fluid bolus at 80 CC (cubic centimeters) an hour. Labs pending, Monitor. Increase metoprolol to 50 mg twice daily. Monitor 02 sat. Monitor CBC CMP. history of small ischemia infarcts. A review of the January 2026 MAR/TAR revealed the metoprolol 50 mg order was implemented and administered with the existing metoprolol 25 mg twice a day, with a total of 75 mg twice a day to have been administered. On 1/4/26 at 6:57 AM, a Nursing note documented in part . the resident sob (shortness of breath) at times, breathing treatment given with effectiveness, SPO2 increase from 88% to 92-93% NC 3L, the resident decrease sob.will continue to monitor. This note was documented by Registered Nurse (RN) JJ. On 1/5/26 at 7:57 AM, a Nursing note documented in part . monitoring for increase RR (respirations) and sob due to previous shift reported. during nighttime, noted the resident increase his breathing from 22-24/minute, breathing treatment given, spo2 between 90-93%/3L/NC, early morning lung sound diminished, crack? Noted, occasionally moaning, Tylenol 650 given through peg-tube for fever and pain, BP 153/75, 93, noted the resident RR increase to 26-30, SPO2 declining under 88%/NC/5L, breathing treatment given, no improve, SPO2 continue to go down to less 85%, non-breathing applying with 15L, (Doctor name) have called, not get answer, left message regarding the situation, and also awaiting for call back, due to the resident rapidly change condition, 911 called, BP 168/89, HR 107, Spo2 <80% with non-breathing 15L, 911 arrived around 06:35am and transferred the resident to the hospital. This note was documented by Registered Nurse (RN) JJ. A review of the medical record revealed no orders or documentation for a breathing treatment to have been administered for the time of the above change of condition. A standing order for Tylenol 650 mg to be given four times a day, was signed for the 6:00 AM dose as administered. A review of an ambulance form dated 1/5/26, documented in part . Call. 01/05/2026 06:29:25. sitting up in bed unresponsive hyperventilating. Staff states they noted pt became less responsive and has a declining SPO2 for the past 20 min. Pt is unresponsive, GCS (Glasgow Coma Scale) 3 (unresponsive). Pt is on NRB (non-rebreather) @ (at) 15LPM (liters per minute). SPO2 59% RESPS 30. Rhales Bilat. (bilaterally). Placed NPA (nasopharyngeal airway) and began BVM (bag valve mask) ventilations w/15lpm 02. SPO2 increased to 77% . Transported P1 without incident or change in LOC (level of consciousness) Care transferred to staff. On 1/14/26 at 8:12 AM, RN JJ was interviewed and asked to recall the change of condition with R99 on 1/5/26 that caused the resident to be transferred to the hospital. RN JJ stated the resident was stable all night. They laid the resident down to complete a dressing change for their wounds. RN JJ stated the incident happened so fast. RN JJ stated they called the Doctor and left a message. RN JJ stated R99 did not improve so they called 911. RN JJ was asked what time and what breathing treatment they provided to R99, as there was no documentation of a breathing treatment to have been administered during the change in condition. RN JJ stated they could not recall what treatment they provided to the resident and was unsure of the time. RN JJ was asked if they had received a physicians order to provide the treatment for the change of condition and RN JJ stated they did not. RN JJ was asked how long they allowed the breathing treatment to be administered and how long they waited for the Physician to return their call before they decided R99 was not improving and still in respiratory distress. RN JJ estimated a 10 minute time frame. RN JJ stated the resident was hyperventilating and they obtained a pulse ox and called 911. RN JJ was asked to recall the actual value of the pulse ox that was obtained, as they documented that it was less than 85% and RN JJ could not recall. RN JJ was asked why they had not documented the actual values of R99's pulse ox, noting multiple times that the pulse ox was less than the value recorded and RN JJ did not have a response. RN JJ was asked the time they administered the Tylenol for the resident's fever during the chain of events and RN JJ stated it was a scheduled Tylenol and when they laid R99 down to do their dressing change they felt that they were . a little bit hot. RN JJ stated they did not check R99's temperature until they called 911. RN JJ stated they called the doctor, gave the breathing treatment without a physician order with no improvement and called 911. RN JJ was asked if the doctor ever called them back and RN JJ stated they did not. When asked the facility's protocol if they are unable to get a hold of the Physician and RN JJ stated there are no back up Physicians to call for emergencies. RN JJ was asked if they had notified the Physician on 1/4/26 when they noted the resident's pulse ox had decreased to 88% with shortness of breath and RN JJ stated they had not, because the resident improved with the breathing treatment. An audit for the actual administration times of R99's January 2026 medications was requested from the Director of Nursing (DON) and Corporate Clinical Support (CCS) BB on 1/14/26 at 8:42 AM. A second request was made for the audit of the administration times to the DON, Administrator and CCS BB on 1/14/26 at 10:54 AM. On 1/14/26 at 10:59 AM, the DON replied the facility did not have access to provide the audit to the surveyor. On 1/14/26 at 11:18 AM, the survey team contacted the survey team manager to assist with obtaining the medical record audit for review. The Administrator informed the survey manager that the document would be provided. A third request was made at 11/14/26 at 11:48 AM, to the Administrator, DON CCS BB. At 12:31 PM, the Administrator responded that the facility did not have access to the times the medications were signed out. The email was forwarded to the survey team supervisor. A fourth request was made at 5:11 PM and a fifth request at 5:20 PM, to the Administrator, DON & CCS BB. The audit was not provided by the facility for review before the end of the survey. On 1/14/26 at 2:10 PM, Physician KK (the physician contacted by RN JJ on 1/2/26) was interviewed and asked if they recalled receiving a message on 1/2/26 regarding R99's change in condition, and Physician KK stated they could have but could not necessarily recall. Physician KK read RN JJ 's note regarding the Physician to not have returned the call and asked the facility's protocol if the nurses' are unable to reach the Physician during an emergency. Physician KK stated their voicemail message verbalizes if they are unable to get ahold of them to call the Administrator and Director of Nursing, who will then get ahold of the Physician based on the severity of the situation. Review of a facility policy titled Change in Condition dated 8/9/23, documented in part . The nurse will notify the. resident's physician/practitioner. when there is. A significant change in the resident's physical. status, such as deterioration which includes life-threatening conditions or clinical complications. A need to alter the resident's medical treatment. The nurse will document in the resident's medical record information relative to the resident's change in medical. assessment, notifications, interventions, and response. No further documentation was provided by the end of the survey. Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure hospice communication/care was provided and appropriately documented for one (R4) out of two residents reviewed for hospice. Findings include: On 1/12/26 at approximately 10:47 AM, R12 was observed lying in bed. The resident was alert but very confused and could not answer most questions asked. A review of R12's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Anorexia, Type II diabetes and dementia. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 0/15 (severely cognitively impaired). An order dated 8/27/24 read: Admit to (name redacted) Hospice. A review of R12's care plan noted: Focus: Hospice.Resident is at risk for grief, withdrawal, depression or anxiety.Interventions:.Collaborate care with hospice company to meet resident's needs.(12/4/2025)).HOSPICE VISITS-specify days and services provided 8/30/24). On 1/13/26 at approximately 12:01 PM, Registered Nurse (RN) EE was asked if they knew where any Hospice communication documents were located. RN EE was able to locate a thin binder near the nurse's station. The binder documents did not include the names and dates of the hospice care representatives that were visiting R12. On 1/14/26 at approximately 3:47 PM, an interview and record review of the binder were conducted with the Director of Nursing (DON) and Corporate Clinical Support (CCS) Nurse BB to determine the care and workers Hospice was providing, CCS Nurse BB made a call to the Hospice company. Hospice told CCS Nurse BB that R12 gets services from both a Nurse and a Certified Nursing Assistant (CNA) one time per week. The names of the care givers were provided. Both the Surveyor and CCS Nurse BB went to review the sign-in-sheets with Front Desk GG. Staff GG was not able to find any sign-in sheets for Hospice CNA for the past three weeks. CCS Nurse BB reported that it would be in the best interest of R12 to obtain new Hospice services as they were not performing necessary visits for R12. The facility policy titled, Hospice (dated 3/20/24) was reviewed and documented, in part, the following: .The purpose of this policy is to ensure Hospice services are available to residents at the end of life.In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness.provide the facility with the most recent hospice plan of care specific to each resident.communicating with the hospice provider and documenting such communication to ensure that the needs of the resident are addressed.Ensuring the facility is communicating with hospice representatives.Ensuring the hospice information is available within the facility.

This citation pertains to Intake #MI00147295. Based on observation, interview, and record review the facility failed to administer an erythropoietin stimulating agent (ESA-medication that stimulates the bone marrow to produce more red blood cells) as ordered by physician(s) for one (R104) of one Resident reviewed for quality of care resulting resulted in avoidable hospitalization s (due to critically low hemoglobin levels), blood transfusions, with feelings of frustration, helplessness, and diminished quality of life. Findings include: A complaint received by the State Agency revealed that R104 did not receive a medication that was ordered by the physician to be administered regularly resulting in hospitalization s due to low hemoglobin. The complaint also revealed that the facility failed to follow-up on the concern despite the concern was brought to the facility's administration's attention on multiple occasions by R104 and family members. Review of the clinical record revealed R104 was originally admitted on [DATE]. R104 had multiple hospitalization s in the recent past that included 12/14/23; 4/5/24; 8/28/24; and 9/6/24. R104's admitting diagnoses included chronic normocytic anemia (low hemoglobin level), CKD (chronic kidney disease), respiratory failure, dry gangrene right 5th toe, and diabetes. Based on the Minimum Data Set (MDS) assessment dated [DATE], R104 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicative of intact cognition. Review of R104's resident profile document (face sheet) in the Electronic Medical Record (EMR) revealed three family member names listed as emergency contacts. An initial observation was completed on 9/30/24 at approximately 11:10 AM. R104 was observed in the bed and was receiving oxygen via nasal cannula. R104 was queried about their care. R104 reported that they were not getting a medication to maintain their hemoglobin level that was prescribed by the physician. They were ordered to get the medication weekly (every Friday) and they had not received it for several months. When questioned if they had brought up the concerns with the facility administration, R104 reported that they had addressed the concerns directly with the facility administrator and the Physician, most recently two weeks ago. R104 added they also had a meeting with the facility administration that included their family members a few months ago and the concern was brought up during that meeting. R104 reported that facility administration had not resolved the medication concern that that they had brought up and they had to involve their family. A follow-up e-mail was sent by their family members after the meeting as they were still not receiving the medication. R104 confirmed that they had not received the medication to date. When queried if they had received any response for not receiving the ordered medication, R104 added that they were notified by the Administrator that the medication was expensive and it was not covered by their insurance and the facility would not cover the cost. R104 added that they did not have the funds and said they did not understand how it was cost effective for the facility to keep sending them out to hospital every few months to get the medication and blood transfusions. A follow-up observation was completed on 10/1/24 at approximately 11:55 AM. R104 was observed in their bed with their oxygen on. R104 reported they recently went out to the hospital due to low hemoglobin. They added they received a blood transfusion and received the medication (Aranesp) needed during their hospital stay. They also saw a hematologist during their recent hospital stay and they recommended to continue the medication weekly. They added that the specialists at the hospital were trying to figure out why their hemoglobin levels were dropping and they recommended getting the medication to maintain the levels. R104 added they can feel when their hemoglobin levels drop. They added that they were very upset and frustrated with the medication that they were not receiving and the lack of follow-up from the facility administration for several months that resulted in multiple hospitalization s and blood transfusions. Review of R104's electronic medical record (EMR) included a nursing progress dated 9/30/24 at 15:51 (after the concern was brought to the facility's attention during survey) read, Physician gave order to start Retacrit 40000 units weekly (medication used to treat anemia) until resident follow up with hematologist for any changes. A practitioner progress note dated 9/26/24 at 11:38 AM read in part, patient has been hospitalized several times due to low blood levels. No GIB (gastro-intestinal bleed i.e. bleeding in stomach). Ferrous sulphate and Aranesp (medication for anemia) ordered. Aranesp DCd (discontinued) due to insurance non-coverage . Further review of EMR revealed that R104 had a hospitalization on [DATE] and had returned to the facility on [DATE]. Review of hospital records dated 9/9/24 revealed that R104 had called the EMS on 9/6/24 due to complaints of chest pain. Hospital records revealed a lab report dated 9/9/24 that revealed a low hemoglobin level of 8.4 g/dl (gram/dilution) (normal level 11-12 g/dl). R104 was administered Aranesp on 9/8/24. A physician progress notes dated 9/9/24 read under plan that read in part Chronic normocytic anemia - extensive workup on previous admission including colonoscopy (procedure examine the colon), EGD (esophagogastroduodenoscopy - a procedure to examine the upper gastrointestinal tract including the food pipe and stomach); attributed to CKD (chronic kidney disease) .Receives weekly darbepoetin-alfa (Aranesp) injections - continue on this. Monitor regular CBC (complete blood count). Review of hematology oncologist consult during hospitalization (dated 9/4/24) read in part, Principal problem: Anemia - unspecified .plan: patient will benefit from Retacrit 40,000 units weekly. Review of discharge medications order from hospital included Aranesp and read inject 300 mcg (microgram) into skin every 7 days for 360 days on Fridays. Further review of R104 EMR revealed Aranesp was not ordered after they were readmitted to the facility on [DATE] and did not receive the medication. Further review of the EMR revealed the facility staff and providers were aware that that the R104 was ordered to receive this medication weekly. There was no evidence in R104's EMR that the facility made any attempts to obtain the medication and/or communicated and followed up with the resident. Review of EMR revealed a practitioner notes dated 9/24/24, that read in part patient has been hospitalized several times due to low blood levels. No GIB (gastro-intestinal bleed i.e. bleeding in stomach). Ferrous sulphate and Aranesp (medication for anemia) ordered. Aranesp DC (discontinued) due to insurance non-coverage .Plan: chronic anemia of CKD- labile .request a substitute for Aranesp. There was no evidence in EMR on any follow-up after and no substitute was ordered. R104 was unaware of any follow up regarding a substitute. A practitioner note dated 9/20/24 at 13:26 read, this is a --[age and gender omitted]-- on ferrous sulphate for chronic low blood levels associated with CKD. Patient was hospitalized 3 weeks ago for low hemoglobin and CHF (congestive heart failure) exacerbation .Plan: Chronic anemia of CKD labile-No labs found since readmission .continue Aranesp and ferrous sulphate . It must be noted that R104 did not receive Aranesp since they were readmitted from the hospital on 9/4/24. Review of discontinued orders on EMR revealed that Aranesp was ordered on 9/6/24 and was discontinued on 9/9/24 after they were readmitted the hospital on 9/7/24. Review of R104's discontinued physician orders revealed an order for Aranesp dated 4/19/24 (after readmission from hospital on 4/17/24) that read Aranesp (albumin free) injection solution prefilled syringe 200 MCG/0.4 ML (Darbepoetin Alfa) - inject subcutaneously one time a day every Friday for Anemia. Review of Medication Administration Record (MAR) revealed that R104 did not receive the medication from 4/19/24 through 7/15/24. The medication was discontinued on 7/15/24 and it was not re-ordered and R104 was transferred out to hospital on 8/28/24 with a critically low hemoglobin of 6.9 g/dl. Further review of EMR revealed a physician progress note dated 9/5/24 that revealed that R104 was seen by the provider after readmission from hospital. The note read, this is a [age and gender omitted] with pertinent medical history of GIB, anemia of CKD and CHF who was sent out for low hemoglobin of 6.6. Upon arrival to ED (emergency department patient was transfused 2 units capital PRBCs (packed red blood cells) for hemoglobin of 6.9 .O2 (oxygen) need increased due to hypoxia (decreased oxygen in blood) hematology oncologist (doctor who specializes in blood related diseases) recommended Procrit (medicine similar to Aranesp) .plan: chronic anemia of CKD-labile .continue Aranesp. A nursing progress note dated 8/28/24 read, patient transferred to hospital r/t low hemoglobin per physician order. A practitioner note dated 7/15/24 read, Plan: chronic anemia-labile -last hemoglobin 9.5 from 10.8. Continue ferrous sulphate. Aranesp has been on hold for several months due to insurance discrepancy . but did not address alternatives for the medication and or any attempts to receive the medication at any off-site locations. A nursing progress note dated 7/15/24 read, Discussed with physician. Aranesp will be dc (discontinued). HGB will continue to be monitored. A physician note dated 6/18/24 revealed that R104 was seen for regulatory visit and medication reconciliation. The section Diagnosis/status/Plan read in part, Acute blood loss anemia - labile last hemoglobin 9.3 .continue Aranesp. Practitioner notes dated 5/22/24, 5/20/24, 5/7/24, and 4/20/24 read that R104 was currently on ferrous sulfate and Aranesp for chronically low blood levels/anemia. It must be noted that R104 was not receiving this medication during this time (since 4/19/24). R104 had not received their medication prior to their hospitalization s. A nephrology (kidney specialist) consult dated 4/5/24 (during hospitalization ) read, recurrent acute on chronic anemia- previous extensive workup done - admission hemoglobin-6.4 .plan: will give Aranesp 300 mcg once a day and needs to continue weekly Aranesp 200 mcg at discharge. He thinks he did not receive the Aranesp dose for last 3 weeks . An interview was completed with R104's family member on 10/1/24 at approximately 12:25 PM. This family member reported they had reached out to the facility Administrator on multiple occasions regarding their medication concern. The family member also reported that they had attended a meeting with the facility administrator and social worker on 7/25/24 and had brought up the concern. They added follow up e-mails were sent to the facility administrator on 7/28/24, 8/2/24 and 8/15/24. An interview was completed with Nurse Practitioner (NP) M on 10/2/24 at approximately 7:55 AM. NP M confirmed they were following the care of R104 under supervision of the attending physician. The attending physician/Medical Director was on vacation and was unavailable for interview. During this interview NP M was queried why R104 was not receiving Aranesp and what was their expectation if a resident was not receiving a medication that was ordered. They reported that they were aware that R104 was not receiving the medication a few months ago. During this initial interview NP M did not have computer access and they provided information based on what they could remember. They reported that their expectation is for the facility staff to notify them timely if a resident did not receive any of their medications. They added that R104 had multiple causes of anemia and they were trying to get a follow-up hematology oncologist appointment. They were queried about multiple hospitalization s related to low hemoglobin levels and recommendations from the specialists to continue the medication at the facility; and why it was not addressed. It was shared that R104 had an order to receive the medication for over three months and did receive any doses. They reported that it was a valid concern and they should have looked for an alternative medication/treatment and addressed it. They reported that they will review the chart and call back with any additional information. Later that day at approximately 10:55 AM, NP M called back and reported that R104 had extensive work up during hospitalization . They added that the medication was not indicated if the hemoglobin is a level below 10 per pharmacy based on the recent discussion. There was no further explanation of why R104's hemoglobin was monitored closely and not administer the medication as indicated/recommended by the specialists to maintain their hemoglobin levels. They reported that they were on vacation when R104 was hospitalized in September. They were notified of the concerns and they reported that they understood the concerns. An interview with Unit Manager (UM) N was completed on 10/1/24 at approximately 12:15 PM. UM N was queried about the medication (Aranesp) for R104. They reported that R104 was on this medication and the physician discontinued the medication in July as R104's hemoglobin was stable. When queried about R104's low hemoglobin in April and in August when they needed hospitalization s and transfusions and why Aranesp that was ordered, but were not administered. UM N reviewed the EMR and reported that R104 was on the 2nd floor and had moved to 1st floor (on 5/29/24) and they had identified on 7/15/24 that R104 had missed this medication (since 4/17/24) and they had followed up with the provider (NP M) and notified that R104 had not been getting the medication and they had written a note. They added that the NP M discontinued the order for Aranesp. An interview with the Director of Nursing (DON) was completed on 10/01/24 at approximately 2:55 PM. Regional Nurse Consultant was present during the interview. The DON was queried about the facility's process to ensure that that residents received the medications that were ordered by the physician upon admission/readmission. They reported that the admitting nurses reconciled the orders and unit managers followed up after to ensure that residents received their medications. If there was any missed medication that nurses notified the physician and followed up with their unit manager. The DON was queried if they were aware of R104 not receiving their Aranesp since 4/17/24 due insurance discrepancy and had hospitalization s due to low hemoglobin. They reported that they were unaware that they did not receive the medication in July over an extended period of time. The DON reported they understood the concern and the medication should have been ordered and administered and did not provide any further explanation. During an interview was completed with the administrator on 10/1/24 at approximately 2:35 PM. They were queried if they were aware of medication concerns for R104 from the resident and the family. The administrator reported that they had a meeting with R104 and their family and they recalled the conversation about the medication. When queried why R104 was not receiving the medication that was ordered for several months and was hospitalized multiple times and needed transfusions, the administrator reported that they were not clinical and they had to check with the clinical team. They were queried if the DON was part of their meeting and they were not sure. When queried about the insurance discrepancy/coverage that was reported by R104, evidenced by the documentation in the EMR, the administrator reported that they were not aware of any insurance concerns and they should be getting the medications as ordered by their physician. A review of the facility provided document titled Medication Administration with a revision of 12/19/19, read in part, It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURE: 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer and record medications. 2. Medications must be administered in accordance with the written orders of the ordering/prescribing physician. NOTE: If a dose seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current diagnosis or condition, the nurse should contact the physician. 3. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR) 12. Should a drug be withheld, refused, or given other than the scheduled time, the nurse must enter an explanatory note. NOTE: The Director of Nursing and attending Physician must be notified when two (2) doses of a medication are refused or withheld. 13. Medications ordered for a particular resident may not be administered to another resident .

This citation pertains to Intake Number(s): MI00142885, MI00142866, MI00142560, and MI00142461. Based on observation, interview, and record review, the facility failed to protect three (R810, R808, and R809) residents' rights to be free from physical and verbal abuse by staff and residents. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that a staff member (Certified Nursing Assistant - CNA 'E') slapped R810, it was observed by facility, and on camera. A review of a second complaint submitted to the State Agency revealed that R810 was assaulted by CNA 'E' while seated in a wheelchair. A review of a Facility Reported Incident (FRI) submitted to the State agency revealed it was reported that CNA 'E' physically abused R810 and it was witnessed by staff. On 5/7/24, an onsite investigation was initiated. On 5/7/24 at 12:28 PM, R810 was observed sleeping on her bed. R810 did not respond when name was called. A review of a police report dated 1/29/24 revealed they were dispatched to the facility on [DATE] at 3:23 PM for a report of assault. The police report documented, The caller stated that a worker at the facility assaulted a patient. The police report noted that the former Administrator of the facility (Administrator 'M') was interviewed by police. The following was documented, (Administrator 'M') advised that (Housekeeper 'F') .witnessed an assault today. (Housekeeper 'F') informed (Administrator 'M') that she saw an assault occur on the second floor in the hallway. (Administrator 'M') reviewed video footage and found the assault that (Housekeeper 'F') had witnessed . .The video shows (R810) sitting in her wheelchair in the hallway by herself. A care worker at the facility (CNA 'E') is seen walking from the bottom of the video screen towards (R810). As (CNA 'E') steps next to (R810's) wheelchair, (CNA 'E') attempts to grab (R810's) hand. (R810) flinches and recoils her hand backwards so that (CNA 'E') cannot grab it. (CNA 'E') then strikes (R810) in her mouth with her left hand. (CNA 'E's) hand was open when she struck (R810) . The police report included a summary of their interview with CNA 'E' which revealed CNA 'E' came to the police station with attorneys and the following was noted, .(CNA 'E') explained that there are some very combative patients at (facility name). (CNA 'E') said the resident listed as the victim in my report wasn't her patient and wasn't sure of her name .(CNA 'E') did know (R810) liked to wander and wasn't allowed out of her area because she was combative .Before the incident, (CNA 'E') said staff had told her (R810) couldn't be allowed on her floor/wing. Somehow, (CNA 'E') was alerted that (R810) was trying to leave her area. (CNA 'E') went to the back of (R810's) wheelchair to pull her away from door, but (R810) was too strong. Then (CNA 'E') tried to push the wheelchair, but (R810) started spitting. (CNA 'E') said (R810) spit on her hand and at her. (CNA 'E') described (R810) as 'carrying on.' Then (CNA 'E') demonstrated what appeared to be a swatting motion with her left hand. (CNA 'E') said her action was a knee-jerk reaction . .Summary between the video and (CNA 'E's) statement: (CNA 'E') stated that (R810) was 'carrying on' and was very strong. (CNA 'E') also stated she tried moving (R810) by pulling and pushing the wheelchair. The video showed that (CNA 'E') never tried pushing or pulling (R810's) wheelchair. (R810) smacks (CNA 'E's) hand when (CNA 'E') tries to grab her hand, but it doesn't do anything physically that is combative. I cannot tell if (R810) spit at (CNA 'E') when she is grabbing (R810's hand) .Status: Sent to (county prosecutor's office) to review for charges of Vulnerable Adult Abuse on (CNA 'E') . It was further documented in the police report that on 2/16/24, the county prosecutor issued Vulnerable Adult Abuse 4th Degree and Assault and Battery charges on CNA 'E'. On 2/29/24, CNA 'E' was arraigned at the court. A review of a Narrative Report written and signed by Housekeeper 'F' revealed, .I witnessed a nurse slap a elderly women <sic> in a wheelchair across her face. Onec <sic> the nurse notice I witnessed it she immediately ran over to me and started apologizing several times. I immediately walked over to the elderly patient and ask if she was ok. The patient shook her head no and started pointing at the nurse who slap her across her face . A review of the facility's investigation revealed a summary that documented Housekeeper 'F' reported on 1/29/24 that she witnessed CNA 'E' slap R810 in the face. It was noted that R810 could not be interviewed due to her cognitive status. The Administrator and Director of Nursing (DON) reviewed the video for that area and confirmed that the incident occurred. It was documented that abuse was substantiated. A review of a letter sent to CNA 'E' on 4/2/24 revealed the State Agency intended to revoke her nurse aide certificate due to the abuse allegation. A review of CNA 'E's personnel file revealed an Employee Termination Form dated 2/1/24 that documented, Reason for Termination .Abuse - Employee slapped a resident in the face . On 5/7/24 at 12:21 PM, a phone interview was attempted with Housekeeper 'F'. Housekeeper 'F' was not available for interview prior to the end of the survey. On 5/7/24 at approximately 10:00 AM, Human Resources (HR) Director 'A' reported CNA 'E's employment at the facility was terminated due to slapping a resident. On 5/7/24 at 12:40 PM, an interview was conducted with the current Administrator at the facility who is also the Abuse Coordinator. The Administrator did not work at the facility at the time of the physical abuse by CNA 'E' toward R810 and was not aware that is occurred. On 5/7/24 at 1:25 PM, a review of the video footage of the incident on 1/29/24 was conducted in the presence of the Administrator and the DON. In the video, CNA 'E' approached R810 who was seated in a wheelchair in the hallway. CNA 'E' attempted to grab R810's right hand and R810 swatted CNA 'E's hand away. Then CNA 'E' smacks R810 across the mouth using an open hand. A review of R810's clinical record revealed R810 was admitted into the facility on [DATE] with diagnoses that included: bipolar disorder, anxiety disorder, and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R810 had severely impaired cognition and exhibited physical and verbal behaviors and rejected care at times. 49083 R808 and R809 A review of a Facility Reported Incident (FRI) revealed an allegation of resident-to-resident physical abuse involving R808 (perpetrator) and R809 (victim) that occurred on 2/10/24 at 9:45 AM. On 5/8/24 a record review revealed R808 was admitted to the facility on [DATE] with diabetes, neuropathy (nerve damage affecting the hands and feet), heart disease, and chronic obstructive pulmonary disease (COPD). A Brief interview mental status (BIMS) score evaluated in February 2024 revealed a score of 15/15 indicating R808 was cognitively intact. Clinical record review of R809 revealed readmission to the facility on [DATE] with a diagnosis of diabetes, pancreatitis, bipolar, dementia, anxiety, dysphagia (difficulty swallowing), and a Percutaneous Endoscopic Gastrostomy (PEG) Tube (surgically placed tube into the stomach to deliver nutrition). A BIMS score evaluated in February 2024 revealed a score of 9/15 indicating R809 was moderately cognitively impaired. On 5/8/24 at 10:30 AM, R809 was interviewed and immediately referred to R808 as a hot head R809 recalled the event and stated he was in his wheelchair and R808 just came up and hit him in the back of the neck. R809 stated that it was a hard hit, did not result in any trauma, but it hurt at the time. R809 further stated that R808 announces R809 is not allowed in the activities room and tells him he is not welcome. On 5/8/24 at 10:40 AM, Licensed Practical Nurse (LPN) Q stated R809 frequently is hostile to other residents, swears, steals food from the delivery cart, from other residents' trays, and is not well liked by other residents. On 5/8/24 at 11:00 AM, R808 recalled the FRI and replied that he and R809 used to be roommates and never got along with each other. R808 stated they were separated and are on opposite ends of the building and that R809 frequently swears at other residents and is always stealing food off resident trays. R808 stated on the day of the incident, R809 was in his wheelchair blocking the pathway and R808 told him to move R808 responded fuck you at which time R809 acknowledged hitting R808 in the back of the head. On 5/8/24 at 2:51 PM, The Director of Nursing (DON) and Regional Nurse Consultant G indicated the statement made by LPN Q regarding R809 was new information, and the DON and G were unaware of the behaviors. The DON and G indicated the staff need to document such behaviors and will follow up with the staff. On 5/8/24 at 4:41 PM, An interview with staff witness to the incident Certified Nurse Assistant (CNA) R recalled walking towards the second-floor nutrition room and overheard R808 say move and R809 replied Fuck You CNA R walked towards the corner by the elevators and confirmed observation of R808 hitting R809 in the back of the head. A review of a facility policy titled, Abuse and Neglect, updated 3/24/23, revealed, in part, the following: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse .Abuse defined as the willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .

This citation pertains to intake: MI00143440. Based on observation, interviews, and record reviews the facility failed to ensure the facility staff consistently identified worsening of pressure wounds, accurately assessed/identified pressure wounds, and timely/accurately implemented treatment for pressure wounds for one (R803) of one resident reviewed for wound care, resulting in an infection to the left heel wound that required intravenous (IV) antibiotics. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of proper wound care for R803. On 5/8/24 at approximately 2:30 PM, R803 was observed lying on their back in bed sleeping. R803 was observed to have a pink tie-dyed shirt with a green comforter covering their lower body. R803 did not open their eyes to verbal stimuli and continued to sleep. Review of the medical record revealed R803 was initially admitted to the facility on [DATE] with a readmitted [DATE], with diagnoses that included: Chronic kidney disease (Stage 4), gastrostomy, epilepsy a neuromuscular dysfunction of bladder. Review of a Nursing Admission Screening/History dated 5/10/23 at 6:10 PM, documented no skin impairments. Review of an admission Nursing note documented in part . has L (left) posterior calf stage III (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole-rolled wound edges are often present. Slough and/or eschar may visible but does not obscure the depth of tissue loss) . measuring 9.0x1.5x0.2 . R (right) posterior calf stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) . measuring 2.3x0.7 . sacral stage IV . measuring 8.5x13.5.1.5 . Resident as fungal rash to mid back . Review of a Braden scale for predicting pressure sore risk dated 5/10/23, documented Very High Risk with a score of 9.0. Review of the physician orders on 10/5/23, documented a treatment for cleansing of the left heel with normal saline, then apply betadine gel to wound bed and pad with abd (abdominal dressing)/kerlix, three times a week and prn (as needed) was ordered, however a start date was not noted. Review of the medical record revealed no documentation of a wound identified to the left heel or the characteristics of the wound to the left heel. Review of a physician order, documented to cleanse left lateral heel with normal saline, then apply betadine gel onto wound bed, pad with abd/secure with kerlix, to be done three times a week and prn was ordered on 10/12/23 and started. This order was implemented a week after the initial physician's order on 10/5/23. Review of the progress notes documented the following in part: On 10/12/23 L heel DTI (deep tissue injury- Intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue). On 11/3/23 open area to left heel On 11/13/23 L heel DTI deteriorating with 100% eschar Review of the November 2023 Medication Administration Record (MAR)/ Treatment Administration Record (TAR) documented the following treatment: Betadine Eternal Solution, Apply to L heel topically every day shift for wound care cleanser with ns (normal saline), apply betadine-soaked gauze or ointment, cover with ABD (abdominal) and kerlix 3x week and PRN (as needed). This order was supposed to be applied on 11/4/23, however was not and documented as applied on 11/5 and 11/6/23 and not applied again on 11/7/23. Review of a Wound Consultation dated 11/9/23, documented the following in part . Lateral Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed . wound encounter measurements are 2.5cm (centimeters) length x 2.5cm width with no measurable depth, with an area of 6.25 sq (square) cm . The wound margin is undefined Wound bed has 76-100% eschar. The wound is deteriorating . Left, Lateral Heel . Wound Cleansing- Normal Saline, Primary Dressing- Medihoney/Manuka Honey, Secondary Dressing ABD pad, Kling/kerlix, Dressing Chage Frequency- PRN, 3x per week . Review of the physician orders and TAR/MARS for November 2023, revealed the treatment to the left heel did not start as directed by the wound clinician until 11/14/23, five days after the wound clinician changed the treatment. Review of a Wound Consultation note dated 12/7/23, documented the following in part, . Lateral Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed . wound encounter measurements are 4.5cm length x 3.4cm width, with an area of 15.3 sq cm. There was no drainage noted. The wound margin is undefined Wound bed has 76-100% eschar. The wound is stable . Review of the progress notes revealed R803 was transferred to the hospital on 12/8/23 for a PEG (Percutaneous Endoscopic Gastrostomy) tube replacement, however the resident was admitted to the hospital. Review of the hospital records revealed the following: Review of a surgical wound consultation dated 12/10/23 at 9:57 AM, documented the following in part, . She was found to have multiple wounds on nursing admission skin assessment . This patient is known to our service . wounds last evaluated by our service on 10/30/23 . was treated with . bilateral heel wounds with non-sting barrier wipes . Left heel. (Unstageable pressure injury- Full-thickness skin and tissue loss in which the extent of tissue damage withing the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar)- present on admission . Measurements: 6cm x 7.5cm. Unable to determine the wound depth. Base: Open, moist, tan/black necrotic base. Drainage: There is moderate creamy . The wound is malodorous (unpleasant offensive odor) . Right heel. (Deep tissue injury)- present on admission. Measurements: 2.5cm x 2.2cm. Unable to determine the wound depth. Base: Area of purple/black non-blanching intact skin . Xerotic (dry scaly appearance skin) surrounding skin with no erythema . Review of an Infectious Disease consultation dated 12/11/23 at 9:51 AM, documented in part . ABT (antibiotic) management, wounds/urine . Although all wounds show progression, L heel wound is most severe. It is unstageable, with necrotic base and malodorous discharge . Will do XR (x-ray) of L foot. Considering progression of wound and active drainage, suspecting osteomyelitis of calcaneus. Will likely start empiric treatment for osteomyelitis even if XR negative due to severity of wound . Limiting antibiotics prior to podiatry evaluation for possible L heel debridement is best to ensure proper deep wound cultures, However low threshold to restart antibiotics if clinically deteriorating . Review of a Podiatry Consultation dated 12/11/23, documented in part . Reason For Consultation: Infected left heel wound . It is a soft boggy eschar with malodorous serous drainage emanating from the periphery of this wound . A deep tissue injury is noted on the right heel. It is an area of purplish-black discolored skin that is nonblanchable. The skin is intact . On the posterior aspect of the left heel, there is a soft, boggy eschar formation noted. It is an unstageable pressure wound. It measures 5.6 cm x 7.5 cm. There is a malodorous serous drainage emanating from the periphery of this soft, boggy eschar formation . I applied 5% topical lidocaine anesthesia to this area x20 minutes. I then sharply excisionally debrided the necrotic, soft, boggy eschar formation in the posterior aspect of the left heel using a sterile #10 blade utilizing aseptic technique. An underlying stage IV pressure wound is noted. There was necrotic, slough tissue, and devitalized subcutaneous tissue at this area . the bone itself was soft. It is most likely infected . Post-excisional wound debridement measurements 5.9 cm x 7.5 cm deep to the level of the calcaneus bone . This indicated the facility staff and wound team failed to identify the worsening of R803's left heel wound and failed to identify the development of the right heel wound. The was no documentation of the facility staff to have informed R803's representative of the worsening of left heel wound or the development of the right heel wound. Review of the medical record documented R803 was readmitted to the facility on [DATE]. Review of the readmission nursing assessment dated [DATE] at 5:56 PM, documented in part . Decubitus ulcer of sacral region, decubitus ulcer of right leg, pressure injury right heel, decubitus ulcer of R&L (right and left) ischium . The assessment failed to identify the left heel wound. Review of the physician orders revealed no treatment implemented for the left or right wound heels until two days later on 12/20/23. Review of the December 2023 MAR/TAR documented the following in part, . Triad Hydrophillic Wound Dress External Paste (Wound Dressings) Apply to Bilat (bilateral) heels topically every shift for wound treatment. Cleanse with wound cleanser remove excessive residual Triad before application. Apply thick layer of Triad ointment to cover bilat heel wounds. Cover with dry flat 4x4 gauze and secure with kerlix and medipore tape . Started on 12/20/23. Review of a Wound Consultation dated 12/21/23, documented in part, . Left, Lateral Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed . wound encounter measurements are 6cm length x 6.5cm width, with an area of 39 sq cm. There was no drainage noted. The wound margin is undefined Wound bed has 76-100% eschar. The wound is stable . Orders . Cleansing- Normal Saline . Dressing- Medihoney/Manuka Honey . Secondary Dressing- ABD pad, Kling/kerlix . Frequency- PRN, 3x per week . The right heel wound was not identified or assessed. This indicated the Wound Consultation was not an accurate assessment as the left heel wound was diagnosed as a Stage IV wound at the hospital and review of the medical record revealed the resident was currently on Intravenous (IV) antibiotics for the left heel wound infection (for 38 days) at the facility. Review of the December 2023 MAR/TAR documented the treatment as directed by the wound clinician on 12/21/23 was not implemented as directed. Review of a Wound Consultation dated 12/28/23, documented in part . 12/28: Patient returned back to the facility after being discharged from the hospital . currently on IV ABX (antibiotics). New DTI noted to right heel . Left, Lateral Heel is a Deep Tissue Pressure Injury . 6.5 cm length x 6cm width, with no measurable depth, with an area of 39 sq cm. There is a Small amount of fresh blood drainage noted which ha no odor . 51-75% eschar . Right Heel is a Deep Tissue Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurement are 2.5cm length x 2.2cm width with no measurable depth, with an area of 5.5 sq cm . Wound Orders . Left, Lateral Heel . Wound Cleansing- Normal Saline, Primary Dressing- Medihoney/Manuka Honey, Secondary Dressing- ABD pad, Kling/kerlix . PRN, 3x per week . Right Heel . Wound Cleansing- Acetic Acid, Primary Dressing- Medihoney/Manuka Honey, Secondary Dressing- Bordered foam, Dressing Change Frequency- PRN, 3x per week . Review of the Physician orders, December 2023 MAR/TAR and January 2024 MAR/TAR documented did not implement the right and left heel wound orders as directed by the wound clinician. The previous Triad Hydrophillic Wound Dress External Paste order stayed implemented for both heels until it was discontinued on 1/4/24, two weeks after the order was originally changed by the wound clinician. Review of the January 2024 MAR/TAR revealed orders implemented on 1/6/24- Medihoney Gel to the right heel topically every Tuesday, Thursday, and Saturday. This was not wound order directed by the wound clinician. Further review revealed an order to the left hell for Medihoney every Tuesday, Thursday and Saturday implemented on 1/6/24, which is also not the exact order as directed by the wound physician. This order was discontinued on 1/17/24 and new orders was not implemented until 1/20/24 for both the left and right heels, resulting in no treatment to the heels for three days. Review of a Wound Consultation dated 2/1/24, documented a Unstageable Pressure Injury to the right heel. Review of a Wound Consultation dated 2/29/24, documented a . Transfer of Care . for the right and left heel wounds. Podiatrist that will be moving forward in managing patient's chronic wound. Wound care is signing off . No further wound assessments, consultations or follow-up care identified in the medical record. On 5/8/24 at 3:13 PM, the Director of Nursing (DON) and Wound Nurse (WN) O was asked to provide any documentation or consultation regarding R803's left and right heels from 2/29/24 when they were discharged from the wound consultant's services. Shortly after, WN O provided one consultation dated 3/11/24. Review of a . Foot Clinic & Wound Care Center consultation dated 3/11/24, documented in part . Bilateral heel wounds - please apply Santyl to the black, necrotic, fibrotic tissue. Change dressings daily. If there is excess drainage, change dressing twice per day. Her heels must be floating at all times. They are not to leave the offloading boots. While in bed keep a pillow under her calf just above the wound to float heels from bed. If skin gets macerated, apply betadine to this area prior to dressing. Follow up next week . No other consultations from this Foot and Wound clinic were provided by the DON or WN O and no further consultations were identified in the medical record. Review of the medical record revealed on 3/15/24 the resident was transferred to the hospital for decreased urine output and acute kidney injury. Review of a Medical ICU (Intensive Care Unit) consult dated 3/15/24, documented in part . Bilateral heel wounds with necrotic eschar and mucopurulent discharge . Review of a Podiatry consult dated 3/18/24, documented in part . A 10.0 cm x 8.0 cm stage IV pressure wound is noted on the posterior aspect of the left heel. A 6.5 cm x 4.0 cm stage IV pressure wound is noted on the posterior aspect of the right heel . Both wounds were tender to direct pressure as the patient did open her eyes when I was palpating the heel wounds and she was making facial gestures with pressure applied to both heels, even while being intubated . A soft, boggy, black eschar formation was noted on the posterior aspect of both heels . An extensive amount of malodorous purulent discharge was noted from the left heel stage IV pressure wound. Some serosanguineous drainage was noted from the right heel stage IV pressure wound . They both extended deep to bone and calcaneus bone was exposed on the posterior aspect of each of the heels. Clinically, each of these wounds were considered to be actively infected due to the exposed calcaneus bone as well as the purulence and [NAME] pus from the left heel wound . Review of the medical record revealed the resident was readmitted on [DATE]. Review of a Wound Consultation dated 4/16/24, documented a . Right Heel . Unstageable Pressure Injury . Which was not an accurate assessment as the wound was already staged at a stage IV during their hospitalization . On 5/8/24 at 11:34 AM, WN O was interviewed and asked the facility's process on the ordering and implementation of the wound clinician wound orders and WN O explained they had started employment with the facility in February 2024, however they explained that they would complete wound rounds with the wound clinician weekly. Once completed with the rounds or after the resident's assessment they would order and implement the resident wound orders as directed by the wound clinician. WN O was asked why the wound orders were not implemented timely and accurately and asked about the inconsistent wound assessments. WN O stated they would check into it and follow back up. On 5/8/24 at 3:13 PM, the Director of Nursing (DON) was also, asked why the facility staff failed to identify the worsening of R803's heel wounds, timely/accurately implement the orders as directed by the wound clinician, and accurately and consistently completed wound assessments. The DON explained the facility employed a different wound nurse until about December 2023, when the previous wound nurse resigned. The DON stated the facility had recently been undergoing a big transition. The DON stated they would look into it and follow back up. At 5:34 PM, the DON returned and stated the Facility's Quality and Assurance program had identified skin concerns at the facility. The DON was asked if they had identified any skin concerns with R803 and the DON showed that resident R803 was picked up on one of the skin audits, however the staff documented no concerns. The DON was then asked if they felt their skin audits were effective considering the audit/staff did not identify the concerns of the skin impairments with R803 and the DON stated the audits are a concern and is currently still ongoing. No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake #MI 835 Based on observation, interview and record review the facility failed to promptly identify skin concerns, timely implement preventative interventions for residents noted at high and very high risk for the development of pressure sores, timely report skin concerns to the physician and consistently perform treatments for three (R95, R114 and R393) out of four residents reviewed for pressure ulcers, resulting in the residents developing Stage IV, Stage III and Stage II pressure ulcer(s) at the facility. Findings include: Review of a complaint submitted to the State Agency (SA) documented allegations of the facility failing to provide adequate care to prevent and treat pressure wounds for resident R393. Review of a facility policy titled Skin Monitoring and Management- Pressure Ulcer, dated 7/11/2018 . A resident having pressure ulcer receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing . The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services . Assessment/evaluation should include but not be limited to . Measuring the wound . Staging the wound . Describing the nature of the wound . Describing the characteristics of the wound . R95 On 7/26/22 at approximately 11:12 AM, R95 was observed lying in bed receiving oxygen via a nasal cannula (tubing that consists of two prongs leading into the nostril and hooked around the ears). A non-labeled/dated piece of what appeared as gauze was observed behind the resident's left ear. R95 was alert and able to answer questions asked. R95 reported that he had been in the facility for about a month. When asked what was behind his left ear, R95 responded that he had a sore behind the ear. When asked if he had the sore when he entered the building, he stated that he did not. A review of R95's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (cognitively intact) and required extensive one to two person assist for most Activities of Daily Living. Continued review of R95's clinical record revealed, in part, the following: Braden Scale (4/4/22): Score of 10 (High Risk). An order detail note (7/8/22): Consult wound care to evaluate B/L (bilateral) Ear skin alterations. *There was no indication in R95's clinical record that there was a wound care evaluation to the B/L ear or order for treatment until 7/26/22 as seen below. Skin Alteration Evaluation: 7/26/22: Site: Left ear .Type: Pressure: Length: 2.0, Width 0.5 .Depth.4 .Stage III .Acquired: In-House Acquired. Order: Obtain foam ear protectors for nasal cannula (7/26/22). Review of R95's Care Plan documented, in part the following: Focus: The resident has oxygen therapy ineffective gas exchange .Interventions: Change out oxygen tubing every Thursday . Focus: Resident has actual stage III to sacrum (6/28/22) resident has stage III pressure injury to posterior L ear (7/26/22) .Interventions: *no interventions pertaining to the Stage III pressure injury to posterior L ear were noted in the resident's care plan. On 7/27/22 at approximately 11:51 AM, an interview was conducted with Wound Nurse EE. When asked about the facility acquired State III Pressure Wound to the Left ear, Nurse EE confirmed that it was acquired at the facility. When asked what interventions were put in place to protect R95 who was a high risk for Pressure Sores and was continuously wearing O2 tubing, Nurse EE stated that he started to complain that it was hurting and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse EE noted that any resident wearing oxygen tubing should wear ear protectors all the time but was not able to place orders. R114 On 7/26/22 at approximately 9:28 AM, R114 was observed lying in bed. The resident had severe contractions, dry cracked lips that appeared to have dried blood and while alert was not able to answer any questions asked. The resident appeared to be crying but could not explain why. Nurse O was interviewed and reported that the resident had just been changed and often gets upset following a brief change. A second observation of R114 was made on 7/26/22 at approximately 12:27PM. The resident was observed lying on her left side. No boots were observed on either the right or left foot. Review of R114's clinical record documented the resident was admitted to the facility (hereinafter facility #2) on 4/2/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's MDS noted the resident was severely cognitively impaired and required extensive one to two person assist for most ADL's. Continued review of the clinical record noted the resident resided at a sister facility (herein after facility #1) from 9/30/2021 to 4/1/22. A document titled, Discharge Instructions and accompanying documents provided by facility #1 revealed, in part: 1. Date of Discharge: 4/1/2022 .You are being discharged to the following location: Name of Location (Facility #2) . Order Summary Report: Active orders as of 3/31/2022: cleanse left lateral foot with normal saline, apply triple verbal antibiotic ointment and cover with dry dressing qday .Low air loss mattress to bed . Review of R114's clinical record following transfer to facility #2 documented the following: Braden Scale (4/4/22): Score of 8 (Very High Risk). Care Plan: Focus: Resident has unavoidable pressure ulcer status (4/4/2022): Interventions dated 4/4/2022: Encourage good nutrition and hydration in order to promote healthier skin (4/4/2022) .Observe skin daily with care activities. Report any changes in coloration, integrity etc. to nurse . *It should be noted that those were the only interventions put in place following the Braden Scale Score noted as Very High Risk. In addition, based on Discharge documentations from facility #1 that indicated R114 had a Low Air Loss Mattress, that intervention was not put into place upon entry to the facility. Further there was no documentation that noted that on 4/4/22, R114 had unavoidable pressure ulcer status. Documents provided by facility #1 noted that R114 had a stage II pressure ulcer on the left foot and right hip that had resolved. Continued review of R114's clinical record from documented as follows: Wound #1 Skin Observation Tool (4/26/22): L lateral foot DTI (deep tissue injury). An order dated 4/26/22 documented: Cleanse with [MEDICATION(S)] to wound bed. Cover with ABD, wrap with kerlix. Treatment QD and PRN R114's Treatment Administration Record (TAR) noted [MEDICATION(S)] Solution order to L. Lateral Food Wound was documented as given on 4/27, 4/28, 4/29, 4/30 (no treatment was documented as given on 5/1, 5/2, 5/3). An order dated 4/26/22 documented: bilateral soft heel protectors. An order dated 5/17/22 documented: Wound L Lateral foot DTI .Length .2.5 .Width .2.5 .Depth .2 .Clean with Dakin's .Apply Silver (Ag+) .Cover with ABD .Kerlix (D/C 6/14). Review of R114's TAR for the order noted above documented no treatment was done on 5/22, 5/23, 5/27, 6/3, 6/4, 6/11. A General Progress Note dated 5/31/22 (authored by Wound Nurse EE) noted: Nurse Practitioner AAA from wound care clinic is in to visit today. Resident has a L later foot Stage III . A document titled Pressure Ulcer Unavoidable evaluation (dated 6/7/22): Risk factors: 1. Terminally ill (blank/nothing checked). Two or more of the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Two or more of the following treatments (blank/nothing checked). 4. Lab Results 2.9 serum [MEDICATION(S)] (below 3.4) and Hgb Blood 8.1 below 12mg. A Wound Care Progress Note: (6/14/22) (authored by Wound Nurse EE) noted: L foot Stage IV . A Skin Observation Tool (6/23/22) noted: Resident has a L lateral foot stage IV measuring 2.0 x 1.5.Apply calcium alginate .cover with ABD, wrap with Kerlix. The order started 6/22/22 and per the TAR missing treatment was noted on 6/25, 6/27, 7/3 and 7/10. Wound #2 6/14/22 Default eMAR Note: Skin assessment .one time a day every Tue .Resident has a skin alteration noted to right hip . * No further information/descriptions as to skin alteration was found in the clinical record on 6/14/22 and 6/15/22. 6/16/22: General Progress Note (5:50 PM): Resident has a new injury to R hip. The Skin Observation Tool (6/16/22): has no note as to the R hip and addressed only the L foot stage IV. An order dated 6/16/22 documented: Xeroform Oil Emulsion Gauze Pad .apply to R hip topically every day shift for wound care .cleanse, pat dry. Apply 2-layer xeroform, cover with border foam. (D/C 6/28/22). The MAR/TAR was reviewed and noted that R114 did not start receiving the treatment until 6/17/22 and did not received treatment on 6/25/22 and 6/27/22. A General Progress Note (6/23/22): Resident has a L lateral foot stage IV .R has a L hip stage II .R has a UTD (unstageable) measuring 3.0x1.8x.1 . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Skin Alteration Evaluation (7/12/22) noted: Site: Right .hip .Type .Pressure .Length 3.5 .Width .4.5 .Stage IV .Acquired: In house .Unavoidable. A Skin Alteration Evaluation (7/22/22) noted .Site: Right .hip .Type .Pressure .Length 3.5 .Width 4.0 .Copious purulent drainage with odor . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound #3 Skin observation (6/23/22) R has L hip stage II measuring 3.0 x1.8 x.1 An order dated 6/21/22 read: Medi honey Dressing Gel .Apply to L hip wound with a D/C order 7/5/22. Review of the MAR/TAR noted the resident did not receive the treatment on 6/25/22 and 6/27/22. General Progress Note (6/28/22): .Nurse Practitioner from wound care clinic .Resident has L hip UTD (unstageable) measuring 2.5 x 3.0 . A second order dated 7/5/22 read: Medi honey Wound/Burn Dressing Gel . Apply to L hip wound with a D/C order of 7/12/22. Review of the MAR/TAR noted the resident did not receive treatment on 7/3/22 and 7/10/22. A Skin Alteration Evaluation dated 7/12/22 read: Site .Left Hip .Type Pressure .Length 2.0 .Width .Stage: Unstageable .In house Acquired. A Skin Alteration Evaluation dated 7/22/22 read: Site .Left Hip .Type Pressure . Length 2.0 .Width . Stage IV .In house Acquired .copious purulent drainage with odor .resident put on [MEDICATION(S)] .q 12 hours x 14 days .'. On 7/27/22 at approximately 11:53AM, R114's wounds were observed. Wound Nurse EE was present. The resident's low-air loss mattress was set at normal pressure (there were two options visible normal and low). No offloading devices were noted on the feet or R/L hip area. The left wound was half dollar in size, depth was noted (stage IV). A left foot wound below the pinky toe was dime size, pink in color and appeared to be healing. The right hip wound was the size of quarter, red and open with minimum depth. The resident was moaning in pain when the treatments were removed. On 7/28/22 at approximately 11:02 AM, an interview and record review were conducted with the Director of Nursing (DON) and Wound Nurse EE. When asked what interventions were put into place upon admission and following a [NAME] Score of High Risk, Wound Nurse EE reported that she was told per facility policy, low air loss mattresses are not provided to residents until a pressure ulcer has developed. When asked about R114's transfer from a sister facility #1 and interventions provided there, Wound Nurse EE was not aware of that information. When asked how it was determined on 4/4/22 (two days after admission) that R114 had unavoidable pressure ulcer status. Wound Nurse EE noted that she did not originally include that statement in the resident's Care Plan and could not give an explanation. When asked about the order for bilateral heel protectors. Wound Nurse EE reported that R114 likes to kick them off. Wound Nurse EE was asked to provide documentation that noted staff indicated the resident kicked them off and they were not being worn. When asked as to the delay in treatment pertaining to the 6/14/22 note that indicated discoloration to the Right hip, the DON reported that the Nurse who put the note in the system incorrectly and it was not seen by other staff until 6/16/22. When asked about the several missed treatments by Staff, the DON indicated they should be noted in the MAR/TAR. On 7/28/22 at approximately 2:21PM, a phone interview was conducted with Wound Doctor (WD) ZZ. WD ZZ was asked about interventions put into place for resident's, including R114, who enter the building with a Very High Risk [NAME] Score. WD ZZ noted that residents will receive a foam pressure reducing mattress and barrier cream. When asked about R114 not receiving an air loss mattress until 4/26/22, WD ZZ responded that to his knowledge insurance does not pay for the mattress until it has been determined that the resident has a pressure ulcer. WD ZZ was aware that the facility had some extra low air loss mattresses but noted that it often is a battle as to who gets the mattresses. When asked about the floating botties, WD ZZ reported that he remembered R114 as very contracted and needed the floating booties. When asked about R114 and documentation that indicated the wounds to the foot and hip(s) were unavoidable, WD ZZ reported that they determined the status based on lab results that indicated a low [MEDICATION(S)] rate and low Hgb level. WD ZZ noted that surprisingly the resident's protein rate was still very good. When told that the resident's electronic record indicated several mistreatments and asked whether that would alter the determination as unavoidable, WD ZZ reported he was not aware of any mistreatments and indicated that treatments ordered should be administered. R393 Review of the medical record revealed R393 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set assessment dated [DATE] documented severely impaired cognitive skills for daily decision making and required extensive staff assistance for all Activities of Daily Living (ADLs). Review of a readmission nursing assessment dated [DATE] at 3:45 PM, documented in part . SKIN . Scar on right top foot, BL (bilateral) LE (lower extremity) scattered discoloration, left arm [CONDITION(S)] +1, right hip open area, BL dry heels and buttocks 3 open areas . There was no measurements or wound characteristics documented. Review of a facility policy titled Skin Monitoring and Management- Pressure Ulcer, dated 7/11/2018 . A resident having pressure ulcer receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing . The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services . Assessment/evaluation should include but not be limited to . Measuring the wound . Staging the wound . Describing the nature of the wound . Describing the characteristics of the wound . Review of a May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was started on 5/21/2022. Review of the progress notes revealed no documentation of the physician being notified of the skin concerns identified on the admission body assessment and no documentation of the physician who ordered the Peri Guard Ointment. On 8/1/2022 at 2:03 PM, Registered Nurse (RN) T (the RN who admitted R393 on 5/20/22 and also serves as one of the facility's unit managers) was interview and asked if they informed the physician on the skin issues identified on the admission skin assessment for R393. RN T stated they did not inform the physician. When asked the name of the physician they obtained the order from for the Peri Guard Ointment for the open wounds identified on the right hip and buttocks, RN T stated they did not receive the order from a physician. When asked if they ordered the treatment without a physician consent, RN T admitted they ordered the ointment without the physician consent. When asked if that was the normal protocol in the facility to not inform the physician of identified skin assessment concerns and implement treatment without their approval, RN T did not reply. On 8/2/2022 at 8:55 AM, the Medical Director (MD) V (primary physician for R393 and the physician name used to input the order for the Peri guard ointment) was interviewed and asked if RN T notified them of R393's readmission skin assessment concerns on 5/20/22 and if they gave the order to start Peri guard ointment for the open wounds on the right hip and buttocks, MD V stated the nurse did not inform them of the skin concerns identified on the readmission assessment and they did not give the order for Peri guard to be started on open wounds. The Peri guard ointment continued until R393 was evaluated by Wound Nurse (WN) EE on 5/25/2022. Review of the WN EE note dated 5/25/22 at 3:28 PM, documented in part . Skin assessment completed on resident r/t (related to) reports of impaired skin integrity. Resident has a healed wound to R (right) buttock. Healed wound to right hip, dry scabbing . open abrasion on inner R thigh. Open abrasion inner L (left) leg. Open abrasion L rear shoulder. Multiple fluid filled blisters on BLE (bilateral lower extremities) and BUE (bilateral upper extremities). Fragile skin on L hip. Wound care NP (Nurse Practitioner) notified. Orders given . WN EE failed to document the measurements, staging and wound characteristics as documented in the facility's policy. Review of the May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - Apply dry dressing to R hip for protection, every day shift for protection, cleanse with NS (Normal Saline), pat dry, apply dry dressing (5/26/22). - Cleanse open abrasions to R inner thigh, L inner leg, and R rear shoulder with NS, pat dry. Apply dry dressing. Every day shift for wound care cleanse with NS, pat dry, apply dry dressing (5/26/22). - Protective dressing to R buttock every day shift for wound care cleanse with NS, pat dry, apply protective dressing (5/26/22). - Xeroform Oil Emulsion Gauze Pad, apply to L buttock topically every day shift for wound care cleanse with NS, pat dry, apply 2-layer xeroform. Cover with border foam (5/27/22). - Xeroform Oil Emulsion Gauze Pad, apply to L inner leg topically every day shift for wound care cleanse with NS, pat dry. Apply 2-layer xeroform. Cover with border gauze (5/27/22). - Xeroform Oil Emulsion Gauze Pad, Apply to L rear shoulder topically every day shift for wound care cleanse with NS, pat dry. Apply 2-layer xeroform. Cover with border gauze (5/27/22). - Xeroform Oil Emulsion Gauze Pad, Apply to R inner thigh topically every day shift for wound care cleanse with NS, pat dry. Apply 2-layer xeroform. Cover with border gauze (5/27/22). On 8/2/22 at approximately 10:30 AM, WN EE was interviewed and asked about the assessment on 5/25/2022. WN EE stated they assessed R393 because they were told R393's wife had concerns. WN EE then explained that a full body assessment was completed with the wife present. When asked WN EE stated they are not certified in Wound Care and have a license as a Licensed Practical Nurse (LPN). WN EE stated the wound physician did not consult with the resident and was unable to evaluate the resident due to the resident being transferred to the hospital on 5/27/2022. WN EE stated after their body assessment they called the Wound Nurse Practitioner to tell them of their findings and treatment was given to WN EE via telephone. Review of the progress notes documented the resident was transferred to the hospital on 5/27/2022 at 12:23 PM, for a change in condition. Review of ED (Emergency Department) to Hosp (Hospital)- Admission document dated 5/27/22, documented in part . Wound . 05/27/22 . Abrasion Distal; Right; Anterior Thigh . Left Axilla . Left Heel . Left; Anterior Thigh . Right Heel . Right; Anterior . right; Anterior Ankle . Left; Anterior Foot . Review of hospital wound consultation dated 5/28/2022 at 9:34 AM, documented in part . Reason for Consultation/Chief Complaint: Evaluation of the patient's multiple wounds . He was found on current RN (Registered Nurse) admission skin assessment to have multiple wounds . The patient is known to our Surgical Wound Care service. His stage 2 coccyx/left buttock wound and left heel DTI (Deep Tissue Injury) were last evaluated . on 5/9/2022. The coccyx/left buttock wound was noted to have been healed at that time. Outpatient wound care therapy is not known . Wound Care service, is now consulted to assess the patient's wounds . Sacrum . 9.5 cm (centimeters) x 7 cm x 0.3 cm . Wound base- Moist, pink/red base with full thickness tissue loss, extending down to subcutaneous tissue . Right hip . 1.5 cm x 4 cm . Unable to determine wound depth . The center of the wound with a dry brown eschar base . Left hip . 8 cm x 5 cm x 0.2 cm . red base with partial thickness tissue loss, extending down to dermis . Left posterior shoulder . 1.5 cm x 5 cm x 0.2 cm . pink base with partial thickness tissue loss, extending down to dermis . Left upper back . 2.2 cm x 2 cm. Unable to determine wound depth . Dry brown eschar base . Left anteromedial knee . 4.5 cm x 1.6 cm x 0.2 cm . pink base with partial thickness tissue loss, extending down to dermis . Xerotic skin along the bilateral legs and feet . Left lateral leg/ankle . 13 cm x 2 cm. Unable to determine wound depth . Intact non-blanchable maroon skin . Right anteromedial leg . 4.5 cm x 1.6 cm. Unable to determine wound depth . Intact non-blanchable maroon skin . Right medial ankle . 1.2 cm x 2 cm . Intact non-blanchable maroon skin . Right medial foot . 1.2 cm x 2 cm . Intact non-blanchable maroon skin . Right 1st MT (Metatarsal) head . 2 cm x 2 cm . Intact non-blanchable maroon skin . Left lateral leg . 13 cm x 2 cm . Intact non-blanchable skin . Left heel . 2.8 cm x 2 cm . Intact non-blanchable maroon skin . Right heel . 1 cm x 1.8 cm . Intact non-blanchable maroon/brown skin . Open stage 3 sacral pressure injury, Open unstageable right hip pressure injury, Open stage 2 left hip pressure injury, Open stage 2 left posterior shoulder pressure injury, Open unstageable left upper back pressure injury, Open stage 2 left anteromedial knee pressure injury. Left lateral leg/ankle DTI (Deep Tissue Injury), Right anteromedial leg DTI, Right lateral ankle DTI, Right lateral ankle DTI, Right lateral foot DTI, Right 1st MT head DTI, Right heel DTI, Left heel DTI . This assessment revealed the facility failed to identify multiple wounds at various stages.

Based on interview and record review, the facility failed to prevent a significant medication error for two (R393 and R135) of two residents reviewed for significant medication errors, resulting in R393 not receiving multiple doses of anti-[CONDITION(S)] medication and being hospitalized and R135 not receiving multiple doses of an antibiotic. Review of the medical record revealed R393 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognitive skill for daily decision making and required extensive staff assistance for all Activities of Daily Living (ADLs). Review of the April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The next dose documented as administered was on 4/15/22 and 4/18/22 both at 9 AM. All other doses were documented as not administered. Review of the progress notes documented the following: A Nursing note dated 4/13/2022 at 4:54 PM, . [MEDICATION(S)] Solution . Give 25 ml via PEG-Tube every 12 hours for [CONDITION(S)] on order . A Nursing note dated 4/14/2022 at 1:04 PM, . [MEDICATION(S)] Solution . Give 25 ml via PEG-Tube every 12 hours for [CONDITION(S)] on order . A Nursing note dated 4/18/2022 at 8:41 AM, . [MEDICATION(S)] Solution . Give 25 ml via PEG-Tube every 12 hours for [CONDITION(S)] pharmacy called, and need CII (Controlled medication) prescription, Dr. notify <sic> . Review of the census revealed R393 was transferred to the hospital on 4/18/2022 and readmitted back into the facility on [DATE]. Review of the May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Solution . ([MEDICATION(S)]) Give 25 ml via PEG-Tube every 12 hours for seizures The staff did not administer this on 5/11/22 or 5/12/22. Further review of the medical record revealed R393 was transferred to the hospital on 5/12/22 and readmitted back into the facility on [DATE]. Review of the hospital paperwork (dated 5/12/2022) provided to the facility upon readmission (on 5/20/2022), documented the Principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Solution . Give 250 mg via PEG-Tube two times a day for Seizures. Out of the 14 doses that should have been administered to the resident, only 9 doses were documented as administered. Further review of the progress notes revealed the following: A Nursing note dated 5/21/2022 at 12:12 PM, . [MEDICATION(S)] Solution . Give 250 mg via PEG-Tube two times a day for Seizures n/a (not applicable) awaiting on script . A Nursing note dated 5/23/2022 at 10:09 AM, . [MEDICATION(S)] Solution . pharmacy notified . A Nursing note dated 5/24/2022 at 8:49 AM, . [MEDICATION(S)] . Pharmacy notified . A Nursing note dated 5/25/2022 at 10:58 AM, . [MEDICATION(S)] . No CII form. MD (Medical Doctor) and pharmacy contacted . A Nursing note dated 5/26/2022 at 8:36 PM, documented in part . [MEDICATION(S)] . MED (medication) not available at this time . A Nursing note dated 5/27/2022 at 11:09 AM, documented in part . [MEDICATION(S)] . Med not available. Pharmacy contacted and will be in tonight's shipment . On 8/1/2022 at 12:20 PM, the Director of Nursing (DON) was interviewed and asked about the missed doses of [MEDICATION(S)] and how the medication was available for some nurses that signed the medication off as administered but not available for the other nurses documenting that the medication was unavailable. The DON stated they would look into it and follow up. At 2:59 PM, the DON and Assistant Director Of Nursing (ADON) B returned and ADON B stated they called the pharmacy and the pharmacy confirmed that [MEDICATION(S)] ([MEDICATION(S)]) was never delivered to the facility in April or in May until May 26th when two doses were delivered. It was clarified with the DON and ADON B that every nurse that signed in April and May 2022 that they administered the resident's [MEDICATION(S)] medication had indeed not administered it because it was not delivered from the pharmacy, both the DON and ADON B confirmed that as being accurate. When asked, the DON stated they were not aware that there were issues with obtaining R393's [MEDICATION(S)] medication until asked by the surveyor. The Nurse's note documented on 5/27/2022 confirmed the resident was sent to the hospital before the delivery was made by the pharmacy. R393 did not receive one dose of their [MEDICATION(S)] [CONDITION(S)] medication while admitted in the facility as prescribed by the physician. On 7/26/22 at approximately 10:39 AM, R135 was observed sitting in his wheelchair. His right foot was wrapped. The resident was alert and able to answer questions asked. R135 reported that he had been in the building for two weeks due to an infection in his right foot. R135 stated he was moved to his current room two days ago. The resident had a Peripherally Inserted Central Catheter (PICC) line. When asked about medication administration, R135 stated that he has not had his medication administered since Sunday (7/25/22) because the line was clogged and they were waiting for a PICC line specialist to unclog it. On 7/26/22 at approximately 3:23 PM, R135 was observed again in his room. When asked about his PICC line status, R135 reported that they still have not unclogged it. A review of the resident's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Use 500 mg Intravenously every 6 hours for antibiotic. A review of R135 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 7/19: (12:00 AM) 7/20: (6:00AM, 12:00PM, 6:00PM) 7/21: (12:00AM, 6:00AM) 7/26: (12:00AM, 6:00AM, 12:00PM) 7/28: (12:00AM, 6:00AM, 12:00PM, 6:00PM) 7/29: (12:00AM, 6:00AM) A general progress note dated 7/20/22 (9:42 AM): Writer contacted RN access about discontinue of current PICC .Awaiting ETA for RN . It should be noted that there was no indication as to the delay in response to replace the PICC line. R135 missed six doses of the ordered antibiotic. A general progress note dated 7/26/2022 (12:33 AM): .IV clogged, IV assess contacted . It should be noted that R135 missed an additional three doses of the ordered antibiotic. A progress note dated 7/28/2022 (2:42 AM): Pt Picc line clogged It should be noted that R135 missed six does of the ordered antibiotic. It should be noted that R135 missed an additional six doses of the ordered antibiotic. On 8/1/22 at approximately 10:45 AM, an interview was conducted with the Director of Nursing (DON) and Assistant DON B. When asked why there were so many missed administrations of R135's antibiotic through the PICC line and whether they were able to address the root cause as to why the line kept clogging. The DON noted that they were never contacted by any of the nursing staff and noted that staff was contacting the access RN (Registered Nurse -paid vender) for assistance. When asked if they were aware of delay in response by the access RN the DON noted again they were not aware. The DON stated that staff are aware that could contact her and/or the ADON B who were and stated that they were trained and able to assist with PICC line clogging and replacement. On 8/2/22 at approximately 8:53AM, the Medical Director was informed of the missed antibiotic administration due to possible PICC line clogging and/or replacement need. The Medical Director stated that there was no reason a resident should miss so many doses of an ordered antibiotic and staff could have contacted her directly. On 8/2/22 at approximately 1:46PM, a phone interview was conducted with Nurse WW. Nurse WW was assigned to R135 on 7/28/22. When asked about R135 and the failure to administer the resident's antibiotic through the PICC line, Nurse WW stated it was clogged and they needed to contact the access nurse. When asked if they responded to the contact, Nurse WW reported that they did not on her shift. When asked if she contacted the DON, Nurse WW stated that she did not. A facility policy titled, Catheter Insertion and Care (October 1, 2010) was reviewed and documented, in part, the following: Policy .Peripheral IV catheters will be inserted by Nurses with demonstrated competency in IV therapy . contracts with the call center to make arrangements for a .PICC line insertion .3. The Infusion Nursing Agency will contact the family nurse or physician in approximately one hour .* It should be noted that the document provided did not contained only 18/53 pages.

This citation pertains to Intake MI 868 Based on interview and record review, the facility failed to ensure documented details regarding a resident's hospital transfer for one (R701) of three residents reviewed for hospitalization , resulting in the delay of transportation to the hospital and essential health information not being conveyed to the emergency department for evaluation and continued treatment. Findings include: A complaint was filed with the State Agency that read in part, .ER (emergency room ) Doctor called me at 11:10 pm, stating that [R701], had been rushed in by the paramedic and was nonresponsive . She stated that they intubated him and upon attempting intubation they found a plastic bag in his airway. [Name of ER Doctor] stated that she was going to call the nursing home for more information . Review of the closed record revealed R701 was originally admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R701 had severely impaired cognition and required the extensive assistance of staff for all activities of daily living (ADL's). Review of R701's progress notes revealed a general note on 1/5/22 at 9:42 PM by Licensed Practical Nurse (LPN) B that read, sent pt (patient) out to hospital apon [sic] observation pt was having trouble breathing and hard to arouse. stats (oxygen in blood) were low and 911 was called. EMS (Emergency Medical Services) arrived stats still were low so pt was transferred to [Name of Local Hospital]. On 2/8/22 at 8:57 AM, LPN B was interviewed by phone and asked about R701 on 1/5/22. LPN B explained she had worked the midnight shift, 7:00 PM to 7:00 AM. She had just started her shift and was doing her rounds when she saw R701 having a difficult time breathing around 7:15 or 7:20 PM. LPN B continued that she had pulled R701 up in bed, but continued to breath hard and fast, so she called 911 and they took him to the hospital. When asked if she had any communication with the emergency department (ED), LPN B explained the doctor called from the ED and wanted to know R701's medication list and that she had pulled a plastic bag from his airway. Review of R701's record revealed no transfer or discharge form. On 2/8/22 at 12:46 PM, LPN F was interviewed and asked about transferring a resident to the hospital. LPN F explained there was a form in the computer charting record titled, eInteract Transfer Form that the nurse filled out when sending a resident to the hospital. On 2/8/22 at 12:49 PM, Registered Nurse H was interviewed and asked if there was a paper transfer form. RN H explained when transferring a resident to the hospital the only form was in the computer, the nurse filled it out and printed it along with the medication list and sent it with the resident. RN H continued that she usually sent the residents recent lab results also. Review of the EMS documentation by [Name of Local Fire Department] read in part, Dispatched for a . patient in respiratory distress, upon arrival . patient is lying in bed responding only to pain, staff on scene states patient normally talking, patient tested positive for Covid 3 days ago .transport delay at (facility) due to staff having no patient info (information), once info was obtained patient was transported priority 1 . On 2/8/22 at 5:25 PM, LPN B was interviewed by phone again and asked about a transfer form. LPN B explained she had not done a transfer form because the computer in the COVID-19 unit where R701 was did not print, so another nurse not on the COVID-19 unit had to print out something for EMS. On 2/9/22 at 8:03 AM, the Director of Nursing (DON) was interviewed and asked what documentation should be sent when transferring a resident to the hospital. The DON explained the nurse sending a resident should complete a transfer form and send it along with a medication list. When asked if there was any review of discharges, the DON explained in clinical meeting the discharges are gone over to make sure all the documentation is in the record. Review of a facility policy titled, Discharge or Transfer updated 1/28/20 read in part, .1. Transfer/Discharge: Emergency: a. Contact 911/EMS Transport; b. Contact primary physician; c. Complete transfer/discharge form and attach copies of: i. Face sheet, ii. Advance Directives, iii Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation pertains to intake #'s: MI 073, MI 279 & MI 624 Based on observation, interview, and record review, the facility failed to: consistently perform skin assessments, implement and perform pressure ulcer prevention interventions, ensure wound care consults were placed, ensure appropriate wound care treatments were ordered, and ensure attending physician/physician extenders were aware of their resident's skin status for four residents (R#'s 502, 504, 509, and 510), of six residents reviewed for pressure ulcers, resulting in the development of unstageable pressure ulcers and transfers to acute care facilities. Findings include: A review of a facility provided policy titled, Skin Monitoring and Management-Pressure ulcer) dated [DATE] was conducted and read, POLICY: It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives the necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing . R502 A complaint was filed with the State Agency (SA) that alleged R502 entered the facility on [DATE] for rehabilitation following a fall and noted the resident did not have any pressure sores upon entry. The Complainant alleged R502 acquired a pressure ulcer on her buttocks at the facility which became infected, and the resident was sent to (name redacted) Hospital on [DATE]. The Complainant reported that R502 expired at the hospital on [DATE]. A review of R502's hospital records revealed, in part the following: [DATE] .Disposition: Admission: Patient presented today from SNF (skilled nursing facility) in notably dehydrated state .On full exam multiple ulcers noted .including stage IV disease and obvious necrotic tissue. A surgical wound care consult notes documented, in part: .Patient has wound of sacral region as well a bilateral heels and right hip .Wound Sacrum measuring 10x10 cm (centimeters) Full thickness skin loss with depth indeterminable at this time secondary to necrotic slough tissue: Base: 100% necrotic slough .Drainage: scant serous drainage .Odor: Foul Assessment .Open unstageable (obscured full thickness tissue loss) sacral pressure injury. Suspected deep tissue injury to bilateral heel. Suspected deep tissue injury right posterior thigh .urinary incontinence. Fecal incontinence. Dementia. Pain .Recommendations: Sacrum - Dakin's dressing .turn q 2 hours with placing pillow between knees and ankles. Specialty mattress .Antibiotics . A review of R502's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] (moderately cognitively impaired) and required extensive two person assist for bed mobility and transfers. MDS Section M (skin conditions) revealed No to question A Resident has a pressure ulcer/injury .over bony prominence. A Nursing Admission Screening History ([DATE]) form, section L (skin) was reviewed and was blank on section 1. Note all skin issues and included a note skin is intact no notable skin issues. A Braden Scale for Predicting Pressure Sore Risk development ([DATE]) indicated a score of 18 (At Risk). [DATE]: General Progress Note: .CNA (certified nursing assistant) call for writer to see buttocks during pm care. Writer noted fluid filled blister to right buttock excoriation and redness to B/L buttocks. Barrier cream applied to buttock . A review of the Treatment Administration Record (TAR) from [DATE] through [DATE] revealed no skin treatments were administered to the resident. A review of the R502's Kardex/Task description did not indicate the resident's turning and repositioning needs. Review of the R502's Care Plan Initiated on [DATE] revealed: Resident has potential/actual impairment to skin integrity r/t (due to) impaired mobility: The interventions placed on [DATE] were as follows: Elevate heels off bed surface while at rest in bed. Encourage and assist resident to participate in mobility activities per additional plan of care. Use a draw sheet or lifting device to move resident. No further interventions were placed in the care plan until [DATE]. A review of Wound Care Nurse (WCN) Bs progress notes for R502 documented, in part as follows: [DATE]: Location: Right olecranon Category II skin tear . There was no mention of any further skin issues [DATE]: Skin: Location: Right elbow .Change/Impairment- intact heal category III skin tear . There was no mention of any further skin issues. [DATE]: Location: sacral. Type of skin Change/Impairment: stage III (full-thickness skin loss, slough or eschar may be visible) bridge pressure ulcer. Measurements 6 x4.5 cm. Current Treatment: [MEDICATION(S)] AG QD/PRN. Treatment Change(s): new. Additional Information: R502 assessed for possible impairment to the integumentary system .stage III pressure ulcer to sacral ulcer bridge together as one treatment and prevention in place for healing. It should be noted that no additional interventions were placed in the resident's care plan. The [MEDICATION(S)] order was not acknowledged or signed by the wound care physician. [DATE]: Location: sacral. Stage III. Measurement(s) 5X3Xcm .Current Treatments: [MEDICATION(S)] AG QD/PRN .Additional Information: R502 assessed for Stage III pressure ulcer to sacral ulcer wound healing well with wound bed 60% pink epithelium tissue 40% loose soft pale grey slough edges attach. WCN B added the following interventions to R502's care plan on [DATE]: Follow physician wound care director orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . It should be noted there was nothing in the electronic record that Wound Physician G had ordered any treatments and/or had seen the resident. [DATE]: Location: sacral. Type of Skin Change/Impairment: stage III pressure ulcer. Measurement(s) 3x2 5x 0.2cm .no treatment . in treatment at this time. [DATE]: Location: sacrum stage III pressure ulcer .Measurement(s): 5x4 cm .weekly assessments show signs of decline over the weekend . *It should be noted that the residents clinical record had four (4) Skin Observation Tool documents dated [DATE], [DATE] [DATE] and[DATE] and all observations noted that appearance of the resident's skin was normal and contained no notes pertaining to pressure ulcers. [DATE]: Location: sacrum. Type of Skin Change/Impairment: Stage III sacrum pressure ulcer. Measurements: 6x4 cm .Additional Information: R502 assessed [DATE] for failing stage III pressure ulcer. Wound bed 100% pale grey eschar light serious drainage signs of infection. Call place to (name redacted) Attending Physician L possible low dose of antibiotic to help possible infection of wound. It should be noted that there were no documents that indicated an antibiotic was ordered for the resident. Further there was no notes in the resident's electronic record that indicated Attending Physician was treating R502 for pressure ulcers or any further notes that R502 was seen and/or treated by a wound physician. On [DATE] at approximately 5:24 PM a phone interview was conducted with Primary Care Physician L regarding R502's wounds and possible notification with WCN B pertaining to an antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R504 On [DATE] at 1:33 PM, an interview was conducted with a family member regarding R504's stay in the facility. R504's family member reported R504 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. They said they were not able to visit R504 in the facility because of the COVID-19 pandemic. They further explained when R504 transferred from the facility to the hospital they were allowed to see them and were shocked to learn he had developed two unstageable pressure ulcers (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). They continued to explain R504 had previously been in an LTAC (Long-term acute care) facility and did not have any pressure ulcers when they transferred from the LTAC to the skilled nursing facility. A review of R504's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged to the hospital on [DATE]. R504's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R504's Minimum Data Set assessment dated [DATE] revealed R504 had severe cognitive impairment, was non-ambulatory, and required total assistance from one to two staff members for all activities of daily living. A review of R504's admission skin assessment dated [DATE] revealed their only skin impairment upon admission was redness to their sacrum. A review of R504's Braden Score (a score calculated to determine the risk for the development of pressure ulcers) upon admission was calculated as a 9, which indicated they were a Very High Risk for the development of pressure ulcers. R504's weekly skin assessments dated [DATE] and [DATE] were reviewed and both assessments documented R504 had no new alterations in skin integrity including open areas, tears, bruising, red areas, or rashes. Continued review of R504's record was conducted and revealed that on [DATE] wound care had been consulted and on [DATE] an order was placed by former Wound Care Nurse 'B' for Triad Hydrophilic Wound Dress Paste (a topical wound care cream/paste) to be applied topically in a thick layer for excoriation to their buttocks. A review of former Wound Care Nurse 'B's progress notes for R504's skin revealed the following: A note documented [DATE] that read, .Location: bilateral buttock. Type of Skin Change/Impairment: excoriation. Measurement(s): 8x6cm (centimeters). Description: .pink base expose epithelium <sic> tissue . A note documented [DATE] that read, .Location: bilateral buttock. Type of Skin Change/Impairment: excoriation. Measurement(s): 7.6x4cm .Description .:moist pink with new scar formation . A review of R504's Certified Nursing Assistant (CNA) Kardex (care guide) and tasks were conducted and did not include any directives that indicated R504 would need frequent turning and repositioning assistance. R504's care plans were reviewed and revealed there were no care planned interventions for turning and repositioning, and a specialty mattress had been added on [DATE], two days before their transfer to the hospital. A review of R504's emergency department hospital records was conducted on [DATE] and read, .Problem List .Pressure injury of back, unstageable. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Pressure injury of sacral region, unstageable. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 2:40 PM, the facility's Director of Nursing (DON) was asked to provide any wound care documentation and evidence R504 had been followed by Dr. 'G', the facility's wound care consultant physician. At 4:15 PM, the DON reported the only information in R504's clinical record about their skin was that R504 had excoriation to their buttocks. The DON further reported they had no documentation to show R504 had been followed by Dr. 'G'. R509 On [DATE] at 3:55 PM, a review of R509's clinical record was conducted and revealed R509 admitted to the facility on [DATE] and readmitted on [DATE]. R509's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R509's most recent MDS assessment upon re-admission to the facility revealed R509 had intact cognition, was non-ambulatory, and required extensive to total assistance from one to two staff members for transferring, bed mobility, dressing, toilet use, personal hygiene, and bathing. On [DATE] at 4:00 PM, R509 was observed in their bed. It was noted R509's bed had a low air mattress in place, however; the machine that pumped the air for alternating pressures was not on and functioning, and a light on the pump indicated it was in Standby mode. At that time, R509 was interviewed about the condition of their skin, and they reported they had a pressure ulcer to their buttocks. R509 was asked if staff assisted them to turn and re-position in bed and R509 stated, Not very often, a couple times a day maybe. R509 was then asked if staff assisted or encouraged them to turn during the overnight hours and shook their head no. A second review of R509's clinical record was conducted and revealed that since their re-admission to the facility on [DATE], R509's weekly skin assessments had only been documented as performed on [DATE] and [DATE]. R509's treatment administration records were reviewed and revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R509's CNA Kardex did not reveal any indication R509 was to be assisted with turning and repositioning. A review of R509's care plan was conducted and included an intervention for the low air loss mattress but did not have any interventions for turning and repositioning. On [DATE] at 9:25 AM, a second observation of R509's low air loss mattress pump was conducted, and it was observed the pump was not functioning and a light on the pump indicated it was on Standby mode. R510 On [DATE] at 9:45 AM, R510 was observed in their bed. At that time R510 was asked if they had any wounds and said they had a pressure ulcer on their right lateral malleolus (the bony projection of the ankle) and they went out of the facility to a wound care physician once a week. R510's permission was obtained to observe the dressing and when granted, an undated, occlusive, white dressing was in place on their ankle. The dressing was also observed to have shadowing on its exterior from wound exudate that had seeped into the absorbent part of the inside of the dressing. On [DATE] at approximately 10:00 AM, a review of R510's clinical record was conducted and revealed a re-admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R510's most recent MDS assessment revealed R510 had intact cognition. A review of R510's most recent wound care consult dated [DATE] from their outside wound care provider was conducted and revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R510's Treatment Administration Records (TAR's) was conducted and revealed R510's order for Santyl had been discontinued on [DATE]. It was further noted R510's TAR did not have the Santyl treatment documented as completed on [DATE], [DATE], and [DATE]. On [DATE] at 1:00 PM, an interview was conducted with WCN 'A' about R510's right lateral malleolus pressure ulcer. WCN 'A' said the facility's wound care Nurse Practitioner (NP) resolved R510's ankle wound when they rounded on [DATE]. On [DATE] at 1:05 PM, an observation of R510's right ankle was conducted with WCN 'A'. WCN 'A' observed the undated dressing with the shadowing of exudate. WCN 'A' removed the soiled dressing, and it was observed a small, approximately 1 cm (centimeter) x 1 cm x less than 1 cm round ulceration with a small amount of serous (yellowish) drainage was present on R510s right lateral malleolus. At that time, it was brought to WCN 'A's attention the outside wound care practitioner for R510 had ordered Santyl to be continued for two to three weeks after their [DATE] appointment. WCN 'A' said that upon the NP's recommendation, they discontinued the Santyl order after the NP rounded on [DATE]. When asked why an undated dressing was in place on [DATE] without an order, and after the NP resolved the wound, WCN 'A' said they did not know, but they would be looking into what happened. On [DATE] at approximately 2:30 PM an interview was conducted with the facility's Director of Nursing (DON). The DON reported that she had been employed by the facility for approximately four months. When asked about any further documents that might explain the acquired pressure ulcer for R502 and any possible wound physician notes, the DON explained that she had completed an audit of residents that had pressure sores and noted that there were some concerns with WCN B, and she was terminated. At the time of the interview, the DON did not express the specific concerns as to the termination of WCN B but noted she had moved offices and wound attempt to locate her notes and further documentation. A request for Wound Nurse B's personnel file was made. A review of WCN B personnel record revealed, in part, the following: Disciplinary Action Record .Describe the reason(s) disciplinary action . (name redacted) Nurse B was treating and writing treatment orders without a physician consent. The Director of Nursing audited the wound care resident's medical records and wound care log. It was identified that there were incorrect diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, incorrect document on facility acquired vs community acquired. The wound care log was reviewed with Wound Care MD. There were 32 wounds that Nurse B was treating without his knowledge. When reviewing the treatment orders for these residents it was identified that Nurse B put the orders under the primary care physician, NP (nurse practitioner) and PA (physician assistant) names. The MD/NP/PA were interviewed and stated that they were unaware of treatment orders being written in their names .Employee is suspended pending investigation .date [DATE] . A Reason for Termination form dated [DATE] documented, in part: (name redacted) was treating and prescribing medications to 32 wound care residents without physician consent .[DATE] . On [DATE] at approximately 11:15 AM a second interview was conducted with the DON and Corporate Nurse M. After asking for additional information pertaining to the 32 residents noted to have received treatment by WCN B, a document was provided that indicated the names of the residents that were treated by WCN B but were not seen by Doctor G. The DON reported that in an effort to determine the discrepancies they went through the wound log with Doctor G, and he noted that he had not seen the resident and would not have always approved the orders. The DON reported that she discovered that treatment orders for wounds were signed off by attending physicians or their extenders, but that was not the Policy of the facility. On [DATE] at approximately 1:45 PM a phone interview was conducted with Wound Care Physician G. When asked about R502 and other residents being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He noted that he found it strange he was only treating approximately eight residents for wounds at such a large facility, where he said he usually followed close to twenty. He was unaware of R502's wounds until [DATE] following an audit by the DON. When asked whether he would have implemented different treatments for R502 and other residents with wounds, he reported most likely he would have.

This citation pertains to Intake Number(s): MI 572. Based on observation, interview, and record review, the facility failed to ensure one (R912) of two residents reviewed for falls, had appropriate interventions in place to prevent falls. Findings include: A complaint was submitted to the State Agency that alleged the following: On Saturday May 29, 2021, around the time from 3:15 pm-3:45 pm, I received a call from the nurse stating (R912) fell and she sent her to the hospital. The nurse (Registered Nurse - RN D) told me that two aides, (Certified Nursing Assistant - CNA P and F) found her on the floor .She said that there was a wedge on one side of her and a pillow on the other side. We came to the conclusion that when (R912) coughed she may have fell off the bed on to the floor, which I have always feared. (R912) has spasms when she coughs, or sneezes and the staff knows that I also spoke to the DON (Director of Nursing) (Former DON Q) that day and she apologized and said that she will be getting her a bigger bed. She also stated that the material of the mattress is slippery .The reason why (R912) fell out of the bed is because her bed is small. She doesn't have enough room for them to turn or reposition her. When they moved her to another room last September, the bed she had was broken. When they replaced it, it was a smaller bed. I spoke to (DON Q), and at that time she said she would try but it has to be a justification for why she needs a bigger bed or bariatric bed. The only way to justify it would be if she fell . I told her that I want to prevent that from happening. Now, nine months later she has fallen. I have always said that because of her condition, the aides and nurses should be checking in on her a lot more often to make sure she's ok. It only takes a moment for something to happen and I'm afraid for her because she is nonverbal and immobile. I have been on Zoom with her plenty times and had to call on another phone to get them to help her because she coughed herself to the edge .It's unfortunate that my sister had to fall in order for them to get another bed. It could've been fatal, but it wasn't. I hope there will be some changes from now on and this could help someone else in the facility that may be a fall risk . On 11/3/21 at 10:37 AM, R912 was observed lying in a larger sized bariatric bed. R912 had a [CONDITION(S)] (a tube inserted into a surgically place hole in the windpipe to assist with breathing) and feeding tube, and a catheter. R912 did not respond when addressed. Review of R912's clinical record revealed R912 was admitted into the facility on [DATE] with diagnoses that included: chronic [CONDITION(S)] with [CONDITION(S)], dysphagia, [CONDITION(S)], [CONDITION(S)] status, contractures, type 2 diabetes mellitus, seizures, and [CONDITION(S)]. A Minimum Data Set (MDS) assessment dated [DATE] revealed R912 had severely impaired cognition and was totally dependent of staff for bed mobility and activities of daily living (ADLs). Review of incident and accident reports for R912 revealed the following: An incident report dated 5/29/21 that documented, Resident was observed on floor laying on her right side with pillow positioned under her elbow (next to bed) at 3:15 pm by nursing assistant during round .Patient unable to give description .42 inch mattress with bolsters due to uncontrolled spasms during coughing . On 11/3/21 at approximately 10:00 AM, RN D was interviewed via the telephone regarding R912's fall on 5/29/21. R912 reported she did not remember a lot of details because it was a long time ago, but R912 was found on the floor by the CNAs. When queried about how R912 fell , RN D stated, We think because when she coughs her whole body spasms and moves around in the bed which caused her to fall out. RN D reported R912 has a bigger bed with bolsters to prevent her from falling out. RN D reported R912 had a standard sized bed at the time of the fall but could not remember if she had a larger bed before. On 11/3/21 at 11:30 AM, the DON was interviewed regarding any changes in beds R912 had prior to her fall on 5/29/21. The DON reported she would look into it, but she did not work in the facility at the time of the fall. On 11/3/21 at 11:54 AM, CNA F was interviewed about R912's fall on 5/29/21. CNA F reported it occurred after 3:00 PM when she did final rounds waiting for the next shift to arrive. CNA F reported that herself and CNA P did a bed check and when they got to R912's room she was on the floor. CNA F stated, She has been known to spasm from coughing. Her whole body spasms. CNA F reported R912 had a standard bed at the time of the fall on 5/29/21 and it was at times difficult to position the resident in that size bed. R912 further reported that when R912 coughed, her legs would sometimes end up hanging over the edge of the bed. When queried about whether R912 ever had a larger bed, CNA F reported when R912 was in a different room she had a bigger bed and then was switched to a standard sized bed but was not sure why it was switched from the bigger bed. On 11/3/21 at 12:45 PM, and interview with Maintenance Assistant E was conducted. Maintenance Assistant E reported R912 was in a 42 inch bed when she was in room [room number redacted], then went to the hospital or had a room change and was placed in a 36 inch bed. Maintenance Assistant E reported DON Q said R912 did not need a 42 inch bed, but the CNAs were all in agreement that a bigger bed was needed for safety and ease of care. R912 was changed to a 42 inch bed after she fell on [DATE]. On 11/4/21 at approximately 2:30 PM, the DON was interviewed. When queried about where it would be documented if R912 had a special sized bed in the past and if there would be a care plan or assessment, the DON reported she did not work in the facility at that time and none of the current nurse managers did either. The DON reported she could ask the Administrator. On 11/4/21 at approximately 2:40 PM, the Administrator was interviewed. When queried about where it would be documented if R912 had a special sized bed in the past and if it would be in a care plan or assessment, the Administrator reported he would not know, and the current DON and nurse managers did not work in the facility at that time. On 11/4/21 at approximately 3:00 PM, Maintenance Director G was interviewed. When queried about any knowledge of R912's use of different sized beds, Maintenance Director G reported he recalled R912 was in a 42 inch bed previously and then when her room was changed she was placed in a regular bed. Maintenance Director G stated, Apparently she had strong coughing fits and fell out of bed and then required a 42 inch bed again.

This citation pertains to MI 065 and MI 238 and has three deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #145) of three residents reviewed for change of condition, resulting in multiple missed doses of IV (intravenous) antibiotics, deep vein [CONDITION(S)], pulmonary embolism, and hospital admission. Findings include: On 4/20/21 at 9:15 AM, R#145 was observed lying in bed. R#145 made eye contact but did not verbally respond when spoken to. Oxygen was infusing via nasal cannula and tube feeding formula was hung at R#145's bedside but was not infusing at that time. A review of R#145's clinical record revealed the following: R#145 was admitted into the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#145's resident census revealed the resident was transferred to the hospital on 10/9/20, 10/31/20, 11/13/20, 2/26/21, and 3/14/21. A Minimum Data Set (MDS) assessment dated [DATE] documented R#145 had severely impaired cognition, no behaviors, and was totally dependent on staff for bed mobility, transfers, and all activities of daily living. The MDS indicated R#145 received intravenous (IV) medications during the assessment period, required oxygen therapy, and received all nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube). A General Progress Note dated 10/16/20 at 5:24 PM documented, Resident arrived to facility via ambulance from [hospital name redacted]. Resident admitted to facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident currently being treated with IV ABT (antibiotics) . Midline (catheter tip is 3-8 inches long and inserted into the Antecubital - inner arm in front of the elbow - area and advanced into the peripheral veins - veins in the arms, legs, hands, or feet) noted to right upper arm. Dressing Clean dry and intact .NP (Nurse Practitioner) and Physician has been notified of resident arrival to facility . A Medical Practitioner Note dated 10/19/20 documented, .Pt returned from [hospital name redacted]. Pt sent out for unresponsiveness. Was found to have [CONDITION(S)] (blood infection) and started on IV antibiotics. Pt was evaluated by ID (infectious disease) and was determined to have enterococcus and coagulase negative staphylococcus aureus bacteremia (bacteria present in the blood). Started on [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medications) until 10/26. PICC was placed and patient deemed stable to return to SNF (skilled nursing facility) for LTC (long term care). A Medical Practitioner Note dated 10/22/20 documented, .Follow up .Nursing reports low grade fever this morning of 99.8 (degrees Fahrenheit - F). Pt on ABT for [CONDITION(S)] .Vitals appear stable at this time. Continue to monitor . A General Progress Note dated 10/22/20 at 10:43 AM documented, .Resident had temp. 99.8 (degrees F) @ 9am, PRN (as needed) Tylenol 650 mg administered, NP (Nurse Practitioner) made aware .New orders to get CBC (complete blood count), CMP (comprehensive metabolic panel) (laboratory tests) once a week x 3 weeks and vanco trough levels twice a week received and in place. A General Progress Note dated 10/23/20 at 6:49 AM documented, Resident in bed. IV ABT in progress .picc line intact. A General Progress Note dated 10/24/20 at 5:59 PM documented, Resident has right upper are <sic> is red, swollen and warm to touch around midline (PICC line) site. His arm is warm from the midline site down to his elbow. Np notified. Order given to send out a cbc and Also need venous Doppler (an ultrasound to check for circulation in the veins to detect any blockage). order placed stat (with no delay). A General Progress Note dated 10/24/20 at 6:09 PM documented, Order for venous Doppler to right upper arm called into [radiology company name redacted] .However Writer was informed that X-ray tech are gone for the day and wont be back in until 8am tomorrow morning. Np Notified awaiting response. A General Progress Note dated 10/24/20 at 7:49 PM documented, Writer informed RN (Registered Nurse) that stat cbc need to be done on resident, however. Writer got RN [RN name redacted] to come and attempt to draw blood. However after several attempts she was unable to draw blood due to [CONDITION(S)] noted I <sic> upper and lower extremities. Upon assessment of resident arm writer noted that residents midline is still in his arm but out of place. NP has been notified awaiting response. Endorsed to night nurse to follow up. A General Progress Note dated 10/24/20 at 8:03 PM documented, Received response from to have RN draw blood fro <sic> midline. However the RN that was assisting me she think it needs to come out and be replaced because its out of place. Awaiting response from NP. A General Progress Note dated 10/24/20 at 8:29 PM documented, NP gave order to have call access team to assess and repair/replace. Order endorsed to night nurse. A General Progress Note dated 10/25/20 at 12:03 PM documented, Venous ultrasound complete showing positive for DVT and 2 clots. MD and NP has been notified Order given to start [MEDICATION(S)] (an anticoagulant medication) 5mg twice a day. Also a follow up call was given to [radiology company] for ETA (estimated time of arrival) .going to reach out to the nurse for ETA. she will give a call back to the facility with ETA. A General Progress Note dated 10/25/20 at 12:26 PM documented, ETA for midline Nurse is 4pm. NP notified of ETA. order given to add all missed doses of ABT to the end. A General Progress Note dated 10/26/20 at 9:55 AM documented, [Physician and Nurse Practitioner names redacted] of pt's venous Doppler .Results: Conclusion: Acute RIGHT UPPER extremity DEEP venous [CONDITION(S)] involving the RIGHT mid Brachial vein. Acute RIGHT upper extremity SUPERFICIAL venous [CONDITION(S)] (SVT) involving the RIGHT cephalic vein . The Radiology Report dated 10/25/21 documented R#145 had a PICC line in right basilic vein (indicating that it had not yet been replaced). A Medical Practitioner Note dated 10/26/20 at 10:10 AM documented, Late Entry: Received phone call from nursing. Pt had new onset calor (warmth), [CONDITION(S)] (reddening), and swelling to RUE with associated midline catheter. Venous Doppler ordered and patient has new RUE (right upper extremity) DVT and SVT. Started on [MEDICATION(S)]. Midline ordered to be changed out. Pt missed several doses of ABT due to midline malfunction. Will add doses on to the end. [CONDITION(S)] better on exam. RUE appears better since midline came out. New midline present in left arm. Will continue [MEDICATION(S)] for 3-6 months. Vitals stable. Wound care following. Continue to monitor . ASSESSMENT 1. RUE DVT . (Note: R#145 first presented with swelling, redness, and warmth to the right upper extremity on 10/24/20). A General Progress Note dated 10/31/20 at 11:34 AM documented, Previous RN notified writer that pt had respiratory distress earlier today and was put on 3L (liters) O2 (oxygen) NC (nasal cannula). RN was making her rounds and found pt in respiratory distress. Pt appeared diaphoretic (heavily perspiring), labored breathing using accessory muscles, skin was purple and red in color. VS (vital signs) BP (blood pressure) 169/100 (high), HR 101 (elevated), RR (respiratory rate) 32 (normal rate is between 15 and 20 breaths per minute), Pulse Ox 89% 3LO2NC, left arm midline & Glucose 311 (elevated). Breathing txt (treatment) was administered & pt's Pulse Ox went up to 91%. Nonrebreather (a mask used to deliver oxygen in an emergency situation) placed. Notified [physician name redacted] (and) ordered RN to send pt to the Emergency Department. Notified Manager, DON . Hospital documents for R#145 from their 10/31/20 to 11/4/20 admission documented R#145's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medical Practitioner Note dated 11/9/20 documented, .PLAN .AC (anticoagulant) stopped in hospital as DVT was PICC line related. Continue SQ (subcutaneous) [MEDICATION(S)] for now . Further review of R#145's clinical record was conducted and revealed the following: There were no physicians orders for R#145's IV (Note: the progress notes written by nurses and the NP use the terms midline catheter and PICC line interchangeably despite being different types of IV catheters) between the time the resident was readmitted into the facility from the hospital on 10/16/20 and discharged to the hospital on 10/31/20. There were no care plans in place for care of R#145's IV between 10/16/20 and 10/31/20. An After Visit Summary from the hospital dated 10/31/21 documented, .Discharge Orders: .IV/PICC Care . On 4/23/21 at 12:05 PM, and interview was conducted with the DON. When queried about what should be in place for residents who were admitted into the facility with IV catheters, the DON reported there would be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time, the DON was asked to verify if there were any orders for R#145's IV, the care of R#145's IV, and if there was a care plan in place. The DON reported there were no orders for R#145's IV upon readmission into the facility on [DATE]. No additional information was provided prior to the end of the survey. A facility policy regarding midline catheters was requested. A document with instructions on how to perform a dressing change was received, but it did not include information about what was required for a resident with an IV. DPS #2: Based on observation, interview, and record review the facility failed to administer an intravenous (IV) antibiotic and/or [MEDICATION(S)] patch per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #116: A complaint was received by the State Agency which alleged R#116 had not been receiving an IV antibiotic medication as ordered. On 4/20/21 at approximately 3:20PM R#116 was observed seated upright to the side of the bed in the resident's room. The resident was queried in regard to their stay at the facility and explained that they had not been receiving their medication at a time prior. Review of the clinical record for R#116 revealed the resident was admitted to the facility 3/23/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a minimum data set (MDS) assessment for the resident dated 3/26/21 revealed the resident scored 15 out of 15 on a brief interview for mental status (BIMS) exam, which indicated the resident was cognitively intact. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of grievance form for R#116 dated 4/5/21 at 4:10PM documented, I'm fed up with the traumatizing care I receive in this facility. I have missed 3 doses of treatment since last night. Each time I've complaint <sic>, the administration has repeatedly assured me that things will be better. By the way, my orthopedist did not mistakenly write a prescription medication every 4 hours . On 4/22/21 at 12:22PM, the facility's Director of Nursing (DON) was queried in regard to R#116, and explained, in part, that she had write-ups for two different nurses. The DON explained this was related to one nurse who admitted being late with doses, and at the end of the shift was signing out multiple doses at once. The DON explained another nurse was written up related to late administration. Disciplinary action forms were then requested from the DON. Review of disciplinary education referenced above documented the following: Review of a DISCIPLINARY ACTION RECORD WORK RULES sheet dated 4/6/21 for Nurse 'OO' documented the following dates of infraction: 3-25, 3-26, 3-27, 3-28, 4-1, 4-4. The reason for disciplinary action was documented as follows: Falsifying or misrepresenting Records or making statements Known to be False to influence decisions made by company. -Signing meds out at end of Shift. Residents Stating the <sic> received meds late. Unable to verify times meds where <sic> passed based on documentation. The plan for improvement section documented, Touch patient then document. Employee comments documented, I know I need to get better. Review of R#116's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Due 3/24/21 at 9:00PM, documented as administered 3/25/21 at 12:44AM -Due 3/25/21 at 1:00AM, documented as administered 3/25/21 at 3:24AM -Due 3/26/21 at 1:00AM, documented as administered 3/26/21 at 5:04AM -Due 3/26/21 at 5:00AM, documented as administered 3/26/21 at 5:07AM -Due 3/27/21 at 1:00AM, documented as administered 3/27/21 at 5:26AM -Due 3/27/21 at 5:00AM, documented as administered 3/27/21 at 5:38AM -Due 3/28/21 at 9:00PM, documented as administered 3/28/21 at 11:49PM -Due 3/29/21 at 1:00AM, documented as administered 3/29/21 at 3:30AM -Due 3/31/21 at 9:00PM, documented as administered 4/1/21 at 1:56AM -Due 4/1/21 at 1:00AM, documented as administered 4/1/21 at 5:03AM -Due 4/1/21 at 9:00PM, documented as administered 4/1/21 at 10:57PM -Due 4/4/21 at 9:00PM, documented as administered 4/4/21 at 11:10PM Review of a DISCIPLINARY ACTION RECORD WORK RULES sheet signed on 4/2021 for Registered Nurse (RN) 'PP' documented the following reason for disciplinary action: FAILURE TO ADMINISTER IV ABX (antibiotics) WITHIN TIME FRAME ALLOWED. Review of the plan for improvement documented, TIME MANAGEMENT TO ASSURE IV ABX ARE ADMINISTERED WITH 1 HR (hour) BEFORE AND 1 HR AFTER TIME FRAME. Resident #29: On 4/20/21 the Medical record for R#29 was reviewed and revealed the following: R#29 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#29's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/5/21 revealed R#29 needed supervision for most of their activities of daily living. R#29's BIMS score (Brief interview of mental status) was 11 indicating moderately impaired cognition. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#29's March and April 2021 MAR (medication administration record) revealed R#29's [MEDICATION(S)] Patch was not available for administration on 3/25, 3/27, 3/28, 3/29, 3/30, 4/1 and 4/6. On 4/22/21 at approximately 9:20 a.m., R#29's medical record was reviewed with Unit Manager C (UM C) pertaining to R#29's [MEDICATION(S)] patches not being available for administration for consecutive days in a row. UM C indicated if a resident does not have their medication the pharmacy needs to be called for a drop ship of the medication which it can be delivered in two hours. UM C indicated that the nurses should have notified the pharmacy for the need of delivery of R#29's [MEDICATION(S)] patches and that the missed administrations could have been avoided had the nursing staff followed facility protocol. Resident #449: On 4/21/21 at 12:21 PM, a phone interview was conducted with the complainant that alleged R449 was not receiving medication as ordered and was concerned the facility were not properly monitoring the resident. Review of R449's hospital records at the time of admission into the facility included: .4/9/2020 .Covid Positive Stepdown from intensive care unit status post [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record revealed R449 admitted into the facility on [DATE] at 6:36 PM and discharged on [DATE] to the hospital per resident request and had not returned to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge return anticipated MDS assessment dated [DATE] documented R449 had intact short term memory with independent cognitive skills for daily decision making, had no behavior concerns, and was occasionally incontinent of bowel and bladder. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Ordered on 4/12/20: [MEDICATION(S)] (a blood pressure medication) Tablet 25 MG (milligrams) give 1 tablet by mouth two times a day for [CONDITION(S)] (hypertension). Ordered on 4/12/20: [MEDICATION(S)] (a blood pressure medication) Tablet 5 MG give 1 time a day for [CONDITION(S)]. There were no blood pressure parameters included for either of these medications to indicate when to hold this medication, or when to call the physician. This was not completed until the orders for both medications were revised on 4/17/20 which read, .hold for SBP (systolic blood pressure)<110; HR<60. Ordered 4/12/210 - 4/20/20: [MEDICATION(S)] Aerosol Powder Breath Activated 180 MCG (micrograms)/ACT (actuation) 1 puff inhale orally every 12 hours for wheezing. Review of R449's documentation for blood pressure and respirations including the vitals tab, progress notes and Medication Administration Records from 4/11/20 to 4/19/20 revealed multiple missed opportunities and blank entries. There were only five blood pressure results between 4/11-4/19/20 which documented: on 4/12/20 at 5:27 PM = 118/58; on 4/18/20 at 8:59 AM = 156/74; on 4/18/20 at 5:06 PM = 136/67; on 4/19/20 at 8:51 AM = 141/66; and on 4/19/20 at 4:17 PM = 123/64. There was no documentation as to whether the physician had been notified of the elevated result on 4/18. There was only one respiration result documented on 4/12/20 at 5:27 PM. There was only one respiration assessment completed on 4/16/20 at 3:26 PM. On 4/22/21 at 2:45 PM, an interview and record review was completed with the Director of Nursing (DON). When asked about the frequency of obtaining blood pressure and monitoring for the resident's respirations, the DON reported respirations should be obtained every shift and blood pressure should have parameters in place and depending on those, medication would be held, or the physician would be contacted. The DON was queried about why this had not been done, given the resident's status at the hospital just prior to admission and in accordance with acceptable standards of practice, the DON reported they were unable to offer any further explanation. The DON reviewed the available documentation and confirmed there was no further documentation available for review. Review of a facility policy with a subject Administration of Drugs dated 7/11/18 and revised 12/19/19 documented, in part, It is the policy of this facility that medications shall be administered as prescribed by the attending physician . DPS #3 Based on observation, interview and record review the facility failed to ensure consistent documentation of collaboration for hospice services for one resident (R#134) of two residents reviewed for hospice services, resulting in the potential for facility staff, the resident and/or family to be unaware of hospice visits and care they provided. Findings include: On 4/20/21 the medical record for R#134 was reviewed and revealed the following: R#134 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#134's MDS (Minimum Data Set) with an ARD (assessment reference date) of 4/1/21 revealed R#134 needed extensive assistance with most of their activities of daily living. R#134's BIMS score (brief interview of mental status) was 11 indicating moderately impaired cognition. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #134's Hospice provider] D/T (due to) [CONDITION(S)] . A review of R#134's careplan revealed the following: Resident has a terminal prognosis r/t (related to) her diagnosis. Resident will be assisted to feel comfortable with her dignity maintained .Intervention-Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met . On 4/21/21 at approximately 2:38 p.m., A Hospice collaboration log (a log for R#134's hospice provider to document what services were performed for R#134) was reviewed at the Nursing station with Social Worker NN (SW NN). The collaboration log revealed only one entry from the Hospice admission Nurse on 3/31/21. The rest of the collaboration log was blank with no further visits or provision of care being documented. SW NN indicated that the log should have been filled out for every visit and it was not being completed. SW NN reported there was no excuse for the lack of documentation and that they will have to call R#134's hospice provider to inform them that they needed to document the services that were being provided in the collaboration log. SW NN was queried if they could tell from the log what services had been provided from the hospice provider since 3/31/21 and they indicated they could not. On 04/21/21 at approximately 2:46 p.m., during a conversation with Unit Manager C (UM C), UM C was queried regarding the lack of documentation of hospice visits in R#134's hospice collaboration log. UM C indicated the hospice provider should have been documenting in the hospice collaboration log what they did for R#134 when they visited them. A facility document titled Hospice/Palliative Care was reviewed and revealed the following: It is the policy of this facility to administer hospice or palliative care, also known as comfort care, when medically appropriate for residents who wish to participate to such principle of care as ordered by the physician. Hospice/Palliative care is primarily directed at providing relief to a terminally ill patient through symptom management.

This citation pertains to intake #MI 418. Based on observation, interview and record review, the facility failed to provide consistent supervision, and ensure fall assessments were completed, and adequate interventions were implemented for three (R98, R101, and R451) of eight residents reviewed for accidents, resulting in residents sustaining multiple falls, some with injuries requiring medical treatment and the increased potential for serious harm and injury. Findings include: According to the facility's policy Fall dated 7/11/18, .Resident will not be moved until a nurse evaluates the resident's condition .Initiate neurological checks for any fall where a resident hit his/her head or for any unwitnessed fall .Notify the physician for further orders and follow instructions. (All falls must be reported to the physician) .Document all appropriate information in the medical record .If condition from fall is life threatening, the nurse shall initiate EMS (Emergency Medical Services) stat and then place a call to physician .A fall without injury is still a fall .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Resident #101: On 4/20/21 at 3:33 PM, R101 was observed seated in a gerichair recliner in a reclined position across from the second floor east nursing desk. R101 was observed to have two bandages to the forehead and the left knee was observed to have an open abrasion without any bandage. R101 was unable to participate in an interview due to significant cognitive limitations. Review of the clinical record revealed R101 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: multi-system degeneration of the autonomic nervous system, pain in left ankle and joints of left foot, [CONDITION(S)], dementia in other diseases classified elsewhere with behavioral disturbance, and [CONDITION(S)]. According to the Minimum Data Set (MDS) assessment dated [DATE], R101 had moderately impaired cognition with trouble concentrating, had no behavior concerns including no hallucinations or delusions, required extensive assist of one person for bed mobility, dressing, eating, toilet use, personal hygiene, required extensive assist of two plus persons for transfers, walking in room and corridor, used a walker and wheelchair, and had one fall since admission without injury. Review of the physician orders revealed R101 was prescribed [MEDICATION(S)] Tablet 5 MG (milligrams) by mouth two times a day for anticoagulant (a blood thinning medication). Additionally, R101 had been prescribed a onetime order for [MEDICATION(S)] ([MEDICATION(S)] - an antipsychotic medication) 12.5 MG by mouth one time only for Combative behavior for 1 day (received on 4/7/21 at 3:56 PM). Review of the progress notes revealed R101 had 12 fall occurrences between 3/3/21 and 4/22/21. Documentation for these falls included: On 3/3/21 at 7:35 AM, .found on floor next to bed - no injury - bilateral bed mats ordered, and scoot bed ordered , bed low to floor . On 3/5/21 at 7:39 AM, the Interdisciplinary Team (IDT) recommended scoop mattress, floor mats and for R101 to be up in the chair during waking hours for closer supervision. On 3/8/21 at 6:45 (no am/pm noted), .resident lying on right side of bed .offered toileting after meals . On 3/9/21 at 12:49 PM, the IDT recommended R101 be placed in lounge for closer supervision and activities. On 3/10/21 at 12:02 PM, .res (resident) observed on floor mat at bedside around 11:30 am .morning care provided res placed in w/c (wheelchair), closed <sic> monitoring is in place - will provide a low bed and require resident to be up for meals each day . There was no IDT follow up documentation provided for review following this fall. R101 was sent to the hospital on 3/15/21 due to difficulty breathing/change in condition and returned to the facility on [DATE] at 4:00 PM. On 3/19/21 4:58 AM, .assigned aide called nurse to room at 12:19 AM - res observed on floor on top of the floor mat lying on right site <sic> - no injury - resident has a baseline confusion and can't state reasons for fall On 3/19/21 at 2:57 PM, (Name of Assistant Administrator/AA 'O') upon walking into the 2W dining lounge he saw resident stand up from his w/c and asked res to sit back down for safety - res then sat back in chair - (Name of AA 'O') started speaking to another res in the same room and saw R101 in corner of his eye tipping forward out of his chair - res was on his hand and knees and did not hit his head .Per residents daughter resident at home rocks back and forth so he can stand up from w/c . The IDT follow up documentation to these two falls on 3/19/21 at 6:24 noted a recent dose reduction to an antidepressant medication on 3/16/21 and also that R101 had increased impulsivity and was awaiting psych evaluation and therapy to evaluate for proper wheelchair as the resident may need a high-backed wheelchair. R101 was sent to the hospital on 3/19/21 due to unresponsiveness with short periods of apnea and returned to the facility on [DATE]. On 3/22/21 at 6:48 PM, .The patient also became anxious and began to get out of the bed .the patient was required to sit at nursing station for one on one monitoring for the rest of the shift. On 3/24/21 at 7:48 PM, Nurse Practitioner (NP 'Q') documented, .Pt c/o (complained of) severe constant left ankle pain since last night after hitting his ankle on the wheelchair .ordered left ankle XR (x-ray) to r/o (rule out) fx (fracture) . There was no documentation of any investigation into the resident hitting their ankle on the wheelchair provided by the end of the survey. On 3/25/21 at 4:37 PM, .pt was observed in the dining room on the floor crawling on the floor .pt was assisted to a standing position and put back into the wheelchair . On 3/25/21 at 6:23 PM, the IDT review of this fall included staff to remain in the dining room when R101 was present and to have therapy evaluate the wheelchair (already an identified intervention on 3/19/21). Review of the post fall documentation provided by the facility also identified, Falls in past 90 days and/or since admission: 4 .Root Cause (s) and Contributing Factors as determined by IDT: impulsive, in dining room without staff present .Was this fall preventable? Yes .how could fall have been prevented? staff to not leave unattended in dining room .What changes do we need to make when caring for resident to prevent him/her from experiencing the same type of fall? staff to not leave unattended in dining room .What action(s) does leadership need to take to decrease reoccurrence at system level, i.e., was there a task, judgement, communication, and/or system error that requires further review? staff to not leave unattended in dining room . On 4/4/21 at 6:39 PM, .res was observed on floor by activity worker in dining room . Review of the post fall documentation on 4/6/21 at 9:44 AM for the fall on 4/4/21 documented, Falls in past 90 days and/or since admission: 6 .Root Cause (s) and Contributing Factors as determined by IDT: Impulsive due to disease process attempts to self-transfer/ambulate without cognitive and/or strength to do so safely .What changes do we need to make when caring for resident to prevent him/her from experiencing the same type of fall? Staff to reach out to family for phone conversation when resident becomes anxious/impulsive .What action(s) does leadership need to take to decrease reoccurrence at system level, i.e., was there a task, judgement, communication, and/or system error that requires further review? Additional monitoring when possible . On 4/7/21 at 3:32 PM, Registered Nurse (RN 'S') noted they had contacted NP 'Q' regarding R101's combative behavior and anxiety, but there was no details of what these behaviors were, or any circumstances. According to the Medication Administration Record (MAR), R101 received this medication on 4/7/21 at 3:56 PM. On 4/7/21 at 9:40 PM, an entry from Licensed Practical Nurse (LPN 'T') documented, Resident was observed on the floor lying on the left side of his face in a pool of blood. upper lip broken and tooth appear chipped .Doctor and DON contacted without response. 911 called and resident will be taken to the hospital in suspicion of trauma to the head . On 4/7/21 at 11:37 PM, an entry from LPN 'T' documented, .Writer was called to room (number redacted) at around (9:00 PM) and resident was observed on the floor lying on the left side of his face in a pool of blood. Upper lip broken and tooth appear chipped .Resident was a little lethargic, Doctor and DON contacted without response. 911 called and resident will be taken to the hospital on suspicion of trauma to the head and internal bleeding because patient is on blood thinner .EMS (Emergency Medical Services) with disapproval, that writer shouldn't have sent the resident out to the hospital and that she could make the writer's life miserable if this happens next time, this is not an emergency' - she said. I called both you and the DON without response and had to do what is best for the resident and not business. No supervisor on the floor, I was concerned about head trauma and internal bleeding because resident is on blood thinner . R101 returned to the facility on [DATE] around 2:00 AM. Review of the post fall documentation on 4/8/21 at 9:00 AM for the fall on 4/7/21 at 9:00 PM documented, Falls in past 90 days and/or since admission: 7 .Root Cause (s) and Contributing Factors as determined by IDT: attempted to self transfer from bed, impulsive with poor cognition .What changes do we need to make when caring for resident to prevent him/her from experiencing the same type of fall? 15 minute monitoring until psych evaluates medication with concern for recent GDR . On 4/8/21 at 2:12 PM, NP 'Q' documented, .Nursing staff called yesterday afternoon reporting that pt was being defiant and combative. Nursing staff reported that she was concerned that resident was going to fall. Verbal order given for psych consult and [MEDICATION(S)] 12.5 mg PO x 1 for chronic dementia w/ behaviors. Per nursing documentation, it was noted that pt had a fall on last night and was sent to the ED. Pt returned last night w/ no new orders. Pt seen and examined today. Pt reports wellbeing and is w/o (without)complaint .Diagnosis/Status/Plan .Acute lip laceration s/p fall .Lip laceration noted. No other injury noted during full body exam . There was no identification of the onetime antipsychotic medication as a potential contribution to the fall in the post fall documentation on 4/8/21. On 4/13/21 at 7:24 PM, .while passing medication at around 1150 am the activity aide told the writer that the patient was on the floor. writer went into the room to find pt sitting on his bottom on the floor on the side his of bed. writer left pt in the same spot on the floor, writer went to get help from another cena to help get pt in bed. and when I walked in room the pt was already put back in the bed by his aide writer notified ADON and the daughter of pt fall . There was no documented IDT follow up to review interventions to prevent future occurrences for this fall. On 4/15/21 at 5:33 PM, .Writer was called into patient room and observed patient on floor on knees in front of room door. Geri chair at end of pt bed .Skin tear observed to left knee .Care plan updated . On 4/22/21 at 9:59 AM, an entry indicated R101 was to move to another room on the second floor. On 4/22/21 at 8:44 PM, an entry (not identified as a late entry) by Registered Nurse (RN 'I') documented, Writer entered lounge and saw pt. laying face down next to Geri-chair. Pt. was assessed .Writer noticed two abrasions noted to forehead. Unit manager notified. There was no documentation provided that this fall incident had been documented when it occurred (4/21/21 before dinner), been investigated, whether the physician had been notified, or that neurochecks had been initiated to monitor for changes or risks due to R101 being on blood thinning medication. On 4/21/2021 at 5:58 PM, an entry from NP 'Q' documented, .Staff and other residents reports a fall on last night .Diagnosis/Status/Plan .Acute forehead abrasion s/p (status post) fall- labile - no injury noted on full body exam. [MEDICATION(S)] to forehead BID (twice a day) x 7 days Review of the treatment administration records revealed the first documented wound care had not been provided until 4/22/21 at 12:03 PM. On 4/23/21 at 10:29 AM, an interview was conducted with the Director of Nursing (DON) to review R101's falls. When asked what the facility's process was to review falls, the DON reported the IDT usually meet the next morning and also completed a QAPI (Quality Assurance Performance Improvement) form to discuss what to do for interventions and update the care plan. The DON indicated the post fall assessments would be located under the assessments tab and the QAPI form was not available but would look into whether that could be provided for review. When asked about the therapy documentation, the DON reviewed the surveyors access and reported those were not available and could print what was needed. The DON was asked about the lack of supervision as identified during the post fall documentation, acknowledged similar concerns, and reported that the facility was working on hiring more staff, but was limited at times. When asked about the fall noted on 4/22/21 by RN 'I', the DON reported that they had found out about R101's fall from 4/21/21 only last night from another resident. The DON further reported that when RN 'I' was asked about it, they had reported they had seen the resident following the fall and picked up R101 themselves and had only implemented a behavior care plan that the DON reported had since been discontinued. The DON reported RN 'I' had not completed an incident report, notify the physician, or initiated any neurocheck monitoring. The DON also indicated the entry read as if there was a fall on 4/22, but RN 'I' should have indicated it had been a late entry. On 4/23/21 at 10:45 AM, an interview was conducted with RN 'I' who was currently assigned to the facility's first floor. When asked about R101's fall incident on 4/21/21 and what had been done following the fall, RN 'I' reported, It was on afternoon before dinner. I was his nurse. I walked in the lounge. (R101) was face down and had two abrasions on forehead. When asked if the gerichair was in a reclined position, or if the leg rest had been positioned down, RN 'I' reported they were not able to recall the positioning but did state, He was lying next to it on the side. When asked what was done following that, RN 'I' reported, I notified Unit Manager (UM 'C') and saw there was a care plan for behavior where he lays on floor. When asked if there were any neurochecks initiated given R101 received blood thinning medication, and whether the physician had been contacted, RN 'I' reported they had not and offered no further explanation. On 4/23/21 at 11:16 AM, the DON provided additional IDT-INTERDISCIPLINARY POST FALL FOLLOW UP V2 and reported the days the resident had multiple falls, they were not able to print both follow ups. The DON reported these documents were done when IDT reviewed the falls which usually occurred the next day unless it was over a weekend. The DON reported they had tried 15 minute monitoring for R101 but due to staffing challenges that was difficult and there were not many other interventions left to try. The DON reported the neurocheck forms were maintained in the miscellaneous tab and were scanned in by medical records. The DON confirmed there were only 2 neurocheck documents on 3/10 and 3/19. There were no other neurochecks documented following any of the other fall occurrences. The DON was queried as to whether the one time antipsychotic medication that had been ordered on 4/7/21 may have contributed to the fall on 4/7/21 and the DON reported that had been a consideration as well but confirmed documentation did not reflect that. When asked about how and/or when R101 was provided with a gerichair recliner, instead of high backed wheelchair as suggested in one of the post fall recommendations, the DON reported therapy was responsible for evaluating resident's chair needs. The DON was unable to offer any further explanation into R101's falls. There was no additional documentation provided by the end of the survey. On 4/23/21 at 1:08 PM, an interview was conducted with the Director of Therapy (Staff 'N'). Staff 'N' was asked about R101's therapy needs and reported R101 was last discharged from therapy on 4/16/21 and at that time was assessed as safe to use a high-backed wheelchair with elevating leg rests and was able to self-propel around the unit. When asked about the gerichair recliner, Staff 'N' reported they were not notified of the resident's fall from 4/20 until yesterday (4/22) and had put their eyes on him and would be doing another evaluation today for appropriateness of the gerichair. When asked how the resident who was last assessed as being able to self-propel from a high-backed wheelchair was able to maneuver a gerichair recliner, Staff 'N' offered no response. Staff 'N' was unable to verify when R101 had been provided with the gerichair recliner but reported sometimes nurses would provide them and would be going to assess R101 to see if in correct chair today. Resident #98: On 4/20/21 at 3:02 PM, R#98 was observed in bed awake. R#98 appeared anxious and restless, was mumbling softly, was holding onto pillows, and trying to throw her legs over the side of the bed attempting to climb out. An over the bed table was observed on the other side of the room, not within reach of the resident. R#98 pointed to the cup placed on the table and softly spoke about not wanting to be alone. R#98's call light was not within reach of the resident. At that time, Certified Nursing Assistant (CNA) BB brought a fresh cup of water and placed it on the overbed table across the room from the resident. The straw was inserted into the cup and the straw wrapper was intact covering the top portion of the straw. On 4/20/21 at 4:00 PM, R#98 was observed in bed, pointed at the water cup, was mumbling softly, and appeared restless. On 4/20/21 at 4:45 PM, R#98 continued to appear restless and reached toward the water and was attempting to shift her body in the bed. At that time, CNA Z who was identified as R#98's assigned CNA, was interviewed. When queried about the placement of R#98's water and the resident's restlessness, CNA Z nervously answered that he was pulled to work on that hallway and did not know much about the residents. CNA Z began moving R#98's bed up and down with the remote and stated, What do you want me to do? When queried about whether R#98 was able to reach the water, CNA Z said he did not know. When queried about whether R#98 should be left in the room when restless, CNA Z reported he did not know. When queried about where the CNAs would look to find out about a resident's care, CNA Z reported he did not know. When queried about who the assigned nurse was, CNA Z reported he did not know. At that time, Registered Nurse (RN) AA was interviewed. RN AA reported she was R#98's assigned nurse. When queried about R#98, RN AA reported the resident was a fall risk and required one to one assistance with eating and drinking. When queried about R#98's restless behavior, RN AA reported she would look into it. R#98's clinical record was reviewed and revealed the following: R#98 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: [CONDITION(S)], chronic obstructive pulmonary disease, Moderate protein calorie malnutrition, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], dysphagia, and dementia. A MDS assessment dated [DATE] documented R#98 signed onto hospice services, was severely cognitively impaired, had no behaviors, and required extensive assistance with bed mobility, transfers, and eating. The MDS documented R#98 had two or more falls with no injury. Incident Reports for R#98 were reviewed since their admitted [DATE]. Between the dates of 11/13/20 and 4/1/20, R#98 fell 21 times as follows: 1. On 11/15/20 at 12:11 PM, R#98 was observed on the floor. It was documented R#98 had a low bed and a fall mat on the right side of the bed, there were no witnesses, and the resident was ambulating without assistance. 2. On 11/15/20 at 5:52 PM (approximately 5 hours after the previous fall), R#98 was observed on the floor with her legs crossed. It was documented the activities department was to provide additional one to one (1:1), R#98 was alert and not oriented to person, place, or time, there were no witnesses, R#98 had a low bed and a fall mat on the left side of the bed (the previous incident report documented a fall mat on the right side of the bed). It was documented R#98 was ambulating without assistance. 3. On 11/16/20 at 3:12 PM the activities coordinator heard R#98 fall in her room. R#98 was found sitting on the padded floor next to the bed. It was documented R#98 had a low bed and a fall mat to the right side of the bed. The floor mat was removed, and R#98 was placed on 15 minute monitoring for three days. It was documented R#98 was ambulating without assistance. 4. On 11/30/20 at 3:00 PM, a Certified Nursing Assistant (CNA) observed R#98 on the floor on their knees. 5. On 12/1/20 at 2:20PM, R#98 was observed seated on her buttocks with her hands on the side near doorway to room. It was documented there was a fall mat on the right side of the low bed. 6. On 12/2/20 at 2:55 PM R#98 was observed by staff lowering herself to the ground to sit on the floor. It was documented R#98's call light was not on, she was wearing non-skid socks, and was standing at the dresser yelling at staff about wanting to be on the floor. 7. On 12/8/20 at 5:39pm, R#98 was observed on her left knee in her room and sustained a skin tear to left knee noted with blood. R#98 reported she was trying to pick something up from the floor. 8. On 12/15/20 at 4:38 PM, R#98 was found by the doorway to her room seated on her buttocks on the floor. R#98 reported she was trying to go to the bathroom. 9. On 12/16/20 at 2:21 PM, R#98 was observed easing herself from the low bed to the floor and crawling on the floor. 10. On 12/20/20 at 5:42 PM, R#98 was observed leaning down in wheelchair reaching for something on the ground and slid out of the wheelchair and landed on her knees. Dycem seat grip was documented as an intervention to be added to R#98's wheelchair when she was up out of bed. 11. On 12/23/20 at 11:46 PM, it was documented R#98 was agitated and combative at the beginning of the shift and was placed in bed at 11:15 PM. The incident report documented, While dr. was called for possible medications, few minutes later resident slide out of the bed to the floor .resident is confused . 12. On 12/26/20 at 1:15 PM, R#98 was observed on the floor mat in her room. 13. On 1/3/21 at 2:30 PM, it was documented R#98 was in a wheelchair in the hallway. It was documented, around 2:30 resident was observed lying on her back on the floor in front of nurse station .redness noted at middle nose . Interventions documented, .psych consult and continue current fall risk care plan. Facility to initiate many room changes to open rooms to provide a quieter environment with less stimulation for this resident .resident to move downstairs . It was documented that R#98 sustained a bruise to the face and Staff heard a loud noise and observed resident's w/c tilted to the left and resident on the floor on her back on hallway floor. 14. On 1/6/21 at 5:27 PM, R#98 was observed sleeping on the floor mattress during medication pass. It was documented R#98 preferred to sleep on floor mattresses at times. 15. On 1/12/21 at 5:53 PM, R#98 was observed lying on the floor on her back with her head still on bed. 16. On 2/1/21 at 8:20 PM, the following was documented, writer walked into residents room at 9:10 pm to administer HS (bedtimes) medications. while in room resident was lying across the bed, blood noted on the floor, bump noted on left upper eye with blood noted around swollen left eye .unable to state reasons for falls . 17. On 2/3/21 at 7:43 PM, R#98 was observed on the floor mattress by her bed by the floor nurse. It was documented R#98's head was on the frame of the bed side table, that R#98 was seen by the CNA 15 minutes before the fall while passing meal trays, and R#98 was unable to state what happened. It was documented R#98 sustained a laceration above her right eye that was bleeding. Interventions documented were a scoop mattress and R#98 was to be in view of staff at nursing station during mealtimes. 18. On 2/12/21 at 7:37 PM, R#98 was observed seated on the bathroom floor. It was noted that R#98 was checked on by the CNA 15 to 20 minutes prior to the fall and R#98 was in bed resting. It was documented that R#98 was to be kept in view of staff during waking hours . 19. On 2/22/21 at 12:27 PM, R#98 was observed on the side of the bed on the floor mat on her knees and reported she was trying to get out of bed. Interventions documented R#98 was to be taken to the bathroom after lunch and kept in view of staff during waking hours. 20. On 2/24/21 at 6:00 PM, R#98 was observed on the floor by her bed facing the door .It was documented R#98 was to receive one on one supervision when awake to be done by nurses and CNA by 30 min rotation and Q (every) 10 minute rounds while asleep . 21. On 4/1/21 at 6:30 PM, R#98 was observed by the CNA with her knees on the floor with her head and arms on the bed. It was documented R#98 sustained a small laceration above right eyebrow and was observed sleeping in bed 15 minutes prior to incident. R#98 was unable to give a description of the incident. It was documented R#98 was currently under direct observation and staff should attempt to wake prior to dinner and in view of staff . On 4/21/21 at 3:30 PM, R#98 was observed seated in a geriatric chair at the nurses station with a staff member. At 4:23 PM, R#98 was observed seated at the nurses station with a staff member watching a television show on a tablet. On 4/22/21 at 9:45 AM, an interview was conducted with the Director of Nursing (DON). When queried about what was in place for R#98 due to the history of 21 falls, the DON stated, (R#98) should always be at the nursing station in a gerichair when awake and staff is required to check on her constantly to ensure she is not awake and alone in her room. Observations from 4/20/21 were shared with the DON. The DON reported R#98 should not have been left in the room alone, especially if she was awake and the staff who entered her room should have intervened. When queried about where interventions were documented, the DON reported on the care plan and Kardex. A review of R#98's care plans was conducted, and the following was revealed: A care plan initiated on 11/14/20 and revised on 2/11/21 documented, (R#98) is at risk for falls r/t (related to) dementia, psychoactive medication use, poor safety awareness and balance impairments. Resident has multiple falls secondary to her impulsive behavior . An intervention initiated on 12/1/20 documented, Anticipate and meet resident's needs by checking patient every 15 mins. An intervention initiated on 11/4/20 documented, Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition. A care plan initiated on 4/1/21 documented, (R#98) has had an actual multiple falls r/t Unsteady gait, [CONDITION(S)] and increase anxiety (sundowners episodes). An intervention initiated on 4/1/21 documented, Attempt to wake prior to dinner. Place in common area. An intervention initiated on 1/6/21 documented, In view of staff during waking hours. An intervention initiated 2/24/21 documented, 15 min rounds while asleep. An intervention initiated 2/22/21 documented, Toilet after lunch and keep in view of staff during waking hours. Resident #451 On 4/20/21 at 11:20 AM, R451 was observed dressed and sitting on the side of the bed. Fall mats were observed folded and standing up against the wall next to the left side of the bed, on the right side, fall mats were observed folded and pushed to the far side of the room. R451 was asked if the fall mats were ever placed next to the bed. R451 appeared confused and explained the mats were not comfortable to sit on, then began to talk about an unrelated topic. Review of the clinical record revealed R451 was admitted into the facility on [DATE] with diagnoses that included: anxiety disorder, vascular dementia, and [CONDITION(S)]. According to the MDS assessment dated [DATE], R451 scored 99 on the BIMS exam, indicating severely impaired cognition. The MDS also indicated R451 required the assistance of staff for all ADL's. Review of R451's fall care plan initiated 4/15/21 revealed an intervention that read, Neuro-checks for post fall. Place resident in a low bed with bilateral floor mat [sic] while in bed. Review of an I&A for R451 revealed on 4/14/21 Resident was seen lying naked and sleeping on the floor. In the action taken it read, .Place resident in a low bed with bilateral floor mats while in bed. Frequent monitor and follow safety precautions. On 4/21/21 at 8:16 AM, 4/21/21 at 1:54 PM, 4/22/21 at 8:05 AM, R451 was observed either sitting on the side of the bed or lying in the bed with the fall mats noted to be in the exact same position folded against the wall and folded pushed to the side of the room. On 4/22/21 at 9:29 AM, the DON was interviewed and asked about R451's fall mats. The DON explained they should be on the floor next to the bed anytime R451 was in bed. The DON was informed of the observation of the fall mats in the same position since 4/20/21. The DON had no explanation.

This citation pertains to intake(s): MI 536, MI 689, MI 981, MI 533, MI 535, MI 864 & MI 981. Based on interview and record review, the facility failed to consistently complete weekly skin assessments, identify and report worsening of a wound, implement timely treatments and/or consistently complete treatments, consistently turn and reposition and maintain an effective wound vac for six residents (R#'s 909, 913, 916, 918, 919 & 935) of seven residents reviewed for pressure ulcers, resulting in the worsening of wounds (R#'s 909, 913, 916, 918 & 919) , a defective wound vac (R#935), resident (R#916) that entered the facility with no pressure ulcers, to have developed a stage III (within 42 days of admission) and for R#918 who required hospitalization and surgical debridement for an infected necrotic sacral ulcer (that developed within 4 days from the facility first identifying the wound). Findings include: R#918 On 10/29/20 at 11:55 am, an interview with the complainant revealed the following in part, . they didn't notice that he had a sore on his bottom . the wounds are badly infected . his wounds is still really bad . the facility kept saying they were understaffed . A review of the clinical record revealed the following: R#918 was admitted into the facility on [DATE] with a readmission date of [DATE] and [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented long- and short-term memory problems and required staff assistance for all Activities of Daily Living (ADL's). A late entry documented on 6/6/20 at 8:10 am with the effective date of 5/24/20 at 8:09 am documented in part, . CNA (Certified Nursing Assistant) reported open area of resident coccyx area to writer, assess area noted open pink base with discoloration area noted, (doctor name redacted) notified and orders rec'd (received) for [MEDICATION NAME] gel daily and prn (as needed) . Another late entry with a created date: 5/29/20 at 1:21 pm, with an Effective Date: 5/23/20 at 4:12 pm completed eight days prior to the 6/6/20 note, documented the same findings as the 6/6/20 note. The Treatment Administration Record (TAR) documented [MEDICATION NAME] wound treatment start date as May 24th at 7 pm. This entry was crossed out by the writer. Review of the weekly skin assessments revealed the following: 5/2/20 Appearance of skin- normal, temperature of skin- warm, skin turgor- normal, Patient has NEW alteration in skin integrity? Including open areas of any type, bruising, red areas, rashes, etc.- No. Further review revealed no documentation of alterations in skin integrity noted for this assessment. 5/9/20 Appearance of skin- normal, temperature of skin- warm, skin turgor- normal, Patient has NEW alteration in skin integrity? Including open areas of any type, bruising, red areas, rashes, etc.- Yes. Right 5th toe digit - open area, mushy heels. The facility failed to complete 5/16/20 & 5/23/20 Weekly skin assessments. A care plan titled The resident has st (stage) 4 pressure ulcer to sacrum r/t (related to) Immobility this care plan was Initiated and Created on 6/3/20, 10 days after being identified by the facility staff. The clinical record was reviewed and revealed no documentation or interventions implemented by the facility's Interdisciplinary Team (IDT). A wound consultation dated 5/26/20, documented the wound physician assessing the resident's right heel, right 5th toe and left ankle. The coccyx was not assessed at this consultation, indicating staff failed to notify the wound doctor of the resident's coccyx wound. The clinical record was reviewed and there was no documentation found of notification to the wound doctor until the initial consultation on 6/9/20. The facility failed to have the resident's coccyx wound assessed in a timely manner. A review of the Bed Mobility (turning and positioning) documentation sheets revealed the facility failed to complete the tasks on the following shifts: April 2020: Night shift- 2nd, 3rd, 6th, 9th & 10th, Evening shift- 13th, 17th and 24th, Day shift- 18th and 26th. May 2020: Night shift- 6th, 10th, Evening shift- 4th, 5th, 14th, 18th, 19th, 21st, 27th, 28th, Day shift- 13th, 22nd, 27th. On 5/28/20 a transfer form was completed to send the resident to the hospital for alerted <sic> mental status. The transfer form documentation failed to identify and inform the hospital staff of the resident's coccyx wound at the time of the transfer. A Debridement of Sacral Decubitus Ulcer - Operative Note dated 6/2/20 at 9:19 am documented in part, . Left sacral decubitus ulcer, stage 4 . Left sacral wound debridement . Findings: Left sacral decubitus ulcer, stage 4, 10 cm x 7 cm x 4 cm (L x W x D) . A hospital discharge summary dated 6/2/20 at 2:41 pm, documented in part . Date of admission 5/28/20, Date of Discharge 6/2/20. Discharge Final Diagnosis: [REDACTED]. Patient had debridement of the sacral decubitus ulcer by general surgery . infectious disease who recommended Vanco (antibiotic) and [MEDICATION NAME] (antibiotic) for minimum of 3 to 4 weeks . On 10/29/20 at 12:39 pm the Director of Nursing (DON) was queried on the missing skin assessments, shower sheets, delay in identifying pressure ulcer, delay in identifying worsening of wound, delay in wound assessment by the wound physician, delayed implementation of sacral/coccyx care plan and why the IDT (risk management, dietician etc.) failed to implement further interventions for R#918. The DON requested time to look into the questions. At 1:13 pm, the DON stated the facility identified major concerns with wounds and implemented a wound nurse who is now consistently assessing the wounds, showers are back on scheduled board, skin assessments are being completed during showers and the facility completed extensive additional education and training with their staff. The DON stated that the concerns have been discussed at their QAPI (Quality Assurance Performance Improvement) meetings and the facility have identified a huge improvement overall. The DON confirmed the facility could not provide any additional information or documentation for R#918 regarding the facility's deficient practices for the resident's wound. On 10/29/20 at 2:17 pm, the Wound Care Coordinator (WCC) G was queried regarding the concerns noted for R#918's wound and stated they were recently hired and was not employed by the facility during the time of the resident's care. On 11/10/20 at 10:42 am, Licensed Practical Nurse (LPN) P, the nurse that documented the late entry that first identified the resident's wound was queried on their late entries, why a wound consult was not completed after identifying the wound and LPN P replied that they didn't remember why the late entry was documented twice on two different days and why the wound consult was not completed for the wound doctor to assess on 5/26/20. When asked, who they notified of the resident's wound, LPN P stated in part, . I notified (unit manager D name redacted) the unit manager . On 11/10/20 at 11:35 am, Unit Manager (UM) D was queried on being notified by LPN P regarding the resident's coccyx/sacral wound and UM D replied that they were not notified by LPN P of the residents wound when it was first identified. R#913 On 10/29/20 at 8:52 am, a phone call interview with the complainant revealed the following in part, . she was septic from an ulcerated wound and had to be put on hospice . Review of the medical record revealed the following: R#913 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] documented a BIMS score of 15 (indicating intact cognition) and was dependent on staff for all ADL's. A Nursing Admission Screening/History dated 6/24/20 documented in part, . Skin, Sacrum, Pressure . the nurse failed to document the length, width, depth, and stage of the pressure ulcer. A review of the preadmission paperwork from the discharging hospital revealed the following (dated 6/24/20), . Instructions . Sacral wound: Allevyn silicone boarded foam dressing. Cleanse wound with normal saline, keep area clean and dry. Reposition patient every 2 hours . The admission (June 2020) Treatment Administration Record (TAR) revealed the following order in part, . Sacrum wound care every day and night shift, Cleanse with NS (normal saline). Pack wet to dry dressing cover with DD (dry dressing) This order was not the recommended order documented on the hospital discharge paperwork for the resident's sacrum wound, however this order was documented on the resident's discharge paperwork as the recommended treatment for [REDACTED]. A review of the clinical record revealed no weekly skin assessments documented on the resident's sacrum wound. The facility failed to complete two weekly skin assessments for this resident. A Wound Consultation dated 6/30/20 documented in part, . Initial consult . coccyx wound, 7.5 x 6.5, neurotic, unstageable . Santyl to coccyx QD (every day) . A Wound Consultation dated 7/7/20 documented in part, . Coccyx ulcer, 8.0 x 7.5 . A review of the clinical record revealed no identification from the facility staff of worsening of the wound or notification to the physician of the wound worsening. On 7/9/20 at 10:27 am, a nursing note documented the resident being transferred to the hospital for a blood transfusion. The clinical record was reviewed and the last vital set (temperature, heart rate, blood pressure, respiration, and oxygen saturation levels) were taken on 7/8/20. There were no documented vital signs for 7/9/20. A review of the hospital records for 7/9/20 admission revealed the following in part, . Pt (patient) brought in by EMS (Emergency Medical Services) . rapid heart rate. Pt was initially sent in by facility for low hgb (hemoglobin) and need for transfusion. However, on ems arrival pt. found to have hr (heart rate) between 120's to 140's. Pt awake but confused . An Infectious Diseases consultation note dated 7/13/20 at 8:06 am documented in part, . Labs notable for leukocytosis (increase in the number of white cells in the blood, especially during an infection) of 22.8K (normal 4.5-11.0K) . A hospital discharge summary documented in part, . admitted for a fib (an irregular, often rapid heart rate)/fever. Found to have bacteremia (bacterial infection that has spread to the bloodstream), thought to be from wound. Id (Infectious Disease) consulted. No abt (antibiotics) per family request as goal of comfort. Was in A fib, initially [MEDICATION NAME], d/c (discharge) on oral meds. D/c home with hospice . On 10/28/20 at 12:34 pm, the DON was queried regarding the facility not following the hospital discharge instructions for the Sacral/Coccyx wound, the lack of weekly skin assessments, and the failure of the facility to identify and report the worsening of the wound to the wound physician. The DON stated they would look into it. At 4:13 pm, the DON returned and confirmed findings and stated the facility could not provide any additional information or documentation. R#919 A complaint was submitted to the State Agency regarding the worsening in the resident's coccyx pressure ulcer being down to the bone. A review of the resident's record revealed the following: R#919 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] documented a BIMS score of 00 indicating severely impaired cognition and required assist from staff for all ADL's. A Nursing Admission Screening dated 5/5/20 documented in part, . Coccyx, Pressure, 0.5 (Length) 0.5 (Width) 0.0 (Depth), Stage II (Partial thickness loss of dermis) . Pt. (patient) assessed by manager and orders in place for treatment . An admission Braden Scale for Predicting Pressure Sore Risk dated 5/5/20 documented a score of 13.0, indicating a Moderate Risk. A weekly skin assessment dated [DATE] documented no new measurements for the resident's Coccyx pressure ulcer. The assessment documented in part, . open wound on coccyx . see wound consult, treatment in place . A Wound Consultation dated 5/12/20 documented in part, . Initial Consult . Coccyx Ulcer 7.0 x 8.5 . Stage III (Full thickness tissue loss. Subcutaneous fat may be visible) . [MEDICATION NAME] to both QD (everyday) . The wound consultation was completed seven days after admission and revealed worsening of the wound from admission. A review of the clinical record revealed no documentation of staff identifying or informing a physician of the wound worsening since admission. A care plan dated 5/14/20 (three days after being diagnosed with [REDACTED]. Administer treatments as ordered and monitor effectiveness . Assess/record/monitor wound healing . Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (medical doctor) . A weekly skin assessment dated [DATE] documented no new measurements for the resident's Coccyx pressure ulcer. The assessment documented in part, . open wound to sacrum, see wound consult, treatment in place . A Wound Consultation dated 5/19/20 documented in part, . Coccyx ulcer . 8.0 x 8.5, Necrotic, Unstageable . The residents progress notes were reviewed and revealed no documentation of the facility staff identifying or notifying the physician of the wound worsening from the 5/12/20 consultation. The resident was inpatient at this facility for a total of two weeks and 2 days, admitted with a stage II that progressed into a larger, necrotic, and unstageable pressure ulcer to their Coccyx area. On 10/28/20 at 11:09 am, the Director of Nursing (DON) was queried on why the facility staff failed to identify the worsening of the wound during daily toileting/brief changes and showers and why there was no documentation of the staff notifying the physician of the worsening of the wound since admission despite the treatment of [REDACTED]. The DON was then asked to provide any additional information and/or documentation regarding the residents wound or physician documentation of the wound and no further documentation was received by the end of survey. R#916 A review of the clinical record revealed the following: R#916 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderately impaired cognition and required staff assistance for all ADL's. A Nursing Admission Screening/History dated 5/13/20 documented no skin issues or concerns upon admission into the facility. An admission Braden Scale for Predicting Pressure Sore Risk dated 5/13/20 documented a score of 16.0 indicating At Risk. For the weeks of 5/17/20 and 5/24/20 the facility failed to complete the resident's skin assessments. A 6/3/20, 6/10/20 and 6/17/20 weekly skin assessments documented the following in part, . Appearance of skin: Normal Patient has NEW alteration in skin integrity? Including open areas of any type, tears, bruising, red areas, rashes, etc. No . Additional comments or information related to skin: no new skin changes noted . The assessment revealed no alterations to the resident's skin integrity. A Nursing note dated 6/17/20 at 15:10 (3:10 pm) documented in part, . on 6/16/2020 resident was seen by (doctor name redacted) regarding wound care of MASD (Moisture Associated Skin Damage) on bilateral buttocks, orders rec'd (received) for [MEDICATION NAME] every shift and prn (as needed). No c/o (complaints of) pain and discomfort noted . The clinical record was reviewed and revealed no documentation of prior identification of changes with the resident's skin. A Wound Consultation dated 6/16/20 documented in part, . Initial Consult . Open wound coccyx . Coccyx wound 3.0 x 5.5 . A Nursing note dated 6/24/20 at 11:28 am documented in part, . on 6/23/20 resident was seen by (doctor name redacted) regarding wound care, orders rec'd (received) for [MEDICATION NAME] gel to coccyx/bil. (bilateral) buttocks due <sic> stage 3 pressure ulcer . Continue with treatment plan of care . The clinical record was reviewed and revealed no identification by the staff of worsening of the wound (for that past week) or any notification to the physician of any skin changes. A Wound Consultation dated 6/23/20 documented in part, . Follow Up Evaluation . Coccyx Ulcer . Coccyx Ulcer 6.0 x 5.0 . All care plans were reviewed and revealed no care plan for the resident's changes in skin (MASD or stage III). Further review of the clinical record revealed no dietary intervention for wound healing documented. On 10/28/20 at 9:37 am, the DON was asked to provide any additional documentation and/or explanation on the resident's weekly skin assessment that weren't completed, the staff failing to identify and notify the physician for the worsening of a wound and failing to implement wound care plans. At 2:32 pm, the DON confirmed that they could not provide any further information and/or documentation of the resident's wounds. R#935 A complaint submitted to the State Agency, reported the facility not properly caring for a resident's wound vac. R#935 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED].>A review of the clinical record revealed the following: Encounter for other orthopedic aftercare, chronic osteo[DIAGNOSES REDACTED] right ankle/foot, type 2 diabetes mellitus with foot ulcer and [MEDICAL CONDITION] stage 2. A MDS dated [DATE] documented a BIMS score of 15 (indicating intact cognition) and required staff assistance for all ADL's. Further review of the clinical record revealed the resident was admitted with a right heel diabetic ulcer, measurements 7.5 L (length) x 5.4 W (width) x 1 D (depth)- stage III. On 3/7/20 at 8:34 pm, a Nursing note documented in part . Resident's dressing changed with wet to dry dressing due to wound Vac missing hardware . Further review revealed no documentation indicating how long the resident's wound vac was missing the necessary hardware or if it was ever replaced. A review of the resident's March 2020 Treatment Administration Record (TAR) revealed on 3/7/20 despite the wound vac missing hardware and the nurse performing a wet to dry dressing to the resident's wound, the nurse signed the TAR on 3/7/20 as completed for the Wound Care for Surgical Ulcer to Left leg. Apply wound vac with [MEDICATION NAME] over entire ulcer site, placed under foal. Change wound q (every) 3 days. Every 72 hours for wound . Further review revealed no order for the wet to dry dressing that was performed as indicated in the Nurse's note. A note documented on 3/10/20 at 1:14 pm, documented the resident being sent to the hospital for an evaluation and blood transfusion. An attempt was made to contact the nurse that wrote the 3/7/20 note regarding the resident's hardware, however, was unsuccessful. On 10/28/20 at 2:40 pm, the Director of Nursing (DON) was queried regarding the missing hardware to resident wound vac, how long the hardware was missing, if the wound vac was ever fixed and functional before the resident transferred to the hospital, the nurse implementing a wet to dry dressing without a physician's orders [REDACTED]. The DON stated they would look into it; however, they were not employed by the facility at that time. Shortly after, the DON stated they were unable to find any additional information or documentation regarding all concerns. R#909 On 10/28/20, review of a concern submitted to the State Agency indicated that R#909's wound treatments were not being completed. On 10/28/20 the medical record for R#909 was reviewed and revealed the following: R#909 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#909's MDS assessment with an Assessment Reference Date (ARD) of 8/13/20 revealed R#909 needed extensive assistance from facility staff with most of their activities of daily living. R#909's BIMS score was 14 indicating intact cognition. Section M indicated R#909 had an unhealed pressure ulcer. A Nursing Admission Screening/History form with a lock date of 8/8/20 revealed the following: A. Admission Details: 1a. Reason for admission from paperwork-Stage 2 Pressure injury of R. (right) buttock and hip .L. Skin: Relevant History/DX (diagnosis)-Stage 2 Pressure injury of R. buttock and hip .Site: 21)-Right iliac crest (rear)-Pressure .31)- Right buttock-pressure . A review of R#909's progress notes revealed the following: An entry on 8/7/20 documented, Pt. (patient) A&Ox4 .Skin assessment completed upon arrival. Skin is very dry. Stage 1 pressure ulcer along upper, mid, and lower portion of back. Abrasion and Stage 1 pressure ulcer on coccyx. Yeast under fold of stomach. Feet have dry skin beginning to peel and crack open. NP (Nurse Practitioner) notified of arrival. Orders and assessments endorsed to midnight nurse . An entry on 8/10/20 documented (R#909 demographics) admitted as a full code, allergy to [MEDICATION NAME] on a NAS (no added salt diet) bedside 8/10/20, integumentary system is grossly impaired with assessment to right lateral side of back with excoriation bridge together 20x10cm 100% pink base [MEDICATION NAME] tissue with irregular edges scant amount of serous drainage, no infection. Periwound skin abnormal with yeast rash under abdomen folds. Right lateral hip stage III pressure ulcer 5x2.5x0.01cm clean with light serous drainage ulcer 75% pink base [MEDICATION NAME] 25% loose soft pale white slough. No infection Periwound skin texture moisture and color is normal. Treatments as order: right lateral back xeroform gauze QDPRN (every day as needed) right thigh santyl QDPRN . A review of R#909's Physician orders [REDACTED]. Silver [MEDICATION NAME] Cream 1 % Apply to affected area topically one time a day for wound treatment: Start date-8-8-20, Discontinued 8-14-20. Review of the August TAR (treatment administration record) revealed no documentation of treatment being completed on 8/8, 8/11, and 8/12. xeroform sheet to right lateral side as needed: Start date 8-14-2020. Review of August TAR revealed no documentation of treatment being completed in August 2020. xeroform sheet to right lateral side every day shift for excoriation to right lateral side: Start date 8/15/20. Review of August TAR revealed no documentation of treatment being completed on 8/15 and 8/16. Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to right lateral thigh topically every day shift for pressure ulcer for 30 Days: Start date 8-15-20 with an ending date of 9-14-20. Review of August TAR revealed no documentation of treatment being completed on 8/15 or 8/16. Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to right lateral thigh topically every day shift for pressure ulcer for 24 Days Apply santyl with 4x4 gauze and cover with 6x6 border gauze dressing: Start date 8-20-20 with an ending date of 9-13-20 .Review of September TAR revealed no documentation of treatment being completed on 9/6 . A review of R#909's careplan revealed the following: No careplan was provided for R#909's pressure ulcers. On 11/4/20 at approximately 12:26 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding R#909's wound treatments not being documented as completed on the TAR. The DON acknowledged that some of the treatments were not completed as ordered for R#909 and indicated that they had identified the facility had a problem with wound treatments being completed when they started working and had been working to correct it. The DON was queried why R#909 initially only had a topical cream ordered for their wound and the DON indicated that was not an appropriate order for R#909's wound and that a dressing should have been ordered when they were admitted . The DON was queried regarding the progress note on 8/10/20 that indicated a [MEDICATION NAME] gauze treatment was in place, but no order for it was observed in R#909's record until a start date of 8/14/20 and they indicated that they were aware and that R#909 was a resident that they had identified as one that had a problem with getting their wound care. At the end of the conversation the DON was queried for any additional documentation pertaining to R#909's wounds. None was received by the end of survey. A facility policy titled Skin Monitoring and Management- Pressure Ulcer dated 07/11/2018 documented in part . A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing . A skin risk assessment should be completed on a weekly basis . A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the resident's clinical record . A licensed nurse (which can be the facility wound nurse) must assess/evaluate at least weekly each wound . This assessment/evaluation should include but not be limited to: Measuring the wound, Staging the wound, Describing the nature of the wound . Describing the location of the wound, Describing the characteristics of the wound, Describing the progress with healing, and any barriers to healing which may exist, Identifying any possible complications or signs/symptoms consistent with the possibility of infection . If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative nurse's note documenting that notification . Licensed Nurse should document skin evaluations in accordance with this policy in the resident's clinical record . Re-evaluate existing treatment regimen in connection with the resident's clinical presentation . if any wound is non-healing or not showing signs of improvement after 14 days or any time a wound is worsening . On shower days, CNA (Certified Nursing Assistants) to observe the resident skin . Communicate findings to nurse . Licensed nurse to acknowledge findings, document pertinent information in resident's clinical record, and respond/obtain and implement treatment order as appropriate . Weekly skin check conducted by a facility licensed nurse . Any changes in the condition of the residents skin as identified daily, weekly . or otherwise, must be timely communicated to: The resident's physician, The resident/responsible party, Others as necessary to facilitate healing . A facility policy titled Change in Condition- Reporting (dated 7/11/18) documented in part, . Any sudden or serious change in a resident's condition manifested by a marked change in physical . will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident's condition. Licensed nurse will notify, consistent with the resident's authority, the resident's representative of the change of condition and what steps have been taken. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met . Resident plan of care will be updated .

This citation has three deficient practices. This citation pertains to intake number(s): MI 422, MI 900, and MI 630. Deficient Practice #1 Based on interview and record review, the facility failed to develop and implement interventions to prevent falls, thoroughly assess for injury after a fall, and determine the root cause of the fall for two (R#922 and R#917) of ten residents reviewed for accidents, resulting in R#922 falling from bed, being found in a pool of blood, sustaining multiple lacerations to the head and arm, including one that extended to the skull bone, and requiring an emergency transfer to the hospital where the resident received multiple staples and sutures to their head and R#917 falling repeatedly with the potential for injury. Findings include: R#922 A complaint was submitted to the State Agency that alleged the following: (R#922) resides in Skilled Nursing. Last night, EMS (Emergency Medical Services) was dispatched to (R#922's) home due to her falling. (R#922) was in her bed when EMS arrived, staff members picked (R#922) up before EMS arrived. Per (R#922), she fell out of her bed due to staff members putting her bed up too high, to the point that if she tried to get out, she would fall. When staff members were asked about the height of the bed, they stated that it was at a normal height. (R#922) had marks/bruises that were bandaged and were bleeding through the bandages. (R#922) also had a laceration on her right eye, right ear, right arm, and left leg. Upon arrival to the ER (emergency room ), (R#922) began to vomit. (R#922) is unsteady on her feet, she is obese. An unannounced, onsite investigation was conducted at the facility to investigate the complainant's allegations. A review of R#922's clinical record was conducted and revealed the following: R#922 was admitted into the facility on [DATE] with diagnoses that included: COVID-19, urinary tract infection, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and history of [MEDICAL CONDITION]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#922 had a Brief Interview of Mental Status (BIMS) score of 4 out of 15 which indicated the resident had severely impaired cognition. R#922 also required physical assistance of at least two staff members for bed mobility and transfers only occurred once or twice during the assessment period with assistance of one staff member. The MDS documented R#922 did not have any falls during the assessment period. A progress note dated 5/20/20 at 11:26 PM documented, Called in by the aid (R#922) was observed on the floor in a right side lying position with head under the chair. Prior to the fall, patient was told not to get out of the bed without held <sic> and to use her call light. There was a pool of blood. Upon assessment, skin laceration was observed on the head and on the right elbow .Bleeding was stopped temporarily by gauze dressing applied .911 called and patient was taken to the hospital . A progress note dated 5/21/20 written by the former Director of Nursing (DON) of the facility documented, Place low bed in room once returned from the hospital. A Fall Risk Assessment completed on 4/11/20 at the time of R#922's admission into the facility documented the resident was at moderate risk for falling, had no history of falls, and overestimates or forgets limits. A Post-Fall assessment dated [DATE] documented R#922 had a history of [REDACTED]. It was documented R#922 was not doing usual activities at the time of the fall. Previous interventions were documented as Use of call light. The assessment was signed by Nurse Q on 5/21/20. A Nursing Home to Hospital Transfer Form for R#922 documented the resident was transferred to the hospital on [DATE] due to a fall. It was documented R#922 had pain on the top of their scalp. The form was signed as completed and sent by Nurse D on 5/21/20 at 9:34 AM (the day after the fall occurred). A falls care plan was created on 4/11/20. An intervention was initiated on 5/21/20 to keep the bed in the lowest position. On 11/4/20 at 9:30 AM, any incident reports, investigations, and grievance forms for R#922 were requested. On 11/4/20 at approximately 9:45 AM, the DON reported there were no investigations for R#922 and there was one incident report. When queried about R#922's fall that occurred on 5/20/20, the DON reported they did not work in the facility at that time and the incident report was the only document related to R#922 that she was able to find. At that time, the DON was queried about the CNA who was assigned to R#944 at the time of the incident. The DON reviewed R#922's clinical record and the assignment sheets for 5/20/20. The clinical record revealed R#944 had a room/unit change from the 2 East unit to the 1 East unit on 5/20/20. The DON reported it appeared to occur in the afternoon. According to the DON and the assignment sheets from the night shift on 5/20/20, CNA V was assigned to R#922 on the 2 East Unit during the night shift and Nurse Q was the nurse assigned to R#922 on the 1 East Unit on the night shift. The Documentation Survey Report (a report that documented care provided by the CNAs) for May 2020 was reviewed with the DON. The Evening shift (3:00 PM - 11:00 PM) did not have any documentation of care provided to R#922 on 5/20/20. CNA V documented care was provided to R#922 during the night shift (11:00 PM - 7:00 AM) at 6:34 AM, however, R#922 was no longer in the facility at that time. The DON reported CNA V should never document that care was provided if it was not. An incident report dated 5/20/20 at 11:41 PM completed by Nurse Q documented the same description as documented in the progress note. It documented R#922 reported she was trying to get off the bed. The Immediate Action Taken documented, .Bleeding was stopped temporarily .911 called and patient was transported to the hospital. In the section that asked, Patient Taken to the Hospital?, N (which indicated no) was documented. The incident report documented there were no injuries at the time of the incident and R#922 had a pain level of 7 (out of 10). In the Injuries Report Post Incident section, the injury location documented top of scalp and right elbow. The Injury Type documented, No Apparent Injury. It was documented that a predisposing environmental factor was low bed. No predisposing situation factors were documented. No Witnesses were documented. On 11/4/20 at 10:50 AM, Nurse Q was interviewed via the telephone. When queried about what occurred with R#922 on 5/20/20, Nurse Q reported they were called into the resident's room by a certified nursing assistant (CNA) who heard a noise. Nurse Q further reported R#922 reported they were trying to go to the bathroom but did not typically use the bathroom and utilized a bed pan. When Nurse Q entered the room, R#922 was lying beside the bed in a pool of blood that was coming from the resident's head. Nurse Q reported the resident could not explain what happened. Nurse Q reported R#922 was sent out to the hospital and the DON (former) and the physician was notified. When queried about why they documented in the progress note that R#922 was told not to get out of bed without using the call light, Nurse Q could not remember. On 11/4/20 at 11:51 AM, CNA V was contacted via telephone for an interview, in addition to a request for the facility to contact the CNA. CNA V was not available for an interview prior to the end of the survey. On 11/4/20 at 12:15 PM, the DON was interviewed. When queried about the protocol when a resident was found on the floor, the DON reported the nurse would be called for assistance, the nurse would complete a full head-to-toe assessment of the resident which would include looking for any redness, range of motion issues, pain, or swelling. The nurse would also observe the body placement and environment, call the physician and family, and send to the hospital if needed. When queried about the facility's protocol when a resident was found on the ground with injuries, the DON reported the incident would be investigated to determine the cause of the incident. When asked what occurred with R#922 and how they ended up on the ground in a pool of blood and what time the incident occurred, the DON reported they did not work at the facility at the time of the incident, but stated, I cannot tell what happened based on the available information. The DON reported they were unsure when R#922 fell or how it occurred. On 11/10/20 at 3:06 PM, EMS staff JJ was interviewed via the telephone. They reported they received a 911 call at 9:58 PM on 5/20/20 and arrived at the facility at 10:05 PM. EMS staff JJ reported when they arrived to the facility R#922 was moved to the bed by staff and appeared very nervous. EMS Staff JJ reported the resident reported staff put the bed up really high and she fell out and was left on the floor for 30 minutes. EMS Staff JJ reported the bed was in a low position when they arrived, however, staff reported R#922 had been lying in a pool of blood which was already cleaned up by the time we arrived. EMS Staff JJ further reported that R#922 had a left leg abrasion, was bleeding from above the right eyebrow, had a laceration behind their right ear. EMS Staff JJ reported it would be unusual for a resident who was found in a pool of blood with multiple lacerations to be cleaned up, put into bed, bandages applied, and the blood cleaned up within a matter of seven minutes (the time the 911 call was received and the time EMS arrived). Hospital record for R#922 were reviewed and revealed the following: ED Provider Notes dated 5/20/20 at 10:39 PM documented, .presenting by EMS from ECF (extended care facility) with fall from approximately 3 feet with head injury. Patient states she fell from as high as her stretcher could go because she tried to get out of bed .Complains of headache .Head: .Laceration (Multiple) present . It was documented R#922 had four areas of injury to the head including a one centimeter (cm) laceration to the right eyebrow that required sutures, a large skin tear to the right side of the forehead, an eight to nine cm laceration to the top of the head that extended through the galea (tough fibrous sheet of connective tissues that extends over the cranium forming the middle layer of the scalp) to the skull (bone) that required 5 sutures and 14 staples, and a two to three cm laceration to the left side of the top of the head that required 2 staples. R#922 also sustained a skin tear to the right elbow. (Note: the facility documented R#922 had an injury to the top of the scalp and right elbow but did not have any documentation of the appearance of those wounds or of the additional injuries noted in the hospital records or reported by EMS Staff JJ). A Grievance and Satisfaction Form dated 6/2/20 at 11:00 AM submitted to the former DON was provided. It documented, Son called the facility to question how (R#922) fell and required 21 cranial stitches. The Investigation section documented, Son asked what were the contributing factors of the fall. It was explained that she had not had a fall since admission. She was in a high low bed positioned lowest to the ground and rolled off the bed. She was immediately assessed and sent to the emergency department for follow up treatment and diagnostics. Diagnostics negative for closed head injury . The Resolution documented, Resident is not returning to facility. Proper measures and documentation from facility staff implemented. It was documented the grievance was resolved on 6/2/20 and the Administrator signed off on the same date. The investigation into the grievance did not address the extent of R#922's injuries including the laceration to the head that required staples or any evidence of an investigation into how the fall occurred or why it was unclear what time the incident occurred. R#917 On 10/28/20 a concern that was submitted to the State Agency was reviewed and indicated that R#917 had multiple falls in the facility. On 10-28-20 the medical record for R#917 was reviewed and revealed the following: R#917 was initially admitted to the facility on [DATE], last admitted on [DATE] and had diagnosed including: [DIAGNOSES REDACTED].#917's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/24/20 revealed R#917 needed extensive assistance with most of their activities of daily living and limited assistance with eating. R#917's BIMS score (brief interview on mental status) was zero indicating severely impaired cognition. A review of R#917's documentation of falls while in the facility was reviewed and revealed the following: 1. Date-2-29-20 at 22:09 .Incident Description: Nursing Description-Staff heard a loud thud, followed by yelling, Staff immediately went into pts (patient) room. Pt was observed laying on her back on the floor in her bathroom. Pt complains of left thigh pain 5/10 and a headache 5/10. Pt has knot located on the right side of her (cut off) .Patient Description-I was trying to get up and forgot to unlock my wheelchair .Immediate Action Taken: Description-Neuros (neurological checks) initiated, Skin assessment done. Pt assisted to bed. PRN (as needed) pain pill given. Pt education provided on use of call light, and safe transfer techniques. NP (Nurse Practitioner) notified, orders to continue neuros given and to send out if pt has any status changes 2. Date-3-10-20 at 17:30 .Incident Description: -Nursing Description-Resident was observed sitting on floor in room screaming HELP. Patient Description- Resident stated she was trying to transfer herself from bed to wheelchair .Immediate Action Taken: Description-Assessed for injuries, 0 noted .Safely transferred to wheelchair. The importance of using call light was explained to resident. Notified NP, .Neuro check initiated . 3. Date-4-2-20 at 15:31 .Incident Description: -Nursing Description-Writer heard screaming coming from patient room. Writer went into patient room and observed patient in bathroom on knees in front of toilet. Patient Description-Patient stated that she was trying to go to bathroom and lost her balance and fell to the floor .Immediate Action Taken: Description- Vital signs taken. Skin assessment complete. Neuro-check complete and on-going. ROM (range of motion) complete. Patient transferred back into wheelchair via facility protocol. Family and NP notified . 4. Date-4-2-20 at 19:41 .Incident Description: -Nursing Description-Pt observed sitting in front of toilet trying to self transfer. Patient Description- I can't do it any more .Immediate Action Taken: Description-ROM, WNL (within normal limits) VSS (vital signs stable), MD (Medical Doctor) notified, family notified. Intervention for therapy eval . 4. Date-5-3-20 at 20:30 .Incident Description: -Nursing Description-Writer was in the hallway and heard resident yelling help, nurse immediately went into resident room and observe resident on bathroom floor. Patient Description-Writer asked resident what happened, and resident stated I fell , I fell while on the toilet .Immediate Action Taken:-Description- obtain vital signs, assess resident skin for injuries none noted, perform ROM, initiated neuro checks, notified doctor and family of the occurrence, assist resident back into wheelchair and placed call light within reach . 5. Date-5-16-20 at 03:40 .Incident Description: -Nursing Description-pt observed on the floor after hearing her call for help, pt complained of pain to her left ribs. Patient Description-Patient unable to give description .Immediate Action Taken: Description- head to toe assessment, ROM, WNL, vitals taken .family and MD notified . 6. Date-5-18-20 at 18:24 .Incident Description: -Nursing Description- Patient observed on the floor lying on back in-between bed and wheelchair. Patient Description- Patient stated she was trying to go to the bathroom .Immediate Action Taken: Description-Assisted to wheelchair x 2 and toileting offered . 7. Date-5-25-20 at 17:10 .Incident Description-Nursing Description- patient observed on floor in the bathroom laying on the left side of her body in between her wheelchair and the toilet. Patient Description- Pt states 'I was trying to get back in my wheelchair.' .Immediate Action Taken: Description- Pt assisted off floor by staff. Vitals taken, skin assessed, pt has bruise under left breast and bruises to right wrist and right forearm. No c/o (complaints of) pain. Neurochecks started, Writer spoke with daughter and MD about pt condition. Pt in room call light within reach. 8. Date-6-3-20 at 16:35 .Incident Description-Nursing Description-Writer was notified by CNA (certified nursing assistant) that patient was on the floor. Writer went into patient room and observed patient on left side, in between her and roommate bed. Patient Description-patient stated she was trying to get up and fell .Immediate Action Taken-Description- Vital sins taken, ROM complete. Skin assessment complete. Neuro-check complete and on-going. Patient transferred back into bed via facility protocol. Care plan updated. Family and NP notified. Invite daughter to visit at window on first floor in private area. 9. Date-6-15-20 at 06:15 .Incident Description: -Nursing Description- (R#917) was observed on the bathroom floor, she had a laceration on her head and was bleeding. Pressure was applied after cleaning it up and dressing was put over it to cover it. Vital signs was taken, neuro checks was started, call light was within reach and pt was told to always call for help when needed. Doctor was notified. Family was notified. Patient Description-Patient unable to give description .Immediate Action Taken: Description-MD notified, neuros started, resident assisted back to bedroom change for regular window visits . On 11/2/20 at approximately 12:37 p.m., R#917's multiple falls were reviewed with the Director of Nursing (DON) along with the corresponding interventions that were implemented on the care plan to reduce the occurrence of R#917's falls. The DON was queried what the facility's process was when a resident in the facility experiences a fall and the DON indicated that an incident/accident document (I&A) is filled out by the Nurse regarding what happened and what was done. In addition to the I&A, the care plan had to be updated with new interventions in an attempt to reduce future falls for the resident that fell . The DON was queried when the nurse is supposed to perform neuro checks and they indicated that neuro checks should be completed for an unwitnessed fall or when a resident hits their head. R#917's fall on 2/29/20 was reviewed and the DON indicated that neuro checks were started and that the intervention that occurred was that R#917 was educated on use of their call light and safe transfer. The DON was queried if that intervention was appropriate for R#917 who had a Dementia [DIAGNOSES REDACTED].#917's lack of ability to remember the education. The fall on 3/10/20 was reviewed and the DON and the DON reported the intervention put into place was again education on using the call light and that neuro checks were started. The DON indicated that the education was still not appropriate for R#917. The fall on 4/2/20 at 15:31 and the 2nd fall on 4/2/20 at 19:41 was reviewed and the DON indicated that both had occurred in R#917's bathroom and that no immediate intervention was put into place for either of the falls until 4/3/20 in which a new intervention was added to R#917's care plan that was to increase the frequency of toileting for 72 hours and to assist the resident to the bathroom. The DON was queried if the intervention was implemented after the first fall in the bathroom if the 2nd fall might have been prevented and they indicated that it might have because the resident would have already been toileted. The fall on 5/3/20 was reviewed and the DON indicated that neuro checks were initiated but no new immediate interventions were put into place to prevent another fall. A new intervention was later added to the care plan on 5/7/20 to offer toileting after bedtime. The fall on 5/16/20 was reviewed and the DON indicated that an activities intervention was added on 5/17 but hat the intervention was not appropriate to prevent the fall. The DON indicated that since it was an unwitnessed fall neuro checks should have been initiated but were not indicated on the I&A. The fall that occurred on 5/18 was reviewed and the DON indicated that no immediate interventions were put into place but that another intervention was added to the care plan a day later which was to increase visual communication between the patient and family. The DON indicated that intervention was not appropriate as it wasn't measurable and wasn't sure how it would have been implemented. The fall on 5/26/20 was reviewed and the DON indicated that no immediate interventions were put into place and that a therapy evaluation was added as an intervention but that the therapy evaluation was not resident specific and that a resident specific intervention should have been added to address the fall. The DON further indicated that after every fall it's standard for a therapy evaluation to occur. The fall on 6/15/20 was reviewed and the DON indicated that no new immediate interventions were put into place to address toileting in the bathroom but that a room change was put into place so family could use the window. The DON indicated that neuro checks were also initiated after the fall on 6/15/20. At that time the DON was queried for documentation for the neuro checks for all of R#917's falls that had neuro checks initiated. On 11/4/20 at approximately 11:22 a.m., during a follow-up conversation with the DON regarding R#917's neuro check documentation for their falls, the DON indicated that they did not have evidence of any neuro checks being completed except for the fall on 6/15/20 in which the neuro checks were not completed. The DON was queried how the nursing staff document that they completed the neuro checks and the DON indicated that they check them off on a neuro check paper document. At that time, any other neuro check documentation was requested for R#917's falls. None were received by the end of the survey except the incomplete neuro check form for the fall on 6/15/20. On 11/9/20 a facility document titled Nursing Administration-Care and Treatment-Fall Prevention (adopted 7/11/2018) was reviewed and revealed the following: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated .4. The Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions .6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments and documentation reflecting notification of applicable disciplines, resident's physician and resident's family/responsible party . Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure two (R#944 and R#945) of 10 residents were properly supervised, resulting in R#945, a resident with known wandering behaviors entering R#944's room and R#944 forcefully removing them from their room. Findings include: On 11/4/20 at 3:00 PM, an observation of the 2 East Unit was conducted. R#945 was observed wandering up and down both hallways of the unit utilizing a specialized walking aid that surrounded the resident and allowed them stability while walking to prevent falls. Certified Nursing Assistant (CNA) I was observed standing in the hallway to the right at a computer screen kiosk. CNA J was seated, slouched in a chair next to CNA I. CNA J was using their personal cell phone. CNA I and CNA J were engaged in personal conversation and complaining about their job. R#945 entered the hallway where CNA I and CNA J were located and entered into R#944's room. R#945 was not redirected from the hallway or from entering the other resident's room. R#944 was observed forcefully removing R#945 from their room by pushing the walking aid out into the hallway and yelling, Get out of here! CNA I stated, I'm going somewhere else to chart. There's too much going on here and stood up and walked down the hallway without addressing the incident between R#944 and R#945. On 11/4/20 at 3:30 PM, the 2 East Unit Manager, Nurse D was interviewed. Nurse D reported CNA J should not have been present on the unit if she was clocked out and staff were not permitted to use their personal cell phones in resident areas. Nurse D further reported CNA I was still on the clock and therefore was responsible to the residents on the unit and should not participate in personal conversation in front of residents. On 11/4/20 at 3: The Director of Nursing (DON) was interviewed. The DON reported if staff are on the clock, they are responsible for residents while being paid. The DON further reported use of personal cell phones was prohibited in resident areas and when staff were done with their shift, they should not stay on the unit. The DON reported that R#945 should have been supervised and CAN I should have intervened when R#945 entered R#944's room and after R#944 forcefully removed R#944. R#945's clinical record was reviewed and revealed the following: R#945 was admitted into the facility on [DATE] with diagnoses that included: [MEDICAL CONDITION] with behavioral disturbances. A Minimum Data Set (MDS) assessment dated [DATE] documented R#945 had severely impaired cognition and no behaviors. Care plans were reviewed and did not include any interventions or goals to address wandering behaviors. R#944's clinical record was reviewed and revealed the following: R#944 was admitted into the facility on [DATE] with diagnoses that included: dementia with behavioral disturbances and [MEDICAL CONDITION]. A MDS assessment dated [DATE] documented R#944 had moderately impaired cognition and no behaviors. Care plans were reviewed and documented R#944 had history of yelling and having hallucinations and delusions. A facility policy titled, Resident Rights - Abuse and Neglect last revised on 6/17/19 was reviewed and documented, .Prevention .Identify, correct and intervene in situation in which abuse .is more likely to occur .This includes analysis of .The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict .Resident who have behaviors such as entering other residents' room . Deficient Practice #3 Based on interview and record review the facility failed ensure a safe transfer for one resident (R#912) resulting in an injury during a mechanical lift transfer. Findings include: On 10/28/20 a concern submitted to the State Agency was reviewed that indicated R#912 was transferred inappropriately and sustained an injury. On 10/29/20 the medical record for R#912 was reviewed and revealed the following: R#912 was initially admitted to the facility on [DATE], last admitted on [DATE] and had diagnosed including: [DIAGNOSES REDACTED]. A review of R#912's MDS with an ARD of 7/16/20 revealed R#912 was dependent on staff for most of their activities of daily living including transfers. R#912's BIMS score was 9 indicating moderately impaired cognition. A progress note dated 7/24/2020 at 1:23 p.m. revealed the following: Nurse notified by CNA (certified nursing assistant): CNA X2 assist using hoyer lift (mechanical lift) to transfer to bed. PT was lifted in lift, as CNA began to lower PT to bed, PT leaned forward and hit his head on bar located on the lift. CNA informed PT to lay back until lift is positioned on bed. Nurse initiated neurological assessment and assess for pain and injury .Pain 2/10. Scratch observed at L (left) eyelid, small amount of bleeding observed. Scratch above L eyelid cleaned, bleeding stopped <1 minute, bandage placed on area. Tylenol 500mg given PO (by mouth). PT (Physical therapy) notified for EVAL of transfer status .Will continue to monitor. A progress note dated 7/24/2020 at 3:30 p.m. revealed the following: Nurse in room with PT completing neurological assessment, no change in LOC (level of care). pain 0/10. Responsible party arrives to room. Nurse introduces self . (family member) states she is upset and doesn't understand how it could have happened. Nurse turns to resident and asked him what happened earlier. Resident states I was up in the air in the thing and hit my head against the bar. (family member) states she wants medical records and to speak to the supervisor because she don't know why it happened Nursing supervisor notified. An Incident form dated 7/24/20 revealed the following: Incident Description: Nursing Description-Nurse notified by CNA (certified nursing assistant): CNA X2 assist using hoyer lift to transfer to bed. PT was lifted in lift, as CNA began to lower PT to bed, PT leaned forward and hit his head on bar located on the lift. CNA informed PT to lay back until lift is positioned on bed. Nurse initiated neurological assessment and assess for pain and injury .Pain 2/10. Scratch observed at L (left) eyelid, small amount of bleeding observed. Scratch above L eyelid cleaned, bleeding stopped <1 minute, bandage placed on area. Tylenol 500mg given PO (by mouth). PT (Physical therapy) notified for EVAL of transfer status .Will continue to monitor .Patient Description-PT states 'I bumped my head on the thing.Immediate Action Taken: Description-Nurse initiated neurological assessment and assessed for pain and injury. Area cleaned, dried and bandage placed on area. Tylenol give for pain .CNA demonstrated appropriate use of hoyer. On 10/29/20 at approximately 11:30 a.m., during a conversation with the DON, the DON was queried regarding the incident for R#912 on 7/24/20 and how the resident hit their head on the hoyer lift bar. The DON indicated that the CNA (CNADD) who placed R#912 in the sling did not properly center them and when the resident raised their head they were too far to the side and hit the hoyer lift bar. The DON was queried what action if any had taken place and the DON indicated that they had to give a 1:1 in-service to the CNA (CNADD) regarding hoyer lift transfer to try and ensure it does not happen again and that they knew how to transfer appropriately On 11/9/20 a facility document titled Policy/Procedure-Nursing Clinical-Mechanical Lifts (adopted 7/11/2018) was reviewed and revealed the following: Policy- It is the policy of this facility to move a resident by mechanical means as needed .10. Place sling on resident's back. Ensure that it is properly placed for support .14. Position resident to ensure comfort .

This citation pertains to intake #'s MI 900, MI 533, MI 981 & MI 689. Based on interview and record review, the facility failed to ensure consistent monitoring of resident weights and implement dietary interventions to prevent significant weight loss for four residents (R#'s 913, 916, 917, 919,) of six residents reviewed for nutrition, resulting in excessive weight loss and poor nutritional intake. Findings include: R#917 On 10/28/20, review of a concern submitted to the State Agency indicated R#917 had excessive weight loss at the facility. On 10/28/20, the medical record for R#917 was reviewed and revealed the following: R#917 was initially admitted to the facility on [DATE], last admitted on [DATE] and had [DIAGNOSES REDACTED]. A review of R#917's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/24/20 revealed R#917 needed extensive assistance with most of their activities of daily living and limited assistance with eating. R#917's BIMS score (brief interview on mental status) was zero which indicated severely impaired cognition. A dietary progress note dated 12/13/2019 documented, Nutrition/Weight- Nutrition assessment completed: (R#917 demographics) here for LTC (long term care) WT (weight) 143.6# 12/5, down x 2 months from 152# 10/2. Recorded intake 75-100% most meals per FAR (food acceptance record). Diet GI (gastrointestinal) soft for dx IBS (irritable bowel syndrome). Meds/labs reviewed. Physician services following for tooth pain. Wt change discussed with pt (patient), pt reports good tolerance to meals, denies chewing/eating difficulty r/t (related to) tooth pain. Potential for wt changes r/t dx (diagnosis) dementia, depression, anxiety, fluid shift/diuretic tx (treatment). Recommend ensure plus once per day to support intake r/t wt change - pt agreeable. Review of R#917's record revealed there were no new Physician orders [REDACTED]. A dietary progress note dated 5/27/2020 documented, Nutrition/Weight Note Text: Wt down from 132.6# 4/12 to 115# 5/22. Physician services recently following for pt refusing to eat/take meds - improved following medication adjustment by psyche services. Recorded intake 50% or more most meals per FAR. Diet regular. Magic cups tid (three times a day) in place for support with good acceptance recorded. Meds/labs reviewed. On [MEDICATION NAME] for dx depression. Potential for wt changes r/t fluid shift/diuretic tx, dx dementia, dx depression/anxiety. Pt able to self manage for dx IBS. Recommend continue magic cups tid (three times a day); add HPJC (juice supplement) tid for increased support; routine wts for trend. A dietary progress note dated 7/6/2020 documented, Nutrition/Weight Note Text: Pt with hospital stay 6/16-6/17 following fall. Pt now under hospice care. WT 115# 6/7, hospital wt 136.7#. Recorded intake 0-25% most meals per FAR. Diet regular, mech (mechanical) soft. Ensure plus tid in place for support. On [MEDICATION NAME] for dx depression. Alb ([MEDICATION NAME]) 2.9L/tp 5.1L 6/18. Skin: impaired. Potential for wt changes r/t hospice status. Diet/supplements per hospice. Staff to continue to assist with meals and encourage intake as appropriate. Further review of R#917's record revealed there were no new Physician orders [REDACTED]. Another physician's orders [REDACTED]. Further review of the physician order [REDACTED]. There were approximately 8 missed opportunities. The identified weight on 3/6 was 134.6 and on 6/7 was 115. A review of R#917's documented weights from March 2020 through June 2020 revealed the following: The only weights completed were as follows: 3/6/2020-134.6 .4/12/20-132.6 .5/22/20-115 .5/31/20-116 .6/7/2020-115. A review of R#917's care plan including revised interventions revealed the following: Focus-Nutritional status: suboptimal intake with potential for wt changes r/t fluid shift, dx depression/dementia, anxiety, pt refusing to eat/take medications, hospice status; recent wt change r/t increased depression/anxiety/refusing to eat/take medications. Under hospice care - overall decline in condition expected/anticipated r/t to end of life care. Date Initiated: 12/02/2015. Revision on 7/8/2020 .Interventions-Review weights and notify physician and responsible party of significant weight change. Date Initiated: 12/02/2015 .nutrition/supplements as ordered Date Initiated: 12/02/2015 .Revision on: 03/23/2020 . On 11/2/20 at approximately 4:19 p.m., during a conversation with Registered Dietician F (RD F), when queried regarding R#917's weight loss and lack of documented weights in R#917's record when the Physician had ordered weekly weights starting in March 2020 and RD F indicated that the DON (Director of Nursing) at the time had stopped doing weights in the building due to the pandemic. RD F was queried how they were able to monitor residents at risk for weight loss when the facility was not obtaining weights and they indicated they had to rely on staff to let them know how much they were eating. RD F was queried why some weights were taken but the weekly weights weren't and they indicated that they were unsure as to why some weights were taken. RD F was queried regarding their order for ensure plus to be started per their progress note on 12/13/19 and RD F indicated that an order was not put in for the ensure plus until February 2020. RD F was queried if an order should have been in place when they added ensure plus to R#917's regimen in December 2019 and they indicated that it should have. R#916 A compliant was submitted to the State Agency on the facility's failure to assist with eating and drinking for a dependent resident, resulting in rapid weight loss. R#916 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderately impaired cognition and required staff assistance for all ADL's. A Nursing Admission Screening/History dated 5/13/20 documented in part, . Weight: 150.0 (Lbs.), Date: 5/16/2020 08:53 (AM), Scale: Last weight obtained-refusal . This is dated three days after admission. A review of the resident's weights completed at the facility, documented one weight of 150.0 lbs. on 5/16/20. A review of the clinical record revealed no other weights documented for this resident. The resident was admitted into the facility on [DATE] and discharged to the hospital on [DATE], with no documented attempts to obtain the resident's weight throughout the resident's stay at the facility. A Nursing note dated 6/8/20 at 3:59 pm, documented in part . Cena reported appetite decreased . The documentation for the Amount of Meal Taken for the month of June 2020 was reviewed and revealed the following: Refusals of meal: 7th dinner, 13th breakfast, lunch, dinner, 21st breakfast and lunch Eaten 25% of meal: 8th lunch and dinner, 9th breakfast, lunch, dinner, 10th breakfast, lunch, 11th breakfast, lunch, 12th breakfast, lunch, 14th breakfast, dinner, 16th dinner, 18th dinner, 19th breakfast, lunch, dinner, 21st dinner and 22nd breakfast. There was no documentation of the resident being offered/assisted with their meals on 20th breakfast, lunch and 22nd lunch. The resident was transferred to the hospital on [DATE] and the admission weight at the hospital was documented as 113 lb. 5.1 oz. Indicating a 36.5-pound loss during the resident's 42 day stay at the facility. Further review of the hospital medical records revealed the following: [MEDICATION NAME] levels 2.7 (normal 3.5-4.9). A laboratory report dated 5/14/20 documented the resident's admitting [MEDICATION NAME] levels of 2.9, noting a .2 decline within their stay at the facility. The hospital medical record revealed recommendation from the hospital Registered Dietician that documented in part, . Severe Protein-Calorie Malnutrition . as evidenced by 8% weight loss x 1 month and moderate depletion of muscle stores . If po (by mouth) intake is poor and aggressive medical nutrition therapy desired, then consider [MEDICATION NAME] placement for enteral nutrition support . A care plan titled Nutrition status: therapeutic diet; potential for wt. (weight) changes r/t fluid shifts with [MEDICAL CONDITION] and diuretic use (dated 5/16/20) documented interventions in part, . Review weights and notify physician of significant weight changes . A care plan titled The resident has an ADL self-care performance deficit r/t deconditioning, [MEDICAL CONDITION], IDDM (insulin dependent diabetes mellitus), mobility limitations (dated 5/14/20) documented interventions in part, . eating: provide 1:1 assistance as resident is visually impaired . On 10/28/20 at 9:54 am, Dietician was queried on the resident's admission weight and weight monitoring while inpatient at the facility. The dietician stated the admission weight is usually obtained with the first 24 hours of admission into the facility. When asked if the documented refusal weight should have been reattempted, the dietician stated that it should have. When asked how they were able to effectively identify/monitor trends regarding the resident's weight if the facility failed to obtain the resident weights, the dietician stated the previous Director Of Nursing (DON) made the decision to only obtain the admission weight and to discontinue all other weights during COVID. The dietician then stated that they would monitor the residents per their intake of meals as documented by the staff. When queried on the frequent documentation of the lack of meal consumption for the resident and no further dietary monitoring or evaluation noted in the clinical chart, the Dietician did not offer any further explanation. When asked what kind of scales were utilized at the facility, the dietician stated . platform, wheelchair and lift scales . On 10/28/20 at 2:32 pm, the Dietician and DON stated they were unable to provide any further information and/or documentation regarding the resident's weight loss. No further information and/or documentation was received by the end of survey. R#919 A compliant submitted to the State Agency, reported a 20-pound weight loss during the resident's two week and two day stay at the facility. The complainant noted the resident's weight to be 145 pounds the day of discharge (5/21/20). R#919 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] documented a BIMS score of 00 indicating severely impaired cognition and required assist from staff for all ADL's. A Nursing Admission Screening dated 5/5/20 documented in part, . Reason for admission from paperwork: COVID 19 recovery . Weight: 165 lbs. (pounds), Date: 5/5/2020 . Standup scale . A review of the resident's weights revealed one documented weight on 5/5/20 at 165.0 lbs. The clinical record was reviewed and revealed no other documented weights throughout the resident's stay at the facility. A Dietary Evaluation dated 5/16/20 (11 days after admission) documented in part weight of 165 lbs. (5/5/20) . Loss of 5% or more in the last month or loss of 10% or more in last 6 months, No or unknown Loss of 7.5% in the last 3 months, No or unknown . Is there any gradual, unintended, progressive weight loss or gain over the last 3 months, No . On average, what is the patient's overall intake of meals? 26-75% of meals . The dietician failed to address the fact that the resident's weight had not been taken since admission. On 10/28/20 at 11:34 am, the Dietician was queried on why the resident's weight was only taken on admission, not monitored throughout their inpatient stay and why 5/16/20 dietary evaluation was completed using the resident's admission weight instead of a current weight for the resident. The Dietician replied the prior Director of Nursing (DON) stopped all weight monitoring during COVID. When asked how they were able to effectively monitor weight loss trends for the resident at the facility during that time, the Dietician stated by what the CNA's documented for food intake. The Dietician was then asked to provide any additional information and/or documentation regarding the monitoring of the resident's weight and any dietary interventions that were implemented and no further information and/or documentation was received by the end of survey. On 10/28/20 at 2:32 pm, the DON stated that they were not employed by the facility at the time and they could not find any further information or documentation to provide regarding the monitoring of the resident's weight loss. The Dietician was also asked to provide any further information or documentation regarding the resident's weight loss and monitoring and provided no further information by the end of survey. R#913 A complaint was received by the State Agency regarding the facility not feeding or giving fluids to the resident resulting in weight loss and dehydration. R#913 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] documented a BIMS score of 15 (indicating intact cognition) and was dependent on staff for all ADL's. A review of the clinical record revealed the following: A Nursing Admission Screening/History dated 6/24/20 documented in part, . Weight: 190 (lbs.-pounds), Dated 6/24/20 20:51 (8:51 pm), Scale: Mechanical Lift . This is the only documented weight for the resident throughout this inpatient stay (6/24/20 - 7/9/20). On 7/9/20 at 10:27 am, a nursing note documented the resident being transferred to the hospital for a blood transfusion. A review of the resident's hospital medical record documented an admission weight of 78.2 kg (kilogram) (172 lb. 6.4 oz). During the resident's 15 day stay at the facility, the resident lost a total of almost 18 pounds. An admission Dietary Evaluation dated 7/3/20 (9 days after admission) documented in part . Most Recent Weight: 190.0, Date: 6/24/20 . Is there any gradual, unintended, progressive weight loss or gain over the last 3 months? No No or unknown was marked off for the following: Loss of 5% or more in the last month or loss of 10% or more in last 6 months, Loss of 7.5% in the last 3 months. The evaluation failed to be completed timely by the facility and failed to complete the evaluation off of the resident's current weight at the time. The dietician failed to address the fact that the resident's weight had not been taken since admission. Further review of the clinical record revealed no identification of the resident's weight loss by the facility staff or any notification to the dietician. A Document Amount of Meal Taken documentation (which is documented by the facility staff) revealed the following: June 2020- 27th breakfast- eaten 25%, lunch- refused, dinner- eaten 25%, 30th lunch- refused, dinner- eaten 25% July 2020- 2nd breakfast and lunch- eaten 25%, 3rd breakfast and lunch- eaten 25%, dinner not documented as offered this night, 4th breakfast and lunch- eaten 25%, 5th lunch- refused and dinner not documented as offered this night, 6th breakfast and lunch- not documented as offered, 7th lunch- eaten 25% and the 8th breakfast and lunch- 0% and dinner not documented as offered this night. On 10/28/20 at 9:54 am, Dietician was queried on the resident's admission weight and weight monitoring while inpatient at the facility. The dietician stated the admission weight is usually obtained with the first 24 hours of admission into the facility. When asked how they were able to effectively identify/monitor trends regarding the resident's weight if the facility failed to obtain the resident weights and the dietician stated the previous Director Of Nursing (DON) made the decision to only obtain the admission weight and to discontinue all other weights during COVID. The dietician then stated that they would monitor the residents per their intake of meals as documented by the staff. When queried on the frequent documentation of the lack of meal consumption by the resident and no further dietary monitoring or evaluation noted in the clinical chart, the Dietician did not offer any further explanation. When asked if the facility implemented a protocol or guidance for the staff to monitor for weight trends, due to the previous DON making the decision to discontinue obtaining the resident's weights and the Dietician stated No. A care plan titled Nutrition status: mechanically altered diet; potential for wt. (weight) changes r/t (related to) fluid shifts, advanced age (created on 7/3/20- 9 days after admission) documented in part, . Goal: Will experience no significant weight change, Interventions: Nutrition as ordered, Honor food preferences, Observe for s/s (signs/symptoms) of fluid imbalance, Review weights and notify physician of significant weight changes, Encourage and assist as needed to consume foods and/or supplements and fluids offered . On 10/28/20 at 2:32 pm, the Dietician and DON was asked if they had any further documentation or information to provide and none was provided by the end of survey. A facility policy titled Nutrition Monitoring & Management Program dated 07/11/2018 documented in part, . It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight . Each resident is to be weighed within twenty-four (24) hours of admission, weighed weekly for four (4) weeks . The weight will be entered into the resident's medical record . the Registered Dietician, the IDT (interdisciplinary team) will further assess nutritional needs and goals of the resident in the context of his/her overall condition, including the following: The frequency with which the resident will be weighed, Any desired changes in weight .

This citation pertains to intake #s: MI 540, MI 086, and MI 463. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program and follow infection control practices according to Centers for Disease Control (CDC) guidelines and facility policy for COVID-19 (Coronavirus Disease 2019) including: failing to consistently and accurately assess the respiratory status of 14 (R#s 802, 803, 806, 807, 808, 809, 810, 811, 812, 814, 815, 816, 817, and 818) of 21 residents reviewed for COVID-19, failed to don appropriate Personal Protective Equipment (PPE) for residents on droplet precautions for COVID-19, wear PPE appropriately, implement isolation precautions and monitor for signs and symptoms of COVID-19 for 5 (R#s 807, 808, 809, 810, 811) of 5 residents admitted from the hospital, ensure three residents (R#s 803, 819, and 821) without COVID-19 were isolated from residents who were positive or had an unknown status for COVID-19, and ensure staff who were assigned to a designated COVID-19 unit were not also assigned to one (R#802) resident who was not positive for COVID-19 and resided on a non-COVID unit. These deficient practices likely resulted in the spread of COVID-19, a serious and potentially [MEDICAL CONDITION], as well as the unidentified signs and symptoms of new onset COVID-19 and unidentified complications from COVID-19, that affected three residents (R#s 814, 816, and 818), who expired in the facility or the hospital after testing positive for COVID-19. The facility was found to be in Immediate Jeopardy (IJ) and all 154 residents who resided in the facility were determined to be at risk of serious harm and death. Findings include: The IJ was identified on [DATE] at 11:00 A.M. The IJ began on [DATE]. The Administrator was notified of the IJ and a request was made for a plan to remove the immediacy on [DATE] at 11:45 A.M. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal verified onsite/offsite by the surveyors. Although the immediacy was removed on [DATE], the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On [DATE], an unannounced, onsite COVID-19 focused survey was conducted. On [DATE] at approximately 8:30 AM, an interview was conducted with the facility's Administrator and Director of Nursing (DON). It was reported that the 1 East Unit and the North side of the 2 East Unit were designated for residents who tested positive for COVID-19. The DON reported there were designated nursing staff assigned to the COVID-19 designated areas of the facility. The DON reported there were no presumptive positive cases of COVID-19 in the facility and the process for presumptive positive cases would be to identify, isolate, swab, and then move to a COVID unit if positive. The DON reported all residents were assessed for respiratory symptoms daily. When queried about PPE used throughout the facility to prevent the spread of COVID-19, the DON reported all staff wore N95 respiratory masks which were used for a couple of days. On the COVID-19 designated units, the DON reported staff must don gowns, gloves, and face shields in addition to the N95 mask and on the other units staff were required to wear N95 masks only. For residents with presumed positive COVID-19, they would be placed on droplet precautions which required the use of gown, gloves, mask, and face shield or goggles. The DON reported there were no residents in the facility as of [DATE] who were presumed or suspected to be positive for COVID-19 and the 1 East Unit and part of the 2 East unit (room numbers redacted) were designated for residents with confirmed positive tests for COVID-19. The DON reported R806 was identified as the first resident in the facility that tested positive for COVID-19. At that time, a list of all residents who currently resided in the facility and were positive for COVID-19 was requested. A list of all residents in the facility with facility acquired COVID-19 was requested at that time (this information was not provided by the facility until [DATE] at 4:49 PM). 1 West Unit On [DATE] at 10:00 A.M., an observation of the 1 West Unit was conducted. Nurse C was observed preparing medications at the medication cart on the 1 West Unit. A surgical mask was observed worn below Nurse C's mouth which exposed their mouth and nostrils. Nurse C pulled the mask over their nose and did not perform hand hygiene before or after making contact with the mask. Nurse C continued to prepare medications. At approximately 10:08 AM, Nurse C was interviewed. Nurse C reported they worked in another building and it was their first time working at that facility. When queried about the use of PPE, including masks, for the 1 West Unit, Nurse C stated, I don't know. I don't work here. I work in the (city name redacted) building. Nurse C reported they did not receive training or report(s) from the previous shift about the PPE protocol for the 1 West Unit prior to starting their shift. When queried about any residents on the unit on isolation precautions, Nurse C reported they did not know. On [DATE] at 10:08 A.M., Certified Nursing Assistant (CNA) B was observed to enter the 1 West Unit. CNA B wore a N95 respirator mask that was pulled down underneath their chin and exposed their mouth and nostrils. CNA B approached the kiosk (a touch screen computer where CNAs document their care tasks). CNA B pulled the N95 mask up over their nose while touching both the inside and outside of the mask. No hand hygiene was performed before or after touching the mask. CNA B proceeded to touch the screen of the kiosk. On [DATE] at approximately 10:10 AM, CNA B was observed at the kiosk with their N95 mask pulled down underneath their chin exposing their mouth and nostrils. A second CNA was observed to be talking with CNA B. Upon approach, CNA B pulled the N95 mask up over their nose, did not perform hand hygiene, and walked away from the kiosk toward the exit doors of the unit. At approximately 10:12 AM, CNA B was interviewed. When queried about the observations of the N95 mask being positioned under their chin, CNA B stated, It's just a habit. It makes my mouth dry. When queried about the proper protocols for wearing an N95 mask and what should be done if they needed to adjust it, CNA B reported they would wash their hands and change the mask. CNA B proceeded to touch the doors, exit the unit, walk down the hallway, press the elevator buttons, and enter the elevator without performing any hand hygiene. CNA B then returned to the first floor via the elevator carrying a food tray. On [DATE] at 10:21 AM, a review of a sign hung on the doors of the 1 West Unit documented, Donning PPE .Fit flexible band to nose bridge .Fit snug to face and below chin .Fit check respirator .Safe Work Practices .Keep hands away from face .Limit surfaces touched .Perform hand hygiene . 1 East Unit On [DATE] at 10:32 AM, an observation of the 1 East Unit was conducted. The unit was designated for residents who tested positive for COVID-19. The closed double doors that led to the unit had signage that read: Attention: This unit is under strict isolation PPE must be donned prior to entering. An interview with Nurse A was conducted upon entrance to the unit. Nurse A reported the unit was designated for COVID-19 residents but, Not everyone is positive. When queried about how it would be known who was positive and who was not, Nurse A stated, There are signs on the doors. The whole unit is on isolation, but not everyone is positive. Everyone is on the same isolation. When queried about PPE use on the 1 East Unit, Nurse A reported gowns, gloves, mask, and a face shield must be worn. When queried about when gowns would be changed, Nurse A reported the same gown was worn for all residents on the unit since the whole unit was on the same isolation precautions. On [DATE] at 10:50 AM, an interview with Nurse E who was assigned to the other hallway on the 1 East Unit was conducted. Nurse E reported R819 tested negative for COVID-19 and would be moved from the unit. Nurse E reported R803 who was on the opposite hall on the 1 East Unit, did not have COVID-19 but remained on the unit because he was on hospice. Nurse E reported the whole 1 East Unit was on droplet precautions, whether or not a sign was on the door. R803's door was observed to be closed. There was no signage on the door. A bin containing gowns, stethoscope, and blood pressure cuff was observed outside of the door. 2 West Unit On [DATE] at approximately 10:20 AM, Nurse 'I' was observed collecting breakfast trays on the 2 West unit from the hall with rooms ,[DATE]. Nurse 'I' was observed to exit a room on the hallway with a finished breakfast try. It was observed Nurse 'I' had gloves on when they exited the room. Nurse 'I' was then observed to open the door of the meal cart (with their gloves still on) and place the tray in the cart. Nurse 'I' then closed the door to the meal cart, removed their gloves, proceeded down the hall to the nursing station and disposed of their gloves in the medication cart garbage receptacle. 2 East Unit On [DATE] at 10:40 AM, an observation of the 2 East unit was conducted. A review of the staffing assignment posted at the nursing station indicated Registered Nurse (RN) 'F' was assigned to all of the rooms on the designated 2 East COVID-19 hall, (a hall on 2 East that was separated from the rest of the unit by closed double doors) as well as one room that was not on the COVID-19 unit. At approximately 10:50 AM, an interview with RN 'F' was conducted regarding their assignment. RN 'F' reported they were assigned all COVID-19 positive residents and one resident (R802) that did not reside on the COVID unit. On [DATE] from 10:45 AM, until approximately 11:30 AM, general observations and interviews of staff on the 2 East COVID-19 designated hall were conducted and the following occurred: At approximately 10:55 AM, an interview with RN 'F' was conducted and they were queried about what type of PPE should be worn when entering a COVID-19 room. RN 'F' reported that a gown, gloves, mask and eye protection should be worn, and hand hygiene should be performed upon entry and exit from the room. At approximately 11:10 AM, CNA 'I' was asked about what type of PPE should be worn in a resident's room on the unit. CNA 'I' indicated that when entering a room, a gown, mask, gloves, and 'goggles' should be worn. It was noted the room numbers for the COVID-19 hall were from ,[DATE]. During the observations, CNA 'H' and 'I' were observed to be in the hallway wearing a yellow isolation gown and an N95 mask. RN 'F' was observed to be wearing a light blue nursing uniform and an N95 mask. RN 'F' was observed to enter a room on the hall with CNA 'H'. RN 'F' was not observed to don a gown, gloves, or a face shield/eye protection upon entering the room. CNA 'H' was not observed to don a face shield/eye protection upon entering the room. RN 'F' exited the room and went to the medication cart in the hallway. At 11:08 AM, RN 'F' was observed to enter another room on the hallway. RN 'F' was not observed to don a gown, gloves, or face shield/eye protection upon entry to the room. RN 'F' exited the room approximately 2 minutes after entering. During the general observations on the unit, neither CNA 'H', CNA 'I', or RN 'F' were ever observed to don a face shield upon entering COVID-19 positive resident rooms. On [DATE] at 11:55 AM, an interview with the facility's DON was conducted regarding RN 'F's assignment and why they were assigned all COVID-19 positive residents on the second floor COVID-19 hall as well as R802 who did not reside on the COVID-19 hall. The DON indicated Licensed Practical Nurse (LPN) 'G' was supposed to be assigned R802's room and RN 'F' was supposed to only be assigned residents on the COVID-19 hallway. At that time, the DON was made aware that RN 'F' reported he had been assigned to R802's care. At approximately 12:00 PM the DON acknowledged RN 'F' had been assigned to R802 and had provided care to them earlier in the morning. The DON indicated the scheduler would be in-serviced on making the nursing assignments. R#803 R803's clinical record was reviewed and revealed the following: R803 was admitted into the facility on [DATE] to the 1 East unit (in the room they resided in on [DATE]) with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment documented R#803 had intact cognition for decision making. R803's physician's orders [REDACTED]. There was no order for droplet precautions. Further review of R803's clinical record revealed a COVID-19 test was not performed as of [DATE]. Respiratory Symptom Evaluations for R803 from [DATE] through [DATE] were reviewed. At the top of the assessment form instructions documented, OBTAIN AND DOCUMENT TEMPERATURE AND PULSE OXIMETRY AT TIME OF SCREENING. A review of the Respiratory Symptom Evaluations revealed the following: Respiratory Symptom Evaluations were not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A Respiratory Symptom Evaluation dated [DATE] at 10:01 PM (signed and locked on [DATE]) documented Most recent O2 Sats (Oxygen Saturation) from [DATE] at 4:17 AM. Respiratory Symptom Evaluations dated [DATE] and [DATE] documented O2 Sats from [DATE]. A Respiratory Symptom Evaluation dated [DATE] documented O2 Sats from [DATE]. Respiratory Symptom Evaluations dated [DATE] and [DATE] documented O2 Sats from [DATE]. Respiratory Symptom Evaluations dated [DATE], [DATE], [DATE], [DATE], and [DATE] documented O2 Sats from [DATE]. Respiratory Symptom Evaluations dated [DATE], [DATE], and [DATE] documented O2 Sats from [DATE]. As of [DATE], the last date O2 Sats were assessed for R803 was on [DATE] as indicated on the above Respiratory Symptom Evaluations and a review of the O2 Sats Summary. R803's progress notes were reviewed and documented the following: On [DATE] a nursing progress note documented, Late entry for ,[DATE]: Pt noted with change in condition, he appears to be more confused and irritable, which is new for this resident. Also noted SOB (shortness of breath), with RR (respiratory rate) ,[DATE], PO2 <sic> (oxygen saturation) on r/a (room air) fluctuates between ,[DATE]%. Supplemental O2 initiated at 2L (liters) at first, then increased to 4L. PO2 <sic> went up to 93%. (Agency name redacted) hospice contacted to report. With small emesis after breakfast and after lunch. There was no documented respiratory assessment for R#803 since [DATE]. On [DATE], a progress note written by Nurse Practitioner (NP) U documented, .[MEDICAL CONDITION] (low blood oxygen) and lethargy. Somewhat irritable .somewhat more disoriented .Will monitor closely . On [DATE], a social service progress note documented R803 wished to remain a full code. On [DATE], NP U documented, .Increased confusion and lethargy. Pt has been having fevers. Pt is likely COVID (positive). No swab as patient is hospice. Will treat him as he is positive . On [DATE], NP U documented, .Confusion, [MEDICAL CONDITION](increased heart rate), dyspnea (difficulty breathing) .Likely has COVID-19. Not tested due to hospice. Isolated and treated as if he had it . A Care Plan dated [DATE] documented, At risk for anxiety .easily upset by room changes .limit room changes . There were no progress notes that documented a conversation about a room change with R803 or documented anxiety exhibited by R803 pertaining to a room change. On [DATE] at 3:00 PM, an interview was conducted with the DON and the Infection Control Preventionist (ICP) via the telephone. The ICP and DON reported that daily Respiratory Symptom Evaluations were to be completed by the nurse for all residents who resided in the facility. When queried about why R803 resided on a unit designated for residents who were positive for COVID-19, the DON reported they were on hospice and did not want to move to another room. The DON reported risks versus benefits of remaining on a unit with residents who were positive for COVID-19 were discussed with R803 and they did not want to change rooms. When queried about whether the hospice agency was involved in the discussion, the DON did not offer a response. At that time, all hospice documentation and the risks vs benefit form for R803 was requested. On [DATE], hospice paperwork was reviewed for R803. The paperwork provided by the facility included the hospice plan of care, but did not include any hospice visits or discussion regarding R803 remaining on a unit designated for residents with COVID-19 or that R803 was presumed positive as documented in NP Us progress note mentioned above. On [DATE], an unsigned Risk Benefit Assessment (emailed by the DON and not included in the clinical record) documented the DON was the assessor on [DATE] and [DATE] and communication was had with R803 and family members. The assessment documented the following: .Your overall risk rating - Low Medium or high - is based on our judgment about whether the BENEFITS of the activity or opportunity outweigh the risks . The Activity documented, Resident is receiving Hospice services for end of life care. He is in a room that is private and has a large patio door where the facility has placed patio furniture so his parents and children can visit daily. It was documented R803 would benefit psychologically from visiting family through the patio door. It was documented family was not permitted and did not want to enter the facility to visit R803. The Potential Risks were documented as Contracting COVID-19. There was no language that explained what could happen as a result of contracting COVID-19, including death. The Precaution in place to reduce the risk documented, Resident is placed at the end of the hall. Resident is in a private room. Resident has a separate isolation cart specified for his unit (room) only. It was documented R803 was at Minimal risk. Resident's condition has been stable. Upon further review of R803's clinical record it was discovered that a COVID-19 test was conducted on [DATE] and the results were positive. On [DATE] at 10:50 AM during an interview with the DON and ICP via the telephone, it was reported that the 1 East Unit was turned into a designated unit for residents who were positive for COVID-19 on [DATE], 2 East was a COVID-19 designated unit as of [DATE], and as of [DATE] the 2 East unit was split and only specific rooms were designated for residents who tested positive for COVID-19. It should be noted the Resident entered into the 1 East unit on or about [DATE] and remained on the unit when it was turned into a designated unit for positive COVID-19 residents despite determination of COVID status. R#806 A review of the facility's respiratory illness line listing for [DATE] and [DATE] was conducted. The line listing identified a COVID-19 test was performed for R806 on [DATE]. R806 had onset of symptoms on [DATE] and tested positive for COVID-19. It was documented R806 was hospitalized , returned to the facility, and could come off of 14-day isolation on [DATE]. A note on the line listing documented, ready to move. On [DATE], R806 was observed to reside on the 2 East unit which was designated for residents who tested positive for COVID-19. A review of R806's clinical record was conducted and revealed the following: R806 was admitted into the facility on [DATE], transferred to the hospital on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The census documented R806 resided on the 1 East Unit until they were transferred to the hospital on [DATE] and was readmitted on to the 2 East Unit on [DATE] (which was a designated unit for residents who tested positive for COVID-19). R806's physician's orders [REDACTED]. an order for [REDACTED]. On [DATE] there was a physician's orders [REDACTED]. A review of COVID-19 tests for R806 revealed positive results on [DATE] and [DATE]. Respiratory Symptom Evaluations for R806 were reviewed from [DATE] until [DATE] and they revealed the following: There were no Respiratory Symptom Evaluations completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A Transfer Form dated [DATE] documented R806 was transferred to the hospital for a fever. Blood pressure, pulse, respiratory rate, and O2 Sats were documented from the previous day ([DATE]). Temperature was documented as 103 degrees Fahrenheit (F) on [DATE] at 11:36 AM. Progress notes were reviewed for R806 and revealed the following: On [DATE], a nursing progress note documented, Covid 19 swab collected this morning per medical director order and for fever, cough symptoms. Pt was started on droplet precautions . At 10:32 AM a progress note documented R806 had a temperature of 101.3 degrees F, a cough, and chest irritation with pain with inhalation. It was documented their temperature increased to 103 degrees F and they were transferred to the hospital. R806 returned to the facility on [DATE] and was placed on the COVID-19 unit. A progress note written by Physician W on [DATE] documented R806 was weak, tired, had poor oral intake, and experienced shortness of breath with minimal exertion. Physician W documented, .Continue droplet isolation until the patient is symptom free for at least 3 days and more than 14 days since the day of sickness . On [DATE], R806 was transferred to the hospital with abdominal pain and was admitted . R806 returned to the facility on [DATE]. A COVID-19 test was performed in the hospital and R806 tested positive. R806 was readmitted into a room on the COVID unit. A progress note written by NP U on [DATE] documented, .PT recently retested positive for covid 19. Will keep in isolation . On [DATE], NP U documented R806 developed a cough over the weekend . Lungs with crackles and rhonchi to right lung . There was no documentation of any fevers or respiratory concerns after R806's readmission into the facility on [DATE] prior to [DATE]. A review of admissions into the facility within the past 14 days ([DATE] through [DATE]) were reviewed and revealed R807, R808, R809, R810, and R811 were admitted into the facility within that timeframe and resided on the 1 West Unit (non-COVID-19 Unit). R#807 On [DATE] a tour of the 1 West unit (Non COVID-19 unit) was conducted. It was observed R807 had a private room and there were no signs or isolation equipment in the area that indicated R807 was on any type of isolation precautions. On [DATE] a review of R807's clinical record was conducted and revealed R807 originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the record indicated R807 discharged out to the hospital and re-admitted to the facility on [DATE], into their same room from the prior admission. A review of a respiratory assessment document in the electronic medical record titled RESPIRATORY SYMPTOM EVALUATION was conducted and the assessment forms contained the directions that read, .A. OBTAIN AND DOCUMENT TEMPERATURE AND PULSE OXIMETRY (oxygen saturation of the blood) AT TIME OF SCREENING . A review of R807's RESPIRATORY SYMPTOM EVALUATION assessment forms was conducted and revealed the following: assessment dated [DATE] at 7:50 AM, it was noted the temperature and pulse oximetry were dated to be obtained on [DATE] at 2:53 AM. assessment dated [DATE] at 8:10 AM, the pulse oximetry was documented as obtained on [DATE] at 1:20 AM. assessment dated [DATE] at 8:05 AM, the temperature was documented as obtained on [DATE] at 12:40 AM. assessment dated [DATE] at 7:54 AM, the temperature documented as obtained on [DATE] at 12:16 AM. assessment dated [DATE] at 6:52 AM, the temperature documented as obtained on [DATE] at 10:32 PM. assessment dated [DATE] at 5:55 AM, the temperature and pulse oximetry documented as obtained on [DATE] at 12:48 AM and 12:49 AM. Continued review of R807's RESPIRATORY SYMPTOM EVALUATION assessment forms also included assessments missing for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] thru [DATE]. R#808 On [DATE] a tour of the 1 West unit (Non COVID-19 unit) was conducted. It was observed R808 had resided in a room on the 1 West unit. R808's room did not have any signs or isolation equipment in the area that indicated they were on any type of isolation precautions. On [DATE], a review of R808's clinical record was conducted and revealed an admission date of [DATE] from the hospital. R808's [DIAGNOSES REDACTED]. A review of a nursing note dated [DATE] at 4:20 PM was conducted and read, .arrived at facility from hospital. admitted to (room # redacted), on s <sic> non-covid unit . A review of R808's physician's orders [REDACTED]. An order on [DATE] (two days after admission) to monitor R808's oxygen saturation and temperatures every six hours. An order on [DATE] (three days after admission) to monitor R808's vital signs every shift. Continued review of the record revealed R808's first RESPIRATORY SYMPTOM EVALUATION assessment form was dated [DATE], two days after their admission to the facility. It was further discovered R808 did not have any documented vital signs for [DATE]. R#809 On [DATE], R809 was observed to be in their room on the 1 West Unit. There was no sign on R809's door that indicated the resident was on isolation precautions. A review of R809's clinical record was conducted and revealed the following: R809 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R809's physician's orders [REDACTED]. A review of Respiratory Symptom Evaluations for R809 revealed no assessment until [DATE] (three days after R809 was admitted into the facility). R#810 On [DATE], R810 was observed to be in their room on the 1 West Unit. There was no sign on R810's door that indicated the resident was on any isolation precautions. A review of 810's clinical record was conducted and revealed the following: R810 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Respiratory Symptom Evaluations for R810 were completed on [DATE] only, as of [DATE]. Progress notes were reviewed for R810 and revealed the following: On [DATE], NP U documented, .Pt had some [MEDICAL CONDITION] while under sedation for her reduction. CXR (Chest X-ray) demonstrated some pneumonia. Covid negative . On [DATE], Physician W documented, .Chest x-ray showed pneumonia because patient was hypoxic, but COVID was negative (in the hospital) . On [DATE], a progress note documented, .Resident states she has no family / only a boyfriend who is sick with COVID in the hospital . Hospital records for R810 were reviewed and revealed the following: The Admission referral to the facility documented a secondary [DIAGNOSES REDACTED]. A History of Physical dated [DATE] documented, .Her CXR showed bilateral airspace disease concerning for atypical/[MEDICAL CONDITION] pneumonia. A COVID-19 swab was sent and is pending .Covid 19 resulted as negative swab .Assessment/Plan: Active Hospital Problems .Pneumonia due to infectious organism .Suspected COVID-19 Virus Infection . A COVID-19 test was conducted in the hospital on [DATE] and was negative. R810 was admitted into the facility on [DATE] (four days after the test). R#811 On [DATE], R811 was observed in their room located on the 1 West Unit. There was no sign that indicated R811 was on droplet precautions. There was no PPE available on the unit. Staff were observed to wear surgical and N95 masks. A review of R811's clinical record was conducted and revealed the following: R811 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A review of R811's Medication Administration Record [REDACTED]. One Respiratory Symptom Evaluation was completed for R811 on [DATE], it was noted R811 was admitted four days prior to the evaluation. Progress notes for R811 were reviewed and revealed the following: On [DATE], a progress note written by NP X documented, .Hospital course complicated by worsening low back pain and [MEDICAL CONDITION]- CXR showed patchy bibasilar interstitial opacities .Pt reports acute dry cough . On [DATE] at 3:00 PM, an interview was conducted with the ICP and the DON via the telephone regarding residents admitted or readmitted from the hospital. The DON reported residents who tested positive in the hospital would remain in droplet isolation on the COVID-19 unit at the facility until seven days after they tested positive and they were asymptomatic for 72 hours without the use of fever reducing medications. When queried about the facility's process for residents who were admitted or readmitted from the hospital whose COVID-19 status was unknown, the DON reported the facility only began accepting residents who were negative for COVID-19 six or seven days ago. The DON further reported that the resident had to have two negative tests in the hospital (one test within at least 72 hours of discharge from the hospital) prior to coming to the facility and would be placed on one of the units designated for residents who did not have confirmed COVID-19. The DON was asked about the guidance the facility followed to determine the above decision and reported it came from the physician, the hospital epidemiologist, and CDC guidance. The DON further reported that the residents who came from the hospital had a Respiratory Symptom Evaluation completed daily to monitor any new signs and symptoms of COVID-19, but they were not placed (TRUNCATED)

This citation pertains to MI 0: Based on interview and record review, the facility failed to ensure a resident who required a two person assist using a lift for transfers was consistently transferred per the resident's plan of care for one (R#703) of three residents reviewed for accidents, resulting in the resident sustaining pain, a hospital visit, a left tibia, left fibula and right third metatarsal fracture. Findings include: Review of documentation provided for a facility reported incident (FRI) for R#703 documented, in part, the following: (R#703) is a long-term care resident. (R#703's) BIMS (Brief interview for mental status) score is 7 indicating cognitive impairment. (R#703) requires extensive assistance for transfer requiring the (brand name) Lift. On 10/17/2019 around 12:30AM, resident was transferred to the hospital per son's request due to leg pain and chest pain. On 10/18/2019, this event was reviewed during the facility's daily morning meeting and per report from facility's Central Intake (CI), resident had a left tibia fracture, bruising to her right lower leg and right metatarsal. Per Central Intake, resident's son was concerned about resident's bruising. A review of the hospital records did not indicate any bruising .Investigation: On 10/16/2019 around 4:30 PM, resident was transferred from room {number redacted) to room (number redacted) per resident and resident's son request. CENA (Certified Nursing Assistant)(CNA 'C'), during an interview reported he transferred the resident using a gait belt, from her bed to the wheelchair. CENA (CNA 'C') reported he transferred resident and did not have her bear weight during the transfer. Per CENA (CNA 'C'), he denied the resident exhibiting any signs or symptoms of pain. CENA (CNA 'C') stated there was no bruising to legs and that she does have chronic pain to legs related to previous surgeries. Per interview with CENA (CNA 'C'), he brought resident in the wheelchair to her new room and elevated her legs on the bed as he knows that resident often experienced pain in her legs/hips and it helped resident to elevate her legs. CENA (CNA 'C') stated that he elevated legs and call light was within reach with no complaints/concerns noted from the resident. CENA (CNA 'C') stated he asked CENA ,(CNA 'D'), to transfer resident back to bed. Per interview with CENA (CNA 'D') she asked CENA ,(CNA 'E'), to assist her to transfer the resident. Per both CENAs, resident complained about her legs <sic> pain before and after the transfer. Per both CENAs, resident appeared more comfortable when she was assisted to her bed and positioned for comfort . Review of the clinical record for R#703 revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] it was documented the resident scored 7 out of 15 on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Also per this assessment it was documented the resident required the extensive assistance of two persons for bed mobility, and assessed transfer as only occurring once or twice with two persons physical assist. Review of a Nursing Home to Hospital Transfer Form dated 10/17/19 for R#703 revealed the reason for the resident's transfer as chest pain. Review of a H&P (History and Physical) document from the hospital for R#703 dated 10/17/19 at 4:40PM noted, in part, a Distal tibial fracture on the left, orbital consulted, obtain x-rays of the right lower extremity as well, given bruising. Neck pain, given unexplained fracture in the left leg and the patient was poor memory, cannot rule out previous trauma . Review of an ED (Emergency Department) Provider note for R#703 dated 10/17/19 at 2:36 AM documented chief complaint (s) as Chest Pain and Leg Pain L (left). Review of the history of present illness (HPI) section of the form documented, Patient .with history of dementia living at ECF (extended care facility) that presents with chest pain. Patient is unable to give a history. Son called and is concerned that she has an infection due to her worsening mental status .Patient saying her chest hurts and leg hurts . Per the review of systems section of the form the musculoskeletal assessment noted the presence of leg pain, while skin was negative for wound. Review of the Physical Exam section of the hospital documentation noted, Musculoskeletal: She exhibits no deformity. Tenderness at minimal palpation of any extremity. No obvious signs of trauma, deformity, or infection . Review of an Orthopedic Surgery Consult dated 10/17/19 at 9:44 PM documented the resident was receiving a consult due to left ankle pain. Per the consult it was documented, (R#703) .presents to the ER (emergency room ) with left ankle pain, chest pain, and AMS (altered mental status). She states that the ankle pain started yesterday morning without any trauma, injuries, or increase in activity. She uses a wheelchair and is non-ambulatory at baseline. The patient endorses numbness/tingling in bilateral feet that started 1 week ago .Imaging: Left tibia.fibula/ankle films show distal tibia and fibula fracture, severe osteopenia, vascular calcifications Right tibia/fibula/ankle/foot films show 3rd metatarsal fracture . Review of a statement by CNA 'C' dated 10/24/19 documented the following: On 10/16/2019 around 4pm I transferred (R#703) from her bed to the chair so she needed to be moved to another room. I used the gait belt for this transfer. When transferring this resident I did not have her bear her weight on her feet. During this transfer patient did not complain about any unusual pain. When I brought resident to her new room, I elevated her legs as I know from being her regular care giver that it helps her with her legs pain. Resident was not grimacing or crying and did not display any unusual behavior. Resident wore her night gown. I did not observe any bruises on the resident's body and resident's legs. I left resident in her new room in the wheelchair with call light within reach and reported to another CENA (Certified Nursing Assistant) that resident arrived to her new room. On 11/12/19 at 10:38 AM, an attempt was made to contact CNA 'C' via telephone, and a voicemail message was left at this time. CNA 'C' returned the call on 11/13/19 at 11:09 AM, and was queried in regard to R#703. CNA 'C' explained that he had been told to transfer the resident to (a specific unit of the facility), and he transported her over via wheelchair. CNA 'C' explained that he couldn't find a hoyer sling (necessary to transfer resident via hoyer lift), and explained the resident had been transferred via a pivot transfer to the wheelchair with a gait belt around the resident. CNA 'C' explained they went to the other unit, went to the room, and couldn't find a sling. CNA 'C' explained he had been with the resident for 45 minutes waiting to get the resident to bed, and explained a sling couldn't be located. Then CNA 'C' explained he heard on the PA (intercom) system that he was needed back. CNA 'C' explained the resident was always having real bad pain in the legs and thighs, and said that before he had come out of the room he had been trying to find some assistance/a sling. CNA 'C' explained he had placed R#703 by the bed, had elevated the resident's legs, had locked the wheelchair, and explained the resident did not express concerns. CNA 'C' said he had gone to the desk to get help or a sling, and said that he had to get back (to different area of building). Review of a statement by CNA 'D dated 10/24/19 documented, (CNA 'C'), another CENA, asked me to help him to transfer (R#703) from her w/c to the bed. Patient was complaining about the leg pain and wanted to go to her bed. I asked another CENA (CNA 'E') to assist me. We both transferred the resident to her bed. During this transfer resident did yield <sic>. We made her comfortable in her bed and left her all <sic> light within the reach. When we left the room patient was comfortable. At the dinner time, I passed her tray and patient was talking on the phone and appeared to be comfortable. Around 9:30 pm I came back to change patient and patient was complaining of legs <sic> pain. I told the Nurse, Nurse advised us to elevate patient's legs After this, patient appeared comfortable. I did not see any bruises or skin tears on the resident. An attempt was made to contact CNA 'D' via telephone on 11/12/19 at 10:44AM, and a voicemail message was left at this time. A return call was not received prior to the exit of the survey. Review of a statement by CNA 'E' dated 10/18/19 at 12:00 PM documented, On 10/16/19 approx (approximately) 4:30 PM I helped (CNA 'D') transfer Resident (identifier redacted) to Bed from W/C (wheelchair) 2 person assist transfer with gait Belt. Resident c/o (complain of) pain after transfer done. An attempt was made to contact CNA 'E' via telephone on 11/12/19 at 10:47 AM. CNA 'E' returned the telephone call and a conversation occurred via phone on 11/13/19 at 2:21 PM. CNA 'E' was queried in regard to R#703, and explained the resident had not been assigned to her. CNA 'E' explained that the resident had been moved to a different unit, and when the resident was moved the resident did not have a hoyer pad underneath her. CNA 'E' explained that she thought the kardex (care guide) had been checked by the other staff involved, and explained that the resident had had a gait belt around them already . Review of a statement by Licensed Practical Nurse (LPN) 'F' dated 10/16/19 documented, I received pt (patient) resting in bed at 7pm. Pt was heard yelling help me periodically. I went in to asses <sic> Pt to see why she was yelling for help. Pt stated Help me, I just want die. When asked what was wrong pt stated she Didn't know. Pt continued to call out in the hallway a few times. Afternoon manager heard Pt and also went in to assess Pt, he also stated she said she didn't know why she was yelling, Pt did not verbalize pain around 11:50-12 AM night manager asked nurse to contact family. I briefly <sic> spoke to son. Pt asked writer for a pillow, and also complained of pain in left leg and requested repositioning. I repositioned her leg and gave scheduled pain med at 12:03 AM. Pt complained chest pain and described pain as dull and aching. VS (vital signs) taken BP (blood pressure) 133/84 P (pulse) 87 SPO2 (oxygen saturation) 96% via Room air. No use of accessory muscles noted EMS (emergency medical services) arrived before I could administer Nitro ([MEDICATION NAME]). MD (medical doctor) notified. Nursing manager aware. Pt was transferred <sic> to hospital. An attempt was made to contact LPN 'F' on 11/12/19 at 11:42 AM, and a voicemail message was left at this time. A return call was not received prior to the exit of the survey. Review of a disciplinary action form for CNA 'C' dated 10/18/19 revealed the staff member had received education due to incorrect transfer of a resident. Review of a disciplinary action form for CNA 'D' dated 10/18/19 documented the staff member had received education due to incorrect transfer of a resident. Per the employee comments section of the form it was documented, The gait belt is already around the resident so I assume she is a gait belt transfer. Review of a disciplinary action form for CNA 'E' dated 10/18/19 documented the staff member had received education due to incorrect transfer of a resident. Review of a plan of care for R#703 dated 4/17/19 documented, The resident has an ADL (activities of daily living) self care performance deficit r/t (related to) Disease Process (impaired mobility, obesity), Limited ROM (range of motion), Stroke, acute [MEDICAL CONDITION]. Review of an intervention per the plan of care, dated 9/23/19, documented, ADL Assist-2 person max assist (mechanical lift) with transfer. On 11/13/19 at 12:45 PM, the facility's Administrator was queried in regard to the FRI investigation for R#703. The Administrator explained, in part, that the facility had not found intentional harm to the resident, and there was a concern with care as three CNAs had not used the (mechanical lift) per the plan of care. The Administrator explained that the staff members had been educated. The Administrator explained that the resident had gone to the hospital, and then they had found out about the [MEDICAL CONDITION] tibia and right metatarsal. When queried as to what staff were to do if they could not find a sling, it was explained that staff should go to management. Review of a facility policy with the subject, Mechanical Lift dated 7/11/18 revealed, in part, the following: .7.Use sling compatible with mechanical lift and appropriate size. 8. There will always be 2 staff to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface .

This citation pertains to intake number MI 768. Based on interview and record review, the facility failed to assess and monitor (including vital signs, blood glucose monitoring, and neurochecks) one (R#801) of six residents reviewed for changes in condition who presented with a decline in ability to participate in care and therapy, lethargy, unresponsiveness, and concerns expressed by the resident's family members such as change in mental status and delusions. The resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when the resident required an emergency transfer to the hospital, had a blood glucose level of 26, agonal breathing, coffee ground emesis (coagulated blood in vomit), hypothermia, required intubation, cardiopulmunary resusitation (CPR), and ultimately died from [MEDICAL CONDITION] on the same day. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator was notified of the IJ on [DATE] at 4:55 P.M. and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. A complaint was received by the State Agency that alleged the following: (R#801), went to (facility name redacted) to receive skilled rehab. She was a direct admit from (hospital name redacted) on [DATE]th. By [DATE]th she was dead. Although we do not blame the skilled facility for her disease process, we are writing this complaint due to the pervasive and repeated disregard for our concerns which our family shared through her short stay at this facility. Repeatedly we reported changes we were seeing (swelling in hands and feet, shortness of breath, fixed delusions - which she never experienced - prior to admission), confusion, not eating, increased weakness, and general decline. We were told repeatedly that the nurse practitioner was notified and there were no concerns. On [DATE]th, I asked if (R#801) should go back to the hospital and was told by staff there were no concerns. On [DATE]th, family was present and was told (R#801) would not get up to participate in rehab but, again, no one was concerned. (R#801's family member) quickly realized (R#801) was worsening (increased confusion, difficult to awake) and it took him almost 75 minutes to get a staff member to come in. It was only due to a maintenance staff who happened to be in close proximity who helped to finally get a nurse to come to her room. It was at this time staff became concerned when it was reported her blood sugar was 23 and EMS (Emergency Medical Services) was notified. By this time, it was too late. (R#801) went into [MEDICAL CONDITION], was intubated, aspirated and went into respiratory distress (repeatedly) and passed away after an awful and painful death. She had the right to die of her disease not of neglect from this facility . An unannounced onsite investigation was conducted from [DATE] through [DATE]. A review of R#801's clinical record was conducted and revealed the following: R#801 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Screening assessment dated [DATE] documented R#801 was admitted into the facility for physical therapy (PT) and occupational therapy (OT), was alert and oriented to person, place, time, and situation, had intact cognition, no confusion, no delusions, no hallucinations, and no [MEDICAL CONDITION] (swelling). R#801's vital signs were within normal limits on admission and blood glucose level was 116. A Baseline Care Plan dated [DATE] documented R#801's goals of PT and OT were to return to the community at discharge. Progress Notes were reviewed and revealed there were no progress notes written between [DATE] and [DATE]. A General Progress Note dated [DATE] at 6:00 P.M. written by Nurse A documented, Resident alert and verbal. Requires minimal assist with care .Request to be seen by MD (Medical Doctor)/NP (Nurse Practitioner) for BLE (bilateral lower extremity) [MEDICAL CONDITION], will continue to monitor . The progress note did not include any documented assessment of R#801's lower extremity [MEDICAL CONDITION] or if the MD or NP was notified of the resident's concern. A late entry General Progress Note written by Physician B on [DATE] for [DATE] at 10:19 [NAME]M. (nine days late) documented, .H&P (History & Physical): presented from (hospital initials redacted) for hematuria (blood in the urine) and [MEDICAL CONDITION] due to blood loss due to metastatic GIST; has been treated with PO (by mouth) [MEDICAL CONDITION], uti (Urinary Tract Infection) was found and was treated; now doing well; no complains .no le (lower extremity) [MEDICAL CONDITION] . There was no mention of R#801's complaint of BLE [MEDICAL CONDITION] on [DATE]. A Skilled Charting assessment dated [DATE] at 2:39 P.M. documented R#801 had 3+ [MEDICAL CONDITION] (Deep pitting, indentation remains for a short time, leg looks swollen) to bilateral feet. A General Progress Note dated [DATE] at 3:24 P.M. written by Nurse A documented, Alert and verbal .Requires minimal assist with care. Attend PT/OT today. #t <sic> [MEDICAL CONDITION] in bilateral feet .MD/NP informed. No new orders at this time. Will cont. to monitor . A General Progress Note dated [DATE] at 6:09 P.M. documented, Resident seen by MD this shift. New order for (brand name of a medication used to treat heart failure) 20 mg (milligrams) po bid (twice a day) x 3 days. Medication started from the back up . A Medical Practitioner Note dated [DATE] at 8:19 P.M. written by NP C documented, CC (Chief Complaint): f/u pain and [MEDICAL CONDITION] .Pt sleeping in wheelchair .Pt concerned about RLE (right lower extremity) swelling .1. RLEE (right lower extremity [MEDICAL CONDITION]): (Brand name for medication to treat heart failure) x 3 days 2. Tyoe <sic> 2 DM (diabetes mellitus): Continue BS (blood sugar) checks, (oral medications to treat diabetes) as ordered. 3.[MEDICAL CONDITION](hypertension): BP (blood pressure) stable, continue current regimen 4. AFIB ([MEDICAL CONDITION]): VSS (vital signs stable), continue (an anticoagulant medication). There were no ordered entered for blood sugar checks. On this date, the only blood sugar check was on admission on [DATE]. Vital signs were checked on [DATE] and on admission only. A General Progress Note dated [DATE] at 8:25 [NAME]M. written by Nurse A documented, CNA (Certified Nursing Assistant) reported to nurse that she was informed that patient was unresponsive. Nurse and CNA assessed resident, resident alert and verbal. No noted distress at this time. There was no documentation by Nurse A regarding the above notification by the CNA, including no vital signs taken, no blood glucose level, and no neurochecks. There was no documentation that the Physician or NP were notified. A General Progress Note dated [DATE] at 10:15 [NAME]M. written by Nurse A documented, PTA (Physical Therapy Assistant) assist stated to nurse that resident was unresponsive. Nurse and orientee assessed resident. Resident alert and verbal, able to response to all questioned. NP notified of resident condition. There was no documentation that Nurse A did a thorough assessment of R#801 including, but not limited to taking vital signs, checking blood sugar level, or performing neurochecks after a second report of unresponsiveness by two different staff members, two hours apart. A General Progress Note dated [DATE] at 11:13 [NAME]M. documented, Resident assessed by NP at this time. Resident responsive with assessment. No new orders given at this time, (R#801's family member) in at bedside. A Medical Practitioner Note written by NP C on [DATE] documented, NP acute visit CC: lethargy HPI: PT informed nurse of increased lethargy and unresponsiveness in AM, nurse informed NP to assess patient (1100 AM). NP in to evaluate patient (1100 AM). Patient responsive and mentating at this time. Vital signs stable per RN at this time (There was no documentation of vital signs taken by the nurse on [DATE]). Neurological signs within normal limits however noted to be drowsy but arousable .NP informed (R#801's family member) who was at bedside that NP would be back to reevaluate patient .Vitals: Vitals stable per RN .Gen: A&O x 2 (decreased from ,[DATE] on previous assessments since admission), Pulm (pulmonary): Lungs diminished (decreased breath sounds) .bilateral lower extremity [MEDICAL CONDITION] .A/P: 1. Lethargy: Pt alert and arousable, neurological signs monitored and within normal limits, VSS per RN. 2. Bilateral lower extremity [MEDICAL CONDITION]: PO (medication to treat heart failure) x3 days 3. Debility: Unable to work with PT this AM d/t lethargy. 4.Type 2 DM. A Medical Practitioner Note written by NP C on [DATE] at 5:10 P.M. documented, NP acute visit cc: [MEDICAL CONDITION] (below normal level of oxygen in the blood), pallor (an unhealthy pale appearance) and lethargy RN notified NP that patient SAT (oxygen saturation) was low, mid 80's and patient was pale in color. NP immediately in to reassess patient at this time. Difficult to obtain BP at this time. O2 (oxygen) sat mid 80's, respirations 16 and labored (increased effort to breathe). Nasal cannula placed on patient. 911 immediately called. STAT (urgent) Blood sugar obtained, blood sugar noted to be 26 (very low blood sugar level that if left untreated could result in a coma and/or death). STAT [MEDICATION NAME] (emergency injectable medicine used to treat severe [DIAGNOSES REDACTED]-low blood sugar) ordered however not available in house. EMS at bedside at this time, Glucose gel (2 tubes) administered to patient at this time, BS recheck post 2 tubes noted to be 32, patient noted to be awake yet remained lethargic. EMS attempted several times to place an IV for IV [MEDICATION NAME] administration, however unable to start line at this time. Patient transferred to (hospital name redacted) for further evaluation and treatment. ROS : deferred d/t lethargy and [MEDICAL CONDITION] O: Vitals: BP difficulty obtaining, P 68, R-16 and labored, SpO2 88%, patient placed on 2l (liters) NC BS: 26 Gen: Lethargic, pale Pulm: Lungs diminished with no rhonchi , rales or wheezes .A/P: 1. [DIAGNOSES REDACTED]: 911 called, BS 26, [MEDICATION NAME] unavailable at facility for administration, glucose gel administered by EMS, EMS unable to obtain IV for [MEDICATION NAME] administration, patient transferred to EC. 2. Lethargy: BS 26, 911 called, [MEDICATION NAME] not available, glucose gel administered by EMS, difficult to obtain BP, HR 68, O2 SAT 88, pt placed on 2L NC, respirations 16 and labored. 3. Bilateral lower extremity [MEDICAL CONDITION]: [MEDICATION NAME] BID x3 days 4. Pt transferred to ER for further eval and mgmt. Grievanceor concern forms for R#801 were requested from the Administrator on [DATE]. On [DATE] at 10:34 [NAME]M., an investigation conducted by the facility was provided and reviewed. The following was revealed: A typed summary completed by the Administrator and the Medical Director of the facility that documented, (R#801) .Family .contacted Assistant Administrator (name redacted) to set up a family meeting to have 'a closure' about their (R#801's) death in the hospital .Family meeting was held on (MONTH) 20, 2019 with Director of Nursing (DON), Assistant Administrator and Administrator .During this meeting, family brought the following complaints: On [DATE], resident's family noticed that patient is more confused and had swollen feet and rash on her arm. Per family they noticed it during the day shift on [DATE]. (Family member's name redacted) said that family brought it up to the Nurse's attention and nurse said, 'She is fine'. Per (family member) she called again on the same day during the afternoon and talked to the receptionist about her (R#801's) confusion and was told that her message will be passed to the nurse .On [DATE] per family, patient appeared ' shaking' and her right had <sic> was swollen. Family said that they told therapist (name redacted) and nurse (Nurse D) about it (it was during the noon time per family). Family said that they did not feel (NP C) addressed their (R#801's) medical condition during the day on [DATE] . .Investigation: .(R#801) was seen by attending Physician (Physician B) on [DATE] (see H&P) where she was assessed to be in stable condition (note the H&P was not documented until [DATE] and did not address the resident's concern about BLE [MEDICAL CONDITION]) .Nurse Practitioner saw resident on [DATE] for leg [MEDICAL CONDITION] and to assess resident's progress. See progress notes from NP. NP started (brand name for diuretic medication to treat heart failure) 20 mg for 3 days to address legs [MEDICAL CONDITION] (the progress notes documented the medication was ordered on [DATE] by the physician) .Patient was seen by OT on [DATE] around 8:00 am-8:30 am and, OT reported to nurse that patient was 'unresponsive'. Per (Nurse A) (see her statement) she went to assess patient and found (R#801) to be responsive, eating breakfast and in stable condition. NP was to see patient (see progress note). NP spoke with (R#801's family member) at that time who was at the bed side and informed him that patient is stable now and she will be back to assess (R#801) again. When NP came back patient was having a labored breathing, blood pressure was not auscultated, pulse was 80, blood sugar was 28. 911 was called immediately, EMS arrived within 5 minutes and resident was taken to ER (see progress notes for details) . .Additional Information: Review of Daily Food Acceptance Record (FAR) showed that (R#801) was consuming between 50% and 100% of her meals on average. Nurses and CENAs who were assigned to this patient were interviewed (see attached notes). Per interviews, no change in resident's condition was reported until (MONTH) 5, 2019. Nurses and CENAs who worked with (R#801) more consistently stated that they did not see any signs of confusion as family reported and that they did not receive this information from the family .(Nurse D) worked from agency and we were not able to reach her yet after multiple attempts to contact agency (as family said that they talked to her about their concerns regarding resident's confusion) .This case was reviewed in details in facility's QAPI (Quality Assurance Performace Improvement) weekly meeting with the presence of the Medical Director (name redacted). (The Medical Director) reviewed (R#801)'s hospital record and facility's medical record. Per hospital record, (R#801) died in the hospital several hours after arrival from [MEDICAL CONDITION]. (The Medical Director) concurred with Facility's investigation . The following statements were included in the facility's investigation: A written and signed statement from Nurse A documented, On [DATE] @ 7:45 [NAME] I was with resident in (room number redacted). Check resident's VS ,[DATE] (BP)-74 (Pulse)-18 (Respiratory Rate)-98.2 (Temperature). Resident did not c/o any discomfort at this time. At 8AM the CNA informed nurse that therapy said the pt was 'unresponsive'. Nurse and assigned CNA went to the resident's room. Resident was alert and verbal. Denied any discomfort. Nurse encouraged resident to eat breakfast, resident ate half of meal .At/or around 9:45 [NAME]M.-10AM therapy in the hall saying again that 'resident is unresponsive'. Nurse and orientee went into check resident. Resident again remains alert and responding and in no acute distress., Writer then messaged NP (NP C) regarding resident. NP and Nurse in resident room. NP assessed resident. Pt in no acute distress. Resident (family member) in at this time. NP had brief conversation with him. Writer informed brother that if NP writes any new orders, I would let him know .At/or around 1:45 P.M. to 2PM writer and orientee took break. Upon returning to the unit, resident paperwork was handed to me, she going out 911. Informed by NP that resident BS 25. 911 arrived. Instant glucose tube given. BS to 32. 911 was unsuccessful at starting IV on resident. Resident transferred by 911. A written and signed statement from OT [NAME] dated [DATE] documented, On [DATE]: OT session started 7:42 [NAME]M. ended 8:32 [NAME]M. My initial contact with patient was this date [DATE]. Patient immediately request to use the toilet. T/F (transferred) patient to WC (wheelchair) with CENA's assistance. Patient was toileted and max difficulty staying seated upright with backward leaning. Patient was cleaned of soiled brief and slacks and returned to bed supine (lying facing upward) with HOB (head of bed) elevated. Patient reported 'I feel dizzy'. Vital signs monitored with O2 SAT 90%-94% on room air and HR (heart rate) ,[DATE] bpm (beats per minute). I asked the CENA to inform nurse of patients lethargy and minimal response/interaction and request nurse to attend to patient. The CENA left the room and returned a few moments later and stated that 'The nurse said she just took her vitals and they were okay, she just needs to eat something and wake up more.' After CENA brought breakfast tray to patient and was setting up, I left the room . A written and signed statement from CNA L (not originally included in the investigation folder provided by the facility) on [DATE] at 2:58 P.M. documented, At about 8:30 am I was walking down the hall and a therapist asked me to assist her with a transfer with a resident. While assisting with care the resident is very sluggish and out of it the therapist and I had to do all care for a <sic> patient. We put her back to bedroom I made her comfortable. Then about 11:30 a different therapist came to me in the hallway asking me who and where was the nurse. At the time the nurse was on a break but the therapist reported to me that the patient was not responsive but breathing and her pulse ox was 88 she attempted to take the patient's blood pressure but the cuff did not fit. I told her I would rely <sic> the message once the nurse returned I told her she went in and asked to patient was she ok. The patient replied yes and she left out. The nurse did not take vitals after either complaint she simply stated she already took her vitals this morning. The nurse (Nurse A) was walking up the hallway when it was reported to the CN[NAME] A written and signed statement from PTA N dated [DATE] documented, Yesterday, [DATE], I approached (R#801) in (room number redacted). I attempted to arouse her several times but was unsuccessful. Patient was breathing and had a pulse. I took patient's pulse oxygen and it ranged from ,[DATE]. I alerted (Nurse A) about (R#801) and she responded with 'her vitals were fine this morning.' I alerted the Nurse Practitioner after that. A written and signed statement from Nurse P dated [DATE] documented, Writer observed resident laying in bed looking very lethargic. Writer assisted 1 West Nurse with getting (vital signs monitor). Writer informed by Nurse Practitioner to call 911. Writer called 911. On [DATE] at 11:00 [NAME]M., an attempt to interview OT [NAME] by telephone was made. OT [NAME] was not available for interview prior to the end of the survey. On [DATE] at 11:55 [NAME]M., NP C was interviewed. NP C was asked if notified of a change in condition, what would she expect the nurse to have done prior to calling. NP C stated, Vitals, neurochecks, and blood sugar if diabetic. NP C was queried about R#801's changes in condition from [DATE]. NP C stated, The nurse told me (R#801) was unresponsive in therapy, but I don't think unresponsive was the right word. When I saw her she was alert, but drowsy and her vitals were fine. NP C was asked if she was aware R#801 had two episodes of unresponsiveness during the morning of [DATE] and reported she was unaware. When asked if she was aware that the Nurse did not take a new set of vitals after a change in condition was reported, NP C reported she was not aware. NP C reported that R#801 was stable when she saw her and told R#801's family member that the resident was stable and would come back to check on her. NP C stated, Someone contacted me and said (R#801) was not doing well so I went back in and at that time she had a change in condition. Her blood sugar was very low and [MEDICATION NAME] was not available in the facility. We called 911 right away. Tried to get a blood pressure, but could not. Her heart rate was stable. Her O2 sats were at 88% on room air. Tried to start an IV but her arms were [MEDICAL CONDITION] and it was unsuccessful. She got two tubes of glucose gel. When queried about what kind of blood sugar monitoring should be done for resident with type 2 diabetes, NP C stated, She was on oral diabetic medications. When she first came in, an order to check her blood sugar regularly was not warranted. When queried about any monitoring that should have been done on [DATE] such as vitals or a blood sugar check, NP C reported she did not order additional monitoring and reported R#801 was stable (R#801 did not have vital signs taken after a reported change in condition and a blood sugar level was not taken since [DATE]). On [DATE] at 1:25 P.M., Nurse A was interviewed via the telephone. Nurse A reported she worked at the facility in the past through a contracted agency. Nurse A stated, They stopped using me after a situation with a patient, but I never got any feedback. Nurse A was queried about R#801 on [DATE]. Nurse A stated, I took her vitals at 7:45 [NAME]M., then 30 minutes later they told me she was unresponsive, but she was talking to me. She (R#801) said she was tired and I said 'Let's eat some breakfast' and she ate some breakfast. Then one of the therapists mumbled under her breath that the resident was unresponsive, but she was talking to me like I'm talking to you right now. So I sent a computer message to the NP to take a look at her. (R#801) was here in the doorway of the room and (NP C) was in the room and assessed (R#801) and didn't give any new orders. I took a break and then when I came back she was getting ready to go out to the hospital because her blood sugar was low. They were looking for [MEDICATION NAME] and couldn't find any. Then 911 came. Nurse A reported she did not take R#801's vital signs after each report of unresponsiveness from the staff. Nurse A stated, I went in the room and she could talk both times. I took vitals that morning (prior to a reported change of condition) and they were normal. When queried about how R#801 could be assessed with [REDACTED]. She wasn't unresponsive when I saw her and the NP saw her and didn't give any new orders. On [DATE] at 3:05 P.M., the DON was interviewed. When queried about how a nurse should assess a resident with a reported change of condition, the DON stated, Labs, vitals, blood sugar if they are diabetic, check lungs, notify the doctor, and document everything. The DON was asked what should have been done on [DATE] when R#801 requested to be seen by the MD or NP due to concerns of BLE [MEDICAL CONDITION]. The DON stated, They (nurses) should be monitoring the resident, an assessment should be done and documented, and the physician informed. The DON reported vitals would be taken. R#801's record was reviewed at that time and the DON confirmed there were no vital signs taken by Nurse A or any nurse after [DATE]. The DON reported the physician should have been contacted on [DATE]. The DON reported she was unaware prior to [DATE] there was no [MEDICATION NAME] in the facility and that the backup supply was depleted. When queried about whether or not Nurse A conducted a proper assessment of R#801 upon being notified twice that R#801 was unresponsive, the DON reported she did not. On [DATE] at 8:54 [NAME]M., R#801's family member who was present in the facility on [DATE] was interviewed via the telephone. It was reported that they visited almost every day and stated, We knew things weren't right and they just weren't listening to us. Like she wasn't breathing right and I tried to tell them she was on oxygen in the hospital. R#801's family member reported that on [DATE] he went to the facility on his lunch hour and observed three staff members in R#801's room, including NP C. The family member stated, They were all around the bed and talking very loudly. I kind of held back by the door and the more they talked the more concerned I got. Then (NP C) walked out and told me (R#801) was really tired today and didn't go to PT, but that she had no concerns at all. Then the other two staff left the room and the nurse said, 'She's tired today.' R#801's family member reported he entered the room and sat down and read the paper to R#801 and noticed labored breathing. R#801's family member stated, I walked out into the hallway and asked someone 'Can I talk to the Nurse Practitioner?' and they said, 'She's writing notes and will be back in to see (R#801) in 10 minutes. 30 minutes went by and I found someone else and requested to see the nurse practitioner. At this point, (R#801) was breathing hard and I tried to wake her up and she was completely out of it. She didn't know who I was .Now an hour has gone by and I asked her 'Do you know my name?' and she said, 'Yes and in a raspy, guttural voice said my name. Finally I went to the hall again and a housekeeper was there and I said, 'Look, I need the nurse practitioner. I have been waiting for 90 minutes and something is not right.' He (the housekeeper) was the only one that helped me. R#801's family member further reported that at that time two other nurses came in and checked R#801's blood sugar which was 23 or 24 and stated, Then they brought the blood pressure machine in and it was broken and they had to get another. Nobody would tell me what her blood pressure was and said, 'It's low'. Then (NP C) comes in and tells them to call 911 and I was thinking, 'This was happening days before and you kept saying there were no concerns!' R#801's family member was asked when the family first noticed changes with R#801. R#801's family member stated, When I really noticed things were going bad was I think ,[DATE] when (R#801) was saying, '(another family member's name) was here and wouldn't leave until 10:00 P.M. He would just sit behind me and talk on the phone.' I asked her if she was dreaming and she was adamant and said, 'He even wrote notes all over the walls, but they cleaned it off.' R#801's family member further reported that he called that family member and confirmed they did not visit the resident in the facility and another family member told a nurse that R#801 was experiencing delusions and was very concerned. R#801's family member stated, (NP C) just kept saying, 'She's fine. She went to PT today, she's fine, but she went from fine to swelling to a rash to [MEDICAL CONDITION], to a total decline and then dying. On [DATE] at 11:20 [NAME]M., the Medical Director was interviewed. When queried about what was involved in an assessment by a Physician or Nurse Practitioner of a resident with a reported change in condition, the Medical Director reported it depended on the specific case and what was going on. The Medical Director reported the last set of vitals would be reviewed. When queried about what was known about what happened with R#801, the Medical Director stated, She was supposedly waxing and waning in mental status, but when the physician saw her she did not have any mental status changes. Also when the NP came to assess her she was okay and the family was at the bedside. She was doing therapy. When queried about whether or not vital signs were important during an assessment, the Medical Director stated, The NP spoke with the nurse and the nurse shared the vitals with her. The Medical Director reported he was unaware that the vital signs were only taken prior to the reported changes in condition. The Medical Director stated, As soon as she was not doing well, 911 was called. I reviewed the hospital records and she did not die of [DIAGNOSES REDACTED], she had a [MEDICAL CONDITION]. On [DATE] at 12:17 P.M., the Housekeeping/Laundry Supervisor (Staff Q) was interviewed and asked which housekeeper was assigned to the 1 East unit on [DATE] during the day shift. Staff Q reported that Housekeeper M was assigned during that time. On [DATE] at 12:33 P.M., Housekeeper M was interviewed. When queried about any family concerns brought to his attention on [DATE], Housekeeper M stated, It was probably me, but I can't really remember. On [DATE] at 1:48 P.M., PTA N was interviewed. When queried about her interaction with R#801 on [DATE], PTA stated, I approached the patient and she was supine in bed. She was not opening her eyes so I began rubbing her shin and she opened her eyes and mumbled. I noticed she was breathing differently so I took her O2 SATS and they were within normal limits. I reported it to (Nurse A) and then reported to the Nurse Practitioner (NP C) as well shortly after. PTA N reported this was going to be approximately her third OT session with R#801 and this was different than how she normally presents, especially with not opening her eyes. PTA N reported this happened around 11:00 [NAME]M. On [DATE] at 3:49 P.M., CNA L was interviewed via the telephone. CNA L reported she worked at the facility through a contracted agency and on [DATE] it was the first time she worked with R#801. When queried about what happened with R#801 on [DATE], CNA L stated, It was around 8:00 ([NAME]M.) and I was walking down the hall and a therapist needed assistance (with R#801) who was lethargic and sleepy. (R#801) was in the chair, we helped her to the bathroom and into bed. At that time, she was falling asleep on the toilet and couldn't stand on her own at all. The therapist said she didn't seem energized and was very sleepy so she took her pulse ox and it was at 81%. The therapist told me to notify the nurse, so I did. The nurse (Nurse A) told me it was too early in the morning for therapy and that she already checked her (R#801's) vitals. When queried about whether or not Nurse A took R#801's vitals or assessed R#801 after it was reported to her that R#801 was lethargic and sleepy, CNA L reported she did not. CNA L further stated, About two hours later, around 11:00 [NAME]M. another therapist was asking for the nurse. The same resident (R#801) she was trying to get up for therapy was out of it and not responsive but breathing. She tried to get a blood pressure but the cuff would not fit around her arm because of swelling. Her pulse oxygen I told the nurse (Nurse A) again what the second therapist said and she (Nurse A) got irritated went into the room, woke up the resident and said, 'Are you okay?, the resident said she was and the nurse just said, 'You're just tired, right?' She didn't check anything else, left the room, and went on break. Then later the other nurse, NP, and family was there and (Nurse A) got back from break. The NP said to get a set of vitals and they checked her blood sugar. CNA L was asked if anything were reported to her when she started her shift that day. CNA L reported she started on another floor and then came to 1 East. CNA L stated, Nothing was reported to me, but I did speak to other CNAs who regularly worked with (R#801) and they said she (R#801) is normally pretty independent and alert. On [DATE] at 4:00 P.M., Nurse D was interviewed via the telephone. Nurse D reported she worked in the facility previously through a contracted agency. When queried about any interaction with R#801's family on [DATE] or [DATE], Nurse D stated, I do remember a family member telling me they were concerned because the resident was confused and having delusions and that wasn't her baseline. I looked in the chart and saw she was on antibiotics for a UTI. The Nurse Practitioner was in the building so I let her know the family's concerns and she went in to see the resident. When queried about how the resident presented that da

This citation refers to Intake Number MI 322. Based on observation, interview, and record review, the facility failed to prevent neglect to one (R#803) of three residents reviewed for abuse and neglect, by leaving a resident who was a known fall risk with dementia and receiving end of life hospice services, unsupervised and seated in a wheelchair, resulting in the resident falling from the wheelchair, being found in a puddle of blood, and sustaining a laceration to the forehead requiring sutures. Findings include: A complaint was submitted to the State Agency that alleged, .On 8/5/2019 (R#803) had a fall. (R#803) had been placed in a seated position in her wheelchair but isn't ' to be in a seated position because of a fall risk. (R#803) is to be in a supine position only. An unknown staff member refused to transfer (R#803) into bed so that she could be in this supine position. The staff member then left (R#803) in her room unattended. While unattended (R#803) fell forward out of her chair and onto the floor, striking her head in the process. (R#803's) fall was not discovered for a period a <sic>half-hour to three hours. (R#803) was injured in the fall receiving a one-inch laceration with skull visible above her left eye, bruising to her left shoulder and severe pain . On 8/19/19 at 10:33 [NAME]M., during an unannounced onsite investigation at the facility, R#803 was observed lying in bed in a fetal position at the edge of the bed. Dressings were observed on both of R#803's feet. A large bruise was observed on R#803's right lower arm. R#803's left forehead was observed to have a laceration closed with sutures. When spoken to, R#803 mumbled in another language. R#803's clinical record was reviewed and revealed the following: R#803 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#803 received hospice services. A Minimum Data Set (MDS) assessment dated [DATE] documented R#803 had severely impaired cognition, required two person extensive assistance for bed mobility and transfers only occurred once or twice within the assessment period. There was no locomotion in a wheelchair on or off the unit during the assessment period. R#803 required total assistance from one staff member for eating. The MDS documented R#803 had one fall with an injury. A progress note dated 8/5/19 at 3:30 P.M. documented, pt. observed on room floor .dry dressing applied to laceration above left eye, PRN (as needed) pain meds administered . A progress note dated 8/5/19 at 7:52 P.M. documented hospice was in to see R#803 and gave new orders to send to the hospital. A progress note dated 8/6/19 documented, Returned to facility @ 930a .alert with a language barrier, unable to make needs known, sutures noted over left eye and bruising noted under left eye, bruising noted on left hip . An Incident and Accident (I&A) report dated 8/5/19 completed by Nurse [NAME] documented R#803 was observed on the floor in her room and sustained a laceration to the face. The predisposing situation factors was documented as using wheelchair. No witnesses were documented. Notes documented the following: On 8/6/19 (Certified Nursing Assistant - CNA B) wrote statement stating: At 2:00pm in the afternoon (CNA B) and (CNA H) got (R#803) up and outta <sic> bed to put in the wheelchair. She was sitting up in wheelchair eating grapes, drinking water, and watching TV. I left out of room to assist with team member (CNA D) .We left out of the room at 3:00pm. As I went to grab my things to leave home, (CNA C) came on the floor afternoon shift after doing her rounds on her hall and came up to me rude and disrespectful asking 'who got (R#803) in the chair?' I told her I did. She said to me, well you need to put her back down in bed or she's going to get the DON (Director of Nursing) because she shouldn't be up in her chair and if she falls its <sic> coming back on me. I told her I need help and that morning shift already left. She tells me, Oh well, you better get someone to help you because I didn't get her up, so find away to lay her down cause (CNA C) didn't wanna help and didn't feel like dealing with the son to help put her down. (CNA C) walked away and I walked away to clock out . On 8/6/19 a statement documented, .I, (CNA D) witnesses <sic> (CNA C) walk onto 1 west (unit) asking very loudly why was (R#803) in her wheelchair because she is a fall risk. (CNA C) asked me who had that side and I informed her that it was split. She began to get loud again stating that she wasn't putting her to bed because it was 5 minutes to 3pm and demanded (CNA B) to put her to bed and (CNA B) informed her that (CNA H) had left already. (CNA C) told her she did not care, I walked away and (CNA B) followed behind to avoid confrontation with (CNA C) who was still fussing and yelling about (R#803) being out of bed. On 8/6/19 a statement documented, (CNA H) wrote statement stating: On 8/5/19 I worked with (CNA B) and checked and changed her resident and put her resident in her wheelchair and that was at 2:30pm and she was fine watching TV in her wheelchair. On 8/6/19 it was documented, (CNA C) wrote statement stating: On Monday Aug. 5, 2019 I came on the floor at 2:45pm to check my set before day shift left and I noticed that (R#803) was sitting in her wheelchair and everyone knows that her family doesn't want her up cause she's a fall risk and went and told the aide (CNA B) that she needed to put her back to bed and her responds <sic> was well (CNA H) is gone now and I told her she still needs to go back to because you got her up and she's not to get up cause she can fall by this time I thought she went to put her to bed cause she walked away but she didn't and I was making the water cups and (another resident) yelled help cause the resident was on the floor in a puddle of blood and me and the nurse got her up and cleaned her up. On 8/6/19, Nurse [NAME] wrote a statement stating, On Monday 8/5/2019 approx. @ 2:50pm, (CNA C) informed (CNA B) to put (R#803) back in bed because she couldn't be up in her wheelchair unattended in her room. (CNA C) proceeded to go to ice room and make waters. (CNA B) grabbed her belongings and left the unit. I came out of the nursing office to check and see if pt was laid down and observed pt on the floor. A Interdisciplinary Post Fall Follow Up form dated 8/8/19 documented R#803 had 1 fall in past 90 days and/or since admission. The Root Cause Analysis documented, Resident was in the wheelchair and is unable to sit up for very long as she is weak and is end of life. New interventions implemented were Resident to be one on one when up in wheelchair. On 8/19/19 at 5:00 P.M., CNA B was interviewed via the telephone. CNA B reported she was unaware that R#803 fell on [DATE], received help from another CNA to put R#803 in the wheelchair and left to go home at 3:00 P.M. CNA B stated, (CNA C) didn't want to help me put (R#803) back in bed so (R#803's) son could feed her. CNA B reported she received education that R#803 should be supervised when she is up in the wheelchair. On 8/19/19 at 5:12 P.M., CNA C was interviewed via the telephone. CNA C stated, The shift before had (R#803) sitting up in the wheelchair and refused to put her to bed. We all know to never get her up and leave her in the wheelchair. I went to grab the nurse around 3 or 3:15 (P.M.) at the beginning of the shift to help me get her into the bed (the above statement from CNA C documented she left the resident to go pass water). CNA C reported R#803 is a fall risk and stated, I have never seen her up in the wheelchair. She is not stable. She is bed bound. On 8/19/19 at 5:20 P.M., CNA D was interviewed via the telephone. CNA D reported she did not care for R#803 on 8/5/19. CNA D reported she overheard confrontation between CNA B and CNA C and stated, (CNA C) told (CNA B) 'You need to put her (R#803) to bed' but didn't help her and (CNA H) already left. Then (CNA C) walked off and (CNA B) went home. I heard she fell . Personnel files for CNA B and CNA C were reviewed and did not include any disciplinary or inservice records regarding the above incident. On 8/19/19 at 5:30 P.M., the DON, Administrator, and Assistant Administrator were interviewed. The DON reported that an investigation was completed by Unit Manager, Nurse [NAME] The DON reported R#803 was assisted into the wheelchair and fell out. When queried about whether or not R#803 was safe to be unsupervised in a wheelchair, the DON stated, There was no care plan that said she was supposed to be (supervised) or not up in the wheelchair. When queried about the response by CNA B and CNA C both leaving the resident despite concern by CNA C about R#803 being up in the wheelchair, the DON and Administrator reported they should not have left her. The DON and Administrator were asked if the staff involved were educated after the incident and reported they would look into it. On 8/19/19 at 5:48 P.M., the Administrator provided a Teachable Moment form dated 8/6/19 signed by CNA B that documented, CENA got resident up in (room number redacted) and put her in her wheelchair. Cena said resident was safe & comfortable when she walked out of the room. Cena said when oncoming cena came on she wanted resident put back in bed but was not going to help with transfers. (CNA B) unable to find help to lay pt down then decided since her shift was over to clock out and go home. Resident ended up having a fall .Inform nurse that you are unable to find help and that resident is up in wheelchair before leaving the unit for the day. Making sure residents are safe before clocking out . The form did not indicate who provided the education. On 8/19/19 at 5:52 P.M., the Administrator reported no education was located for CNA C. A facility Abuse and Neglect policy last revised on 6/17/19 documented, It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment .Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional .

This citation pertains to Intake Number(s): MI 425 and MI 494 Based on observation, interview and record review the facility failed to follow up with two wound care consultations as ordered by the physician, follow through with vascular surgeon appointment(s), complete physician ordered wound care and notify the physician of worsening of a wound for three (R#'s 803, 804 and 805) of three residents reviewed for wounds, resulting in delayed treatment, wound care treatment not being completed and worsening of R#804's right foot and toes with the infestation of maggots on and in the wound requiring R#804 to be hospitalized . Findings include: Resident# 804 On 8/12/19 and 8/14/19, the State Agency received two complaints regarding the care of R#804. One of the complainant statements documented in part, . Patient R (right) foot near and on toes, flesh is actively decaying and many maggots are present on and in wound. There appears to be tunneling back toward middle of foot as well. Patient states that she feels very unsafe at the facility she is currently at and would like a social work consult. Patient was found to be soiled upon arrival. Appears to have been left that way for some time. Skin on bottom is significantly broken down, maceration from moisture present in entire area surrounding rectum. Patient injury is unclear in extent as far as depth goes . Hospital records for R#804 obtained from (hospital name redacted) documented the same documentation as noted above. On 8/19/19 an unannounced investigation was conducted onsite at the facility and revealed the following: R#804 was initially admitted into the facility on [DATE] and readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#804 had intact cognition, as indicated by a Brief Interview of Mental Status (BIMS) of 15 out of 15. R#804 required a two persons physical assistance for transfers and was totally dependent on staff for hygiene and bathing. R#804's physician orders were reviewed and revealed the following orders: 6/14/19 Wound consult rt (right) foot [MEDICAL CONDITIONS]. Review of R#804's clinical chart revealed this consultation was never completed. [MEDICATION NAME] Solution (Providone-Iodine), Apply to the right foot (toes) topically every day shift for skin care, cleanse with NS (Normal Saline), pat dry, apply [MEDICATION NAME] solution warp <sic> with Kerlix and apply right foot (toes) topically as needed for skin care cleanse with NS (Normal Saline), pat dry, apply [MEDICATION NAME] solution, warp <sic> with Kerlix (Start date of 6/14/19 and an End date of 7/15/19). Silver [MEDICATION NAME] Cream 1% Apply to 4th digit toe topically as needed for treatment (Start date of 7/16/19, on hold 7/31/19 and then discontinued on 8/2/19). There were no further orders found for R#804's right foot or toes after 8/2/19. 8/1/19 Wound consult rt (right) foot [MEDICAL CONDITIONS]. Review of R#804's clinical chart revealed this consultation was never completed. R#804's clinical record was reviewed and revealed: On 6/14/19 at 17:55 (5:55 pm), A Medical Practitioner note documented in part, . stability visit, medication reconciliation, with transition of care from (previous facility name redacted) . SKIN: Rt (right) foot wounds . SKIN: rt (right) foot toes and heel necrotic . Chronic [MEDICAL CONDITIONS] uncontrolled- consult wound care for rt (right) foot wounds. local wound care . On 7/18/19 at 17:21 (5:21 pm), A Medical Practitioner note documented in part, . Stability visit, medication reconciliation s/p (status [REDACTED]. Pt (patient) also seen by vascular for Rt (right) toes gangrene. F/u (follow up) as outpatient recommended . SKIN: Rt (right) foot wounds . SKIN: rt (right) foot toes and heel necrotic . Chronic [MEDICAL CONDITIONS] uncontrolled-consult wound care for rt (right) foot wounds. Local wound care. Pt (patient) to f/u (follow up) with vascular on 7/22 @10:45 am.Will monitor . Hospital Discharge instructions for R#804 dated 7/16/19 revealed a follow up appointment scheduled on 7/22/19 at 10:45 AM with (Doctor's and facility name redacted). When asked, Wound Nurse F confirmed that the resident did not attend this appointment as scheduled. A physician's consultation titled history and physical examination [REDACTED]. She was also seen by vascular doctor for the right second and third toe gangrene, outpatient treatment is recommended . right foot gangrene second and third toe, odor . Right foot second and third toe gangrene with mild odor, black discoloration. Chronic changes in the right lower extremity skin . [MEDICAL CONDITIONS]. Continue to follow right foot wound, local care, labile, unstable. I did open the dressing myself . Right lower extremity swelling, chronic. Continue to monitor, labile .(7/21/19-date of service). On 7/31/19 at 20:21 (8:21 pm), A Medical Practitioner note documented in part, . Per nursing staff, pt (patient) refuses HD ([MEDICAL TREATMENT]) on today. Pt (patient) seen and examined today. Pt (patient) reports that she is refusing HD ([MEDICAL TREATMENT]) due to uncontrolled severe constant Rt (right) foot pain secondary to gangrene. Pt (patient) currently received Tylenol for pain control. Dose was increased on yesterday. Pt (patient) states that she will not take anything stronger due to past Cardia arrest . Skin- Rt (right) foot toes and heel necrotic . Chronic RLE (right lower extremity) [MEDICAL CONDITION] labile-Pt (patient) continues to refuse additional/alternate pain meds (medications). Cont.(Continue) Tylenol as ordered. Dose increased yesterday. Pt (patient) to f/u (follow up) with surgeon for pending amputation. Will monitor . A physician consultation titled Progress Note documented in part, . Follow up right foot pain, gangrene, and pain control . Her right foot is giving her pain and does not happen all the time but sometimes it becomes unbearable. The patient is very tearful . Right foot gangrene second and third toe. Still metatarsal looks bad. The patient has mild amount of drainage, discomforting today . Dressing will be changed as well, labile .(8/4/19). On 8/11/19 at 18:00 (6:00 pm), A Nursing general progress note documented in part, . Writer went into pt (patient) room and observed dressing to right foot was soiled. Writer began to change soiled dressing, while unwrapping writer observed maggots in wound bed . Physician ordered to send pt (patient) out stat (as soon as possible) . R#804's weekly skin assessments and clinical record were reviewed and revealed no identification of new or further abnormal findings pertaining to R#804's right foot/toes or buttock area. On 8/19/19 at 2:15 pm, WN F was queried regarding R#804's wound care and stated We did the [MEDICATION NAME] once a day treatments. She was seen by an outside surgeon because of the necrotic toes and possibly needing an amputation. When asked why R#804 did not attend their appointment on 7/22/19 (for follow up care for R#804's right foot/toes), a clear explanation could not be provided. WN F was asked if they were notified of the worsening of R#804's right foot/toes and skin changes to the bottom/rectum area from the floor nurses or nursing assistants that provided care for R#804, WN F stated If we were aware we would have seen her. When asked what opportunities the nursing staff could have had to identify R#804's worsening skin conditions, WN F confirmed that staff complete skin assessments on shower days and weekly skin assessments. On 8/19/19 at 3:18 pm, the Director of Nursing (DON) was queried regarding R#804's wound care and could not provide any further information due to being newly employed at the facility. On 8/19/19 at 3:50 pm, the Administrator was queried regarding R#804's wound care and could not provide any further information due to being newly employed at the facility. On 8/19/19 at 4:52 pm, the Medical Director (MD) K was queried regarding R#804's wound care and stated, the leg should have been removed long ago but was unsure on why it wasn't. When MD K was informed that R#804 never had a consultation with wound care as ordered or made it to their appointment that was scheduled on 7/22/19 for follow up care of R#804's right foot/toes, MD K acknowledged that they were unaware of that. R#804's care plans were reviewed and revealed no care plan for R#804's right foot or toes. The WN F, DON and Administrator was asked to provide any documentation pertaining to the above deficient practice and no further information was provided by the exit of survey. Resident# 805 On 8/19/19 at 2:05 pm, an observation of WN F completing a dressing change on R#805 was conducted. The date observed on R#805's right foot dressing was dated 8/17/19. When asked R#805 stated, It's supposed to be changed daily but it wasn't yesterday. A physician order with the start date of 8/16/19 documented, Santyl Ointment 250 unit/GM ([MEDICATION NAME]) Apply to right heel topically every night shift for wound care cleanse with NS (normal saline) pat dry Apply Santyl cover with dry dressing at 7 pm. Review of R#805's (MONTH) 2019 Treatment Administration Record revealed two blank spaces on 8/16/19 and 8/18/19 for R#805's wound care Santyl order to the right heel. R#805 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/19/19 at 3:20 pm, the DON was queried regarding R#805's right heel wound dressing and stated, the nurses should be doing it daily. A care plan titled The resident has pressure ulcer development r/t Hx (history) of ulcers dated 3/12/19 documented in part, . Administer treatments as ordered and monitor for effectiveness . R#803 On 8/19/19 at 10:33 [NAME]M., during an unannounced onsite investigation at the facility, R#803 was observed lying in bed in a fetal position at the edge of the bed. Dressings were observed on both of R#803's feet. When spoken to, R#803 mumbled in another language. There were no pillows or boots observed to offload R#803's from the mattress or prevent R#803's feet and legs from making contact with each other. R#803's clinical record was reviewed and revealed the following: R#803 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#803 received hospice services. A Minimum Data Set (MDS) assessment dated [DATE] documented R#803 had severely impaired cognition, required two person extensive assistance for bed mobility and transfers only occurred once or twice within the assessment period. R#803 was assessed to have one venous/arterial ulcer which was also documented on the admission MDS assessment completed on 4/10/19. Physician's orders were reviewed and revealed the following orders: An order with a start date of 5/21/19 to Apply clean dry dressing to right lateral leg and right heel every day shift every Tue, Thu, Sat for skin care and as needed for skin care . An order with a start date of 7/6/19 to cleanse the left heel with normal saline and apply a medical honey wound dressing gel, cover with dry dressing, and wrap with kerlix every day shift and as needed. August 2019 TARs revealed the treatment to R#803's right lateral leg and right heel was completed on 8/17/19 as scheduled and PRN on 8/18/19 at 2:26 P.M. with next treatment due on 8/20/19. The treatment to R#803's left heel was not completed on 8/5/19, 8/7/19 (marked as refused), 8/9/19, and 8/11/19 (marked as refused). The TAR indicated the treatment to R#803's left heel was completed as scheduled on 8/18/19 and PRN at 2:26 P.M. on 8/18/19. On 8/19/19 at approximately 11:00 [NAME]M., Nurse G was interviewed about any wound care required for R#803. Nurse G reported she was not sure. On 8/19/19 at 11:50 [NAME]M., Wound Care Nurse (Nurse F) was observed while performing wound care to R#803 along with Nurse G. The dressings to R#803's left heel and right leg/right heel were dated 8/19/19 at 7:00 [NAME]M. (they were not signed out as completed on the TAR, scheduled or PRN). R#803 was observed at that time to have no heel protectors or offloading interventions implemented to prevent her feet/legs from coming in contact with the mattress or each other. The dressing to R#803's left heel was observed soiled and falling off. Drainage was observed on the bed sheet. An pink open area was observed on R#803's left heel. Nurse F proceeded to cleanse the wound with normal saline. R#803 flinched and began talking in a foreign language. Nurse F and Nurse G proceeded to remove the dressing from R#803's right foot/leg. The dressing was stuck to the leg and when removed revealed an open area, drainage on the dressing, and the wound began bleeding. Nurse F stated, There was probably just a scab there that came off. I think it just happened. Nobody notified me of it. We were just keeping it wrapped because she has fragile skin. During wound treatment, R#803 continued to speak in her native language, grimace, and pull at her leg. Nurse F' was queried about whether or not R#803 was medicated for pain relief prior to wound care and Nurse F stated, She gets medicated PRN. She's okay when I do wound care. When asked how it was known how R#803 felt when she was speaking in a foreign language, Nurse F stated, Honestly, I don't know what she is saying. Nurse F did not identify R#803's grimacing, speaking in her language, or pulling at her leg as possible signs of pain. After wound treatment was completed, Nurse G stated, I'm going to put a pillow between her legs. Further review of R#803's clinical record did not reveal any documentation of a new open area to the right inner lateral leg (which was observed prior to wound care to be in direct contact with R#803's left leg). The (MONTH) 2019 MAR for R#803 indicated the resident last received pain medication ([MEDICATION NAME]) at 4:04 P.M. on 8/18/19 and it was documented R#803 refused scheduled narcotic pain medication at 6:00 [NAME]M. on 8/19/19 and scheduled [MEDICATION NAME] at 6:00 [NAME]M. However, it was not explained how R#803 refused medications or what her understanding was of the medications as she did not speak English. R#803 last had pain medication at 10:00 P.M. on 8/18/19. A Wound Consultation dated 7/31/19 documented Recommend soft heel boot qd (daily) when in bed. A care plan created 4/4/19 documented R#803 had potential/actual impairment to skin integrity L (left) heel-mixed vascular ulcer per wound doctor. Interventions initiated on 4/4/19 included Follow physician's orders for treatment of [REDACTED]. On 8/19/19 at approximately 2:00 P.M., the Director of Nursing (DON) was interviewed regarding standard interventions for residents at risk of skin breakdown or who already have skin breakdown. The DON reported offloading interventions should be put in place upon admission and/or upon recommendation of the wound care team. R#803's clinical record was reviewed and revealed an intervention for bilateral heel protectors while in bed documented on the Kardex (Certified Nursing Assistant - CNA care guide), but no physician's order or care planned intervention. The DON acknowledged that all treatments should be completed according to physicians orders which would be indicated by a nurse's signature on the TAR. The DON further reported that all new skin alterations would be reported to the physician and Nurse F. A facility policy titled Skin Monitoring and Management- Non-PU (Pressure Ulcer) dated 07/11/2018 documented in part, . It is the policy of this facility that a resident having areas of skin breakdown (unrelated to pressure) receive necessary treatment and services to promote healing, prevent infection, and prevent new non-pressure sores from developing . The nurse responsible for assessing and evaluating the resident's condition on admission is expected to take the following actions . Identify risk factors which relate to the possibility of skin breakdown which include, but are not limited to . generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency . All risk factors identified on assessment should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown . Develop comprehensive care plan if indicated following the evaluation/assessment. Care plans must be individualized and designed to meet the needs of the resident for whom they are being developed . A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation or discoloration, or other unusual findings must be documented in the resident's clinical record . A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each non-pressure ulcer, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: Measuring the non-pressure ulcer, Describing the nature of the non-pressure ulcer (e.g., stasis, surgical wound), Describing the location of the non-pressure ulcer, Describing the characteristics of the non-pressure ulcer, Describing the progress with healing, and any barriers to healing which may exist, Identifying any possible complications or signs/symptoms consistent with the possibility of infection . Re-evaluating existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any non-pressure ulcer is non-healing or not showing signs of improvement after 14 days or any time a non-pressure ulcer is worsening . The weekly review should include the following: arterial ulcers, venous ulcers, diabetic ulcers, non-healing wounds . On shower days, CNAs (Certified Nursing Assistants) to observe resident skin. Identify any areas of skin breakdown, discoloration, tears or redness. Communicate findings to licensed nurse: verbally, in writing via Skin Observation- Shower form . All residents will have a head to toe skin check performed at least weekly by a facility licensed nurse. Then licensed nurse should document the performance of the skin check in the resident's clinical record . Any changes in the condition of the resident's skin as identified daily, weekly, monthly or otherwise, must be timely communicated to: The resident's physician, The resident/responsible party, Others as necessary to facilitate healing .

This citation pertains to intake #MI 055. Based on observation, interview and record review, the facility failed to ensure adequate assessment and investigation into an unwitnessed fall for one (R#801) and ensure an environment free from hazards for three (R#s 801, 802 and 803) of three residents reviewed for falls, resulting in R#801 sustaining a fall and subsequent hospitalization for an acute proximal right femur fracture, and the increased likelihood of continued falls from environmental hazards. Findings include: A complaint was submitted to the State Agency that alleged the resident sustained [REDACTED]. An onsite investigation into this allegation was conducted on 7/31/19. Resident #801 On 7/31/19 at approximately 11:00 AM, the Director of Nursing (DON) was requested to provide any documentation of the facility's investigation, including witness/staff statements regarding the resident's fall on 7/21/19. R#801's clinical record was reviewed and revealed the following: R#801 was admitted into the facility on [DATE] and discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. As of this onsite investigation, R#801 remained hospitalized and was reviewed as a closed record. According to the Minimum Data Set (MDS) assessment dated [DATE], R#801 had severely impaired cognition (scored 4/15 on brief mental status exam), had impaired vision, exhibited no behaviors, required extensive assistance of one person for bed mobility, transfers, and toilet use, used walker and wheelchair for mobility, was continent of bowel and bladder, and had a fall prior to admission, but none since admission. Review of R#801's fall risk assessments since admission documented the resident was determined to be a high risk for falling. Review of the admission fall assessment dated [DATE] documented, in part: High Risk for Falling .Gait .weak .Mental Status .Overestimates or forgets limits . Review of R#801's fall care plan initiated 6/22/19, revised 7/26/19 documented, in part: The resident is at risk for falls r/t Confusion, Gait/balance problems, self transfers. Interventions prior to the unwitnessed fall included: Minimize risk factors in environment; areas free of spills and clutter . (implemented on 6/22/19). Review of R#801's radiology report dated 7/21/19 documented, in part: .Reason for Study .Pain in Right Thigh .Results: There is a fracture involving proximal femur with no displacement .Conclusion: Acute proximal right femur fracture as described . Review of the facility's documentation of R#801's fall included, Reported fall .Date: 7/21/2019 03:12 (3:12 AM) .Around 0310 (3:10 AM), notified by caregiver (no specific staff identified) that pt (patient) is on the floor. Pt observes <sic> on her R (right) side next to her bed, bed was in the lowest position. Pt ice water was on the floor .pt helped back to bed, neuro check initiated, x-ray ordered .Alert confused .Predisposing Environmental Factors .Wet/Slippery Floor . Statements attached to this report included: Name of Certified Nursing Assistant (CNA C) stated she worked 1 west and did not take care of resident. When (name of CNA I) walked off the unit (name of CNA G) took over on 1 east. CNA (CNA F) stated she did not provide any care to the resident. Per phone conversation: Manager (Nurse Manager H) spoke with the nurse (Licensed Practical Nurse/LPN D) about the incident. Nurse stated that she did not witness the fall but the CNA came and informed her that the resident was on the floor. The nurse stated that the resident was trying to grab her water and dropped it on the floor. Then the resident was trying to get up to go to the bathroom and feel <sic>. The nurse stated that she performed range of motion performed <sic> resident complained of pain to the right leg. The nurse called the NP (Nurse Practitioner) and received orders to get an Xray. (There were no statements included for CNA G or CNA I.) On 7/31/19 at 12:45 PM, an interview was conducted with the Administrator and DON regarding R#801's fall on 7/21/19. The DON confirmed the fall was unwitnessed and resulted in a fractured femur and subsequent hospitalization . When asked about the facility's investigation into the events surrounding the fall, the DON reported an investigation was still being conducted. There was no further documentation included into the facility's investigation into the events regarding this fall. On 7/31/19 at 1:12 PM, a phone interview was conducted with LPN D. When asked to recall R#801's fall on 7/21/19, LPN D stated, That was when the aide, I don't know her name, she said the patient was on the floor. After that I saw she was on the floor, did assessment on range of motion and noticed anytime I moved right leg she was like slow down, that hurts .I ordered STAT x-ray and they came like 6:45 AM, so told oncoming nurse to follow up. I was really pissed cause she (CNA I) said she wanted to make a phone call and left the floor and after a couple hours, she still didn't come back. She left and lied to me. I had to reassign. LPN D was asked for specific names of the CNA that left the floor and did not return, nor the name of the CNA that was reassigned and reported that was her first time working with that resident as she normally works at another facility and was just helping out. On 7/31/19 at 1:19 PM, a phone interview was conducted with CNA F who reported working in another area of the facility and did not have any information about R#801's fall incident. On 7/31/19 at 1:25 PM, an interview was conducted with the Administrator and DON regarding R#801's fall on 7/21/19. When asked about the fall, the DON reported R#801 fell while she attempted to get up to go to the bathroom. When asked how that could be determined since the fall was unwitnessed and the resident had severely impaired cognition, the DON offered no further response. The DON further reported that she was still in the process of completing the investigation and had been unable to contact CNA G for a statement. The DON and Administrator were asked about CNA I leaving the floor for hours and the DON stated, When first became aware it was 1 something in AM. I got a text message from our CNA (name of CNA I). I spoke to nurses later and reported to Administrator that we had a staff walk out. He (Administrator) was notified. That was a Saturday at 3:10 AM (date of incident was on Sunday). I'll have to talk with him to see exactly when I called him. She (CNA I) reached out to me, but you walk out, you abandon your job and she was terminated. When asked if CNA I had been reported to the appropriate State Agency, the DON was unsure. The DON further reported, She (CNA I) left around 11:50 that night. She (R#801) was reassigned to another CNA, (name of CNA G). I've been unable to get ahold of CNA G since I became aware of this which is why my investigation is still ongoing. I had another nurse manager call staff to get statements, (name of Nurse Manager H) took statements over the phone, but she's not here today. When asked if the circumstances of CNA I leaving the floor for hours could have contributed to R#801 not receiving adequate care, potentially leading to the fall, neither were able to offer any further explanation. On 7/31/19 at 2:08 PM, the Administrator was requested to provide information on when CNA G was scheduled to work next, and whether she had worked after 7/21/19. On 7/31/19 at 2:09 PM, CNA G was attempted to be contacted at the phone number provided by the facility, however there was no answer. On 7/31/19 at 2:14 PM, a phone interview was conducted with Nurse Manager H. When asked about R#801's fall on 7/21/19 and the concerns regarding staff leaving the floor, Nurse Manager H stated, I was not able to get in touch with (name of CNA G) .Even staff reached out. I helped with putting out calls to see who saw what happened .My issue is I can't figure out anything about the fall, it was unwitnessed. Would assume that she was reaching for water and it fell and then she fell , but we can't confirm if that was actually what happened or not. On 7/31/19 at 2:25 PM, the DON was requested to follow up regarding the scheduling information for CNA G and reported, She (CNA G) was scheduled. I left a message with scheduler, she's regional and doesn't work in the building, she's available by phone. On 7/31/19 at 2:44 PM, the DON reported, (name of CNA G) called off 7/21 and 7/22 and returned on 7/23, and not due back till (MONTH) 2nd. I don't have any investigation completed yet with her (CNA G). At that time, the DON provided another phone # for CNA G. When asked about the staff working following the fall incident and why staff had not obtained a statement at that time, the DON was unable to offer any explanation. On 7/31/19 at 2:48 PM, a phone interview was conducted with CNA G. When asked to recall the specific events from R#801's fall on 7/21/19, CNA G stated, I walked in the room and she was on the floor. Was trying to get out of bed and fell . The nurse checked her and she (R#801) said her leg was hurting. When asked how she could determine the events leading to the fall given it was not witnessed, CNA G stated, I don't but I asked her (R#801) and she said she did that. When asked if R#801 had exhibited any impaired memory or had incontinence, CNA G stated, She's alert but nurse said she was a little confused .I did have to change her at the time, she was incontinent of poop. On 7/31/19 at 3:30 PM, the Administrator and DON were informed of the concern regarding hazardous environment and lack of thorough and complete investigation into R#801's fall and both confirmed as well. The Administrator requested to provide documentation of inservices the facility had done with staff on 7/2/19 regarding proper documentation of incidents but stated, I know that's before her incident. Resident #802 On 7/31/19 at 8:55 AM, R#802 was observed lying in bed facing the wall while tube feeding was actively infusing via a pump. At that time, the headboard and footboard were observed to be loose and slanted to the left side in a slanted position. There were two fall matts, the matt closest to the wall was observed tucked under the bottom feet of the bed. The tube feeding pump was next to the headboard and at that time, the flooring below was observed to have a large spill of tube feeding (same color that was in the tube feeding bag that was currently infusing) with multiple plastic caps stuck on the floor in the spill. There were also plastic caps observed on the bedside dresser next to the tube feeding syringe. On 7/31/19 at 10:59 AM, R#802's bed and soiled, wet floors were observed in the same manner as earlier. On 7/31/19 at 11:40 AM, the Administrator was requested to observe the resident's room. Upon entering the room, the resident had been repositioned in bed, however the headboard and footboards remained loose and leaning to the left, the fall matt remained under the feet of the bed, and the tube feeding spill and plastic caps remained on the floor underneath the tube feeding pump. At that time, the Administrator confirmed the observations. On 7/31/19 at 11:47 AM, LPN J and CNA K were observed in the room and upon entering room, CNA K stated, We're about to provide care. CNA K and LPN J were asked about the head and foot boards and whether they had seen that earlier. LPN J stated, I really didn't notice. CNA K shook her head in a no motion. When asked about the tube feeding spilled on the floor, LPN J stated, As far as what? Was brought to housekeeper's attention yesterday. At approximately 11:50 AM, Maintenance Staff L entered the room and after pulling on the footboard, indicated some hardware was missing. Maintenance Staff L also reported, Those floor mats should be beside the bed, not under the frame like that was (pointed to area of matt under the bed frame). We'll take care of it. When asked if he had been notified of any concerns regarding unsafe resident equipment, Maintenance Staff L reported, Just notified now. When asked what the process was, Maintenance Staff L stated, We have a work order book in a binder at the nursing station. At that time, Maintenance Staff L reviewed the log and stated, There's nothing in here about that. R#802's clinical record was reviewed and revealed the following: R#802 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], R#802 was severely cognitively impaired (scored 00/15 on mental status exam), and required extensive to total dependence with most activities of daily living. Although there were no falls documented on this MDS assessment, the resident had been assessed on the fall risk tools as high risk for falling. Resident #803 On 7/31/19 at 8:57 AM, prior to entering the room and while in the room, there was a very strong, pungent urine odor. R#803 was observed lying in bed with a hat covering his face. A urinary catheter drainage bag was observed hanging from the side of the bed. Below the drainage bag, there was a large wet spill that appeared to be coming from the drainage back and extended approximately 3 feet across the tiles towards the other bed in the room. On 7/31/19 at 11:01 AM, the same wet spill was observed on the floor. There was now a white towel folded and placed underneath the drainage bag. R#803 was asked about the towel and spill but was unable to offer any explanation. On 7/31/19 at 11:03 AM, Housekeeper M was observed two doors down and when asked about whether anyone had let her know about the spill in R#803's room stated, No one said anything to me today about spills. At that time, Housekeeper M observed the wet floor in R#803's room and stated, I'll get in there and take care of that. On 7/31/19 at 11:54 AM, the Administrator was requested to observe R#803's room and confirmed the spill on the floor with the white towel remained. Housekeeper M had not cleaned the room as stated earlier. The Administrator was asked about how the facility ensures safe environments, free from hazards, especially for residents that are at risk for falls and stated, The spills should be cleaned up immediately. R#803's clinical record was reviewed and revealed the following: R#803 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], R#803 had moderately impaired cognition (scored 12/15 on mental status exam), exhibited no behaviors, required extensive assistance of two people, had an indwelling urinary catheter, and had one fall during this assessment period. Review of the facility's Policy/Procedure - Nursing Administration Fall Prevention dated Adopted 07/11/2018 documented, in part: .It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents .The Director of Nursing/designee will be responsible for tracking resident falls . Review of the facility's Policy/Procedure - Infection Prevention and Control Cleaning, Disinfection and Sterilization dated (Adopted 07/11/2018) documented, in part: .It is the policy of this facility to provide supplies and equipment that are adequately cleaned, disinfected or sterilized .CLEANING: Supplies and equipment will be cleaned immediately after use. Gross blood, secretions and debris will be removed as soon as possible. Cleaning may be done in the resident's room or the soiled utility room .

Based on observation, interview, and record review, the facility failed to routinely perform skin assessments, ensure proper positioning of residents, and implement interventions to prevent the development of facility acquired pressure ulcers for five residents (R#'s 41, 22, 49, 26, and 132) who either had existing pressure ulcers or were identified at risk for the development of new pressure ulcers, of 10 residents reviewed for pressure ulcers, resulting in the development of two stage three pressure ulcers, (a stage three pressure ulcer is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue) a stage two pressure ulcer, (a stage 2 pressure ulcer is a partial-thickness loss of skin with exposed dermis) and the likelihood for the worsening of existing pressure ulcers or the development of additional pressure ulcers. Findings include: R#41 On 3/25/19 at 8:49 AM and 4:00 PM, R#41 was observed in bed with their eyes closed. R#41 was receiving tube feeding formula through their feeding tube via an automated pump. R#41's right heel was observed on the mattress and the left heel was observed resting on a pillow. A sheet was covering R#41's toes and no protective soft heel/foot boots were observed to be on R#41's feet at those times. It was also noted R#41 had small dressings on their bilateral ears. On 3/26/19 at approximately 10:00 AM, R#41 was observed in their bed with their eyes closed. R#41's feet were propped on a pillow with the pillow applying pressure to the heels. R#41's legs and feet were covered with a sheet and soft heel/foot boots were not observed to be on R#41's feet. On 3/26/19 at 2:57 PM, R#41 was observed in bed. R#41 was awake, but was not responsive to attempts at verbal communication. R#41's feet were observed propped on a pillow with a sheet covering them. R#41 was not observed to have protective soft heel/foot boots on their feet. Dressings remained in place to R#41's bilateral ears. At that time, an interview with R#41's family who was at the bedside was conducted. The family member indicated they visited the resident daily. R#41's family was queried if they ever observed R#41 out of bed and explained they were concerned that they had never seen R#41 out of the bed. The family member stated, She has a bed sore on her bottom, maybe that's why they don't get her up, but I thought they could still could. That's been a concern for me and her other family. R#41's family member also explained that R#41 admitted to the facility in (MONTH) of 2019 and had recently had to go to the emergency room . The family member stated, She came here with the bedsore she got at (hospital name) and she went back there to have it debrided about a month ago. She came back on IV (intravenous) antibiotics that I think were for the infected bed sore. At that time, a review of R#41's closet was conducted and soft heel/foot boots were observed on a shelf in the closet. On 3/27/19 at 8:32 AM, R#41 was observed in bed with their eyes closed. Dressings were present on R#41's bilateral ears. R#41's right and left heels were resting directly on a pillow with a sheet covering them. R#41 was not observed to have protective soft heel/foot boots on at that time. The heel boots were observed to remain in the closet on the shelf. On 3/27/19 at 9:51 AM, a full body skin assessment for R#41 was conducted with Licensed Practical Nurse (LPN) 'D' with Certified Nursing Assistant (CNA) 'L' assisting. At the time of the skin assessment, R#41 was observed to have dressings on their bilateral ears and was not observed to have protective heel/foot boots on their feet. The skin assessment revealed the following: 1. R#41's great toe on their left foot revealed a stage 2 ulceration on the bony prominence of the great toe knuckle. The wound was approximately 1 centimeter (cm) x 2 cm with a red base and a small amount of dried red drainage. 2. R#41's second digit on their left foot revealed a round, stage 3 ulceration on the bony prominence of the second digit's knuckle. The wound was approximately 2 cm x 2 cm x 0.5 cm. The center of the wound was beefy red turning to pink, to white, to the darker pigmentation of R#41's skin as it moved from the center outward. The edges of the wound appeared to be rolled. It was noted that R#41's skin on their feet and toes was extremely dry with large and small flakes of skin being sloughed off. 3. R#41's left elbow bony prominence was observed to have a round ulceration with rolled edges measuring approximately 2 cm x 2 cm x 0.5 cm. The center of the wound was beefy red turning to pink as it moved from the center outward. White slough was observed in the base of the wound on the right and left side. It was observed that the white bed sheet where R#41's elbow was placed was soiled with an area of pinkish and yellowish stains. The skin assessment also revealed an occlusive foam dressing (approximate 10 cm x 10 cm in size) on R#41's coccyx. The foam dressing appeared to be shadowed with a large amount of wound drainage. A review of R#41's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#41's Minimum Data Set (MDS) assessment dated [DATE] revealed severely impaired cognition, no behaviors or rejection of care, total assistance of two staff members for bed mobility, coding for transferring was activity did not occur, and total assistance of one to two staff members for dressing, eating, hygiene, and bathing. Section M. of the MDS assessment also indicated that R#41 had an existing, non-healed, unstageable pressure ulcer and was at risk for the development of pressure ulcers. A review of R#41's weekly skin assessments documented in the record was conducted and revealed only one skin assessment, dated 1/14/19 that indicated R#41 had a pressure ulcer on her sacrum/coccyx, however the assessment did not include any measurements or staging for the ulceration. A nursing re-admission assessment dated [DATE] read, .Resident have <sic> large open area to coccyx wound bed pink moist with scant amount of drainage . It was noted the assessment did not include the measurement or the type of wound on the coccyx. R#41's Braden Scores (A numerical scale to measure the risk of the development of pressure ulcers) were documented as Very high risk on 3/1/19, High risk on 3/8/19, and a Low risk on 3/17/19. Review of R#41's CNA kardex (care guide) was conducted and read, .FYI HEEL PROTECTORS: (Bilateral/Right/Left) on while in bed . A review of R#41's care plans was conducted and a care plan for R#41's existing wound included an intervention dated 1/24/19 that read, .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . A review of the skin assessment in the record for the observations made with LPN 'D' on 3/27/19 at 9:51 AM was conducted and documented R#41 had a pressure ulcer on their left elbow (stage of wound was left blank), had an open area on their left great toe, and had an open area for a site documented as Other (specify) that was left blank. It was noted the skin assessment did not include assessment of R#41's existing coccyx wound or any descriptions of the wounds the dressings on the ears were covering. On 3/27/19 11:02 AM, an interview with Nursing Unit Manager 'E' was conducted regarding the facility policy for skin assessments. Unit Manager 'E' indicated the assessments were supposed to be done weekly. Unit Manager 'E' was then asked about R#41's missing skin assessments and the discovery of 3 new pressure ulcers on R#41, and Unit Manager 'E' had no explanation why the weekly skin assessments were not completed. Unit Manager 'E' was further queried if any kind of auditing was being done to assure the assessments were being completed and indicated that it was not. When queried about the Braden Scores going from a Very high risk to a Low risk in approximately two weeks time, Unit Manager 'E' stated, It doesn't seem like they are doing those right. Unit Manager 'E' was then asked about the heel boots and indicated they should have been in use. 03/27/19 at 4:59 PM, an interview with the facility's Director of Nursing (DON) and Corporate Nurse Consultant 'K' was conducted. At that time it was indicated skin assessments were supposed to be completed weekly and documented in the resident's electronic medical record. When further queried about the Braden Scores going from a Very high risk to a Low risk in approximately two weeks time, it was indicated that they would look into it. The DON and Corporate Nurse Consultant 'K' were then asked about the quality of the assessment documented by LPN 'D' where sites and types of wounds were not indicated and Corporate Nurse Consultant 'K' stated, We have to get some things in place, the wounds need to be described and with proper assessment then we would be able to determine if there was improvement. R#22 On 3/25/19 at 9:32 AM, R#22 was observed in bed in a hospital gown. R#22 was not responsive to attempts at verbal communication. R#22's upper and lower extremities were contracted and no protective soft heel/foot boots were observed on R#22's feet. On 3/25/19 at 12:00 PM, and approximately 3:15 PM, 3/26/19 at 8:31 AM, and 2:34 PM, and 3/27/19 at 9:08 AM, R#22 was observed in bed clothed in a hospital gown. At those times, R#22 was not observed to have protective soft heel/foot boots on their feet. A review of R#22's clinical record was conducted and revealed and admitted d of 9/13/18 with [DIAGNOSES REDACTED]. A review of R#22's most recent MDS assessment dated [DATE] indicated R#22 was non-verbal, had severe cognitive impairment, and required total assistance of one to two staff members for all activities of daily living. A review of R#22's documented skin assessments in the record was conducted and revealed 3 assessments dated 12/27/18, 1/3/19, and 3/14/19. It was noted R#22 did not have a weekly skin assessments documented for approximately 10 weeks between 1/3/19 and 3/14/19. A review of R#22's CNA kardex was conducted and read, .HEEL PROTECTORS: Bilateral/Right/Left on while in bed. (FYI) . On 3/27/19 at 10:25 AM, an interview with Nursing Unit Manager 'E' was conducted regarding skin assessments. Unit Manger 'E' explained that skin assessments were supposed to be done at least weekly and shower sheets were also done, but further explained the shower sheets were not part of the clinical record. Unit Manager 'E' was also asked about the documentation for the application of the heel boots and indicated that it may have beep put into the CNA task list incorrectly which would mean that the CNA's couldn't document that it had been done. On 3/27/19 at 10:31 AM, a full body skin assessment on R#22 was conducted with Unit Manager 'E'. At the time of the assessment, R#22 was not observed to have the protective heel boots on their feet. A review of R#22's night stand and dresser drawers, as well as R#22's closet was conducted with Unit Manager 'E' and did not reveal heel boots present in the room. 03/27/19 at 4:59 PM, an interview with the facility's Director of Nursing (DON) and Corporate Nurse Consultant 'K' was conducted. At that time it was indicated skin assessments were supposed to be completed weekly and documented in the resident's electronic medical record. At the time of the interview Corporate Nurse Consultant 'K' indicated knowledge of concerns with facility's skin assessments and pressure ulcers and explained that they needed to get things in place. Resident #49 On 3/26/19 at approximately 9:00 A.M., R#49 was observed lying in bed. R#49 did not make eye contact when spoken to and was non-verbal. R#49 was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically placed to deliver nutrition directly to the stomach) and had a [MEDICAL CONDITION] (a surgical opening in the neck to provide an airway). On 3/27/19, R#49's family member was interviewed. R#49's family member reported the resident was unable to talk and had a [MEDICAL CONDITION]. R#49's family member stated, The staff don't always turn and reposition him (R#49). I've been here before from 3-7 (PM) and nobody checked on him. R#49's family member reported that the resident developed a pressure ulcer on his right elbow. R#49's family member reported that R#49 was not evaluated by a physician. When queried about when the pressure ulcer, R#49's family member reported it was about a week ago and stated, I was just told it was kind of like a skin tear. On 3/27/19 at 1:27 P.M., an observation of R#49's right elbow was conducted with Nurse O. Nurse O removed a dry adhesive dressing dated 3/27/19 and revealed a round, pink area of partial-thickness skin loss with exposed dermis over the bony prominence of the elbow approximately 1.5 centimeters (cm) by 1.5 cm. When queried about what was going on with R#49's elbow, Nurse O stated, It was documented as a skin tear, but it doesn't appear to be a skin tear to me. I don't know if it's from him leaning on it or what. Nurse O reported that she would have to readminister the treatment because the dressing was not sticking. The physician's orders [REDACTED]. When queried about whether or not xeroform was present when Nurse O removed the dry dressing from R#49's elbow, Nurse O reported that it was not and reported the treatment was done by the midnight shift nurse. R#49's clinical record was reviewed and revealed the following: R#49 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Progress notes were reviewed since R#49's admission date of [DATE] and revealed an eMAR Note note on 3/25/19 at 6:13 A.M. that documented, .R elbow - Cleanse area with NS, apply xeroform and cover with dry dressing daily every night for skin tear .delegate to next shift . There were no other progress notes that documented the skin alteration to R#49's right elbow. The last weekly skin assessment dated [DATE] (over one month prior) documented, .skin intact no alterations noted . and readmission nursing assessments documented no open areas. On 3/27/19 at 3:25 P.M., an interview with the 2 West Unit Manager, Nurse C was conducted. When queried about the protocol when a skin alteration was identified, Nurse C stated, They notify me, the treatment nurse, and put in a treatment order. Nurse C reported there was no treatment nurse for the facility currently. When asked who determined what type of wound was present, Nurse C stated, The nurse can look at it and make their judgment and then they can be seen by the wound doctor. Nurse C was unable to provide an answer about when the attending physician would be notified or who ordered the treatments. On 3/27/19 at 4:59 P.M., the Regional Nurse Consultant (RNC K) was interviewed and reported the facility has not had a wound care/treatment nurse for a couple months. When queried about the protocol for identifying wounds and assessment of skin, RNC K reported nurses assess skin weekly. The lack of skin assessments for R#49 and R#26 were discussed with RNC K who reported a wound care nurse would have audited to make sure the skin assessments were completed. RNC K reported there should be documentation of all wounds and skin alterations in the clinical record. Resident #26 On 3/27/19 at 3:58 P.M., during an interview with R#26, the resident stated, They don't get me out of bed unless I'm going to [MEDICAL TREATMENT]. I used to have a sore on my buttock. When asked if she was able to reposition herself in bed, R#26 stated, No and they only turn me when I ask them to. A review of R#26's clinical record revealed R#26 was admitted into the facility on [DATE] and readmitted multiple times with the most recent readmitted on 2/28/19. R#26's [DIAGNOSES REDACTED].#26 had moderately impaired cognition and required extensive two person assistance for bed mobility. A nursing care plan documented R#26 was at risk for skin integrity issues to buttocks. A review of weekly skin assessments revealed the last assessment was completed on 12/28/18. R#26 was seen by the Nurse Practitioner on 2/22/19. There was no evidence that R#26's elbow was evaluated by a physician or nurse practitioner. Resident #132 On 3/25/19 at 9:07 AM, R#132 was observed lying on their left side. Both of R#132's legs were observed bent in a way that appeared to be contracted (permanent shortening of muscles, tendons, or ligaments). R#132 was receiving tube feeding formula through their feeding tube via an automated pump. R#132's eyes were open, but did not respond to any questions asked. Review of R#132's clinical record revealed R#132 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], R#132 had a staff assessment of Severely Impaired cognition. The MDS assessment indicated R#132 required the extensive to total dependence of staff for all ADL's. A nursing admission Skin Observation Tool dated 3/6/19 for R#132 documented, Sacrum Stage 3, Left Hand, LUQ (left upper quarter) Peg tube, Left ankle, Contractours, Right heel DTI (deep tissue injury) (injury or damage to the fascia (the layer of fibrous tissue that surrounds muscles, bones, blood vessels and nerves)). Two admission Braden assessments were dated 3/6/19, one scored R#132 a 15, Low Risk, and another was scored 14, Moderate Risk. An order dated 3/7/19 for R#132 was revealed and read, Triad [MEDICATION NAME] Wound Dress Paste (Wound Dressings) Apply to Coccyx topically every night shift for wound care Cleanse NS (normal saline), pat dry apply triad over with boarder gauze. No order was found for the wounds on R#132's heel or ankles. A Wound Consultation sheet dated 3/19/19 documented an initial consult with the Wound Care physician, 13 days after R#132 was admitted into the facility. According to the 'Wounds Report', R#132 had: Wound Site 1, Lt (left) Heel Ulcer 4 x 4 cm Unstagable; Wound Site 2, Lt Lat (lateral) Ankle Ulcer 8.0 x 2.0 cm Unstagable; Wound Site 3, Lt Medial Ankle 1.0 x 2.0 cm Unstagable; Wound Site 4, Rt (right) Lat Foot Ulcer 6.7 x 3.3 cm Unstagable; Wound Site 5, Coccyx Ulcer, 3.3 x 6.6 cm Necrotic; Wound Site 6, Rt Heel Ulcer 7.7 x 5.0 cm Unstagable. On 3/27/19 at 10:02 AM, an observation of wound care for R#132 with LPN 'Z' revealed the multiple wounds documented on the Wound Consultation sheet. It was also observed on R#132's left foot, what appeared to be skin tears at the outer aspect of the ankle and on the lower leg/top of foot. Also a area of blackened skin was apparent between the fourth and fifth toes. On R#132's right foot, what appeared to be two small, round red spots on the outer aspect of the fifth toe there were also two red spots on the outer aspect of the foot. What appeared to be a skin tear was noted on the top of the foot. On 3/27/19 at 11:15 AM, Unit Manager (UM) 'E' was notified of observations of R#132's feet and ankles. UM 'E' indicated a full skin assessment would be done and the physician notified of the findings. UM 'E' was queried about treatments for R#132's wounds. UM 'E' verified there were no treatments ordered for R#132's feet and ankles until after the wound consultation with the physician. A progress note created by LPN 'Z' dated 3/27/19 read, Writer noted while completing resident tx (treatment) to Rt foot skin tear noted to plantar surface of arch NP (nurse practitioner) (name redacted) made aware orders to apply dry dressing wrap with kerlix until seen by would care Dr. all orders carried out. Will continue with plan of care. A 'Skin Observation Tool' dated 3/27/19 read, Right toe(s) Pressure 1.5 x 1.5 cm, Rt ankle Pressure 1.0 x 1.4 cm, rt plantar Skin Tear. The 'Notes' section read, Resident have noted area necrotic to Rt 5th toe and open area to Rt ankle skin tear to Rt plantar resident to be seen on wound rounds as scheduled. On 3/27/19 at 5:04 PM, during a conversation with the DON and Regional Nurse Consultant 'K', they were queried about wound care, assessments and documentation of wounds. Both indicated the need for consistent documentation and increased education for the nursing staff. A review of the facility provided policy titled, Skin Monitoring and Management-Pressure Ulcer adopted 7/11/18 was conducted and read, .A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individuals 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 .F .A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the resident's clinical record. G. A licensed nurse .must assess/evaluate at least weekly each wound, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should included but not be limited to: measuring the wound, staging the wound, describing the nature of the wound .describing the location of the wound, describing the characteristics of the wound .Prevention .Use pressure relieving/reducing and redistributing devices .Monitoring .'Skin Observation-Shower' forms are internal validation measures and should be retained for no longer than one year, in a location that is separate from the resident's clinical record .All residents will have a head to toe skin check performed at least weekly by a facility licensed nurse. The licensed nurse should document the performance of the skin check in the resident's clinical record . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation refers to Intake# MI 742. Based on interview and record review, the facility failed to provide adequate supervision for the resident's accessed needs for one (#701) resident of one reviewed for falls of a sample of three residents, resulting in Resident #701's fall with a right ankle fracture and transfer to the hospital emergency room . Findings include: Resident #701 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders, dated 4/26/16 included admit to hospice. On 6/9/16 at 11:00 am, review of the clinical record for Resident #701 revealed the following. According to the minimum data set resident assessment, dated 4/18/16, for Resident #701, Resident #701 had severely impaired skills for cognitive decision making, dependant on staff for transfer and ambulation, and a history of falls. The behavior care plan, dated 5/12/16 for Resident #701 reflected Resident #701 was at risk for behavior symptoms of transferring without assistance relative to the belief that assistance from staff is not needed. The falls risk care plan, dated 4/18/16 for Resident #701, reflected Resident #701 was at risk for falls due to impaired balance/poor coordination, and history of falls. An incident report, dated 5/4/16, 9:30 pm, location, dining room, for Resident #701, reflected 'Pt (patient) was in wheelchair in dining area. Writer was called by another pt, stating that pt had fallen .Writer asked pt how did fall occur .' An incident report, dated 5/20/16, 9:30 am, location dining room. for Resident #701 reflected 'Resident noted laying on floor in dining room. The nursing progress notes for Resident #701 included: 5/20/16,11:18, 'Patient reported to have fallen in dining area. Patient assessed no present signs of injury .' 5/20/16, 13:07 ' .Family @bedside and c/o (complains of) right ankle swelling noted on resident . 5/20/16, 20:45, ' .family members are upset, stating that she (Resident #701) did not receive any kind of treatment for [REDACTED].' An Xray report, dated 5/20/16, reflected ' .Right ankle series .Impression Bimalleolar Fracture .' On 6/9/16 at 2:00 pm, review of the facility five day investigation, dated 5/21/16, revealed the following from witness statements: Supplemental sample Resident #48: 'Me and Resident #701 were sitting together to eat. She was sitting by me, She went to get up to use the bathroom and suddenly she fell on the floor. I called staff and they came and got her off the floor. On 6/9/16 at 2:30 pm, during an interview, unit manager nurse 'A' confirmed that Resident #701 was not provided supervision while in the dining room. Unit manager nurse 'A' reported that Resident #701 frequently tried to get up and walk without assistance and required frequent reminders. Unit manager nurse 'A' further explained that staff are not assigned to supervise the residents while they are in the dining room in between meal times and that the dining room was used as a lounge by the residents in between meal times .it's across from the nursing station and staff always walk past the dining room. However, Unit manager nurse 'A' reported Resident #48 called out to staff when Resident #701 fell .no staff on the floor had witnessed the fall. On 6/9/16 at 3:30 pm, the Director of Nursing (DON) confirmed Resident #701 was at high risk for falls, however appropriate interventions to ensure adequate supervision for Resident #701 were not identified to limit the potential for falls with injuries. On 6/9/16 at 5:00 pm, during an interview, the facility administrator confirmed Resident #701 was at high risk for falls, however appropriate interventions to ensure adequate supervision for Resident #701 were not identified to limit the potential for falls with injuries. The administrator further stated, ' .we supervise by visual view .' from the hall outside of the dining room. On 6/9/16 at 5:30 pm, the facility policies for supervision of residents with high risk for falls and supervision of residents while seated in the dining room between meal times was requested. Neither policy was presented before the end of the survey. ( )

This citation refers to intake #M 5095 Based on interview and record review, the facility failed to safely transfer one (#501) of three sampled residents reviewed for falls, from a total sample of three, resulting in a busted lip, broken blood vessel in the eye, chest wall bruising, and a fractured clavicle. Findings include: On 9/23/15 at 11:05 A.M., an interview with the complainant was conducted via the telephone. The complainant reported that on 7/14/15, Resident #501 fell during a transfer and fractured his clavicle. On 9/24/15 at 8:30 A.M., hospital records for Resident #501 were reviewed and revealed the following: A Discharge Summary from the hospital, dated 8/2/15, documented that Resident #501 was admitted on [DATE] with a [DIAGNOSES REDACTED].admitted after a fall from Hoyer lift at nursing home on (anticoagulant medication). Sustained chest wall hematomas and L (left) clavicular fracture . Radiology reports were reviewed and revealed the following: 7/15/15 at 2:55 P.M. - CT Chest Abdomen Pelvis W/O IV Contrast - There is a left lateral chest wall hematoma . 7/15/15 at 3:06 P.M. - CT Shoulder Right W/O IV Contrast - Approximately 3 x 6 x 6 cm (centimeter) anterolateral right chest wall and axillary hematoma that is predominantly intramuscular involving the right pectoralis major muscle . 7/16/15 at 1:44 P.M. - Shoulder Complete Left Minimum 2 Views - An acute appearing left clavicle fracture is seen along the level medial scapula . 7/17/15 at 7:46 A.M. - Clavicle Left Complete - Transverse fracture involving the lateral left clavicle . On 9/24/15 at 10:10 A.M., the facility clinical record for Resident #501 was reviewed and revealed the following: Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment, dated 6/19/15 documented that Resident #501 had intact cognition and required extensive physical assistance from at least two staff members for bed mobility and transfers. Progress notes were reviewed for July 2015 and revealed the following: A General Progress Note dated 7/14/15 at 9:43 P.M. completed by Nurse A documented, Pt (patient) was being transferred from w/c (wheelchair) to bed with stand up lift, pt starting sliding while being transferred by staff cenas (certified nursing assistant - CNA). Pt was lowered to floor, pt hit lip in process with some slight bleeding .head to toe completed .will consult PT (physical therapy), pt will be transferred with Hoyer lift until evaluation by therapy . A Default PN Type for eMAR note, dated 9:55 P.M. completed by Nurse A documented, that a PRN (as needed) pain medication was given because Resident #501 complained of shoulder pain. A general progress note, dated 7/15/15 at 12:39 A.M. completed by Nurse A, documented, Pt has small broken blood vessel in right eye, pt complained of shoulder pain, prn medication given .writer notified (doctor) of INR (International Normalized Ratio) results (a test used to monitor patients on blood-thinning medications) .Neuro checks (a neurological assessment conducted after a fall to assess for possible head injury) initiated . Additional doses of PRN pain medication were given on 7/15/15 at 4:34 A.M. and 9:12 A.M. A Change in Condition note, dated 7/15/15 at 12:23 P.M., completed by Nurse E (Unit Manager), documented, Writer called to room for change in condition. Observed patient lying in bed lethargic, responsive, but in and out of sleep while conversating with him, he is cold to touch and his bp (blood pressure) from both arms are 74/58 .62/45. Large bruises noted to right upper arm, extending to right breast/axilla. Patient sustained fall from mechanical sit-to-stand last night. Receives (anticoagulant medication) therapy. 911 called and arrived .at 12:10 P.M .C/O (complained of) pain to bilateral arms .pupil reaction sluggish . A change in condition note, dated 7/15/15 at 2:06 P.M., completed by Nurse C, documented, Resident seen in a.m. alert and able to make needs known, c/o pain in arms, nurse notified physician receiving order to have xrays done .Nurse returned to residents room, to monitor resident post fall and resident was having a change in mental status, residents bp was 74/53, resident lethargic, responded briefly and going back to sleep, pupils sluggish and resident had two large hematomas b/l (bilateral) arms and across his chest, nurse notified physician and sent resident out 911 . An Acute Care Transfer form completed by Nurse C, dated 7/15/15 at 12:02 P.M. documented, Resident had fall last night around 9pm, in a.m. resident c/o pain in arms currently unable to arouse, CT scan needed of brain, hematoma under both arms, and right upper arm. Care plans were reviewed and revealed the following: A care plan initiated 6/13/15 for ADL (activities of daily living) self care deficit r/t (related to) physical limitation, recent respiratory failure, debility, weakness .Transfer with mechanical lift with large size sling created 6/13/15, revised 7/17/15. A care plan initiated 6/13/15 and revised on 7/17/15, for At risk for falls due to impaired balance/poor coordination, unsteady gait, potential medication side effects with interventions that included: Two person assistance using Hoyer lift for transfers, initiated 6/13/15, revised 7/17/15. An Incident Report for Resident #501 was reviewed on 9/24/15 at 1:15 P.M. and documented the following: Date of Incident: 7/14/15 9:24 P.M. Location of Incident: Patient's Room Description of Incident: Pt was being transferred from w/c to bed with stand up lift, pt starting sliding while being transferred by staff cenas. Pt was lowered to floor, pt hit lip in process with some slight bleeding. Pt transferred back to bed with Hoyer lift .pt able to move all extremities, ROM performed. head to to toe completed . Describe cause of incident, if known: as indicated in report Corrective action: as indicated in report. (Handwritten) addendum 7/15/15 at 9 A.M. new intervention for pt to use Hoyer lift. Physician's statement (signed on illegible month/25/15): 1. Extent of Injuries: As indicated in incident report 2. Treatment ordered: As indicated in incident report 3. Disposition of Patient: Patient remains at center Nurse A was interviewed on 9/24/15 at 1:22 P.M. regarding the incident report and progress note documentation for Resident #501 from 7/14/15. Nurse A reported that she completed the incident report for Resident #501. When queried about what happened on 7/14/15, Nurse A stated, He slid from the stand up lift with the aides, CNA B and CNA D and they came and got me. When asked about the status of Resident #501 when Nurse A came to the room, Nurse A stated, He had a busted lip, but he didn't say he had any pain. He was conscious. I called the doctor. Nurse A was asked what she notified the physician of. Nurse A stated, Of the incident. I started neuro checks. He (Resident #501) wasn't experiencing pain. Nurse A was queried about whether or not the physician was notified after Resident #501 began complaining of shoulder pain at 9:55 P.M., approximately 30 minutes after the incident occurred. Nurse A stated, I can't remember. I gave him pain meds because he had an order for [REDACTED]. I called the physician again and gave the INR results because of the blood vessel in his eye. I don't remember if I told him about the shoulder pain, as well. Nurse A reported there was no order for an X-ray given at that time. The Director of Nursing (DON) was interviewed on 9/24/15 at 2:12 P.M. regarding the incident report for Resident #501 that documented he was lowered to the floor during a stand up lift transfer on 7/14/15, the documented broken blood vessel in his eye, large bruises on his arms and chest, and the decline on 7/15/15 when Resident #501 was transferred to the emergency room . The DON was asked what Resident #501's transfer status was prior to the incident on 7/14/15. The CNA Tasks were reviewed and revealed that Resident #501 was 2 person with max extensive level of assist using lift for transfers and was changed to a Hoyer lift on 7/14/15. The DON was queried about how Resident #501 got a busted lip, broken blood vessel in his eye, and large bruises on his arms and chest from being lowered to the floor during a stand up lift transfer. The DON stated, He would have to hold on to the bar with a sling under his arms. He must have slid out of there. When queried about how Resident #501 sustained a busted lip, the DON stated, Maybe he hit on the bar or knee rest or something. I don't know how he got the fat lip. When queried about the large hematomas documented in the progress notes on 7/15/15 and the increased pain that required three doses of PRN pain medication, the DON stated, It happened at night. The nurse (Nurse A) did the right thing. She changed him to a Hoyer lift. That's why we sent him out the next day because he had bruising and pain and he was hard to arouse. The DON was asked if any investigation or follow up was completed regarding the incident on 7/14/15. The DON stated, He was a sick man. I would have to go through a stack of statement forms to see what was done. Statement forms were reviewed on 9/24/15 at 2:55 P.M. and revealed a statement written by Nurse A and signed by CNA B and a statement written by Nurse A. There were no statements from any other staff members, including CNA D. CNA D was interviewed on 9/24/15 at 3:05 P.M. regarding the incident with Resident #501 on 7/14/15. CNA D stated, We were getting him out of the chair with a stand up lift and his knees gave out and he slid down. I got (Nurse A) and she looked him over. When asked about how the stand up lift was used, CNA D stated, You put the belt around him, but it only works if they stand up all the way. He just slid out. He didn't fall, he slid. It was so quick. I tried to grab him, but he's too heavy. I tried to catch him. He was practically on the floor when I laid him down. I could not hold him up with the sling and his wheelchair was already moved away. CNA B was interviewed on 9/24/15 at 3:15 P.M. regarding the incident with Resident #501 on 7/14/15. CNA B stated, Me and (CNA D) were getting him into bed with the stand up lift and he said he can't hold on anymore so he let go. He's a heavy guy. He slid down by the bed to the floor and landed on his butt. CNA D was asked if Resident #501 was injured after he slid to the floor. CNA D stated, I think he hit his mouth. It was bleeding. I didn't see him hit it, but the machine was locked and it still moved. It happened so fast. Nurse C was interviewed on 9/24/15 at 3:48 P.M. regarding what was reported on 7/15/15 about Resident #501 from the previous shift's nurse. Nurse C stated, She reported there was an incident of a fall, but I didn't know how he fell . I ended up sending him out (to the hospital). He was in and out of sleep, but was talking about his arm or shoulder hurting. I tried to do range of motion, but he didn't have any movement without pain. The doctor ordered an Xray. Therapy didn't want to see him either without an Xray .He had bruising under his upper arms. The DON was further interviewed about what interventions were put in place after Resident #501 was lowered to the floor during a stand up lift transfer on 7/14/15. The DON stated, He was changed to a Hoyer lift. When queried about whether or not the staff involved received any education following the incident on 7/14/15, the DON stated, I would have to check. The DON provided a One-on-One Inservice Record for CNA B, dated 7/15/15 for Proper transfers with lifts .Skills check off list to ensure proper procedure was used during transfer for pts. The inservice record was not signed by CNA B. A Lift Program Skills Check-Off Sheet for stand assist mechanical lifts did not have any completed and observed activities checked off by the trainer. The check-off sheet was signed by the trainer on 7/16/15 and not CNA B in the section that documented, I have successfully completed the procedures for operating the (stand assist mechanical lift brand names). I have demonstrated the tasks and understand that these lifts are to be used to comply with the Lifts and Injury-Reducing Devices Program. The DON reported that the one-on-one inservice was not disciplinary in nature. When queried about why only CNA B received the one-on-one inservice and why only CNA B was interviewed after the incident, the DON stated, Because she was the aide who transferred him (Resident #501). When asked why Resident #501 was transferred by only one CNA, the DON stated, Oh. It was a long time ago. I can't say. He was changed to a Hoyer lift after. The facility's policy for mechanical lilfts was requested at 1:30 P.M. on 9/24/15. A section titled, Use of Lifts and Friction-Reducing Devices, from the Lifts and Injury-Reducing Devices Manual, dated 07/2015 was provided by the DON and reviewed at 3:00 P.M. It documented the following: .Although one person can operate most models of hydraulic lifts, it's advisable to have two staff members present to stabilize and support the patient .The location's Interdisciplinary or Care Plan Team must determine and approve the procedure for less than a two-person lift . .Selecting Appropriate Lifting Devices .Determining the method for transferring a patient is a serious matter and cannot be taken lightly; the risk of injury to the patient or the employee is too great . .Specific methods of transferring and lifting are designated for each patient .This information is communicated through the Care Plan assignment and the Kardex . .Extensive Assistance Patients .All patients classified as extensive assist are lifted and transferred between beds, chairs, toilets, and bathing and weighing facilities with the aid of a mechanical lift device. A full-body sling lift .is appropriate for all transfers. However, depending upon the patient's condition and weight-bearing capabilities, a stand-assist lift .may be used as deemed appropriate by professional staff conducting patient screenings. The determination of which lift to use is noted in the patient's Care Plan . The facility's policy on falls was requested on 9/24/15 at 1:30 P.M. and the DON provided document titled, Falls Practice Guide Flowsheet at 3:00 P.M The DON was interviewed regarding the process for assessment and investigation after a fall incident. The DON said, We follow this. When asked to explain the process using the provided flowsheet, the DON stated, I have never actually looked at this. Let me get you something else. We would do a head to toe assessment, interview staff and witnesses, call the doctor and family, and update interventions. The facility's policy for Change in Condition or Fall Occurrence was provided and reviewed at 3:00 P.M. and documented the following: .An evaluation of the patient is completed timely following a fall .Refer to the PREVENT Practice Guide for guidance on the investigation process .Did the patient experience a fall? Yes .Conduct Investigation. Complete: Electronic Incident Report, Witness Statements . ( )

REFER TO INTAKE # MI 401 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES FOR WOUNDS (NON-PRESSURE SORE) TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING, IN ACCORDANCE WITH THE COMPREHENSIVE ASSESSMENT AND PLAN OF CARE FOR 1 RESIDENT (#102) OF 5 SAMPLED RESIDENTS RESULTING IN DELAYED WOUND HEALING AND AND WOUND INFECTION ([MEDICAL CONDITION]). FINDINGS INCLUDE: RESIDENT #102 WAS [AGE] years OLD admitted to the facility on [DATE], AFTER A RIGHT PARTIAL RENAL NEPHRECTOMY. ON 1/6/11, SHE WAS TRANSFERRED TO THE HOSPITAL FOR POST OPERATIVE WOUND INFECTION AND RETURNED BACK to the facility on [DATE]. RESIDENT #102'S NURSING ADMISSION SKIN assessment dated [DATE], DESCRIBED 2 WOUND AREAS AT: SITE #1 RIGHT LOWER BACK FLANK AREA MEASURING 26 CM (CENTIMETERS) LENGTH X 0.5 CM WIDTH WITH NO SIGNS OF INFECTION AND SITE #2 LEFT LOWER ABDOMEN REDDENED SURROUNDING AREA WITH SEROSANGUINOUS DRAINAGE. RESIDENT # 102 ON 1/6/11, WAS TRANSFERRED TO THE HOSPITAL FOR WOUND INFECTION. RESIDENT #102 DID NOT RETURN UNTIL 1/11/11. NURSING ADMISSION SKIN assessment dated [DATE], DESCRIBED WOUND AREAS AS: SITE #1: RIGHT BACK FLANK AREA WITH 9 STAPLES AND PURULENT DRAINAGE; SITE #2: OPEN AREA LEFT LOWER ABDOMEN MEASURING 0.5 CM (LENGTH) BY 0.5 CM (WIDTH) AND 0.3 CM (DEPTH); AND SITE #3: LEFT THIGH [MEDICAL CONDITION] REDDENED AREA (LOOKS LIKE AN ORANGE PEEL). THE SKIN ALTERATION RECORD DATED 1/12/11, DESCRIBED AN OPEN AREA LOCATED AT THE LEFT LOWER ABDOMEN (WOUND #2) WITH MEASUREMENTS: 0.5 CM ( LENGTH) BY 0.5 CM (WIDTH) AND 0.3 DEPTH WITH SCANT SEROSANGUINOUS DRAINAGE. ON 1/26/11 LEFT LOWER ABDOMEN OPEN AREA WAS DESCRIBED AS 0.5 CM (LENGTH) BY 0.5 CM (WIDTH) BY 0.2 CM DEPTH WITH SCANT SEROSANGUINOUS DRAINAGE AND SKIN SURROUNDING ALTERATION: REDDENED. LEFT THIGH (#3)WAS REDDENED (LOOKS LIKE AN ORANGE PEEL). THERE WAS NO EVIDENCE THAT TREATMENT ORDERS HAD BEEN OBTAINED TO TREAT WOUND #2 OR SKIN ALTERATION #3 FROM 1/5/11 THROUGH 1/28/11. NO PHYSICIAN'S REFERRAL OR EVALUATION WAS OBTAINED FOR WOUND #2 AND SKIN ALTERATION #3 WHILE RESIDENT #102 WAS LIVING IN THE FACILITY. TAR (TREATMENT ADMINISTRATION RECORD) DATED 1/5/11 AND 1/12/11, DID NOT SHOW EVIDENCE OF ANY TREATMENT OR DAILY MONITORING FOR WOUND AREAS #2 OR #3. THERE WAS NO DOCUMENTATION OF TREATMENT, ASSESSMENT AND MONITORING FOR INFECTION FOUND IN THE NURSES NOTES REGARDING ANY OF RESIDENT #102'S WOUNDS. NO UPDATED CAREPLAN WAS NOTED SPECIFIC FOR WOUNDS AND TO PREVENT INFECTION. RESIDENT #102 WENT TO SEE THE NEPHROLOGIST ON 1/28/11. RESIDENT #102 DID NOT RETURN TO THE FACILITY BECAUSE SHE WAS TRANSFERRED TO THE HOSPITAL IMMEDIATELY FOR treatment of [REDACTED]. NURSE'S NOTES DATED 1/28/11 AT 10:30 PM DOCUMENTED: "RESIDENT #102 WAS TRANSFERRED THE HOSPITAL AFTER THE DOCTOR'S APPOINTMENT BECAUSE OF SOME COMPLICATIONS FROM HER WOUND AND [MEDICAL CONDITION] OF HER LEFT THIGH." UROLOGY SPECIALIST CLINIC DOCUMENTATION DATED 1/28/11, RECEIVED VIA FAX ON 5/11/11, REVEALED "NEPHROLOGIST WOULD LIKE THE PATIENT TO BE admitted TO THE HOSPITAL FOR IV(INTRAVENOUS) ANTIBIOTIC FOR WOUND [MEDICAL CONDITION]." AN INTERVIEW WITH THE UROLOGY OFFICE PHYSICIAN'S ASSISTANT #16 ON 5/5/11 AT 3:30 PM WAS CONDUCTED BY TELEPHONE. THE PHYSICIAN'S ASSISTANT STATED THAT RESIDENT #102 WAS SENT TO THE HOSPITAL DUE TO COMPLICATIONS OF THE POSTSURGICAL WOUND. RESIDENT #102 HAD INFECTED WOUNDS THAT REQUIRED ANTIBIOTIC TREATMENT INFECTION THROUGH INTRAVENOUS ROUTE. RESIDENT #102 WENT DIRECTLY TO THE HOSPITAL FROM THE UROLOGY OFFICE APPOINTMENT ON 1/28/11. HOSPITAL RECORDS DATED 1/28/11, SHOWED INFECTED POST OPERATIVE WOUND SITE: [MEDICAL CONDITION]. RESIDENT #102 WAS TREATED WITH INTRAVENOUS ANTIBIOTIC. THE DON (DIRECTOR OF NURSING) ON 5/5/11 AT 2:00 PM, STATED THAT THERE WERE NO TREATMENTS FOUND FOR THE LEFT LOWER ABDOMEN AREA OPEN AREA FROM 1/5/11 (FIRST ADMISSION) AND 1/11/11 (SECOND ADMISSION). ALTHOUGH THE ADMISSION ASSESSMENTS DESCRIBED THE OPEN AREA LOCATED AT THE LOWER LEFT ABDOMEN 0.5 CM X 0.5 CM OPEN AREA, THERE WAS NO EVIDENCE THAT DAILY TREATMENT AND MONITORING WAS DONE. THERE WAS NO EVIDENCE THAT OTHER INTERVENTIONS TO PROMOTE HEALING AND PREVENT SPREAD OF INFECTION WAS DONE BY STAFF. NURSE #17 WAS INTERVIEWED ON 5/5/11 AT 1:06 PM, SHE admitted THAT SHE WAS THE NURSE FOR RESIDENT #102 ON THE DAY OF HER DOCTOR'S APPOINTMENT ON 1/28/11. SHE DID NOT RECALL IF SHE DID A DRESSING CHANGE OR ASSESSED THE WOUNDS THAT DAY. SHE DID NOT KNOW ABOUT ANY OTHER WOUND AREA AND WAS UNAWARE OF [MEDICAL CONDITION]. ALL SHE REMEMBERED WAS CONTACTING RESIDENT #102'S FAMILY BECAUSE SHE DID NOT RETURN TO THE FACILITY THAT DAY. ( )