Every finding on record at Optalis Health & Rehabilitation of Muskegon

This citation pertains to Intake #3044470, 3097402, 3124032, and 3152920.Based on observation, interview, and record review, the facility failed to assess and accommodate the needs of one Resident (R108) with physical impairment and limited communication ability of seven residents reviewed for activities of daily living.Findings include:Review of the medical record reflected R108 admitted to the facility 12/12/2019 with pertinent diagnoses that included hemiplegia and hemiparesis (weakness or paralysis to one side of the body) following infarction (stroke) affecting right dominant side and aphasia (inability/difficulty to speak).Review of the Minimum Data Set (MDS) Section B (Hearing, Speech, Vision) dated 6/17/2026 reflected R108's hearing was adequate, speech pattern was no speech, was sometimes understood, but usually understands.The Care Plan reflected R108 had an ADL (activities for daily living) deficit, to keep call light and commonly used articles in reach, had a communication board, and was able to use an iPad.On 8/17/2026 at 9:42 AM, an observation and interview were conducted at the bedside of R108. It was noted that R108 could nod her head but could verbally respond only with ok. It was observed that the rolling bedside table was positioned on the Resident's right side of the bed (flaccid side) and pushed slightly away from the bed. R108 indicated she could not reach her call light (a special adaptive device with high sensitivity to touch). R108 indicated she often could not reach her call light, especially when she had wet herself and she remained wet for long periods of time. R108 indicated this regularly frustrated her.On 8/19/2026 at1:16 PM an observation and interview were conducted with R108 in her room. R108 pointed to her adaptive call light on the rolling table on the Resident's right side. R108 indicated she could not reach the light. Overview of the Resident's area did not reveal a communication board. R108 indicated she did not have one and that she could not use one. R108 indicated she may be able to write with her non-dominant hand and paper and a marker were retrieved. R108 attempted to write but the writing was illegible. R108 indicated and displayed obvious frustration by tensing her jaw, holding her eye tightly shut and increased breathing was observed. R108 indicated that the inability to communicate with staff was upsetting. R108 shrugged a shoulder when asked if she could use a letter board.On 8/19/2026 at 1:36 PM an interview was conducted with Certified Nurse Aide (CNA) P in the hall outside the room of R108. CNA P reported she didn't believe R108 had a communication board, and no one had mentioned this to her before. CNA P reported she interprets the tone of the ok that R108 will speak and that the Resident can shake her head also. CNA P reported that the Resident's call light will be moved for meals and sometimes not put back where R108 can reach it. The interview moved to the bedside of R108, and CNA P moved that adaptive call light closer to R108 who immediately grabbed and initiated the light. CNA P reported that the Resident's television, which is on an articulated arm over the Resident's bed, will sometimes not be put in a position where it can be reached by the Resident.The policy provided by the facility titled Communication Barriers last reviewed 3/10/2025 was reviewed. The policy reflected, It is the policy of this facility to take reasonable steps to ensure that residents with communication barriers have access and equal opportunity to participate in meaningful conversations about their medical care, services, treatment, and activities in the facility. And The facility will provide communication assistance by utilizing communication aids, which may include but is not limited to: (list of devices and methods to be attempted).The policy provided by the facility titled Accommodation of Needs dated 8/21/2023 was reviewed. The policy reflected, The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident., And The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. And Staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity.

This citation pertains to Intake #3044470, 3097402, 3124032, and 3152920.Based on observation, interview, and record review the facility failed to provide dignified care to two residents (R108 and R104) of six residents reviewed for dignity.Findings include: R108 Review of the medical record reflected R108 admitted to the facility 12/12/2019 with pertinent diagnoses that included hemiplegia and hemiparesis (weakness or paralysis to one side of the body) following infarction (stroke) affecting right dominant side and aphasia (inability or difficulty to speak). The Care Plan reflected R108 had an ADL (activities for daily living) deficit, and to keep the call light and commonly used articles in reach. On 8/17/2026 at 9:42 AM, an observation and interview were conducted at the bedside of R108. It was noted that R108 could nod her head but could verbally respond only with ok. It was observed that the rolling bedside table was positioned on the Resident's right side of the bed (flaccid side) and pushed slightly away from the bed. R108 indicated she could not reach her call light (a special adaptive device with high sensitivity to touch). R108 indicated she often could not reach her call light, especially when she had wet herself and she had often remained wet for long periods of time. R108 indicated this regularly frustrated her. On 8/19/2026 at 1:16 PM an observation and interview were conducted with R108 in her room. R108 pointed to her adaptive call light on the rolling table on the Resident's right side. R108 indicated she could not reach the light. R108 indicated that the inability to alert staff when she needed care frustrated and upset her. On 8/19/2026 at 1:36 PM an interview was conducted with Certified Nurse Aide (CNA) P in the hall outside the room of R108. CNA P reported that R108's call light will be moved for meals and sometimes not put back where R108 can reach it. The interview moved to the bedside of R108, and CNA P acknowledged R108 could not reach her call light, moved it closer to R108 who immediately grabbed and initiated the light. R104 Review of a Face Sheet revealed R104 admitted to the facility on [DATE] with pertinent diagnoses which included right hand contracture and limitation of activities due to disability. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R104, with a reference date of 6/24/26 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R104 was cognitively intact. Further review of same MDS assessment revealed R104 was dependent on staff for toileting needs. Review of a current activities of daily living (ADL) Care Plan intervention for R104, initiated 3/11/26, revealed R104 required the assistance of one staff with personal hygiene. In an interview on 3/17/26 at 9:25 AM, R104 reported she needed assistance to use the toilet because she was unable to use her hands. R104 reported call lights often took an hour to be answered, especially in the evenings, and this caused her to use the bathroom in her brief on a regular basis. R104 reported having accidents in her brief made her feel pissed off. Review of facility policy/procedure Resident Rights, reviewed 2/4/26, revealed .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include but are not limited to the resident's. Right to a Dignified Existence to. Be treated with respect and dignity.

This citation refers to Intake 3012437. Based on interview and record review, the facility failed to prevent a fall with injury for 1 of 3 residents (R2) reviewed for accident hazards, resulting in R2 sustaining a fractured nasal bone and lacerations to the face. Findings include: A review of R2's Face Sheet, dated 5/26/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R2's Face Sheet revealed they had multiple diagnoses that included cerebral infarction (a stroke), lack of coordination, and muscle spasm. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/12/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R2 was cognitively intact. In addition, R2's MDS revealed they were dependent on staff for bed mobility (rolling side-to-side) and for toileting hygiene. A review of R2's progress notes, dated 4/26/26 to 5/26/26, revealed the following: - Nursing - Progress Note, dated 4/29/26, revealed, .1900) (7:00 PM) Nurse at med (medication) cart outside res (resident) room heard loud crash then CENA (Certified Nursing Assistant) call out. Nurse entered room and res was laying on floor between bed and Nightstand closer to room door. Nurse noted lg amt (large amount) of blood under res head. Res was answering questions correctly and denied pain. Nurse had CENA obtain ice pack and nurse called on call physician (1902- 7:02 PM), order received to send res to ED (emergency department) to eval (evaluate) and treat. This nurse called 911 and per their instruction did not move res for further assessment. Ice applied to left side of face/ head. EMS (emergency medical services) arrived at about 1915 (7:15 PM) and res out to ED at about 1925 (7:25 PM) . - Nursing - Progress Note, Late Entry: dated 5/6/26 for 4/30/26, revealed, .Resident returned from hospital in stretcher accompanied by 2 EMTs (emergency medical technicians). ER (emergency room) reports resident has a closed fracture of the nasal bone and has stitches in bridge of nose. Resident also has lacerations to forehead that were glued closed. - Progress Note, dated 5/1/26, revealed, .Resident c/o (complaining of) headache and body pain. Resident states, Norco is not working. Provider in facility to eval (evaluate) resident and her meds. - IDT (Interdisciplinary Team) note, dated 5/1/26, revealed, .During cares CNA (Certified Nursing Assistant) noted bruise to resident's posterior RLE (back of her right lower extremity (leg)). Resident did not know the bruise was there but stated I got that in therapy. Resident is at an increased risk of bruising secondary to being on two anticoagulants. - IDT note, dated 5/1/26, revealed, Resident had a witnessed change in elevation from bed to floor. She had obvious injury to her face, and is on blood thinners. In addition, the note revealed that R2 was sent to the emergency department for an evaluation. A review of R2's - Fall Risk Assessment, dated 3/8/26, revealed R2 was routinely incontinent, had moderate/severe unsteadiness, took 3 or more medications that could put her at risk for falls, and had 3 or more diseases/conditions that put her at risk for falls. A review of R2's hospital After Visit Summary, dated 4/30/26, revealed on 4/29/26 R2 was seen in the emergency department for a fall. R2's hospital After Visit Summary also revealed that R2 had a facial laceration to the forehead that required adhesive and stitches to close and a closed fracture of the nasal bone. A review of R2's skin assessment, dated 5/2/26, revealed R2 had a left elbow abrasion, front of left knee abrasion, and facial bruising and sutures. The skin assessment revealed these injuries were from a fall. During an interview on 5/26/26 at 9:00 AM, R2 stated a CNA rolled her out of bed and onto the floor. She stated the CNA was cleaning her up after she had a bowel movement and asked her where the bruise came from. R2 stated she went to look at what the CNA was referring to and she rolled out of bed. She stated the CNA had her on her side facing the doorway when she rolled out of bed. R2 stated she hit her head on her nightstand when she fell. She denied any other injuries. My head broke the fall. She stated the facility sent her to the hospital. R2 stated at the time they were only using one CNA to provide incontinent care to her. She stated the facility now uses two CNA's. R2 stated the CNA at the time of the fall did not seem like she was in a hurry or rushing through the care. She stated, It was just an accident. During an interview on 5/26/26 at 4:50 PM, Certified Nursing Assistant (CNA) D stated she went into R2's room to provide care. She stated she rolled R2 away from her and R2 was too close to the edge. CNA D stated during care she noticed a bruise to the back of R2's leg and asked R2 about it. She stated R2 tried to look at it and it threw off her balance and she rolled off the bed. CNA D stated R2's bedside drawer was open and R2 hit it on the way to the floor. CNA D stated after R2 fell to the floor she opened up the door and told the nurse that R2 had fallen out of bed. She stated the nurse was right outside R2's door with the medication cart and immediately came into the room. She stated when the nurse came in the room she saw that R2 was bleeding and the bed was at a high height (CNA D had raised the bed prior to starting care). CNA D stated the nurse called 911 while she stayed with R2 and tried to clean her up to the best of my ability prior to EMS arriving. CNA D stated she and another aide moved R2's bed because R2 was leaning up against it and R2 was uncomfortable. She stated they did not move R2. She stated EMS arrived and took her to the hospital. During the interview on 5/26/26 at 4:50 PM, CNA D stated R2 was a one-person with care at the time of the incident. She stated they are technically not supposed to roll residents away from themselves when they are alone. She stated she knew she was not supposed to roll R2 away from her at the time. CNA D stated she did it anyway because she was just trying to clean R2 up after she had an extra-large bowel movement in her brief. She stated she should have called for help instead of doing the care herself, but she did not think anything would happen. CNA D stated trying to do the care herself and rolling R2 away from her and not towards her was a lack of judgement. She stated she received individual written education for the incident. A review of CNA Ds Employee Counseling & Corrective Action Record, dated 5/1/26, revealed she received her Final Written Warning on 5/1/26 for Carelessness or Negligence, Neglect of Duty related to a resident (R2) being rolled away from her, rolling out of bed, and sustaining an injury on 4/29/26. She was educated on the proper policy and procedure for repositioning. A review of the facility's Repositioning Policy and Procedure, revised on 4/24/25 and reviewed on 2/2/26, revealed when repositioning a resident in the bed, staff are to position resident so that when they are turned they are in the middle of the bed and they are to reach across the resident and place one hand behind their shoulder and the other behind the hip and gently roll the resident towards you.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen in a current facility census of 87 residents. Findings Include:On 01/12/2026 at 9:27AM, observation in Dining room [ROOM NUMBER], the drain line for the ice machine was not air gapped, the flexible line from ice machine was sitting with the end sitting directly in the drain. On 01/12/2026 at 3:07PM, during interview with Maintenance Manager (MM) R it was found that MM R was not aware the drain line was not properly air gapped. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention.(A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P(B) Paragraph (A) of this section does not apply to floor drains that originate in refrigerated spaces that are constructed as an integral part of the building.(C) If allowed by LAW, a WAREWASHING machine may have a direct connection between its waste outlet and a floor drain when the machine is located within 1.5 m (5 feet) of a trapped floor drain and the machine outlet is connected to the inlet side of a properly vented floor drain trap.(D) If allowed by LAW, a WAREWASHING or culinary sink may have a direct connection.On 01/12/2026 at 9:35AM, observed juice dispenser cobrahead with sugar mold growth on the surface area inside the beverage diffuser. Verbal review of cleaning procedure with Certified Dietary Manager (CDM) P it was indicated the cobrahead was soaked nightly, with no physical agitation of interior of the beverage diffuser. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 01/12/2026 at 9:34AM, observed in kitchen reach in cooler several undated chocolate flavored Mighty Shake containers, in a liquid state, in a larger black container. The Mighty Shakes did not have a pull date, or a facility applied use-by date on the container or the individual shakes. CDM P stated the shakes had been pulled on 01/12/2026 and had not been dated because they were thawing. Review of labeling and Dating Procedure indicates Mighty Shakes are to be assigned an open date/prepare date and a use by date. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .01/12/2026 at 9:30 AM, observed the dishmachine was not displaying final rinse temperature on the machine during the complete wash, rinse and sanitize cycle, making it difficult for staff to determine if dishmachine working properly. At time of observation, CDM P was asked how dishmachine operation was validated that it is working properly CDM P responded, the dishmachine sanitizing cycle was validated using a plate simulator to monitor maximum plate surface temperature. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.(C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.On 01/12/2026 at 9:33AM, observed plate surface temperature for the dish machine was 136 degrees F, when CDM P used the kitchen's plate simulator to verify equipment operation. CDM P stopped the dishwashing process and informed staff to use paper products for upcoming meal. According to the 2022 FDA Food Code Annex 3. Public Health Reasons/Administrative Guidelines section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning.The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature.On 01/12/2026 at 11:00AM, observed Dietary [NAME] (DC) Q cutting tomatoes then pull a head of lettuce out of plastic bag in the cardboard container and immediately begin cutting it into slices. At time of observation CDM P was asked the procedure for produce preparation, CDM P stated staff rinsed off produce prior to preparation. On 01/12/2026 at 11:02AM, Dietary [NAME] (DC) Q was asked if they had rinsed the lettuce prior to cutting, DC Q said they hadn't, DC Q then took the pan of cut fresh produce and discarded it. According to the 2022 FDA Food Code section 3-302.15 Washing Fruits and Vegetables - (A) Except as specified in (B) of this section and except for whole, raw fruits and vegetables that are intended for washing by the CONSUMER before consumption, raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in READY-TO-EAT form. (B) Fruits and vegetables may be washed by using chemicals as specified under S 7-204.12 and a test kit or other device that accurately measures the active ingredient concentration of the fruit and vegetable wash solution may be provided. (C) Devices used for on-site generation of chemicals meeting the requirements specified in 21 CFR 173.315, Chemicals used in the washing or to assist in the peeling of fruits and vegetables, for the washing of raw, whole fruits and vegetables shall be used in accordance with the manufacturer's instructions. Pf

Based on observation, interview, and record review, the facility failed to implement Infection Prevention and Control Policies and Procedures and have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory and other infections among all residents in the facility. Findings include: Resident 16 (R16) Review of an admission Record reflected R16 admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. During an observation on 1/13/2026 at 8:40 AM reflected Certified Nurse Aide (CNA) E was assisting with incontinence care for R16 and wore only gloves and a surgical mask. A sign hanging outside the door reflected R16 required EBP. Review of an R16's physician orders reflected Enhanced Barrier Precautions (EBP): AV Fistula Left Forearm every shift for infection control -Start Date- 8/4/2025. Review of a Care Plan initiated 9/19/2025 reflected R16 required EBP due to indwelling medical device. Interventions included Staff will wear a gown and gloves during high contact resident care activities. Resident 90 (R90) Review of an admission Record reflected R90 admitted to the facility on [DATE] with diagnoses that included Amyotrophic Lateral Sclerosis (ALS), unspecified dementia, and an unspecified lack of expected normal physiological development in childhood. Review of a Care Plan initiated on 1/8/2026, reflected R90 required Enhanced Barrier Precautions (EBP) related to a left hip incision and right groin fissure. Interventions directed staff to wear a gown and gloves during high contact resident activities. During an observation on 1/13/2026 at 8:47 AM, Registered Nurse (RN) F was preparing medications for administration to R90. RN F touched every pill and tablet by handling each dose after pushing the medication out of a blister pack or by pouring a stock medication into her hand before placing the dose in the medication cup. During the same observation of medication administration on 1/13/2026 at 8:47 AM, RN F assisted the surveyor with an observation of R90's bilateral heels and did not don PPE for the resident who is in EBP due to a surgical wound and fistula in the groin. During an interview on 01/14/2026 at 8:39 AM, RN H reported that she and Certified Nurse Aide (CNA) G repositioned R90 in his bed. RN H reported neither she nor CNA G donned PPE for the high contact activity because they did not know R90 required EBP. RN H looked toward the door to R90's room and there was not a sign indicating R90 required PPE. During an interview on 1/14/26 at 8:45 AM, CNA G confirmed that she did not don PPE while she and RN H repositioned R90. CNA G said she did not know R90 required EBP. During an interview on 01/14/2026 at 8:47 AM, the Assistant Director of Nursing (ADON) reported that she was the Infection Control Preventionist (ICP A) at the facility. ICP A said she was not aware that R90 required EBP. ICP A reported that she had been on an extended leave (December 23, 2025 - January 12, 2026) and had not identified that appropriate signage was not in place outside of R90's room. ICP A reported she was told by the facility that all residents who require dialysis need to be in EBP and did not consider the difference between dialysis catheters versus a fistula. ICP A was not aware that residents with ostomies (colostomy or ileostomy, an artificial opening in the abdomen created to evacuate the bowels) do NOT require EBP. Review of the Centers for Disease Control (CDC) and Prevention web page dedicated to answering Frequently Asked Questions (FAQ) revealed: An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters (PICCs)), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. Devices that are fully embedded in the body, without components that communicate with the outside, such as pacemakers, would not be considered an indication for Enhanced Barrier Precautions. Although the data are limited, CDC does not currently consider peripheral I.V.s (except for midline catheters), continuous glucose monitors, and insulin pumps as indications for Enhanced Barrier Precautions. An ostomy in a resident without an associated indwelling medical device, would not be considered an indication for Enhanced Barrier Precautions. (accessed from Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC on 1/13/2026 at 11:36 AM). On 01/12/2026 at 3:50PM, observed on Hall 500 in the housekeeping room, there are white painted, water lines coming out of the wall. At time of observation, the Maintenance Manager (MM) R and Maintenance person S were asked if the lines had access to water and if so if they were on the flushing schedule. Maintenance S said the lines were not being flushed but was unsure if there was water access at these lines. Adjacent plumbing that used to provide water at a hopper are on the flushing schedule. On 01/13/2026 at 8:45AM, MM R explained, the plumbing in the housekeeping closet had remained after removal of the hopper to allow for installation of a sink at a later date. At this time MM R was unable to provide confirmation if the painted water lines were operational and could provide water if opened. Review of [previous facility name] Water Management Program in the Policy, section 3 states a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's systems. R25 Review of R25's admission recorded dated 1/14/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle wasting and atrophy (waste away), burns involving 10-19% of body surface with 0% to 9% third degree burns and unsteady on feet. R25 was his own responsible party. R25 was observed in bed on 1/12/26 at 9:29 AM. R25 had several care concerns. R25 had a C-PAP (Continuous Positive Airway Pressure) machine on his nightstand. The mask was still attached to the hose, and the mask was on the floor. The water tank still had water. No cleaning or storage items were visible. R25 was observed in bed on 1/13/26 at 12:18 PM. R25's C-PAP machine was still on the nightstand with the mask attached to the hose and the mask was on the floor. R25 said he does normally use the machine when sleeping to help him breath, but he can't use it every night. When asked about the cleaning and maintenance of the machine, R25 said no one has cleaned it since admission. During an interview with Unit Manager (UM) I on 1/13/26 at 4:00 PM, UM I said R25's hospital discharge summary did indicate that he used a C-PAP machine. UM I said R25 was transferred to the facility on [DATE] but he did not come with a C-PAP machine. UM I called the Respiratory Therapist that was treating R25 at the hospital and obtained the C-PAP settings and treatment information. UM I said she ordered the C-PAP equipment but did not contact the physician or obtain orders for its use. UM I did not set up a cleaning or use schedule. UM I could not find any record of R25 having a C-PAP machine or information that anyone had cleaned R25's C-PAP machine since admission on [DATE]. Review of the facility CPAP – Continuous Positive Airway Pressure policy dated 9/1/19 did not reveal any instructions or need for cleaning. According to the American Thoracic Society, Patient Education/Information series. www.thoracic.org. What happens if I don't clean my PAP device? If you do not clean your PAP device and supplies, bacteria and mold may begin to grow. This may put you at higher risk of getting sick. Your device and supplies may be more likely to break down earlier if not kept clean. You may notice the device or mask starting to smell bad as well. Author: [NAME] Schotland.

Based on observation, interview and record review the facility failed to develop and/or implement Comprehensive Care Plans for 4 residents (R23, R25, R54 and R90) out of 19 residents reviewed for care planning.R90 Review of an admission Record reflected R90 admitted to the facility on [DATE] with diagnoses that included Amyotrophic Lateral Sclerosis (ALS), unspecified dementia, and an unspecified lack of expected normal physiological development in childhood. Review of an admission assessment dated [DATE] reflected R90 admitted to the facility with a right heel blister measuring 1.0 cm (centimeters) x 1.2 cm without any depth. Review of a Braden Scale-For predicting Pressure Ulcer Risk Evaluation dated 1/8/2026 reflected R90 was at risk for pressure ulcers. Review of a Care Plan initiated on 1/8/2026 reflected Resident (R90) has actual skin breakdown in the following locations: R-heel blister - L (left) hip surgical incision - R (right) groin fissure. Interventions included Encourage the resident to turn and reposition, pressure reducing surface on bed. (The care plan incorrectly identified the heel blister as being on the RIGHT heel. The blister is on the LEFT heel.) Review of a Care Plan initiated on 1/8/2026 reflected R90 was at risk for alteration in skin integrity related to weakness/debility. This care plan included interventions to offload pressure on R90's heels. During an observation on 1/12/26 at 10:05 AM tR90's heels were both on the bed, both feet pressed up against the foot board. During an observation on 1/13/2026 at 9:15 AM, R90's LEFT heel was observed and found to have a scabbed area consistent with the size documented on the admission assessment. R90's heels were left resting on the bed, the bottom of the right foot pressed up against to foot board. During an observation on 01/13/2026 at 2:34 PM, R90 was observed lying in bed, his right foot pressed up against the footboard. R90's left heel was on the mattress. During an observation on 1/14/26 at 8:26 AM R90's left and right heels are resting on the bed. According to the resident, he is feeling awful and did not sleep overnight and complained of a sore neck. R90 was positioned diagonally in the bed, his pillow is not under his head and shoulders. No offloading devices or additional pillows are observed in the room. During an observation and interview on 1/14/26 at 3:20 PM, R90 was observed in the bed with both heels resting on the mattress. R90 reported staff do not elevate his heels off the bed to prevent pressure. R90 said he got out of bed once the day before but does not like the total lift the facility has to use. R23 Review of R23's admission record dated 1/13/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and muscle wasting. R23 was not her own responsible party. Review of R23's Skin – Total Body Eval -V2 dated 12/17/26 and signed by Unit Manager (UM) I revealed, Right thigh rear – possible pressure – unable to determine will require RN (Registered Nurse) assessment or eval by wound nurse for definitive etiology 5.6 x 4.8 x 0.2 (islands of epithelial present within these measurements). Left thigh (rear) – possible pressure – unable to determine will require RN assessment or eval by wound nurse for definitive etiology 5.0 x 5.2 x 0.2 (islands of epithelial present within these measurements. Sacrum – pressure stage 5 – props (sic) to bone 4.6 x 3.8 x 2.2 cm undermining present from 6 -9 o clock at 1.8 cm. Review of R23's admission Evaluation – V 4 dated 12/17/25 at 17:00 (5:00 PM) revealed, Right thigh (rear) pressure length 5.6, width 4.8 depth 0.2, unstageable, left thigh (rear) pressure length 5.0, width 5.2, depth 0.2 unstageable, Sacrum pressure length 4.6, width 3.8, depth 2.2 unstageable. R23 was observed in bed on 1/13/26 at 11:18 AM. R23 was being repositioned in bed during care. R23's knees were touching (skin to skin) and there was no dressing on the back of her left thigh (open wound was visible). During an interview with Registered Nurse (RN) J on 1/14/26 at 7:05 AM, (RN) J said she had just assisted the Certified Nurse Aide (CNA) K reposition R23. R23 was complaining of pain at this time. RN J and K went in to reposition R23 to she could take her pain medication. R23 only had 1 pillow in her bed at this time which was under her head. R23's knees were touching each other, and the back of her thighs were in contact with her calves. During and observation and interview with the Director of Nursing (DON) and [NAME] Nurse Consultant (RNC) D on 1/14/26 at 9:00 AM R23 was not on an Alternating Pressure Mattress (APM). They knew it was not an APM mattress because it did not have a motor or power source. R23 had a dressing on over her entire buttock at this time that did not have a date or staff initials. R23 had one dressing on the back of both thighs dated 1/12/26 and a wound dressing on the back of her left calf dated 1/12/26. During an interview with RNC D on 1/14/26 at 12:25 PM RNC D was informed that the contracted facility Wound Nurse could not treat R23's wounds today because R23 was seen by the wound clinic yesterday. RNC D could not locate any wound clinic notes in R23's medical record and was not aware R23 was receiving wound treatment at a clinic outside of the facility. Review of R23's care plan dated 12/18/25 revealed, Resident has pressure injury/skin impairment pressure areas to buttock area (no indication of skin issue on the back of R23's thighs and calves). Interventions included: APM mattress dated 1/12/26 (not in place on 1/14/26). There was no indication of an outside wound clinic. There were no instructions for turning, positioning or use of equipment/pillows to assist in pressure relief/positioning. R25 Review of R25's admission record dated 1/14/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle wasting and atrophy (waste away), burns involving 10-19% of body surface with 0% to 9% third degree burns and unsteady on feet. R25 was his own responsible party. R25 was observed in bed on 1/13/26 at 12:18 PM. R25's C-PAP machine was on his nightstand. R25 said he does normally use the machine when sleeping to help him breathe, but he can't use it every night. R25 said no one has assisted him with his CPAP or his breathing needs since admission. During an interview with Unit Manager (UM) I on 1/13/26 at 4:00 PM, UM I said R25's hospital discharge summary did indicate that he used a C-PAP machine. UM I said R25 was transferred to the facility on [DATE] but he did not come with a C-PAP machine. UM I called the Respiratory Therapist that was treating R25 at the hospital and obtained the C-PAP settings and treatment information. UM I said she did not care plan R25's C-PAP machine or respiratory care needs. Review of R25's care plan revealed no mention of the use of a C-PAP machine or need of any respiratory care. Review of the facility CPAP – Continuous Positive Airway Pressure policy dated 9/1/19 revealed, Procedure: Verify physician order for CPAP. Obtain CPAP machine and supplies. (The set up of the settings on the machine or adjustments needed are performed by the Respiratory Therapist of DME (durable medical equipment) company with a physician order. Settings ordered by physician. R54 Review of R54's admission record dated 1/12/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: hydrocephalus (fluid on the brain), muscle wasting, unsteadiness on feet and cognitive communication deficit. R58 was not his own responsible party. Review of R54's care plan dated 12/24/25 revealed, deep tissue injury of left calcaneus (heel), interventions included PROFO boot (a pressure reliving device) to bilat (bilateral) on AAT's (at all times) WIB (while in bed) implemented 1/12/26, encourage and assist as needed to turn and reposition; use assistive devices as needed, implemented 12/24/25. Review of R54's care plan reflected ADL (activities of daily living) self-care deficit related to weakness and factors of aging dated 12/24/25 revealed interventions that include: ADL assist of 2 staff, 12/24/25, non-ambulatory at this time, 12/24/25, bed mobility one person assist, 12/24/25, splint wear bi-lateral foot drop boots while in bed, 12/24/25, Transfer EZ stand 2 person assist 12/24/25. R54 was observed in bed on 1/12/26 at 10:22 AM. R54's heels were both in contact with his mattress. No boots or splints were found in his room. R54 said he could not tolerate the weight of any boots on his feet but was willing to allow staff to put a pillow under his legs to float his heel off the surface of the mattress. The Certified Nurse Aide (CNA) called Unit Manager (UM) I to R54's room. UM I confirmed R54 had been refusing boots to both feet. UM I was aware R54 had an unstageable pressure ulcer on his left heel. UM I said she would have staff start using a pillow to keep R54's heels off his mattress. R54 was observed in bed on 1/14/26 at 7:46 AM with 3 pillows under R54's legs bunched up under his knees. Both of R54's heels were in full contact with his mattress. The Director of Nursing (DON) was interviewed at this time and confirmed pillows should not have been placed under R54's knees as this did not remove pressure off his heels. (R54's care plan did not reveal this intervention was implemented).

Based on observation, and interview, the facility failed to maintain general cleanliness and repair of the premises affecting occupants of halls 100, 200 and 400. Findings include: On 01/12/2026 at 9:15AM, observed in the hallway restroom on Hall 100 at the handsink, the cold-water line at faucet is not providing any water, all water access at handsink is coming from the hot-water line which is providing water at 116 degrees F On 01/12/2026 at 9:27AM, observed in Dining room [ROOM NUMBER] on Hall 400, visible mold growth at the bottom of the cabinet where the drain for the ice machine is located. On 01/12/2026 at 10:34AM, the end cap on the handrail near room [ROOM NUMBER] was observed missing, the wall had holes in it, less than a half inch in diameter, and an unsecured ethernet cord was observed coming out of the hole, less than 5 feet up on the wall. On 01/12/2026 at 10:39 AM, the end cap on the handrail near room [ROOM NUMBER] was observed missing, observed broken plastic corner guard by door of room [ROOM NUMBER]. On 01/12/2026 at 10:40AM observed on Hall 100, missing handrail by in office spaces prior to room [ROOM NUMBER], the connectors for handrail remained attached to wall. On 01/12/2026 at 3:10PM, interview with Maintenance Manager MM R, disclosed that the maintenance department was not aware of the issues with the handrail's missing parts, the corner guards or the missing handrail. MM R began this position on 01/12/2026. On 01/12/2026 at 3:30PM, observed an exterior door on Hall 200 by the Therapy room has gaps larger than 1/4 of an inch at bottom of the door. During observation with MM R stated they were not aware of the gaps at the door. On 01/12/2026 at 3:40pm observed the shower room on Hall 300 felt very humid, the shower did not appear to have recently been in use, as the tiles in shower area were observed to be dry.

Based on observation, interview and record reviews, the facility failed to staff the 400 & 500 Hallways to meet the acuity and psychosocial needs of 25 residents including R6 and R70.Findings include:R70Review of an admission Record revealed R70 was re-admitted to the facility on [DATE] with pertinent diagnosis which included Chronic Obstructive Pulmonary Disease, Muscle wasting and atrophy, polyneuropathy, depressive and anxiety disorders.During interview on 1/12/2026 at 10:33 AM, R70 stated, I think they have a staffing problem because when I used to ask to get up the aides could never find another staff member to help. R70 stated, I need a hoyer and 2 people to get out of bed. I quit asking the staff to get me up because they kept telling me No. R70 stated she would like to get out of bed, out of my room, but it probably will not happen.During an interview on 1/13/2026 at 4:34 PM, Licensed Practical Nurse (LPN) X revealed that acuity is high down here (referring to Residents on 400-Hallway), almost everyone is a 2-person hoyer.During an interview on 1/13/2026 at 4:37 PM, Certified Nurse's Aide (CNA) Y revealed R70 had told her the same thing, that there was not enough staff to get her up. CNA Y stated they had 3 aides working on this hallway (400-Hallway). During an interview on 1/13/2026 at 4:39 PM, Certified Nursing Aide (CNA) Z revealed she was working on the 400 hall. CNA Z further revealed during the interview that she has 8 residents that use a hoyer and require 2 people for transfers and care. Everyone in this hallway requires total care. CNA Z stated (Name of R70) does not ask to get out of bed often, but, if she did, I would find someone to make it happen. This surveyor asked, isn't there 2 other aides on this hallway to assist? CNA Z laughed, said I wish, and NO. Then stated we have 1 aide for 500, 1 for 400, then the wrap around aide from the 300-Hallway has 2 rooms on the 400. So, not 3 people in the 400-Hallway and our nurse has all the 400 & 500 residents minus 2 rooms that the 300-Hallway nurse picks up.On 1/13/ 2026 at approximately 4:46 PM LPN X stated, I try to assist the CNA's when I can, but I have all the meds, nursing things and wounds to take care of. But we are struggling because of the level of acuity our residents need.On 1/13/2026 at 4:47PM, Certified Nurse's Aide (CNA) V stated she had the 500-Hallway, and has 5 residents that require a hoyer, and one of her residents is dependent on staff to assist with eating.On 1/14/2026 at 8:24 AM, CNA V stated she was back again this morning working from 6-10 AM because of a call in then she was going home and coming back to work 2-10pm tonight. CNA V revealed she was the only one working the 500-Hallway this morning. Only one resident in the 500-Hallway was observed to be dressed and out of bed prior to breakfast being served.On 1/14/2026 at 8:46 AM, Certified Nurse's Aide (CNA) W was observed handing out breakfast trays. During the observation CNA W revealed they had 3 residents on the 400 & 500- Hallways that required total assistance for eating. During a breakfast observation on 1/14/2026 at approximately 8:45 AM, it was noted there was total of 2 aides and one nurse working the 400 & 500-Hallway. 3 call lights were observed on, both aides were hurrying to finish passing breakfast trays, and 3 residents required assistance with their breakfast.During an observation on 1/14/2026 at 8:56 AM, CNA V entered a room on the 500 Hallway to assist the resident with her breakfast. She came out of the room almost immediately, ran down the hallway to the dining room to grab CNA W to help her boost the resident up in her bed so CNA V could assist resident with their breakfast. CNA W went back to the dining room to help assist residents with their breakfast.Resident #6 (R6)Review of an admission Record revealed R6 was re-admitted to the facility on [DATE] with pertinent diagnosis that included, dysphagia, muscle wasting and atrophy, type 2 diabetes mellitus with foot ulcer, drop foot and neuromuscular dysfunction of bladder.During an interview on 01/13/2026 at 8:31 AM, R6 stated, They do not have enough staff to get me out of bed. R6 revealed he wants to get up but is told they can't do it because they do not have enough staff and make excuses. R6 stated when we get new nurses and CNA's they don't stay very long because they don't have enough help.During an interview on 01/14/2026 at 8:35 AM, R6 revealed he would like to get up today. R6 further stated the staff used to come and get me for activities all the time, but they don't do that anymore. I hardly ever get asked to join, so they must have quit doing them (activities). R6 was asked why do you think that? R6 stated, staffing, they probably don't have enough. R6 also revealed he does not receive showers anymore; he just gets a bed bath. When asked why, R6 stated it's just easier for everyone that way. R6 then stated it's just me and my TV, then staff for a few minutes when they can come in. It's just me and my TV every day, all day. I can't wait for summer so I can go outside.Review of R6's Care Plan revealed, (Name of R6) needs encouragement for meeting emotional, intellectual, physical, and social needs and is able to make independent choices and preferences known. He enjoys going outside, bingo, parties and live music. Date Initiated: 03/12/2021 Review of R6's activity interventions included: (Name of R6) enjoys coming to social events and parties, ensure to invite him. Date Initiated: 01/17/2024 (Name of R6) needs assistance/escort to activity functions. Date Initiated: 10/25/2023 (Name of R6's) preferred activities are: being outdoors whenever possible, fishing, watching tv, checkers, card games, listening to music (50's &a 60's), woodworking, socializing with others. Date Initiated: 10/25/2023During an interview on 1/14/26 at 9:18 AM, this surveyor was informed by the MDS Nurse AA that 2 residents received bed baths and 2 residents received showers today on the 400 and 500-Hallways. MDS Nurse AA stated, For 22 people they have 2 aides and one nurse, we meet state guidelines for staffing. MDS Nurse AA was asked, if a resident requires two aides to assist them in the shower who provides care for all the other residents during that time? MDS Nurse AA remained silent.During the interview a request was made to MDS Nurse AA and Regional MDS Nurse (RMDSN) BB to provide a list with the number of residents on the 400 & 500 Hallways that require 2-person assist, ADL/Personal Care, and feeding assistance/cueing.Review of list provided by MDS Nurse AA and Regional MDS Nurse BB on 1/14/26 reflected the following resident needs on the 400 & 500-Hallways: 13 out of 25 Residents required 2-person assistance for mobility (require the use of a hoyer), 4 out of 24 require assistance with eating (one resident receives nourishment from a feeding tube) and two residents are totally dependent on staff for all ADL care. Upon review, Regional MDS Nurse BB stated that resident acuity on the hallway seem to be quite high.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 Residents (R3, R23 and R25) of 19 Residents sampled.Findings include:: Resident #3 (R3) A review of R3's admission Record, dated 1/14/26, revealed R3 was a [AGE] year-old resident re-admitted to the facility on [DATE] with multiple diagnosis that included hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, muscle wasting and atrophy, and dementia. An observation of 500 hallway on 1/12/2026 at approximately 9:53 AM R3 revealed he was in pain and needed some pain medication. Durning an interview on 1/12/2026 at 9:54 AM, Registered Nurse (RN) C stated, (Name of R3) went on hospice a couple of weeks ago. RN C revealed resident had a significant decline and is no longer really eating and reports increased pain. A review of R3's medical record reflected one of the only indications this resident was being seen by Hospice was the change in payer source as evidenced by the resident admission record. A review of R3's physician orders failed to reflect an order for Hospice Care, there was only an order for a Hospice consult on 1/05/26. Further review of R3's medical record failed to reflect any progress notes, assessments, nor any Hospices Services Agreement/ Contract with a Hospice Provider. On 1/14/26 at approximately 1:00 PM a review of (Name of Hospice Provider's) Binder for the 400 and 500 Hallways reflected (Name of R3) was being visited by Hospice as evidence by CNA (Certified Nurse's Aides) documentation. Review of the documentation indicated the resident was receiving showers/care at the facility by Hospice CNAs. Review of a Hospice policy dated 3/20/2024 reflected that the purpose of this policy is to provide guidelines to ensure hospice services are available to residents at the end of life. Guidelines included the facility has an agreement in place with at least one Medicare certified Hospice to ensure that residents who wish to participate in a Hospice program may do so. The agreement with the Hospice provider will be signed by the facility representative and a representative from the Hospice agency before Hospice services are furnished to any resident. During an Interview on 1/14/26 at 2:18 PM, Regional Nurse Consultant (RNC) D revealed they do not have contract in the facility for (Name of Hospice Company). RNC D further stated the resident went into hospice on 1/5/26, however, they were unable to find an order, contract or progress notes stating this in residents' record. RNC D revealed she had (Name of SW B) contacting (Name of Hospice) for necessary documents/information. R23 Review of R23's admission record dated 1/13/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and muscle wasting. R23 was not her own responsible party. During an interview with Registered Nurse Consultant (RNC) D on 1/14/26 at 12:25 PM RNC D was informed that the contracted facility Wound Nurse could not treat R23's wounds today because R23 was seen by the wound clinic yesterday. RNC D could not locate any wound clinic notes in R23's medical record and was not aware R23 was receiving wound treatment at a clinic outside of the facility. During an observation and interview with UM I in R23's room on 1/14/26 at 2:40 PM, UM I said she assessed and measured R23's wounds on admission. UM I said R23 had multiple wounds on the back of both thighs and calves on admission. UM I said she documented they were all on the back of the thighs and did not indicate the number of wounds just the amount of space involved. UM I said both legs were healing. UM I confirmed that due to the way the leg wounds were being measured it was difficult to assess healing or decline. UM I was not aware until today that 2 different wound services were caring for R23's buttock wound. UM I said R23's buttock wound was healing compared to admission but had not obtained all records from the outside wound clinic. Review of R23's care plan dated 12/18/25 revealed, Resident has pressure injury/skin impairment pressure areas to buttock area (no indication of skin issue on the back of R23's thighs and calves). Interventions included: APM mattress dated 1/12/26 (not in place on 1/14/26). There was no indication R23 was being treated by an outside wound clinic. R25 R25 Review of R25's admission recorded dated 1/14/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle wasting and atrophy (waste away), burns involving 10-19% of body surface with 0% to 9% third degree burns and unsteady on feet. R25 was his own responsible party. R25 was observed in bed on 1/13/26 at 12:18 PM. R25's C-PAP machine was on his nightstand. R25 said he does normally use the machine when sleeping to help him breathe, but he can't use it every night. R25 said no one has assisted him with his CPAP or his breathing needs since admission. During an interview with Unit Manager (UM) I on 1/13/26 at 4:00 PM, UM I said R25's hospital discharge summary did indicate that he used a C-PAP machine. UM I said R25 was transferred to the facility on [DATE] but he did not come with a C-PAP machine. UM I called the Respiratory Therapist that was treating R25 at the hospital and obtained the C-PAP settings and treatment information. UM I said she ordered the C-PAP equipment but did not contact the physician or obtain orders for its use. UM I could not locate any medical information that indicated how long R25 had been using a CPAP machine. There were no physician orders for R25 to use the CPAP machine and no respiratory assessments located in R25's facility medical record. No Respiratory Therapist documentation was in R25's facility medical record. There was no care plan for the use or care of the C-PAP machine R25 in his room and had been using.

Based on observation, interview and record review the facility failed to follow its concern/grievance process and address family and resident concerns for 1 resident (R19) out of 19 residents reviewed for Resident Rights. Findings:Review of an admission Record reflected R19 admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, nutritional deficiency, unspecified and dysphagia (difficulty swallowing). During an interview on 1/12/2026 at 11:58 AM, R19's Family Member (FM) L, who visits R19 almost daily and typically during meals, reports that the ordered magic cup and mighty shake (both nutritional supplements intended to boost protein intake) are not on the resident tray as ordered with every meal. FM L reports the supplements are not on R19's meal tray 75% of the time and he is frustrated by this because R19 has had significant weight loss. FM L reported he has complained about this issue many times. FM L also reported that they have been unable to get resolution to an issue concerning an unsatisfactory haircut the family paid the facility beautician to provide for R19. During an interview on 1/12/2026 at 12:00 PM, R19 reported he was frustrated that the facility doesn't consistently provide the nutritional supplements with his meals as ordered. R19 also reported he was very unsatisfied with his most recent haircut. R19 said he wanted to beautician to cut his hair to a length of one inch all around, not just take one inch off the overall length. R19 said he felt like he looked terrible. R19 said he told facility staff he was upset about these things but nothing happens. During an observation on 1/12/2026 at 12:22 PM, R19's noon meal was served and the ordered nutritional supplements were not served as ordered. A meal ticket placed alongside R19's meal reflected a Magic Cup and Mighty Shake were to be provided. During an observation on 1/13/2026 at 12:21 PM, R19 was observed seated in the dining/activity room with his lunch set before him. The magic cup was present, but the mighty shake was not. Review of the tray ticket showed R19 should have a mighty shake with his meal. A request for all concern/grievance forms pertaining to R19 was requested via electronic mail (email) sent to the Director of Nursing (DON) on 1/14/2026 at 9:46 AM. During an interview on 1/14/2026 at 11:00 AM, the DON provided one concern form pertaining to R19. The concern form did not pertain to the concerns related to R19's haircut or the concerns reported about ordered nutritional supplements. During an interview on 1/14/26 at 9:40 AM, Activity Director (AD) O reported R19 is on the schedule for a haircut on January 22. AD O found a sticky note on her desk that described the issue and how R19 would like His haircut. AD O reported that R19's concern with his haircut was not a new issue. During an interview on 1/14/2026 at 3:14 PM, the Regional Nurse Consultant (RNC) D reported that staff who were made aware of FM L and R19's concerns should have followed the facility grievance process to address the concerns and eliminate the perception facility staff were not responding to resident and/or family concerns. Review of the facility policy Concern (Grievance) Process revised on 5/31/2024 reflected It is the policy of this facility to support each family member's right to voice concerns (grievances) without discrimination, reprisal, or fear of discrimination or reprisal. General guidelines in the policy specify that Concerns/grievances may be submitted verbally or in writing and may be filed anonymously . Concerns/Grievances may be voiced in the following ways: Verbal complaint to a staff member including the Grievance Officer. The staff member will transcribe the concern onto the concern form or assist the complainant with completing the concern form. The designated staff member will investigate the concern, follow-up with the resident and/or person filing the concern/grievance, and resolution of the concern/grievance. The designated staff member will make every effort to resolve the concern/grievance within 5-10 business days and complete the concern form to submit to the Grievance Officer. The Grievance Officer will notify the complainant to determine if they are satisfied with the resolution and document the information on the concern form.

Based on observation, interview and record review the facility failed to assess, monitor and treat 1 Resident's (R25) respiratory condition of 1 Resident reviewed for respiratory care.Findings included:Review of R25's admission record dated 1/14/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle wasting and atrophy (waste away), burns involving 10-19% of body surface with 0% to 9% third degree burns and unsteady on feet. R25 was his own responsible party. R25 was observed in bed on 1/13/26 at 12:18 PM. R25's C-PAP machine was on his nightstand. R25 said he does normally use the machine when sleeping to help him breathe, but he can't use it every night. R25 said no one has assisted him with his CPAP or his breathing needs since admission.During an interview with Unit Manager (UM) I on 1/13/26 at 4:00 PM, UM I said R25's hospital discharge summary did indicate that he used a C-PAP machine. UM I said R25 was transferred to the facility on [DATE] but he did not come with a C-PAP machine. UM I called the Respiratory Therapist that was treating R25 at the hospital and obtained the C-PAP settings and treatment information. UM I said she ordered the C-PAP equipment but did not contact the physician or obtain orders for its use. UM I could not locate any medical information that indicated how long R25 had been using a CPAP machine. There were no physician orders for R25 to use the CPAP machine and no respiratory assessments located in R25's facility medical record. No Respiratory Therapist documentation was in R25's facility medical record.Review of the facility CPAP - Continuous Positive Airway Pressure policy dated 9/1/19 revealed, Procedure: Verify physician order for CPAP. Obtain CPAP machine and supplies. (The set up of the settings on the machine or adjustments needed are performed by the Respiratory Therapist of DME (durable medical equipment) company with a physician order. Settings ordered by physician.

Based on observation, interview and record review the facility failed to ensure ordered supplements were provided to one resident with significant weight loss (R19) out of 2 residents reviewed for nutrition and hydration. Review of an admission Record reflected R19 admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, nutritional deficiency, unspecified and dysphagia (difficulty swallowing). Review of a Care Plan initiated 7/25/2025 reflected R19 was at risk for repeated alteration in skin integrity related to . poor nutritional intake due to dysphagia. An intervention for this focus area of the care plan was to provide diet and supplements per physician order. The Care Plan also indicated R19 required assistance with ADLs (activities for daily living) that included needing set up assistance for eating. Review of a Care Plan initiated on 7/7/2025 reflected (R19) is at unavoidable nutritional risk related to atrial fibrillation (abnormally fast pulse), CHF (congestive heart failure), CKD (Chronic Kidney Disease) stage 3A, HTN (high blood pressure), debility, HLD (high lipids in the blood), dementia, cognitive impairment, unspecified severe protein-calorie malnutrition, sig (significant) weight loss. The goal of the Care Plan focus area is that Resident (R19) will continue to comply with diet recommendations until physician orders say otherwise; (R19) will maintain adequate nutritional status; (R19) will comply with diet orders to reduce risk of aspiration. Interventions included, Alert dietitian if consumption is poor for more than 48 hours; document food acceptance; Supplements as ordered mighty shake and magic cup TID (three times a day) with meals. Review of an Alert Note dated 12/31/2025 revealed Note Text: WEIGHT WARNING:Value: 127.2Vital Date: 2025-12-31 09:41:07.0-10.0% change [ 14.4% , 21.4 ](R19) is a [AGE] year-old male resident with dx of nutritional deficiency, dysphagia, CHF, ckd stage 3a, hypertension, dementia, gerd (gastro esophageal reflux disease), unspecified severe protein calorie malnutrition. (R19) is on a regular diet, mech soft textures and nectar thick liquids. Residents (R19) CBW (Current Body Weight) is 127 lb and his BMI (Body Mass Index) is 19.9, resident is triggering for sig weight loss, 21 lb since July. resident experienced initial sig weight loss upon admission due to being on a puree diet and not liking his food and refusing to eat it. resident previously was on hospice services. resident upgraded to mech soft textures, intake has improved to 50-100% meal consumption, family also brings the resident in food which he consumes. resident receives magic cups and mighty shakes TID to provide additional calories and protein. will continue with supplements to support overall nutritional status. goal is to maintain cbw (current body weight) r regain of weight lost, maintain adequate oral intake and restoration of nutritional status. will continue with current plan of care and continue to closley monitor weight and intake.During an interview on 1/12/2026 at 11:58 AM, R19's Family Member (FM) L, who visits R19 almost daily and typically during meals, reports that the ordered magic cup and mighty shake (both nutritional supplements intended to boost protein intake) are not on the resident tray as ordered with every meal. FM L reports the supplements are not on R19's meal tray 75% of the time and he is frustrated by this because R19 has had significant weight loss.During an observation on 1/12/2026 at 12:22 PM, R19 was served a chicken sandwich and cabbage soup, tomato soup, pudding, cottage cheese, yogurt, and canned peaches. A magic cup and mighty shake were not served to R19 at this time. A Meal Ticket placed alongside the meal served to R19 reflected the ordered supplements were to be served to R19. During an observation on 1/13/2026 at 12:21 PM, R19 was observed seated in the dining/activity room with his lunch set before him. The magic cup was present, but the mighty shake was not. Review of the tray ticket showed R19 should have a mighty shake with his meal. During an interview on 1/13/2026 at 12:25 PM, Registered Dietitian (RD)M confirmed the resident did not have his mighty shake but did have his magic cup. Review of the January 2026 MAR-TAR (Medication Administration Record/Treatment Administration Record) shows staff were documenting R19 received the supplements as ordered during the noon meal on 1/12/2026 despite the supplement not being served on the tray. During an interview on 01/14/2026 10:23 AM Regional Registered Dietitian (RRD) N reported that based on the observations made with R19 and documentation of having received supplements when he did not was a concern. RRD N reported the kitchen staff need to do a better job of making sure that supplements are placed on meal trays. RRD N said a full audit is needed to improve the meal delivery system.

Based on observation, interview, and record review, the facility failed to prevent falls for 1 (R1) of 2 residents reviewed for falls, and unsafe self-administration of medications left at the bedside for 2 (R13 and R27), of 2 residents observed with medications at the bedside.Findings include:Review of R13's admission record dated 1/14/26 revealed R13 was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: acute kidney failure, muscle wasting, unsteadiness on feet, bipolar disorder, and chronic pain syndrome. R13 was her own responsible party. During the medication pass observation on 1/13/26 at 8:00 AM, R13 had a bottle of nasal spray (Nasal Relief Oxymetazoline HCL 0.55 %) on her bedside table. R13 said she had been taking this nasal spray since admission and was assessed to be independent taking it. R13 said she takes it daily around 1:00 pm but denied reporting to any nurse she had been taking the nasal spray. R13 denied being set up with any secure storage for this medication. Licensed Practical Nurse (LPN) U, took the nasal spray from R13 and said she was giving it to the Director of Nursing (DON). During an interview with the DON on 1/13/26 at 12:34 PM the DON said she secured the nasal spray and notified the provider. The DON said R13 had not been assessed to administer this medication independently. Review of R13's January 2026 Medication Administration Record revealed R13 had Fluticasone Propionate Nasal Suspension 50 MCG/ACT ordered starting 7/9/23 and was on hold as of 1/5/2026 then discontinued. Review of R13's current medication orders revealed she did not have any orders for any nasal spray (Nasal Relief Oxymetazoline HCL 0.55 %). Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] with pertinent diagnoses of a displaced fracture of the right femur (thigh bone), emphysema, and mental disorder. During an observation on 1/12/26 at 10:00 AM, R1 was lying in bed and did not want to talk at this time. Review of an Incident Report for R1 dated 8/21/25 at 11:18 AM revealed: Incident Description: Another staff member Alerted this nurse that resident was in need of assistance. Writer entered to observe resident sitting on floor in front of radiator. Resident Description: I tried to use the urinal standing up and just lost my balance. The resident was assisted into a wheelchair with the assistance of 2 staff and had a small laceration <2 cm (centimeters) to the posterior (back) head. R1 was sent to the emergency room due to the use of blood thinning medication. R1 was last seen by Therapy at approximately 11:00 AM. The care plan was updated for resident (R1) to be in a common view area when up in wheelchair. The investigation did not include when R1's toileting needs were last met or an intervention to address the need to stand up unassisted to use the urinal. No Neuro checks in the EMR (electronic medical records) for post unwitnessed fall on 8/21/25. Review of the Activities of Daily Living (ADL) Care Plan initiated 4/30/25 for R1 revealed: (R1) has an ADL self-care performance deficit (related to) Limited Mobility. Interventions include but not limited to: DRESSING: Participates by 1 Assist, initiated 5/1/25. TOILET USE: Participates by 1 Assist, initiated 5/1/25. Interventions post fall included: OT (Occupational Therapy) to assess and eval 2/2 recent illness, weakness, initiated 9/22/25 and PT (Physical Therapy) to assess and eval 2/2 recent illness, increased weakness, initiated 9/22/25. Review of a Fall Care Plan for R1 revealed after the fall on 8/21/25 revealed: (R1) at risk for falls (related to) poor safety awareness, debility, decreased mobility, muscle weakness, and unsteady gait. He has a history of self-transferring. initiated 4/30/25. Interventions: -Assist resident into (wheelchair) and have resident within immediate view of staff, initiated 8/21/25. -If resident is up in (wheelchair), keep in common area at all times for fall prevention as he frequently self-transfers, initiated 8/21/25. These interventions did not address the root cause of the R1 needing toileting assistance. Review of the August 2025 Medication Administration Record (MAR) revealed R1 had an order for 5 mg (milligrams) of Apixaban/Eliquis (an anticoagulant/blood thinner) ordered 4/30/25. Review of the Eliquis/Apixaban Medication Guide dated 5/2025 revealed: Increased risk of bleeding. ELIQUIS can cause bleeding which can be serious and may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting.it may take longer than usual for any bleeding to stop . Call your healthcare provider right away if you fall or injure yourself, especially if you hit your head. Your healthcare provider may need to check you. Review of the Care Plan for R1 revealed no focus or interventions for anticoagulants. R1 Fall #2 Review of an Un-Witnessed Fall Incident Report dated 9/6/25 for R1 revealed at 1:54 PM, Observed resident on his knees leaning on his bed in his room. Resident Description: stated he was trying to fix his bed because the (head of bed) was not working. Immediate Action Taken: . bed removed and another working bed was replaced. No injuries observed. No investigation or statements from staff regarding the bed not working or when R1's needs were last met. No indication neuro checks were initiated. No Neuro checks documented in the EMR (electronic medical record) for R1 from the fall on 9/6/25. Review of an Un-Witnessed Fall Incident Report dated 9/22/25 for R1 revealed at 12:50 PM, Resident was observed laying on the floor next to his bed by Activity Aide. I hit my head a little bit, but not bad. Injuries Observed at Time of Incident: Skin Tear to left elbow and back of the left hand. Review of an Alert Note dated 9/22/25 for R1 regarding the fall on 9/22/25 revealed: Activity aid was walking by resident's room and observed resident laying on the floor next to his bed. The nurse on unit and CNA (Certified Nursing Assistant) came to resident's room to observe resident laying on his left side, his weak arm. Unable to perform full range of motion to left shoulder at baseline, but able to move all other extremities. Resident did not have shoes on completely, and his shorts were down at his ankles when observed. Resident was attempting to dress himself when he had fallen. Resident was assisted with 3 staff members back in the bed and assisted with pulling his shorts up. Resident was then assessed for injuries. Resident stated he hit his head. There were no bruises, bumps or injuries assessed on his head. Resident did have 2 skin tears. One near on his left forearm near his elbow and the other on his left hand. The one on his arm measure 2.5 cm X 1.5 cm and the one on his hand was measured 1.5 cm X 1 cm. Nurse covered with Steris trips and Tegaderm and added treatment order to monitor. Resident's call light was not in reach. Resident normally uses call light when in need of assistance. Call light was wrapped up on and not near his bed. Reminded CNAs to make sure call light is in reach and encouraged resident to use call light when in need of assistance. CNA on the floor stated she did check on him and observed resident attempting to get dressed and offered assistance, but resident refused approximately 10 minutes prior. NP notified and did not feel it was necessary to send resident to the hospital. She asked that close monitoring does occur. Resident was started on neuro checks. No issues with neuro that were out of the ordinary. Resident later stated he wanted to get out of her (sic) and go to the hospital, but there was no reason to send resident to the hospital. Resident soon after was in the dining room [ROOM NUMBER] and attempted to escape out the doors of the dining room trying to get out and leave. This notification was relayed to the nurse on duty by another nurse in the building and a CNA. Resident now has wander guard on right ankle. The investigation did not address why the CNA did not ensure the safety of R1 when she observed R1 standing up and refused assistance. Review of the Neurological Evaluation Flow Sheet 12-Hour Shift documented for R1 dated 9/22/25 revealed checks were done at 12:50 PM, 1:20 PM, 1:50 PM, 2:50 PM, 3:50 PM, 4:50 PM, and 5:50 PM. This was not completed by the facility Fall policy. Review of the Care Plan for R1 revealed no Focus for elopement and no wander guard interventions. No interventions to ensure the call light was in reach. In an interview on 1/14/26 at 2:58 PM, the Director of Nursing (DON) acknowledged the concern of a lack of neurological checks for R1's incident reports and could not provide them. The Neurochecks for the 9/22/25 incident was not completed by the policy and stated they did have a past noncompliance and provided a copy of it dated 10/9/25 but did not meet the criteria as complete. The DON reported that the care plan should be updated with meaningful and person-centered interventions post falls. The DON agreed that a resident on a blood thinning medication and at risk for falls is concerning. Review of the Pas Non-Compliance for dated 10/9/25 titled Neuro completion revealed: Event: Facility failed to start of complete neuro for residents who have had falls. Root Cause Analysis: Nursing staff failed to comply with facility policy by choice or due to lack of knowledge. The facility is utilizing agency staffing. Review of a policy titled Fall Management Guidelines dated 12/13/23 revealed: The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management a residence in the facility. Care Planning: The facility staff, with input of the attending physician, will implement a resident centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the residents modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk and or risk for injury related to falls. The residents care plan and interventions will be reviewed and revised as indicated for the individual needs of the resident and effectiveness of interventions. Complete a neurological evaluation using the Neurocheck Evaluation Form when a resident: . - Has an unwitnessed fall when a head injury may be suspected or is unknown. - After the completion of the initial neurological evaluation with vital signs, continue the evaluations every 30 minutes X2, every hour X 4, every 4 hours X 6, then every shift X for a total of 3 days. Initiate post-fall charting on the resident for a minimum of three days to observe for delayed complications. IDT (Interdisciplinary Team) Review: -The interdisciplinary team will review the resident's fall including: the circumstances surrounding the residence fall and any changes in the residence risk factors, condition, and/or functional status to validate or determine the root cause of the fall. -The interdisciplinary team will review the residence current care plan and interventions to ensure that the interventions are appropriate and the residents post fall intervention(s) correlate to the root cause of the fall in an attempt to prevent future falls. Review of an admission Record reflected R27 admitted to the facility 7/31/25 with diagnoses that included depression, anxiety and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12/15. During an observation on 1/12/2026 at 9:45 AM, R27 was observed getting back into bed after using the restroom. A cup with assorted pills and capsules was noted on the overbed table. R27 reported that the medications were hers and that a purple pill was on the floor under the privacy curtain. A Certified Nurse Aide (CNA) walked into the room and R27 reported that one of her pills had fallen to the floor. The CNA picked up the pill and said he would report the finding to the nurse. Review of the comprehensive Care Plan initiated 7/31/25 did not reflect R27 was assessed as safe to self-administer medications. Review of R27's physician orders did not reflect R27 was allowed to self-administer medications. During an observation on 1/13/2026 at 2:36 PM, Registered Nurse (RN) F opened the medication cart and R27's medications were inspected. The purple pill that was dropped on the floor in R27's room was identified as bupropion 150 mg tablet, an antidepressant. During an interview on 1/13/2026 at 3:04 PM the DON reported that the facility did not have any residents who had been assessed for being safe to self-administer medications. The DON also reported that there would be no way to identify whether R27 truly received all her ordered morning medications.

Based on observation, interview, and record review, the facility failed to ensure proper positioning/support for one (R56) of 3 residents reviewed for positioning.Findings include: Review of a Face Sheet revealed R56 had pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness) affecting the left side and chronic kidney disease. During an observation on 1/12/26 at 10:20 AM, R56 was observed transporting down the hall in a wheelchair with her left arm flaccid and not supported.During an observation on 1/13/26 at approximately 11:00 AM, R56 was observed in bed without support for her left arm. R56 was then transferred to a wheelchair in anticipation of an appointment. R56's arm was not supported and hanging down in her lap as she was transported out of the facility. Review of the Care Plan for R56 revealed: ADL (activities of daily living) self-care deficit related to physical limitations. No goals documented. Interventions included: LUE (left upper extremity) Sling on when seated in (wheelchair) or standing/ambulating as resident will allow, initiated 10/30/25.In an interview on 1/13/26 at 12:41 PM, Occupational Therapist (OT) reported R56 was currently on therapy and is to have a sling in place to support her left upper arm. During an observation and an interview, R56 was lying in bed and no support observed for her left upper arm. Certified Nursing Assistant (CNA) AA reported R56 usually has a sling that is put on her arm before she goes to dialysis, but since she did not have dialysis this day, R56 did not have it on. When asked where the sling was, CNA AA looked all over the room and found it in the closet buried under a pile of clothes.

Based on observation, interview and record review the facility failed to provide care and services according to professional standards to prevent the development and/or worsening of pressure injuries for 3 residents (R23, R54 and R90) out of 5 residents reviewed for pressure injuries. R23 Review of R23's admission record dated 1/13/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and muscle wasting. R23 was not her own responsible party. Review of R23's Skin – Total Body Eval -V2 dated 12/17/26 and signed by Unit Manager (UM) I revealed, Right thigh rear – possible pressure – unable to determine will require RN (Registered Nurse) assessment or eval by wound nurse for definitive etiology 5.6 x 4.8 x 0.2 (islands of epithelial present within these measurements). Left thigh (rear) – possible pressure – unable to determine will require RN assessment or eval by wound nurse for definitive etiology 5.0 x 5.2 x 0.2 (islands of epithelial present within these measurements. Sacrum – pressure stage 5 – props (sic) to bone 4.6 x 3.8 x 2.2 cm (centimeters) undermining present from 6 -9 o clock at 1.8 cm. Review of R23's admission Evaluation – V 4 dated 12/17/25 at 17:00 (5:00 PM) revealed, Right thigh (rear) pressure length 5.6, width 4.8 depth 0.2, unstageable, left thigh (rear) pressure length 5.0, width 5.2, depth 0.2 unstageable, Sacrum pressure length 4.6, width 3.8, depth 2.2 unstageable. R23 was observed in bed on 1/13/26 at 11:18 AM. R23 was being repositioned in bed during care. R23's knees were touching (skin to skin) and there was no dressing on the back of her left thigh (open wound was visible). During an interview with Registered Nurse (RN) J on 1/14/26 at 7:05 AM, (RN) J said she had just assisted Certified Nurse Aide (CNA) K reposition R23. R23 was complaining of pain at this time. RN J and K went in to reposition R23 to she could take her pain medication. R23 only had 1 pillow in her bed at this time which was under her head. R23's knees were touching each other, and the back of her thighs were in contact with her calves. During and observation and interview with the Director of Nursing (DON) and [NAME] Nurse Consultant (RNC) D on 1/14/26 at 9:00 AM R23 was not on an Alternating Pressure Mattress (APM). They knew it was not an APM mattress because it did not have a motor or power source. R23 had a dressing on over her entire buttock at this time that did not have a date or staff initials. R23 had one dressing on the back of both thighs dated 1/12/26 and a wound dressing on the back of her left calf dated 1/12/26. During an interview with RNC D on 1/14/26 at 12:25 PM RNC D was informed that the contracted facility Wound Nurse could not treat R23's wounds today because R23 was seen by the wound clinic yesterday. RNC D could not locate any wound clinic notes in R23's medical record and was not aware R23 was receiving wound treatment at a clinic outside of the facility. During an observation and interview with UM I in R23's room on 1/14/26 at 2:40 PM, UM I said she assessed and measured R23's wounds on admission. UM I said R23 had multiple wounds on the back of both thighs and calves on admission. UM I said she documented they were all on the back of the thighs and did not indicate the number of wounds just the amount of space involved. UM I said both legs were healing. UM I confirmed that due to the way the leg wounds were being measured it was difficult to assess healing or decline. UM I was not aware until today that 2 different wound services were caring for R23's buttock wound. UM I said R23's buttock wound was healing compared to admission but had not obtained all records from the outside wound clinic. Review of R23's care plan dated 12/18/25 revealed, Resident has pressure injury/skin impairment pressure areas to buttock area (no indication of skin issue on the back of R23's thighs and calves). Interventions included: APM mattress dated 1/12/26 (not in place on 1/14/26). There was no indication of an outside wound clinic. There were no instructions for turning, positioning or use of equipment/pillows to assist in pressure relief/positioning. R54 Review of R54's admission record dated 1/12/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: hydrocephalus (fluid on the brain), muscle wasting, unsteadiness on feet and cognitive communication deficit. R58 was not his own responsible party. Review of R54's care plan dated 12/24/25 revealed, deep tissue injury of left calcaneus (heel), interventions included PROFO boot (a pressure reliving device) to bilat (bilateral) on AAT's (at all times) WIB (while in bed) implemented 1/12/26, encourage and assist as needed to turn and reposition; use assistive devices as needed, implemented 12/24/25. Review of R54's care plan reflected ADL (activities of daily living) self-care deficit related to weakness and factors of aging dated 12/24/25 revealed interventions that include: ADL assist of 2 staff, 12/24/25, non-ambulatory at this time, 12/24/25, bed mobility one person assist, 12/24/25, splint wear bi-lateral foot drop boots while in bed, 12/24/25, Transfer EZ stand 2 person assist 12/24/25. Review of R54's SW – Skin Issues, document dated 1/4/26 at 14:00 (2:00 PM) revealed, page 4 area affected left heel, page 10 skin issue – pressure ulcer/Injury, page 11 c. Stable: previously deteriorating wound characteristics plateaued, g. unstageable Pressure injuries presenting as deep tissue injury. Acquired b. Present on admission on set a. New, Staged by b. In-house nursing. Length 7.92, Width 2.44, Depth 0. R54 was observed in bed on 1/12/26 at 10:22 AM. R54's heels were both in contact with his mattress. No boots or splints were found in his room. R54 said he could not tolerate the weight of any boots on his feet but was willing to allow staff to put a pillow under his legs to float his heel off the surface of the mattress. The Certified Nurse Aide (CNA) called Unit Manager (UM) I to R54's room. UM I confirmed R54 had been refusing boots to both feet. UM I was aware R54 had an unstageable pressure ulcer on his left heel. UM I said she would have staff start using a pillow to keep R54's heels off his mattress. R54 was observed in bed on 1/14/26 at 7:46 AM with 3 pillows under R54's legs bunched up under his knees. Both of R54's heels were in full contact with his mattress. The Director of Nursing (DON) was interviewed at this time and confirmed pillows should not have been placed under R54's knees as this did not remove pressure off his heels. (R54's care plan did not reveal this intervention was implemented). Review of an admission Record reflected R90 admitted to the facility on [DATE] with diagnoses that included Amyotrophic Lateral Sclerosis (ALS), unspecified dementia, and an unspecified lack of expected normal physiological development in childhood. Review of an admission assessment dated [DATE] reflected R90 admitted to the facility with a right heel blister measuring 1.0 cm (centimeters) x 1.2 cm without any depth. Review of a Braden Scale-For predicting Pressure Ulcer Risk Evaluation dated 1/8/2026 reflected R90 was at risk for pressure ulcers. Review of a Care Plan initiated on 1/8/2026 reflected Resident (R90) has actual skin breakdown in the following locations: R-heel blister - L (left) hip surgical incision - R (right) groin fissure. Interventions included Encourage the resident to turn and reposition, pressure reducing surface on bed. (The care plan incorrectly identified the heel blister as being on the RIGHT heel. The blister is on the LEFT heel.) Review of a Care Plan initiated on 1/8/2026 reflected R90 was at risk for alteration in skin integrity related to weakness/debility. This care plan included interventions to offload pressure on R90's heels. During an observation on 1/12/26 at 10:05 AM tR90's heels were both on the bed, both feet pressed up against the foot board. During an observation on 1/13/2026 at 9:15 AM, R90's LEFT heel was observed and found to have a scabbed area consistent with the size documented on the admission assessment. R90's heels were left resting on the bed, the bottom of the right foot pressed up against to foot board. During an observation on 01/13/2026 at 2:34 PM, R90 was observed lying in bed, his right foot pressed up against the footboard. R90's left heel was on the mattress. During an observation on 1/14/26 at 8:26 AM R90's left and right heels are resting on the bed. According to the resident, he is feeling awful and did not sleep overnight and complained of a sore neck. R90 was positioned diagonally in the bed, his pillow is not under his head and shoulders. No offloading devices or additional pillows are observed in the room. During an observation and interview on 1/14/26 at 3:20 PM, R90 was observed in the bed with both heels resting on the mattress. R90 reported staff do not elevate his heels off the bed to prevent pressure. R90 said he got out of bed once the day before but does not like the total lift the facility has to use. During an interview on 1/14/26 at 3:30 PM, the Regional Nurse Consultant (RNC) D reported that it would be the expectation that R90's heels would be positioned in order to relieve pressure with a heels up device and that the bed be extended and the footboard removed to prevent the development of additional pressure injuries.

Based on observation, interview, and record review, the facility failed to monitor care to potentially prevent sepsis/hospitalization for one (R1) and failed to assess and monitor moisture associated skin damage (MASD) for one (R4) of two residents reviewed for quality of care.Findings include:Resident #1 (R1)Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] with pertinent diagnoses of a displaced fracture of the right femur (thigh bone), emphysema, and mental disorder. On 9/28/25 R1 received new diagnoses of sepsis and pneumonia. During an observation on 1/12/26 at 10:00 AM, R1 was lying in bed and did not want to talk at this time. Review of an Incident Report for R1 dated 8/21/25 at 11:18 AM revealed: Incident Description: Another staff member Alerted this nurse that resident was in need of assistance. Writer entered to observe resident sitting on floor in front of radiator. Resident Description: I tried to use the urinal standing up and just lost my balance. The resident was assisted into a wheelchair with the assistance of 2 staff and had a small laceration <2 cm (centimeters) to the posterior (back) head. R1 was sent to the emergency room due to the use of blood thinning medication. R1 was last seen by Therapy at approximately 11:00 AM. The care plan was updated for resident (R1) to be in a common view area when up in wheelchair. The investigation did not include when R1's toileting needs were last met. Review of a Hospital Record for R1 dated 8/21/25 revealed R1 went to the Emergency Department post fall at the Nursing Facility. (R1) . is anticoagulated on Eliquis (Apixaban). He was trying to urinate, lost his balance and fell backwards. there is a small abrasion to the right posterior scalp which is hemostatic (coagulation/stopped bleeding). Urinalysis was obtained and R1 was positive for bacteria in his urine. A summary of the Medical Decision Making revealed: urinalysis was notable for suspicious findings for urinary tract infection. There is positive nitrates large leukocytes 2+ bacteria with only 1-5 squamous cells the patient was started on antibiotics for a UTI (urinary tract infection). He is not febrile and otherwise as well appearing. Started on Keflex 1000 mg 3 Times daily due to increased resistance patterns he does need to be higher dose. We did culture his urine and we will contact him if antibiotics need to be changed.Review of the EMR (Electronic Medical Records) for R1 revealed the antibiotic administration of Keflex/Cephalexin 1000 mg (milligrams) ended on 8/28/25. No documentation about the urine cultures from the 8/21/25 hospital visit was followed up on and no ongoing assessing and monitoring of R1's signs and/or symptoms of infections was documented since the diagnosis of a UTI. Review of a Practitioner Progress note dated 9/9/25 for R1 revealed he tested positive for COVID and was currently asymptomatic and was to start Molnupiravir (Lagevrio, a medication to treat mild to moderate COVID) 800 mg (milligrams) twice a day for 5 days. Review of a Nursing Progress note dated 9/14/25 for R1 revealed: Have not had Molnupiravir since Friday. They do not have this in stock in the pharmacy and are suggesting Paxlovid/Nirmatrelvir (medication to treat COVID) instead. Will be missing 3 days' worth of medication. Will run this by provider. No documentation prior to this indicating the missing medication was addressed. Review of a Nursing Progress note dated 9/14/25 for R1 revealed: Resident's last dose of Lagevrio was Friday evening. Contacted pharmacy to find out what is going on and they stated it is on back order and recommends Paxlovid. Notified on-call PA (Physician Assistant) of recommendation and she okayed to change it. Entered order for the 300/100 pack for 5 days. Entered to start tomorrow morning. Did attempt to reach out to pharmacy to find out when that will be in and will adjust start time if needed. Left VM and awaiting return call. Will continue to monitor.Review of the EMR for R1 revealed no ongoing respiratory assessments for COVID once diagnosed on [DATE] were documented. Review of an Alert Note dated 9/22/25 for R1 regarding a fall on 9/22/25 (as 12:50 PM) revealed: Activity aid was walking by resident's room and observed resident laying on the floor next to his bed. The nurse on unit and CNA (Certified Nursing Assistant) came to resident's room to observe resident laying on his left side, his weak arm. Unable to perform full range of motion to left shoulder at baseline, but able to move all other extremities. Resident did not have shoes on completely, and his shorts were down at his ankles when observed. Resident was attempting to dress himself when he had fallen. Resident was assisted with 3 staff members back in the bed and assisted with pulling his shorts up. Resident was then assessed for injuries. Resident stated he hit his head. There were no bruises, bumps or injuries assessed on his head. Resident did have 2 skin tears. One near on his left forearm near his elbow and the other on his left hand. The one on his arm measure 2.5 cm X 1.5 cm and the one on his hand was measured 1.5 cm X 1 cm. Nurse covered with Steri strips and Tegaderm and added treatment order to monitor. Resident's call light was not in reach. Resident normally uses call light when in need of assistance. Call light was wrapped up on and not near his bed. Reminded CNAs to make sure call light is in reach and encouraged resident to use call light when in need of assistance. CNA on the floor stated she did check on him and observed resident attempting to get dressed and offered assistance, but resident refused approximately 10 minutes prior. NP notified and did not feel it was necessary to send resident to the hospital. She asked that close monitoring does occur. Resident was started on neuro checks. No issues with neuro that were out of the ordinary. Resident later stated he wanted to get out of her (sic) and go to the hospital, but there was no reason to send resident to the hospital. Review of a Hospital History and Physical document for R1 dated 9/23/25 revealed: He was also noted to be hypoxic (low oxygen) at the facility with saturations in the mid-80s (normal >=92%). (Facility nurse) tells me that he (R1) . last night that he started to be a little altered, did have a fall throughout the night. Today, was noted to be course in his breathing, they had ordered an x-ray but had not been completed yet, then got progressively more altered as the day went on which is what prompted the ED (emergency department) visit. Patient to be admitted to the ICU (intensive care unit) for septic shock secondary to bacterial pneumonia. Review of the Hospital Discharge Summary for R1 dated 9/28/25 revealed R1 admitted [DATE] for COVID-19 pneumonia and septic shock, initially requiring ICU level care . Blood cultures positive for E. coli (Escherichia coli- a bacterium usually found in the intestines), presumed likely urinary source .In an interview on 1/14/25 at 10:22 AM, the Infection Control/Registered Nurse (RN) A was questioned about R1's urine culture that was to follow the 8/21/25 hospital visit. RN A reported she did not have a copy of the urine culture after reviewing the EMR. RN A reported they are to follow the McGeers criteria for antibiotic use for suspected/diagnosed UTI's. When questioned about the effectiveness of antibiotic use and what to look out for when resident vital signs are not abnormal, RN A reported there were other things to monitor like confusion, an increased need for ADL (activities of daily living) care and any changes or odor with urination. A resident with a UTI should be monitored for urine output and encourage fluids. Anything that does not help a resident get back to his baseline is not on the right antibiotic. The first 24-48 hours should have focused monitoring of infections documented and verified R1 did not have that documented. RN A contacted the hospital after this interview and reported the hospital did not complete a urine culture. RN A reported that the facility should have followed through to make sure R1 was on the correct antibiotics and they were effective. RN A acknowledged R1 did get admitted to the hospital on [DATE] for COVID pneumonia and e.coli bacteremia (blood infection) likely due to a urinary tract infection. Review of the Care Path Symptoms of Urinary Tract Infection (UTI) (In place of McGeers criteria) provided by the facility revealed a pathway for UTI's. If no abnormal vital signs are met (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, finger stick glucose, or a resident is unable to eat or drink), then Evaluate Symptoms and Signs for Immediate Notification: abdominal distension, new or worsened incontinence, suprapubic tenderness, pain/tenderness in testes suggesting epididymitis, gross blood in urine, not eating or drinking, signs and symptoms suggest possible sepsis (a life-threatening medical emergency caused by your body's overwhelming response to an infection). If this is negative, then Consider Contacting (Practitioner) for orders (for further evaluation and management) . in Facility: Monitor vital signs, fluid intake/urine output every 4-8 hours. Oral, IV or subcutaneous fluids if needed for hydration. Check results of urinalysis and culture. Consider antibiotic treatment for 7-10 days if culture positive. DISCONTINUE ANTIBIOTIC IF CULTURE IS NEGATIVE. Update advance care plan and directives if appropriate. In an interview on 1/14/25 at 2:11 PM, the Director of Nursing (DON) was presented with concerns for R1's hospitalization on 9/23/25 and the lack of follow-up cultures and monitoring to his UTI, the DON reported she would look more into it. No more information was provided by the end of this survey. Review of the Care Plan for R1 revealed no UTI care plan prior to hospitalization on 9/23/25. R1's care plan did not address urinary continence or incontinence until R1 was readmitted to the facility on [DATE] after hospitalization. Resident #4 (R4)Review of a Face Sheet revealed R4 originally admitted to the facility on [DATE] and has pertinent diagnoses of osteomyelitis (inflammation or swelling of bone tissue), history of pressure ulcers, and acute kidney failure. In an interview on 1/12/26 at 11:03 AM, the Hospice Certified Nursing Assistant (CNA) X had just completed resident care when asked if there were any wounds on R4. CNA X reported there was too much cream on R4's buttocks to see any open wounds and did not receive any information that R4 had any wounds. R4 was observed laying on his back before and after CNA X provided cares. Review of a Skin Assessment for R4 dated 1/9/26 revealed: Left heel- Continue with current tx (treatment). Sacrum- Continue with current tx. No description or measurements of what type of wounds these were or when they started, and Wound Care was documented as consulted. During an observation and an interview on 1/13/2026 at 8:45AM, R4 was sitting up in bed eating breakfast at a 30-degree angle. R4 did not know or acknowledge he had a wound on his buttocks. During an observation on 1/13/2026 at 10:59 AM, R4 was in bed lying on his back sleeping.During an observation and an interview on 1/13/26 at 2:01 PM, Unit Manager/Licensed Practical Nurse (LPN) I and Registered Nurse (RN) Y went to assess R4's skin when the resident was observed sitting in stool. RN Y reported it was fresh and was not sitting in it for very long. Then R4's buttocks were assessed and verified R4 had purple maceration that was blanchable and looked more like denuded MASD that was potentially due to his times of having loose stools/diarrhea. RN Y verified R4 did have an unstageable scabbed area on his left heel. LPN I did report R4 has a history of pressure ulcers but his current condition is consistent with MASD and reported she will inform the physician and hospice. Review of a Nursing Progress note dated 12/10/25 for R4 revealed: CENA completing cares called nurse into room. Nurse observed open area on res coccyx measuring 2.5cm x 1cm (W x L). Area assessed then cleansed and dressing applied. Area noted to have purple tissue surrounding and red non blanchable area surrounding the purple area. On call unit mgr, physician, and hospice notified of new skin issue.Review of a Nursing Progress note dated 12/15/25 for R4 revealed: Note Text: Resident with reoccurring pressure ulcer on his coccyx. Resident is his own person and frequently turns down offers from staff for repositioning to promote/maintain skin integrity. Wound care treatment initiated. Care plan reviewed and updated. No documentation of R4 refusing repositioning or cares and/or reapproached. Review of a Nursing Progress note for R4 dated 12/17/25 revealed: Skin Issues: #001: New skin Issue. Location: Buttocks - generalized. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Wound is new. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 0 Width (cm): 0 Depth (cm): 0 Area (cm2): 0 Undermining: No. Tunneling: No. Epithelial: 100%. Exudate amount: None. Exudate type: None. Odor after cleansing: None. Periwound: Attached. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing saturation: None 0%. Cleansing solution: Sterile Water. Other primary dressing: triad cream Secondary dressing: No secondary dressing applied. Modalities: None.Review of a Nursing Progress note dated 12/29/25 for R4 revealed: Skin Issues: #001: Skin issue has not been evaluated. Location: Buttocks - generalized. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Wound is new. Staged by: In-house nursing. Undermining: No. Tunneling: No.#002: New skin Issue. Location: Buttocks - generalized. Laterality / Orientation: Medial. Issue type: Other skin issue. Other skin issue description: Bottom reddened, barrier cream applied. Resident encouraged to change positios (sic) yet is refusing. IssuWound (sic) acquired in-house.Wound is new. Signs and symptoms of infection: None. Painful: No. Undermining: No. Tunneling: No. Slough: 0%. Eschar: 0%. Exudate type: None. Odor after cleansing: None. Other primary dressing: Barrier cream.Review of the January 2026 Medication Administration and Treatment Administration Record (MAR/TAR) for R4 revealed the following orders:-10/19/25, an order for Left Heel- Apply skin prep and maintain boot in place while in bed every day shift. - 12/17/25, an order for Wound Care Order Site: buttocks 1. Cleanse wound with NS (normal saline). 2. Pat Dry with gauze. 3. Apply triad cream (a zinc oxide-based hydrophilic paste for managing low to moderate exudate wounds).Review of the Resident Care Task documentation for R4 revealed: - Encourage and assist as needed to turn and reposition; use assistive devices as need. No point of care documentation from staff indicated this was being done. - Encourage and assist as needed to turn and reposition. No point of care documentation from staff indicated this was being done. Review of the Nursing Progress note dated 1/13/26 for R4 (after observation) revealed: Bilateral buttock/sacrum observed with erythema and slight maceration overlying the sacrum. Area is slightly denuded throughout with one area that measures 1.3x0.2 that is denuded down to dermis. Entire area is blanchable. Resident denies pain to area. Physician notified, hospice notified. New order for MASD initiated.Review of the Care Plan for R4 revealed: Focus: Left heel wound and reoccurring pressure ulcer to sacrum + H Related to pressure injury, with risk for delayed wound healing secondary to progressing comorbidities, Debility and generalized weakness with decreased physical mobility. Date Initiated: 12/10/2025.Interventions included: -Provide wound care as ordered by physician and wound consult recommendations. Date Initiated: 07/22/2025-Resident has been educated on the importance of frequent repositioning. Date Initiated: 12/12/2025.-Risk factors reviewed and unavoidable from to be completed due to ongoing declineresulting hospice participation, and reoccurring pressure ulcer to sacrum. Date Initiated: 12/10/2025-Skin Evaluation weekly. Check oral cavity for redness, sores, white patches in themouth, dried cracked lips or other manifestations reflecting oral conditions. Checkskin for open areas, bruises, abrasions, DTI, incisions. Date Initiated: 07/22/2025- Monitor wound for any significant changes (decline or improvement), alert physician of any changes. Date Initiated: 07/22/2025- Provide wound care as ordered by physician and wound consult recommendations. Date Initiated: 07/22/2025Review of the ADL (Activities of Daily Living) Care Plan, initiated 1/13/25 for R4 revealed:- Assist resident to meet toileting needs either with utilization of bathroom and urinal per resident request, preference, and as needed. Res prefers to be toileted for bowel movements. Date Initiated: 03/21/2025.- Bed mobility: 1 assist, Date Initiated: 10/08/2025.- TOILET USE: Participates by: 2 assist and EZ stand. Date Initiated: 09/12/2025.No indication R4 is incontinent.

Based on observation, interview and record review the facility failed to complete a baseline care plan within 48 hours of admission for 2 Residents (R23 and R25) of 2 residents reviewed for baseline care plans.Findings included:Resident 23Review of R23's admission record dated 1/13/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and muscle wasting. R23 was not her own responsible party.Review of R23's Skin - Total Body Eval -V2, dated 12/17/26 and signed by Unit Manager (UM) I revealed, Right thigh rear - possible pressure - unable to determine will require RN (registered nurse) assessment or eval by wound nurse for definitive etiology 5.6 x 4.8 x 0.2 (islands of epithelial present within these measurements). Left thigh (rear) - possible pressure - unable to determine will require RN assessment or eval by wound nurse for definitive etiology 5.0 x 5.2 x 0.2 (islands of epithelial present within these measurements. Sacrum - pressure stage 5 - props (sic) to bone 4.6 x 3.8 x 2.2 cm undermining present from 6 -9 o clock at 1.8 cm.Review of R23's admission Evaluation - V 4 dated 12/17/25 at 17:00 (5:00 PM) revealed, Right thigh (rear) pressure length 5.6, width 4.8 depth 0.2, unstageable, left thigh (rear) pressure length 5.0, width 5.2, depth 0.2 unstageable, Sacrum pressure length 4.6, width 3.8, depth 2.2 unstageable.R23 was observed in bed on 1/13/26 at 11:18 AM. R23 was being repositioned in bed during care. R23's knees were touching (skin to skin) and there was no dressing on the back of her left thigh (open wound was visible).During an interview with Registered Nurse (RN) J on 1/14/26 at 7:05 AM, (RN) J said she had just assisted the Certified Nurse Aide (CNA) K reposition R23. R23 was complaining of pain at this time. RN J and K went in to reposition R23 to she could take her pain medication. R23 only had 1 pillow in her bed at this time which was under her head. R23's knees were touching each other, and the back of her thighs were in contact with her calves. During an observation and interview with the Director of Nursing (DON) and [NAME] Nurse Consultant (RNC) D on 1/14/26 at 9:00 AM in R23's room, R23 was not on an Alternating Pressure Mattress (APM). They knew it was not an APM mattress because it did not have a motor or power source. R23 had a dressing on over her entire buttock at this time that did not have a date or staff initials. R23 had one dressing on the back of both thighs dated 1/12/26 and a wound dressing on the back of her left calf dated 1/12/26.During an interview with RNC D on 1/14/26 at 12:25 PM RNC D was informed that the contracted facility Wound Nurse could not treat R23's wounds today because R23 was seen by the wound clinic yesterday. RNC D could not locate any wound clinic notes in R23's medical record and was not aware R23 was receiving wound treatment at a clinic outside of the facility.Review of R23's care plan dated 12/18/25 revealed, Resident has pressure injury/skin impairment pressure areas to buttock area (no indication of skin issue on the back of R23's thighs and calves). Interventions included: APM mattress dated 1/12/26 (not in place on 1/14/26). There was no indication of an outside wound clinic. There were no instructions for turning, positioning or use of equipment/pillows to assist in pressure relief/positioning.During an interview with facility Social Worker (SW) T on 1/14/26 at 12:57 PM, SW T reported residents baseline care plans are done during the initial care conferences. SW T confirmed that R23's care plan started within 24 hours of admission, but the care conference was not done until 5 days after admission and there was no indication that the care plan was reviewed with R23's responsible party. SW T was not aware R23 was still seeing an outside provider for her wound care. Resident 25Review of R25's admission record dated 1/14/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle wasting and atrophy (waste away), burns involving 10-19% of body surface with 0% to 9% third degree burns and unsteady on feet. R25 was his own responsible party. R25 was observed in bed on 1/13/26 at 12:18 PM. R25's C-PAP machine was on his nightstand. R25 said he does normally use the machine when sleeping to help him breathe, but he can't use it every night. R25 said no one has assisted him with his CPAP or his breathing needs since admission.During an interview with Unit Manager (UM) I on 1/13/26 at 4:00 PM, UM I said R25's hospital discharge summary did indicate that he used a C-PAP machine. UM I said R25 was transferred to the facility on [DATE] but he did not come with a C-PAP machine. UM I called the Respiratory Therapist that was treating R25 at the hospital and obtained the C-PAP settings and treatment information. UM I said she did not care plan R25's C-PAP machine or respiratory care needs.Review of R25's care plan revealed no mention of the use of a C-PAP machine or need of any respiratory care. Review of the facility CPAP - Continuous Positive Airway Pressure policy dated 9/1/19 revealed, Procedure: Verify physician order for CPAP. Obtain CPAP machine and supplies. (The set up of the settings on the machine or adjustments needed are performed by the Respiratory Therapist of DME (durable medical equipment) company with a physician order. Settings ordered by physician.During an interview with facility Social Worker (SW) T on 1/14/26 at 12:48 PM SW T said R25's baseline care plan was done on 12/15/25, 4 days after admission and confirmed R25's care plan was not started until 12/18/25 (7 days after admission). There was no indication R25's advocate or R25 were aware of the care plan dated 12/18/25. SW T was not aware R25's respiratory needs found on admission had not been care planned or fully addressed.

Based on interview and record review the facility failed to address Pre-admission Screening/Annual Resident Review (PASARR) in a timely manner for 2 Resident's (R11 & R12) out of 19 resulting in them being completed late.Findings include: Review of Policy & Procedure for Pre-admission Screening/Annual Resident Review (PASARR) Revised Date 3/10/25, revealed, It is the policy of the facility to screen any resident with mental illness and/intellectual/development disabilities through the PASARR process to ensure appropriate nursing facility services and specialized services are provided. Further review of the Policy Procedure reflects that, The Social Service employee or designee, is responsible for verifying that the PAS and/or ARR processes are completed appropriately and timely. The PASARR process must be completed in the following situations, Prior to admission in Nursing Facility; After a significant change in the resident's condition; and Not less than annually. The procedure also reflected the Annual Resident Review is due within one year of the previous one being submitted or as indicated on the Level II evaluation. An annual review can be completed in advance but no sooner than 90 days from the due date. Resident 11 (R11)Review of R11's PASARR Level I completed on 6/16/25 reflected R11 had a diagnosis that include: Anxiety Disorder, Schizophrenia, Major Depressive Disorder, Obsessive Compulsive Disorder and Post-Traumatic Stress Disorder.Review of R11's Electronic Medical Record (EMR) on 1/12/16 at 12:29 PM revealed PASARR Level I was completed on 6/16/25. R11's EMR failed to reflect a Level II PASAR had been completed.Review of R11's EMR revealed the previous year's Level I was completed on 6/14/24 and Level II was completed on 7/25/24. Review of R11's 7/25/24 Level II reflected the next Level II needed to be completed by 7/24/25.During an interview on 1/12/26 at 12:42PM, Social Worker (SW) B revealed the facility had some issues and that his contact from OBRA is aware. SW B was asked to provide a copy of R11's Level II.During an interview on 1/12/26 at 12:52 PM, Social Worker (SW) B revealed R11did not have a completed Level II PASARR in his EMR. SW B further revealed he had reached out to his OBRA contact and Level II had been completed on 8/18/25. SW B confirmed it was completed late. On 1/12/26 at approximately 3:30 PM, SW B provided an OBRA Level II letter dated 8/18/25 (letter was not part of R11's record.) Resident#12 (R12)Review of R12's diagnosis included Disorganized Schizophrenia and depression resulting in the need to complete an OBRA Level II PASARR.Review of R12's EMR on 01/13/2026 at 8:16 AM, revealed R12 had PASSAR II letter dated December 02, 2024. Review of the letter revealed, If the above-named individual (Name of R12) remains in the nursing facility, a Level II Evaluation is needed by December 01, 2025.Review of R12's EMR reflected Level II for 2025 was not completed.During an interview on 1/13/2026 at 11:27 AM, SW B stated me and the guy from OBRA are working on the issue. SW B further stated, not getting Level I and Level II's done timely was a problem because of the company transitioning from (Name or Previous Company) they were sending emails to former company and not to the New Company.SW B revealed, I started a tracking sheet to track residents OBRA Level I & II's and I started on plan of correction. SW B revealed they started catching the Level II's not being done back in November.During interview on 1/13/26 with SW B stated R12's Level II was not completed but the S Level I had been completed on 12/08/25. SW B confirmed both the Level I & Level II should have been completed prior to 12/1/25.During an interview on 1/13/26 at 11:49 AM, Regional Nurse Consultant (RNC) D stated she was not aware of any concerns regarding PASARR's. RNC D also revealed the facility was not working on any Plan of Correction regarding PASARR's.

Based on observation, interview, and record review, the facility failed to assess and monitor ongoing irritation and drainage of a PEG tube (Percutaneous Endoscopic Gastrostomy tube) insertion site for one (R20) of 2 residents reviewed for tube feedings. Findings include:Resident #20 (R20)Review of a Progress note dated 1/6/26 for R20 revealed: Resident red and irritated around peg site, cleansed (with) normal saline and applied skin guard cream and split sponge. Review of a Skin assessment dated [DATE] for R20 revealed no skin concerns.During an observation and an interview on 1/13/26 at 10:52 AM, Licensed Practical Nurse (LPN) V was questioned about the condition of R20's PEG tube (Percutaneous Endoscopic Gastrostomy tubes). At this time LPN V went to change the split gauze covering the abdominal insertion site and the PEG tube bumper (base of the PEG tube before its inserted). The gauze had some reddish clear drainage, and the insertion site was red (about a nickel sized area) and crusted with some clear drainage. LPN V reported she changed it the day before, but it did not have much drainage but did it when she first came on shift. LPN V reported the night shift nurse usually changes the dressing. When questioned about the PEG site, LPN V reported it was concerning and will notify the physician.Review of a Skin assessment dated [DATE] (day after observation) for R20 revealed no skin concerns. Review of the Electronic Medical Record (EMR) revealed no documentation the physician was notified on PEG tube insertion site concern and no follow up Review of a policy titled Tube Feeding- Overview issued 8/9/23 revealed: Feeding tubes (nasogastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.

Based on observation and interview the facility failed to provide a dignified dining experience for all residents for at least 3 of 5 residents (R19, R79 and R94) in a dining/activity room out of 19 residents reviewed for Resident Rights. During an observation of the noon meal in the dining/activity room on 1/12/2026 at 12:10 PM, R79 and her husband were complaining about being served cabbage too frequently. R79 received cabbage soup with her meal and at approximately 12:20 PM. R79 and her husband were asked if she would have preferred the tomato soup. They responded, yes. When asked if they wanted staff to get tomato soup, they responded they have to make meal choices before 10:00 AM for the lunch meal. They said they have been told no in the past when asking for substitutions. Several staff were in the area and did not respond to providing the alternate soup choice. During an observation of the noon meal in the dining/activity room on 1/12/2026 at 12:18 PM R94 was sitting at a table in the middle of the room with 3 other residents. They were talking loud about not being able to get butter with their vegetables and staff not being concerned about their meal concerns. The facility Registered Dietitian (RD) M was in the room at the time. RD M told R94 she would add butter to his meal ticket. RD M told the other residents they needed to take their concerns to the food council meeting. Staff did not bring any butter to the table for the other residents who requested additional butter. During an interview with the Regional Registered Dietitian (RRD) N on 1/14/26 at 9:56 AM the food concerns that were observed in the dining/activity room at the noon meal on 1/12/26 were discussed. RRD N said RD M was new to the facility and long-term care. RRD N said the facility policy is to address dislikes and concerns at the time of the meal in addition to the food council meetings. RRD N said R79 should have been offered alternative to the cabbage soup when staff heard her voice concerns of dislike. RRD N said they generally have more food and just because the meal ticket did not show the other soup it still should have been offered. During an observation of the noon meal in the dining/activity room on 1/12/2026 at 12:22 PM. Registered Nurse (RN) H walked up to R19 and proceeded to announce he needed to be tested for COVID-19. RN H inserted a swab into R19's left nare and swabbed in a circular motion. RN H then inserted the swab into R19's right nare and repeated the procedure. RN H then put the swab with nasal secretions into the package it was retrieved from and left the dining room. R19 had his meal in front of him and two guests seated at the table with him. During an observation on 1/12/2026 at 12:30 PM, RN H returned to the dining room and swabbed the nostrils of an unknown female resident seated at a table across from R19. The unknown female resident was seated at a table with her noon meal in front of her along with 3 other unknown residents. The COVID-19 testing was done in full view of several other residents and staff in the dining room. During an interview on 1/13/2026 at 8:50 AM, the Infection Control (IC) nurse A reported that testing for COVID-19 should not be done in a public area out of respect for each resident's dignity and privacy.

This citation pertains to intake number MI00134976 and MI00135157. Based on observation, interview, and record review, the facility failed to accurately assess a new onset of swelling with pain and monitor pain for 1 resident, Resident #1 (R1) reviewed for pain management. This deficient practice resulted in R1 sustaining prolonged sever pain and suffering when the extent and origin of a new onset of left hip swelling and increased pain was not thoroughly assessed caused a delay in treatment and surgery to occur. Findings include: R1 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of (but not limited to) Alzheimer's/Dementia (short- and long-term memory impairment), stroke with left sided weakness, osteoarthritic, and a left femur (leg) fracture with surgical repair. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which represented R1 had severe cognitive impairment. R1 required extensive staff assistance of 1-2 with all activities of daily living. According to the Pain Care Plan dated 9/22/18 last revised on 6/11/19 reflected a focus area of pain related to stroke residual pain. The Pain Care Plan had just two interventions listed. -The resident's pain is aggravated by sitting to long on coccyx. Last revised on 9/22/18. -The resident's pain is alleviated/relieved by repositioning often. Last revised on 9/22/18. According to the February Medication Administration Record (MAR) reflected the following as needed pain medications given on 2/22/23: -Norco Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 0.5 tablet by mouth every 8 hours as needed for pain. On 2/22/23 it was signed out at 9:49 AM by Registered Nurse (RN) B for a pain level of 5 (moderate) and once more at 8:36 PM by Licensed Practical Nurse (LPN) C for a pain level of 5. -Acetaminophen Tablet 325 MG, give 2 tablets by mouth every 4 hours as needed for General Discomfort. There were no doses signed out as given on 2/22/23. Record review of the X-ray order for a 2 View Left Hip and Pelvis Dx (diagnosis) Pain Created by (name of RN B) on 2/22/23 at 1408 (2:08 PM) Revised by (name of RN B) on 2/22/23 at 1408 (2:08 PM) Signed by (name of Provider) on 2/22/23 at 17:47 (5:47 PM) During an interview on 3/14/23 at approximately 2:20 PM, CNA F stated she worked on 2/22/23 from 2:00 PM to 10:00 PM and was assigned to R1. CNA F stated the previous shift reported that R1 repeatedly asked to go to the bathroom and had increased behaviors. CNA F stated that approximately 2:15 PM, she observed R1 in her room by the closet doors, seated in her wheelchair. CNA F stated that R1 was visibly upset and swinging her arms about. CNA F stated that R1 grabbed her shirt and when she attempted to back up away from R1, R1 slid forward out of the wheelchair. CNA F stated that R1 had her bottom off the wheelchair seat, her left leg caught up in the footrest behind her and her right foot forward. CNA F stated she called out for help and CNA G entered the room. CNA F stated together they lifted R1 off the floor and back into the wheelchair, pushed the wheelchair over to the bed and then transferred R1 into bed. CNA F stated that R1 remained upset and combative with the CNA F and CNA G. CNA F stated she did not report the fall/incident to R1's nurse. CNA F stated that she did not know that was considered a fall and did not report the incident until she was interviewed by the NHA on 2/27/23. A record review the progress note dated 2/26/23 at 1:50 PM, entered late for 2/22/23 (4 days later) at 2:44 PM, written by RN B was reviewed. The note reflected, Late Entry: Note Text: CNA notified nurse that resident was having pain to her left hip. Resident would not allow CNA to get her out of bed d/t (due to) the pain she was having. Nurse assessed bilateral hips. Minimal swelling noted to the left side compared to the right. Nurse administered PRN pain medication at that time and notified on call physician of findings NP ordered an x-ray to be completed for her left hip and pelvis. Nurse faxed order over to (name of company) Diagnostics. During a telephone interview on 3/15/23 at 11:55 AM, this surveyor read the progress note written RN B on 2/26/23 to her. When asked why the progress was entered on 2/26/23 for an assessment done on 2/22/23 (4 days later), RN B stated she worked 6:00 AM - 6:00 PM on 2/26/23 and it was her first day back after being off. RN B stated she heard from other staff members that R1 had sustained a fractured hip and was hospitalized . When asked if R1's ROM (range of motion) was assessed, RN B stated, No, not unless it's indicated. She (R1) would barely let me touch it. RN B stated she medicated R1 with Norco, but the MAR reflected that Norco was signed out at 9:49 AM and rated the pain at a 5 for moderate pain. This was inconsistent with RN B statement that R1 would barely let me touch it. No other pain medication was signed out as given until 8:36 PM (11 hours later). When asked why the progress note and the X-ray order were done after 2 PM when the Norco was given at 9:49 AM, RN B stated she was behind in her charting. When asked if she reassessed R1 during the remainder of her shift and RN B stated, Nothing more on my shift. When asked why R1's Resident Representative was not notified to of the new onset of joint swelling with increase in pain and to obtain permission for the X-ray, RN B stated, I wasn't thinking about that at the time, and you don't need permission to order an X-ray. When asked about the assessment finding that R1 wouldn't allow you to touch her, why the X-ray wasn't ordered STAT instead of routine, RN B stated, That's the way the doctor ordered it. When asked if the new onset of swelling and pain along with the pending X-ray was reported in the shift-to-shift report with LPN C on 2/26/23 at 6:00 PM, RN B stated, Yes. During a telephone interview on 3/14/23 at 5:50 PM, LPN C stated that she was assigned to R1's care from 6:00 PM on 2/22/23 until 6:00 AM on 2/23/23. LPN C stated that she was unaware of R1's new hip swelling, increased pain, and X-ray order. LPN C stated that she did not recall that R1's change in condition was reported to her in the shift-to-shift report and had she known she would have specifically assessed R1 for that. LPN C stated that no X-rays were taken during her shift. During a telephone interview on 3/15/23 at 1:45 PM, CNA H stated that she worked from 10:00 PM on 2/22/23 until 6:00 AM on 2/23/23 and was assigned to R1. CNA H stated that R1 complained about her left leg hurting and she noticed an abrasion on R1's left knee. CNA H stated that she assumed R1 hit her knee on the TV that swings out from the wall over the bed on a long extending bracket. According to the February MAR, no pain medication was provided on the night shift. During an interview on 3/14/23 at 2:35 PM, LPN D stated she worked the day shift 2/23/23 and started at 6:00 AM. LPN D stated that early in the shift CNA I reported that R1 had pain and refused to get up. LPN D stated she went to assess her right away. LPN D stated, I saw her (R1) leg inverted, jacked up, and swollen. I called the doctor and sent her to ER about 9:30 AM. When asked what R1's pain level was, LPN D stated that she did not attempt ROM and rated R1's pain a 10 on 10 pain scale which was severe. LPN D stated it took 4 people to lift R1 onto the EMS cart when they arrived and R1 really cried out when then moved her. During an observation and interview on 3/15/23 at 12:15 PM, CNA I and CNA J reposition R1 in bed. R1 had visible discomfort with repositioning with mild facial grimacing noted. R1 had noted surgical wounds in different stages of healing on her left leg and an abrasion to the left knee approximately 2 cm x 1 cm. CNA I stated that she was assigned to R1 the morning of 2/23/23 when R1 was transferred to the hospital. CNA I stated that she knew right away that something was wrong with R1's hip from just looking at it, it was protruding and red. CNA I stated that she went to get the nurse right away. CNA I stated, I noticed a bandaid on her left knee that was new so, I pulled it back to see what was under it. According to the Femur X-ray dated 2/23/23 at 1:22 PM reflected, Impression 1. Displaced comminuted left intertrochanteric fracture . According to the Wound Summary in the hospital records dated 2/23/23 reflected an abrasion to the anterior (front) knee that was covered with a bandaid upon arrival from the facility. According to the Fixation Left Hip IM Nail (L) Operative Noted dated 2/23/23 at 3:35 PM reflected, Based on the tension required for reduction with traction, I suspect the fracture is greater than 24 hours. It may coincide with the abrasion noted on her left knee in terms of timing. During an interview and record review on 3/16/23 at 1:40 PM, the Director of Nursing and the Unit Manager, LPN A was asked about RN B's note that was a Late Entry on 2/26/23 for a pain assessment on 2/22/23 at 2:44 PM. Both the DON and UM, LPN A stated they were dissatisfied with RN B's note. Both agreed that the X-ray should have been ordered STAT and a call placed to R1's Resident Representative for notification and permission. UM, LPN A stated the nurse should always notify the manager or DON when ordering an X-ray, so no one is caught off guard. When asked if an assessment of increased joint swelling and pain should include a ROM assessment, both said yes and indicated it was their expectation to rate the pain level and do follow-up assessment regarding the pain.

This citation pertains to intake number MI00134976 and MI00135157. Based on observations, interview, and record review the facility failed to assess, monitor, and prevent falls for 3 residents, Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3), reviewed for falls. The deficient practice resulted in R1 sustaining a leg fracture and delay in treatment after a fall went unreported and no preventative measures put in place to prevent reoccurrence. R2 and R3 sustained repeated falls with the lack of follow-up assessments to thoroughly monitor and prevent further falls. Findings include: R1 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of (but not limited to) Alzheimer's/Dementia (short- and long-term memory impairment), stroke with left sided weakness, osteoarthritic, and a left femur (leg) fracture with surgical repair. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which represented R1 had severe cognitive impairment. R1 required extensive staff assistance of 1-2 with all activities of daily living. During an interview on 3/14/23 at approximately 2:20 PM, CNA F stated she worked on 2/22/23 from 2:00 PM to 10:00 PM and was assigned to R1. CNA F stated the previous shift reported that R1 repeatedly asked to go to the bathroom and had increased behaviors. CNA F stated that approximately 2:15 PM, she observed R1 in her room by the closet doors, seated in her wheelchair. CNA F stated that R1 was visibly upset and swinging her arms about. CNA F stated that R1 grabbed her shirt and when she attempted to back up away from R1, R1 slid forward out of the wheelchair. CNA F stated that R1 had her bottom off the wheelchair seat, her left leg caught up in the footrest behind her and her right foot forward. CNA F stated she called out for help and CNA G entered the room. CNA F stated together they lifted R1 off the floor and back into the wheelchair, pushed the wheelchair over to the bed and then transferred R1 into bed. CNA F stated that R1 remained upset and combative with the CNA F and CNA G. CNA F stated she did not report the fall/incident to R1's nurse. CNA F stated that she did not know that was considered a fall and did not report the incident until she was interviewed by the NHA on 2/27/23. CNA F stated that she received education and discipline for not reporting the fall. During a telephone interview on 3/15/23 at 2:54 PM, CNA G stated that she worked 2:00 PM until 10:00 PM on 2/22/23. CNA G stated that about 2:15 PM, she was passing waters in the hallway when she heard CNA F call out for help. CNA F stated that she entered R1's room and observed R1 in front of her wheelchair (facing her with her bottom off the seat), slid down resting on her own legs, on the floor and next to the closet door. CNA G stated that R1 was fighting them. Both CNAs lifted R1 and placed her back into the wheelchair. CNA G stated that they moved R1 next to the bed and transferred R1 into bed. When asked about R1's behavior and response during this process, CNA G stated that R1 continued to swing her arms at them, yelling and swearing at them. CNA G stated that they felt it was better to put her into bed then to leave her up in the wheelchair. CNA G stated that she also received education and discipline for not reporting the fall. Review of the Risk for Changes in Mood and Behavior care plan dated 10/11/18 reflected interventions such as, Remove self if resident is safe and find another staff member to assist. Remove self from situation if resident is safe and come back later to attempt care. Date Initiated: 12/24/18. Review of the Resistant to Care plan of care dated 2/21/18 reflected interventions such as, If resident resists with ADL's (activities of daily living), ensure safe environment, leave, and return 5-10 minutes later and try again. Dated Initiated: 2/21/22 and Praise the resident when behavior is appropriate. Date Initiated: 2/21/22. The NHA provided a copy of the incident/accident report dated 2/24/23 for R1's fall on 2/22/23 at approximately 2:15 PM for review. The facility's incident report was not updated after further details of the fall circumstances were discovered on 2/27/23 during CNA F and CNA G's interviews. The report did not identify the root cause of the fall nor any interventions to prevent future falls from reoccurring. During an interview and record review on 3/16/23 at 1:40 PM, the Director of Nursing and the Unit Manager (UM), LPN A was asked if the facility did a root cause analysis of R1's fall and circumstances surrounding the fall. Both stated the follow up portion of the fall investigation was not completed and therefore nothing more could be provided for review. The UM, LPN A stated that contributing factors to the fall were identified as combative behaviors with care which can change by the minute. When asked what the facility's expectation was for staff who are attempting to provide care to a combative resident, and the DON stated we educate on how to handle residents with behaviors and do not expect staff to provide care until the behavior subsides. The DON stated it's not good for the resident nor the staff. Both agreed that the staff should ensure the resident is safe and then reapproach. The UM, LPN A stated the care plan was changed from a 1-person physical assist to 2 person assist. When asked if there were any changes or education for the staff regarding behavior management, both stated, no. According to the care plans there were no updates regarding behavior management. R2 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R2 admitted to the facility on [DATE] with diagnosis of (but not limited to) Dementia (short- and long-term memory impairment), heart failure, and chronic kidney disease. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which represented R2 had severe cognitive impairment. R2 required extensive staff assistance all activities of daily living. During an interview and observation on 3/15/23 at 11:08 AM, R2 was seated on the side of his bed, dressed in a t-shirt and a brief. R2 had dressing to his feet and was wearing oxygen. The Surveyor attempted to interview R2, but he was unable to answer any specific questions. The care plan for Mobility dated 1/19/23 was reviewed and reflected the following intervention that included (but not limited to), The resident is totally dependent on 2 staff for transferring. Date initiated: 1/19/23. The care plan for Falls dated 1/19/23 was reviewed and reflected the following interventions that included (but not limited to), Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition. Date initiated: 1/19/23. Floor mat on floor next to bed when in bed. Date initiated: 1/23/23. Follow facility fall protocol. Dated initiated: 1/19/23. Frequent rounding and offering toileting throughout the night. Date initiated: 3/6/23 . During an interview and record review on 3/16/23 at 1:40 PM, R2's progress notes, neurological checks, post fall documents, care plans and 72-hour post fall documentation was reviewed from 1/21/23 - 3/1/23, with the DON and UM, LPN A. UM, LPN A stated that after a fall occurs the nurses will do Alert Charting each shift for 72 hours following the fall to assess and monitor for latent signs, symptoms and injuries of the fall. UM, LPN A stated the nurses are aware of which residents to chart on because it is kept in the Alert Charting Binder. R2 sustained 5 falls in a 5 1/2 week period and the following is a timeline according to the documents provided for review: #1 - 1/21/23 at 6:20 AM, R2 was observed on the floor, beside his bed. R2 was not able to answer any questions related to the fall and had no initial injuries. The immediate intervention was to lower the bed and provide nonskid socks. #2 - 1/22/23 at 3:00 AM, R2 was observed on the floor and R2 was not able to answer questions regarding the fall. There was no indication that ROM was assessed according to the fall report. The root cause was not identified, the immediate action was left blank and there was no indication of the 72-hour follow-up monitoring in the progress notes. Both the DON and UM, LPN A confirmed there were missing documents and assessments. #3 - 2/6/23 at 7:00 AM, R2 was observed on the floor next to the bed. R2 stated, I slipped off the bed. R2 was alert but confused and sustained an abrasion to the top of the scalp. The report reflected a sleep log was initiated but neither the DON nor UM, LPN A could locate it for review. There was no 72-hour follow-up monitoring documented for 2/8/23 and 2/9/23 to review. #4 - 2/12/23 at 10:30 AM, R2 was observed on the floor and stated he was trying to get out. No new interventions were added to the care plan and there was no 72-hour follow-up monitoring documented for 2/13/23, 2/24/23, and 2/15/23 to review. #5 - 3/1/23 at 4:11 AM, R2 was observed on the floor beside of the bed. R2 was confused and unable to answer questions regarding the fall. There was no root cause identified, no immediate intervention identified, no documented notification of the doctor or the Resident Representative, and no documented 72-hour follow-up monitoring in the progress notes for 3/2/23, 3/3/23 and 3/4/23. The intervention of frequent rounding and offering toileting throughout the night was added to the care plan 5 days later, on 3/6/23. Both the DON and the UM, LPN A identified that the required documentation for falls is not being completed by the staff and stated they would be doing further education on that. During an interview on 3/15/23 at 11:12 AM, when asked which residents on her assignment were identified as high risk for falls, RN L identified two other residents and did not identify R2 as high risk. During an interview on 3/15/23 at 11:20 AM, CNA M and CNA N were asked which residents on their assignment were high risk for falls and both identified three residents on the hall and did not identify R2 as high risk. R3 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with a readmitted [DATE] with diagnosis of (but not limited to) schizoaffective disorder (hearing voices), obsessive compulsive behavior, and muscle weakness. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represented R3 had severe cognitive impairment. R3 required extensive staff assistance all activities of daily living. During an interview and observation on 3/15/23 at 11:25 AM, R3 was reclined in his bed under the blankets. R3 verbalized that he is hard of hearing. R3 had sutures to his right eyebrow and the bridge of his nose. R3 reported that he fell and hurt himself. When asked specific questions regarding the falls, R3 was not able to answer. There was no visible call light noted and when R3 was asked if he had one, R3 pointed to the wall behind him and stated, Back there. The call light cord extended from the wall and lead up under the blankets. R3 was unable to locate it after being cued that it was under his blanket. The care plan for Falls dated 1/3/23 reflected the following interventions of, Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition. Date initiated: 1/3/23. Medication review r/t (related to) increase ADLs (activities of daily living) needs. Date initiated: 2/24/23 .Anticipate and meet resident's needs. Date created 3/14/23. During an interview and record review on 3/16/23 at 1:40 PM, all fall related documentation was reviewed with the DON and UM, LPN A for R3's falls from 1/19/23 to 3/7/23. The following is a timeline: #1 - 1/19/23 at 6:30 PM, R3 was observed crawling on the floor in the hall. R3 stated that he had fallen out of bed trying to get away from the voices. UM, LPN A stated she recalled R3 being extremely fearful and unable to manage, so R3 was subsequently sent to the ER and returned on 1/21/23. #2 - 2/23/23 at 11:45 AM, R3 was observed on the floor, flat on his back. R3 sustained a laceration to the right scalp that measured 1.8 cm x 0.4 cm x 0.3 that required a visit to the ER to close it. R3 was unable to answer questions regarding the fall. There was no root cause identified on the fall report and UM, LPN A was unable to locate the documentation for review. There was no 72-hour documentation and monitoring to review for 2/24/23 the day after the fall with injury. UM, LPN A confirmed there was no monitoring of for 2/24/23 located in the progress notes. #3 - 3/7/23 at 4:29 PM, R3 was observed by staff leaning forward in his wheelchair and fell on to the floor. R3 sustained a laceration to the right eyebrow and the nose. R3 was sent to ER to have the wounds sutured and returned the same day. UM, LPN A confirmed by searching the progress notes that no 72-hour follow-up and monitoring was done for 3/8/23, 3/9/23 or 3/10. The DON stated the root cause was the resident leaning forward in the wheelchair, possibly sleeping and stated the facility implemented a high back wheelchair to be used. This intervention was not located on the care plan, so the DON added it during this interview. During an interview on 3/15/23 at 11:33 AM, when asked which residents on her assignment were high risk for falls, RN O pulled out her report sheet and identified two residents that were marked high risk for falls and did not identify R3 as high risk.

This citation pertains to intake number MI00134976 and MI00135157. Based on observation, interview, and record review, the facility failed to prevent neglect for 1 resident, Resident #1 (R1) reviewed for abuse/neglect. The deficient practice resulted in R1 sustaining a femur (leg) fracture after staff did not following the plan of care and sustained a fall with serious injury that went unreported and unassessed with prolonged severe pain and emotional suffering to occur, when R1 was denied appropriate medical care from being rendered for approximately 19 hours. Findings include: The facility provided a copy of the Policy/Procedure - Nursing Administration, Abuse and Neglect dated 7/11/18 and updated on 10/31/22. The policy reflected, The administrator is the abuse coordinator in this facility and is responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect .Neglect is the failure to care for a person in a manner, which would avoid harm and pain .Neglect may or may not be intentional. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress .Signs and symptoms of suspected abuse/neglect 1. Prolonged interval between trauma/illness and seeking medical attention . R1 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of (but not limited to) Alzheimer's/Dementia (short- and long-term memory impairment), stroke with left sided weakness, osteoarthritis, and a left femur (leg) fracture with surgical repair. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which represented R1 had severe cognitive impairment. R1 required extensive staff assistance of 1-2 with all activities of daily living. An interview and observation was conducted on 3/14/23 at approximately 4:00 PM with R4, who was in her bed watching TV. R4 was the roommate of R1 on 2/22/23 and 2/23/23. R4 stated that on 2/22/23, R1 was making a ruckus in the hall on the 1st shift, and they moved R1 back to her room. R4 stated just after second shift came on, she recalled R1 giving the staff quite a time. R4 stated that R1 was in her wheelchair, next to the foot of R4's bed (which is next to the closet doors). The surveyor was able to observe and confirm the area R4 was describing. When asked if the privacy curtain was open or closed the afternoon of 2/22/23, R4 stated it was opened all the way and she could see the staff interacting with R1 near the foot of her bed. The surveyor observed that R4's head of bed was against the wall and R1's bed was placed with the foot of the bed facing R4's bed with the right side placed against the wall. R4 confirmed the beds were still in the same placement. When the privacy curtain was pushed open it still provided privacy to R4's upper body while in bed, but R4 was unable to view R1's bed. R4 stated R1's wheelchair was facing the door and when CNA F came in to put R1 to bed, she saw R1 grabbing at CNA F as CNA F went around to the back of the wheelchair. At that time R1 started propelling herself forward in the wheelchair as CNA F held the wheelchair (from behind) and R1 slid forward out of the wheelchair hitting R4's over the bed table as R1 landed on the floor sending the table into foot of R4's bed. R4 stated another CNA came in and they lifted her back to her wheelchair and then into bed which she could not see from where she was laying in her bed but recalled hearing them fighting with her and remembered the privacy curtain moving during that time. R4 stated, (Name of R1) doesn't always take her pain medication and it's just awful to hear her cry when they clean her. According to R4's MDS dated [DATE], Section C: Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which represented R4 was cognitively intact. During an interview on 3/14/23 at approximately 2:20 PM, CNA F stated she worked on 2/22/23 from 2:00 PM to 10:00 PM and was assigned to R1. CNA F stated the previous shift reported that R1 repeatedly asked to go to the bathroom and had increased behaviors. CNA F stated that approximately 2:15 PM, she observed R1 in her room by the closet doors, seated in her wheelchair. CNA F stated that R1 was visibly upset and swinging her arms about. CNA F stated that R1 grabbed her shirt and when she attempted to back up away from R1, R1 slid forward out of the wheelchair. CNA F stated that R1 had her bottom off the wheelchair seat, her left leg caught up in the footrest behind her and her right foot forward. CNA F stated she called out for help and CNA G entered the room. CNA F stated together they lifted R1 off the floor and back into the wheelchair, pushed the wheelchair over to the bed and then transferred R1 into bed. CNA F stated that R1 remained upset and combative with the CNA F and CNA G. CNA F stated she did not report the fall/incident to R1's nurse. CNA F stated that she did not know that was considered a fall and did not report the incident until she was interviewed by the NHA on 2/27/23. CNA F stated that she received education and discipline for not reporting the fall. During a telephone interview on 3/15/23 at 2:54 PM, CNA G stated that she worked 2:00 PM until 10:00 PM on 2/22/23. CNA G stated that about 2:15 PM, she was passing waters in the hallway when she heard CNA F call out for help. CNA G stated that she entered R1's room and observed R1 in front of her wheelchair (facing her with her bottom off the seat), slid down resting on her own legs, on the floor and next to the closet door. CNA G stated that R1 was fighting them. Both CNAs lifted R1 and placed her back into the wheelchair. CNA G stated that they moved R1 next to the bed and transferred R1 into bed. When asked about R1's behavior and response during this process, CNA G stated that R1 continued to swing her arms at them, yelling and swearing at them. CNA G stated that they felt it was better to put her into bed then to leave her up in the wheelchair. CNA G stated that she also received education and discipline for not reporting the fall. A record review the progress note dated 2/26/23 at 1:50 PM, entered late for 2/22/23 (4 days later) at 2:44 PM, written by RN B was reviewed. The note reflected, Late Entry: Note Text: CNA notified nurse that resident was having pain to her left hip. Resident wound not allow CNA to get her out of bed d/t (due to) the pain she was having. Nurse assessed bilateral hips. Minimal swelling noted to the left side compared to the right. Nurse administered PRN pain medication at that time and notified on call physician of findings NP ordered an x-ray to be completed for her left hip and pelvis. Nurse faxed order over to (name of company) Diagnostics. According to the February Medication Administration Record (MAR) reflected the following as needed pain medications given on 2/22/23: -Norco Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 0.5 tablet by mouth every 8 hours as needed for pain. On 2/22/23 it was signed out at 9:49 AM by Registered Nurse (RN) B for a pain level of 5 (moderate) and once more at 8:36 PM by Licensed Practical Nurse (LPN) C for a pain level of 5. -Acetaminophen Tablet 325 MG, give 2 tablets by mouth every 4 hours as needed for General Discomfort. There were no doses signed out as given on 2/22/23. Record review of the X-ray order for a 2 View Left Hip and Pelvis Dx (diagnosis) Pain Created by (name of RN B) on 2/22/23 at 1408 (2:08 PM) Revised by (name of RN B) on 2/22/23 at 1408 (2:08 PM) Signed by (name of Provider) on 2/22/23 at 17:47 (5:47 PM) During a telephone interview on 3/15/23 at 11:55 AM, this surveyor read the progress note written by RN B on 2/26/23 to her. When asked why the progress was entered on 2/26/23 for an assessment done on 2/22/23 (4 days later), RN B stated she worked 6:00 AM - 6:00 PM on 2/26/23 and it was her first day back after being off. RN B stated she heard from other staff members that R1 had sustained a fractured hip and wanted to make sure her note was entered. When asked if R1's ROM (range of motion) was assessed, RN B stated, No, not unless it's indicated. She (R1) would barely let me touch it. RN B stated she medicated R1 with Norco, but the MAR reflected that Norco was signed out at 9:49 AM (not at 2:00 PM) and rated the pain at a 5 for moderate pain. This is inconsistent with RN B statement that R1 would barely let me touch it. No other pain medication was signed out as given until 8:36 PM (11 hours later). When asked why the progress note and the X-ray order were done after 2 PM when the Norco was given at 9:49 AM, RN B stated she was behind in her charting. When asked if she reassessed R1 during the remainder of her shift and RN B stated, Nothing more on my shift. When asked why R1's Resident Representative was not notified to of the new onset of joint swelling with increase in pain and to obtain permission for the X-ray, RN B stated, I wasn't thinking about that at the time, and you don't need permission to order an X-ray. When asked about the assessment finding that R1 wouldn't allow you to touch her, why the X-ray wasn't ordered STAT instead of routine, RN B stated, That's the way the doctor ordered it. When asked if the new onset of swelling and pain along with the pending X-ray was reported in the shift-to-shift report with LPN C on 2/26/23 at 6:00 PM, RN B stated, Yes. During a telephone interview on 3/14/23 at 5:50 PM, LPN C stated that she was assigned to R1's care from 6:00 PM on 2/22/23 until 6:00 AM on 2/23/23. LPN C stated that she was unaware of R1's new hip swelling, increased pain, and X-ray order. LPN C stated that she did not recall that R1's change in condition was reported to her in the shift-to-shift report and had she known she would have specifically assessed R1 for that. LPN C stated that no X-rays were taken during her shift. During a telephone interview on 3/15/23 at 1:45 PM, CNA H stated that she worked from 10:00 PM on 2/22/23 until 6:00 AM on 2/23/23 and was assigned to R1. CNA H stated that R1 complained about her left leg hurting and she noticed an abrasion on R1's left knee. CNA H stated that she assumed R1 hit her knee on the TV that swings out from the wall over the bed on a long extending bracket. According to the February MAR, no pain medications were administered on the night shift for R1. During an interview on 3/14/23 at 2:35 PM, LPN D stated she worked the day shift 2/23/23 and started at 6:00 AM. LPN D stated that early in the shift CNA I reported that R1 had pain and refused to get up. LPN D stated she went to assess her right away. LPN D stated, I saw her (R1) leg inverted, jacked up, and swollen. I called the doctor and sent her to ER about 9:30 AM. When asked what R1's pain level was, LPN D stated that she did not attempt ROM and rated R1's pain a 10 on 10 pain scale which was severe. LPN D stated it took 4 people to lift R1 onto the EMS cart when they arrived and R1 really cried out when then moved her. LPN D stated she received a call from the hospital shortly after sending her asking what she had eaten for breakfast because they needed to send her to surgery to repair a fracture. During an observation and interview on 3/15/23 at 12:15 PM, CNA I and CNA J repositioned R1 in bed. R1 had visible discomfort with repositioning with mild facial grimacing noted. R1 had noted surgical wounds in different stages of healing on her left leg and an abrasion to the left knee approximately 2 cm x 1 cm. CNA I stated that she was assigned to R1 the morning of 2/23/23 when R1 was transferred to the hospital. CNA I stated that she knew right away that something was wrong with R1's hip from just looking at it, it was protruding and red. CNA I stated that she went to get the nurse right away. CNA I stated, I noticed a bandaid on her left knee that was new so, I pulled it back to see what was under it. CNA I stated that LPN D came to her shortly after sending R1 to the emergency room , and needed to know what R1 had eaten for breakfast because she had broken her hip and needed to have surgery. According to the Femur X-ray dated 2/23/23 at 1:22 PM reflected, Impression 1. Displaced comminuted left intertrochanteric fracture . According to the Wound Summary in the hospital records dated 2/23/23 reflected an abrasion to the anterior (front) knee that was covered with a bandaid upon arrival from the facility. According to the Fixation Left Hip IM Nail (L) Operative Noted dated 2/23/23 at 3:35 PM reflected, Based on the tension required for reduction with traction, I suspect the fracture is greater than 24 hours. It may coincide with the abrasion noted on her left knee in terms of timing. During an interview and record review on 3/16/23 at 1:40 PM, the Director of Nursing and the Unit Manager, LPN A was asked about RN B's note that was a Late Entry on 2/26/23 for a pain assessment on 2/22/23 at 2:44 PM. Both the DON and UM, LPN A stated they were dissatisfied with RN B's note. Both agreed that the X-ray should have been ordered STAT and a call placed to R1's Resident Representative for notification and permission. UM, LPN A stated the nurse should always notify the manager or DON when ordering an X-ray, so no one is caught off guard. When asked if an assessment of increased joint swelling and pain should include a ROM assessment, both said yes and indicated it was their expectation to rate the pain level and do follow-up assessment regarding the pain. During a telephone interview on 3/14/23 at 1:30 PM, R1's Resident Representative stated that he was not notified of the new onset of left hip swelling, increased pain nor that an X-ray that were ordered on 2/22/23 at 2:08 PM. R1's Resident Representative was upset that the facility was not notifying him of changes in condition with R1 and asking permission for X-rays. R1's Resident Representative stated that he was not made aware of anything until he got a call the morning of 2/23/23 informing him that R1 needed to be sent to the emergency room for evaluation. R1's Resident Representative stated that doctor (at the hospital) told him about the fracture and gave him two treatment options. The first option was to not fix it and manage R1's pain for the rest of her life or surgery to fix it, which they could not even guarantee R1 would survive. R1's Resident Representative stated that was the hardest decision he's ever had to make for someone, but he didn't want to see R1 suffer.

This citation pertains to intake # MI 663 Based on interview and record review, the facility Administrator failed to follow established risk management and abuse/neglect prevention policies and procedures, resulting in an Immediate Jeopardy when beginning on [DATE], the Administrator did not (a) report and investigate the sudden and unexpected death of Resident #800 and (b) report and investigate an allegation of neglect that resulted in the death of Resident #800. This deficient practice resulted in the potential for the Administrator to continue to arbitrarily not report allegations of abuse and neglect and not follow established risk management guidelines for sudden and unexpected deaths and policies and procedures for reporting and investigating allegations of Abuse/Neglect and ensuring the safety of all residents during an investigation. This deficient practice has the high likelihood to cause serious injury, harm, and/or death to further residents if the administrator does not follow established policies and procedures to protect them from abuse or neglect. Findings: Review of a Nursing Progress Note dated [DATE] reflected that Resident #800 (R800) had died suddenly and unexpectedly that evening. During an interview on [DATE] at 11:15 AM, Social Worker (SW) A recalled that the morning of [DATE], at the leadership team meeting, the following related to the unexpected death of R800 was discussed: (a) all staff were very upset as (R800) was very well liked, and (b) the Administrator directed staff to bring any concerns related to the death of (R800) straight to her. She didn't want us looking into anything. Review of the facility policy/procedure Risk Management Guidelines, last updated [DATE], reflected the following: Trigger events are unusual situations or adverse events that meet one or more of the following criteria: (1) require reporting to the state agency or law enforcement, and/or (2) result in harm or have the potential for serious harm, and/or (3) have any likelihood or potential for civil, criminal, or regulatory action. These events necessitate discussion and guidance in the handling, documenting, and/or resolution of such situations or events. The Nurse Consultant (Regional Nurse Consultant H) should immediately be notified via phone call by Administrator for the following types of triggered events .sudden or unexpected death. The Administrator will send an email to the appropriate risk management group and inform the risk management team of the triggered event. The Administrator will entirely complete the Risk Management Report in point click care . The following are examples of trigger events and should not be considered all-inclusive: unexpected resident death .choking requiring intervention with negative outcome . any allegation of neglect. During an interview on [DATE] at 3:45 PM, the Administrator reported not following Risk Management Guidelines and did not report the sudden and unexpected death of R800. When asked why it was not reported, the Administrator shook her head, shrugged her shoulders, and stated I don't know. Review of a Nursing Progress Note dated [DATE], and written by 3rd shift Licensed Practical Nurse (LPN) Q revealed the following: Went in resident's room and the second I walked in, this resident and her roommate began expressing their concern over their other roommates death (R800) two days ago. Both resident's very upset. Expresses desire to talk to management. During an interview on [DATE] at 6:10 PM, LPN Q reported the following regarding the death of R800 on [DATE] and the conversation had with the roommates of R800 on [DATE] when LPN Q first spoke with the roommates after coming on shift: (a) both roommates wanted to talk about what happened and both were very upset, (b) both roommates shared concerns about the manner in which R800 died , (c) both reported that they had tried to get help for R800 on the evening of [DATE], but staff would not listen, (d) one of the roommates went out into the hallway several times to get staff to help but was told to return to her room and mind her own business, and (e) LPN Q wrote up a Grievance Form for each of the roommates, that evening, and placed the grievance forms under the Administrator's door. Review of two grievance forms date [DATE], reflected LPN Q wrote the above mentioned forms for each of R800's roommates and placed them under the door of the Administrator's office. During an interview on [DATE] at 3:25 PM, the Administrator reported not receiving or seeing the two grievance forms that were written by LPN Q on [DATE] on behalf of R800's roommates. During an interview on [DATE] at 3:30 PM, R800's roommate S stated that the Administrator came to speak with roommate S in her room, roommate S shared concerns with the Administrator about the care of R800 on the evening of [DATE] and the Administrator asked roommate S to not share that information with anyone else. During an interview on [DATE] at 3:30 PM, the Regional Nurse Consultant (RNC H) reported being first made aware of any concerns related to death of R800 during a staff in-service on [DATE]. LPN Q asked RNC H during the in-service if RNC H knew anything about the investigation into R800's death. RNC H immediately reported the concern to the Administrator. During the same interview, the Administrator confirmed that RNC H did report an allegation of neglect on [DATE] regarding the death of R800. The Administrator then indicated the allegation was not reported to the State Agency as required. When asked why the allegation of neglect was not reported to the State Agency, the Administrator responded I could have reported it but I did not. The Administrator did state that an investigation was started on [DATE] and provided the survey team with written statements from staff regarding the death of R800. Review of written statements by staff regarding the death of R800 revealed the following: (a) written statements were received from RN C (the nurse on duty the evening of [DATE] and responsible for the care of R800) and dated [DATE], (b) written statements were not obtained from LPN D and LPN I, both of whom were present during the code blue that was activated when R800 was found unresponsive, not breathing, and had no heartbeat, (c) a written statement was obtained from LPN Q after the Administrator advised LPN Q of not seeing or receiving the two grievance forms that LPN Q reported to have filled out on behalf of R800's two roommates the evening of [DATE], (d) a written statement was obtained from CNA G, dated [DATE], that detailed concerns regarding the care of R800 on the evening of [DATE], and (e) no interview statements were taken from either of R800's roommates. During an interview on [DATE] at 3:30 PM, RNC H indicated that on [DATE] RNC H asked the Administrator if the allegation of neglect related to R800's death had been reported to the State Agency and was told by the Administrator that the allegation had not been reported to the State Agency. During the same interview, the Administrator confirmed that the above conversation occurred. RNC H asked the Administrator again on [DATE] and [DATE] if the allegation had been reported to the State Agency. The Administrator responded that it had not been reported as required. The Administrator confirmed that the conversations with RNC H did in fact occur on [DATE] and [DATE]. During the same interview on [DATE] at 3:30 PM, the Administrator reported that RN C was suspended from work on [DATE] and [DATE] pursuant to the investigation into the allegation of neglect. The Administrator also reported not making HR (human resources) aware of the suspension and not placing any paperwork in RN Cs personnel file related to the suspension. The Administrator indicated that notifying HR of a suspension and filling out paperwork regarding the suspension was standard practice. When asked why the Administrator did not report the suspension to HR nor fill out any paperwork regarding the suspension, the Administrator shook her head, shrugged her shoulders and stated I don't know. During the same interview, the Administrator reported that the allegation of neglect had not been reported to law enforcement and that RN C was allowed to return to work on [DATE] because the Administrator found no concerns related to the death of R800. Review of a staff schedule report for RN C reflected that RN C had not been previously scheduled to work on [DATE] and [DATE]. The staff schedule report did reflect that RN C worked on [DATE] and [DATE] despite an investigation being initiated on [DATE] into the alleged neglect of R800 by RN C. During an interview on [DATE] at 11:00 AM, RN C reported receiving a message from the facility and was advised not to answer any calls from the State until the facility was able to speak with RN C about the work days of [DATE] and [DATE]. Review of the facility policy/procedure Abuse and Neglect, last revised [DATE], revealed: POLICY- It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse .neglect or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the (7) seven federal components of prevention and investigation. DEFINITIONS-Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. 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. Examples of neglect include .Ignoring call lights or cries for help. If neglect/abuse is suspected the facility will: (1) take immediate steps to assure the protection of the resident's. This may involve separation from the alleged abuser .(2) Notify the appropriate/designated authority (State Agency) that an investigation is being initiated immediately following intervention for the resident's safety, (3) conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim, (4) notify law enforcement authorities and press charges if indicated, (5) report the investigation findings to the appropriate State agencies, as required by law .the facility will investigate all allegations of abuse/neglect. the facility will protect resident's from harm during the investigation by- if the alleged perpetrator is an employees, the employee will be immediately suspended from working pending the result of the investigation. The alleged staff will not be allowed back to work until the final investigation is forwarded to the appropriate State Agencies. On [DATE], Regional Nurse Consultant (RNC) H was verbally notified and received written notification of the immediate jeopardy at F835, identified on [DATE] and that began on [DATE], due to the Administrator's failure to report and investigate the sudden and unexpected death of R800 and report and investigate an allegation of neglect. On [DATE] the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: -On [DATE] the facility terminated the employment of RN C and reported the allegation of neglect to the State Agency -On [DATE] all resident's were rounded on by clinical staff and interviewed to ensure any allegations of abuse/neglect are immediately reported to the Administrator. The Administrator will immediately report any allegation of abuse/neglect to the State Agency. The Administrator will inform the Regional Director of Operations (RDO) of any allegation of abuse/neglect. The RDO will provide oversight to ensure adherence to the Abuse/Neglect Policy. -On [DATE] the Administrator and Director of Nursing will ensure all facility staff are interviewed to ensure any allegation of abuse/neglect had been reported to the Administrator. -On [DATE] the RNC educated the ADM and DON on the Emergency Situations and Care of Resident's Policy and Procedure. The DON then initiated educating nursing personnel on the Emergency Situations and Care of Resident's Policy and Procedure. Any staff absent will be in-serviced prior to their next scheduled shift. Special focus was given to staff (a) ensuring that each resident received timely medical attention to prevent neglect and (b) responding timely to emergency events. -The DON will review residents with acute changes in condition weekly and then monthly to ensure adherence to the Abuse/Neglect Policy and Procedure and the Emergency Situations and Care of Resident's Policy and Procedure. QAA committee will review audits for ongoing compliance. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

This citation pertains to intake # MI 663 & MI 2013 Based on interview and record review, the facility failed to protect one residents' right to be free from neglect (Resident #800) resulting in an Immediate Jeopardy when beginning on [DATE], the facility failed to prevent neglect for Resident #800. This deficient practice led to Resident #800 being found unresponsive after choking on vomit, requiring emergency medical intervention, and subsequent death and the potential for further residents to experience serious harm, injury and/or death if not corrected. Findings Include: Resident #800 (R800) Review of an Admission Record revealed R800 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R800 required extensive assistance from 2 staff person for bed mobility, transfers in and out of bed, and bathing. Review of Advance Directive documents revealed that R800 was full code status. During an interview on [DATE] at 2:04 PM, R800's roommate R reported the following details related to the evening of [DATE] and R800's death: roommate R (a) went out to the desk multiple times and begged Registered Nurse (RN) C to come help R800 who was vomiting and choking (b) roommate Rattempted at one point to scoop vomit out of R800's mouth with a wash cloth to try and help R800, (c) each time roommate R went to the desk to try and get help for R800, RN C told roommate R to mind her own business and go back to her room, and (d) reported that RN C did not come to the room at any time to check on R800 until an aide came in and saw that R800 was already dead and called a code blue. I told the aide that she was too late (R800) was already dead. Roommate R then went on to say that Certified Nurse Aide (CNA) E then told the two roommates if you knew (R800) was in trouble, why didn't you sit her up. Roommate R indicated I'm still traumatized, was sobbing while discussing the details of R800's death, and she was my friend and I had to listen to her choke on her vomit and die. Roommate R went on to say that RN C continued to work at the facility, and she did not feel safe at the facility and initiated a quick discharge home. I can't believe they would let (RN C) still work there after letting (R800) die. I had to get out of there. Review of Social Service progress notes, dated [DATE], reflected roommate R requested to be discharged immediately to home, AMA (against medical advice) if needed. Progress Notes reflected that roommate R discharged home on [DATE]. During an interview on [DATE] at 3:30 PM, R800's roommate S stated the following regarding the unexpected death of R800 on the night of [DATE]: (a) it was awful, we couldn't help her, but we could hear her throwing up and choking (b) roommate R kept going out to get the nurse to help but (RN C) just yelled at her to go back to our room and mind her own business, it was loud, I could hear the yelling, (c) RN C did not check on R800 until the aide called a code blue, and (d) the administrator spoke to me about what happened, I told her what happened, and she told me not to talk about it with anyone. During an interview on [DATE] at 5:36 PM, CNA G reported the following regarding the care of R800 the evening of [DATE]: (a) heard roommate R tell RN C several times that R800 needed help and that RN C just told (roommate R) to go back to her room, (b) went to R800's room, R800's mouth was full of vomit, the head of the bed was flat, (c) raised the head of bed and helped R800 get the vomit out of her mouth, (c) cleaned up R800, obtained a set of vitals, and told RN C that R800 was sick and had not been feeling well that afternoon and evening and R800 did not eat dinner, (d) at the end of shift (10 PM) on [DATE], CNA G left an emesis basin next to R800 and told RN C that R800 was really sick and needed to be sent out. (RN C) doesn't listen to our opinions. Review of a vitals record for R800 reflected that the last set of vitals that were taken by staff on [DATE] occurred at 7:22 PM. Vital signs were within normal limits. During an interview on [DATE] at 8:17 AM, CNA E reported working the night of [DATE] from 10 PM to 6 AM on [DATE] and noted the following regarding the unexpected death of R800: (a) roommate R came out of the room because R800 needed something, (b) CNA E went into the room, the light was on, R800's eyes were weird and lips were blue, (R800) was gone. (c) CNA E called a code blue, got the nurse (RN C) and (RN C) came in and started working on R800, (d) CNA E indicated that this was the first time RN C had checked on R800 since (CNA E) coming on shift at 10 PM, (e) stated staff were all shocked when (R800 ) died , it's not like she was at the end of her life. During an interview on [DATE] at 11:30 AM, Licensed Practical Nurse (LPN) D stated the following regarding the events related to R800's unexpected death on [DATE]: (a) was down on her assigned hall assisting a resident off a bed pan when LPN D heard the code blue called, (b) quickly finished with the resident and went to R800's room on the 400 hall, (c) entered R800's room, RN C was at bedside, and RN C reported that R800 was not breathing, (d) observed R800's lying flat in the bed, lips were blue, and there was vomit in R800's mouth that RN C was trying to clear out, (e) called for a back board, initiated chest compressions initially without the back board, the back board arrived and was placed, and resumed chest compressions, (f) RN C was bagging (providing oxygen and ventilation's) R800 and vomit was coming out of R800's mouth, (g) EMS arrived and took over bagging, and needed suction to get the vomit out of R800's mouth and throat, (h) staff brought the suction machine but it was not working and had to go get the other one from the other crash cart, and (i) LPN D stayed in the room with EMS in case they needed something, and until R800 was pronounced dead. Review of an Emergency Cart and Oxygen Inventory Checklist for the 400 hall, with instructions to check equipment on top of the cart every day on 3rd shift. Any missing or non-operating equipment should be replaced immediately, revealed the cart was not checked 18 days in [DATE] and 13 of 17 days in [DATE]. During an interview on [DATE] at 9:02 AM, LPN I stated the following regarding the events related to R800's unexpected death on [DATE]: (a) was working on another hall on the other side of the building when she heard a code blue was called on 400 hall, (b) immediately went to 400 hall, no one could say for sure if 911 had been called, so LPN I called 911, (c) entered R800's room to find LPN D doing chest compressions and RN C bagging R800, (d) took turns with LPN D doing chest compressions on R800, and (d) while being bagged R800 had vomit coming out of her mouth and throat, staff turned R800 on her side to get the vomit out and then went back to doing chest compressions. LPN I indicated that when EMS arrived, she went back to her unit to continuing caring for residents. Review of ambulance/emergency medical services (EMS) run sheet reflected the following times and disposition for response to the facility call on [DATE] for assistance with R800: dispatch received 911 call from facility at 11:17 PM, EMS at the facility at 11:24 PM, EMS at R800's bedside at 11:26 PM and life saving measures initiated by EMS, and R800 was pronounced dead at the facility at 11:57 PM on [DATE]. During an interview on [DATE] at 11:00 AM, RN C reported the following related to the evening of [DATE] and the unexpected death of R800: (a) a CNA notified RN C that R800 had vomited, not sure of time but it was evening and after dinner, (b) RN C gave R800 a PRN (as needed) dose of [MEDICATION(S)] (a medication used to treat nausea/vomiting) and assessed lung sounds which were clear and vital signs which were within normal limits, (c) CNA E approached the medication cart (can't recall the exact time) and stated that R800 was not doing well and was unresponsive, (d) RN C went to R800's room and found the resident with no pulse, not breathing and immediately called a code (blue), (e) EMS was notified, the AED (automatic external defibrillator) was brought in, nursing staff started CPR (cardiopulmonary resuscitation), and when EMS (emergency medical services) arrived, RN C left R800's room, and (f) EMS came out of the room just before midnight and pronounced (R800) dead. When asked specifically if roommate R had been concerned about R800 and had alerted staff that R800 was throwing up and needed help, RN C stated yes she did come for help, but (roommate R) had been a care aide in the past and was always crying wolf about something being wrong with the roommate. When asked specifically about the amount of vomit and how many times R800 had thrown up, RN C replied, just that one time when I gave the [MEDICATION(S)] and it wasn't a ton. RN C indicated that after receiving the [MEDICATION(S)], R800 nodded that she felt better and that was the only time she vomited. Review of an Emar (electronic medication administration record) for R800, dated [DATE], reflected the following medication was given: [MEDICATION(S)] Oral Tablet 4 mg (milligrams), one tablet by mouth every 6 hours as needed for nausea/indigestion was given by RN C on [DATE] at 8:42 PM. Review of a nursing progress note, written by RN C on [DATE] reflected .Cna reported resident was unresponsive. Resident immediately assessed and found to be asystole and without respirations. Code blue called. CPR started and EMS called. Ems arrived at 2220 (this documented time is incorrect per EMS run sheet) and took over cpr/code. Um (unit manager) notified. Ems stopped code and called time of death at 23:57 (11:57 PM) . MD called and report given with order received for release of remains. Family called and notified of mothers passing with several family members coming in to visit. After family left funeral home called and arrived to take residents remains to their facility. Review of the last physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:00 PM, Family Member (FM) T reported (a) visiting with R800 2 weeks prior to her death and that R800 was up in a wheelchair laughing and joking, (b) R800 was remembering details about their youth, they were raised in the same house, and was clear as a bell, and (c) R800 looked so good and was happy. During an interview on [DATE] at 2:06 PM, Family Member (FM) U reported (a) just saw R800 2 days prior to her unexpected death and we talked, she was perfect and (b) after visiting the body at the facility in the early hours of [DATE], was told that if the family wanted an autopsy, they would have to pay for it. So, the family chose not to have an autopsy. On [DATE], the Administrator was verbally notified and received written notification of the immediate jeopardy at F600, identified on [DATE] and that began on [DATE], due to the facility's failure to protect a resident from neglect that lead to death. On [DATE] the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: -On [DATE] the facility terminated the employment of RN C and reported the allegation of neglect to the State Agency -On [DATE] all resident's were rounded on by clinical staff to ensure all needs were met. The ADM (administrator) and DON (Director of Nursing) audited current grievance logs for any concerns related to unmet resident needs. The DON reviewed all records of resident's that had expired in the past 30 days or who had an acute change in condition, for any unmet needs. -On [DATE] the RNC ( Regional Nurse Consultant) educated the ADM and DON on the Abuse/Neglect Policy and Procedure. The DON then initiated education with all facility personnel regarding the Abuse/Neglect Policy and Procedure. -On [DATE] the RNC educated the ADM and DON on the Emergency Situations and Care of Resident's Policy and Procedure. The DON then initiated educating nursing personnel on the Emergency Situations and Care of Resident's Policy and Procedure. Any staff absent will be in-serviced prior to their next scheduled shift. Special focus was given to staff (a) ensuring that each resident received timely medical attention to prevent neglect and (b) responding timely to emergency events. -The DON will review residents with acute changes in condition weekly and then monthly to ensure adherence to the Abuse/Neglect Policy and Procedure and the Emergency Situations and Care of Resident's Policy and Procedure. QAA committee will review audits for ongoing compliance. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on interview and record review, the facility failed to ensure staff providing direct patient care had an active unrestricted nursing license and able to practice in the State of Michigan. This deficient practice resulted in an immediate jeopardy beginning on 5/11/22 when Unlicensed Staff B, acting with the authority of a licensed nurse, provided nursing care to residents and subsequently dispensed controlled substances in error for 4 Residents (#21, #30, 49, and #5). Additionally, the facility failed to ensure licensed nursing staff were competent and trained to perform their duties (medication administration) resulting in significant medication errors for 6 Residents (#21, #20, #25, #21, #43, and #36) and the potential for serious harm, injury, and/or death. Findings: Review of the Licensing and Regulatory Affairs license search for Unlicensed Staff B revealed that beginning on 5/11/22 the Licensed Practical Nurse license was suspended. Review of Unlicensed Staff B's Time Sheet revealed she worked the following shifts after the suspension of her license: 5/13/22 on the 300-400 unit 5/16/22 on the 400-500 unit 5/17/22 on the 300-400 unit 5/20/22 on the 400-500 unit 5/23/22 on the 200 unit (night shift) 5/26/22 on the 200 unit (night shift) 5/27/22 on the 200 unit (night shift) 5/31/22 on the 400-500 unit 6/1/22 on the 300-400 unit 6/2/22 on the 300-400 unit 6/6/22 on the 400-500 unit (night shift) 6/10/22 unknown unit (night shift) 6/13/22 on the 200 unit 6/18/22 on the 300 unit 7/3/22 on the 200 unit 7/7/22 on the 400-500 unit During an interview on 07/21/2022 at 2:31 PM, Unlicensed Staff B reported that she was aware that her license had been under review/probation for an incident involving her failure to administer a blood thinner causing a resident to become subtherapeutic as well as falsely charting that the blood thinner had been administered. Unlicensed Staff B reported that she had been on probation ever since the incident. Unlicensed Staff B reported that she did not notify the staffing agency at the time of her hire that her nursing license was in a probationary period. Unlicensed Staff B reported that she was not aware that her nursing license had been suspended but reported that she had not paid the required fees to ensure she was in compliance with the Board of Nursing. Resident #21 (R21) Review of an Admission Record revealed R21 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/7/22 the [MEDICATION(S)] was administered as follows: *7/7/22 1 400 mg capsule at 8:00 AM *7/7/22 1 400 mg capsule at 1:00 PM *7/7/22 1 400 mg capsule at 4:00 PM *7/7/22 2 400 mg capsule at 10:00 PM Indicating R21 received an extra dose of [MEDICATION(S)] 400mg by Unlicensed Staff B on that date. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/2/22 the [MEDICATION(S)] was administered as follows: *6/2/22 1 tablet at 2:00 PM *6/2/22 1 tablet at 4:00 PM Indicating R30 received 2 doses of narcotic medication 2 hours apart by Unlicensed Staff B. Review of R30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/7/22 the [MEDICATION(S)] was administered as follows: *7/7/22 1 tablet at 10:00 AM Indicating Unlicensed Staff B did not administer R30 his morning dose of [MEDICATION(S)]. Resident #49 (R49) Review of an Admission Record revealed R49 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R49's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R49's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/13/22 the [MEDICATION(S)] was administered as follow: *6/13/22 1 capsule at 7:30 AM *6/13/22 1 capsule at 6:00 PM Indicating the 2nd dose of [MEDICATION(S)] was administered late by Unlicensed Staff B. Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/7/22 the [MEDICATION(S)] was administered as follows: *7/7/22 1 capsule at 10:00 AM Indicating the morning dose of [MEDICATION(S)] was not administered by Unlicensed Staff B. Resident #51 (R51) Review of an Admission Record revealed R51 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R51's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R51's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/16/22 the [MEDICATION(S)] was administered as follows: *7/16/22 1 tablet at 12:00 AM *7/16/22 1 tablet at 4:00 PM Indicating R51 did not receive a dose of [MEDICATION(S)] on 7/16/22 from Licensed Practical Nurse (LPN) H. Resident #20 (R20) Review of an Admission Record revealed R20 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R20's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/17/22 the [MEDICATION(S)] was not administered by LPN H. Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R25's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R25's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/17/22 the [MEDICATION(S)] was administered as follows: *7/17/22 1 tablet at 7:52 PM Indicating R25 did not receive a dose of [MEDICATION(S)] from LPN H the morning of 7/17/22. Resident #21 (R21) Review of an Admission Record revealed R21 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/8/22 the [MEDICATION(S)] 7.5/325 mg was administered as follows: *7/8/22 1 tablet at 12:00 PM *7/8/22 1 tablet at 4:00 PM *7/8/22 1 tablet at 9:10 PM Indicating R21 did not receive the 7:30 AM dose of the medication from LPN H. Review of R21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/8/22 the [MEDICATION(S)] was administered as follows: *7/8/22 1 400 mg capsule at 8:10 AM *7/8/22 2 400 mg capsule at 9:10 PM Indicating R21 did not receive the 1:00 PM dose of the medication from LPN H. Resident #43 (R43) Review of an Admission Record revealed R43 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R43's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R43's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/19/22 the [MEDICATION(S)] was administered as follows: *7/19/22 1 tablet at 6:30 AM (was not documented as administered as a PRN medication on the MAR.) *7/19/22 1 tablet at 10:00 AM Indicating R43 received doses of [MEDICATION(S)] 3.5 hours apart. Review of R43's Medication Administration Record on 7/19/22 at 10:30 AM revealed there was no documentation that LPN I had administered the 8:00 AM dose of [MEDICATION(S)] (Indicating late controlled substance administration). Important to note that the MAR and observation indicated the [MEDICATION(S)] had not been administered as of 7/19/22 at 10:30 AM, review of the documentation on the Controlled Drug Receipt/Record/Disposition Form obtained on 7/19/22 at 2:48 PM revealed documentation that the [MEDICATION(S)] was administered on 7/19/22 at 10:00 AM resulting in inaccurate controlled substance administration and/or inaccurate controlled substance documentation. Resident #36 (R36) Review of an Admission Record revealed R36 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R36's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4:00 PM, and 12:00 AM). Review of R36's Medication Administration Record on 7/19/22 at 10:30 AM revealed there was no documentation that R36 had received the 8:00 AM dose of [MEDICATION(S)] (Indicating late/missed controlled substance administration). During an observation on 07/19/22 at 10:33 AM, Licensed Practical Nurse (LPN) I had 2 preset medication cups setting on the top of her medication cart with multiple pills in each cup. LPN I then brought both medication cups into R43 and R36's room to administer the medication. (Note: the medications for R43 and R36 were administered outside of the nursing standard of practice of 1 hour before and 1 hour after the ordered time). During an interview on 7/21/22 at 2:03 PM, Nursing Home Administrator reported that she was not notified from the staffing agency nor Unlicensed Staff B that her nursing license was suspended as of 5/11/22. NHA reported that Unlicensed Staff B was immediately removed from the schedule and reported that her last date worked was 7/7/22. During an interview on 7/19/22 at 4:10 PM, Director of Nursing (DON) reported that LPN H had been hired on 6/9/22 and had orientation with the facility nursing staff. DON reported that LPN H would be receiving additional 1:1 orientation and education due to the ongoing medication errors identified during the survey. During an interview on 7/25/22 at 11:05 AM, Nursing Home Administrator reported that all resident's narcotic sheets were being reviewed for errors. No additional documentation regarding medication errors was produced prior to survey exit on 7/26/22. On 7/25/22 the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 7/25/22 due to the facility's failure to ensure staff providing direct patient care had an active unrestricted nursing license and were able to practice in the State of Michigan. A written plan for removal for the immediate jeopardy was received on 7/26/22 and the following was verified on 7/26/22: (Facility) is providing the following information to demonstrate that the immediacy of the cited deficiency F726 has been removed. Response to Cited Areas: No specific residents were identified in the IJ Notice. All residents are at a potential risk. Staff member B worked a total of 13 shifts from 5/13/22 to 7/7/22, this was confirmed on 7/21/22. Unlicensed staff B was confirmed to not have worked at the facility after 7/7/22. Unlicensed staff B will not pick up any future shifts at the facility. On 7/21/22 a call was placed to the staffing agency for unlicensed staff B, notifying the agency of the findings and that the individual was not eligible to work. All licensed staff employed or contracted, professional licenses were validated on 7/21/22 to be active and unencumbered to work in the State of Michigan. Other Residents at Potential Risk: A 100% audit was started on 7/25/22 by the facility nurse management team The audit consisted of verification of all current resident to ensure medications, including narcotics and treatments were administered/completed as ordered by the attending physician At this time 10 out of 66 residents have been identified concerns with medication/treatment administration. On 7/25/22, the facility pulled the 24-hour report for the 13 identified shifts staff B worked to identify if any residents experienced a change in condition or any negative outcomes. 0 out of 10 had identified concerns with a change in condition or negative outcome. A 100% audit was completed on 7/21/22 by the facility administrative staff to validate all professional staff, whether employed directly by the facility or through agency contracts have license that are active and unencumbered. 0 out of 34 had identified concerns with their license. On 7/22/22 a review was completed of the Health Disciplinary Action Reports, published by the State of Michigan's Licensing and Regulatory Affairs ([NAME]) department for the month of July to ensure facility professional staff, employed and contracted, did not have any pending action. 0 out of 34 had identified pending actions on their license. Process Implemented to prevent further incidence: On 7/22/22, the Human Capitol Partner was educated on pulling the Health Disciplinary Action Reports, published by the State of Michigan's Licensing and Regulatory Affairs ([NAME]) department weekly to ensure facility professional staff, employed and contracted, did not have any pending action. The Administrator and Regional Nurse Consultant have reviewed the Controlled Drugs, Administration of Drugs, and Medication Errors policies and deemed they meet clinical and regulatory standards. On 7/25/22, the facility-initiated education for licensed nurses to ensure the necessary skills and competencies for administration of medications including controlled medications and identifying and reporting a medication error. Licensed nurses who have not received the education will be removed from the schedule until the education is completed. As of 7/26/22, 2 out of 3 facility nurse managers have received training. As of 7/26/22, 6 out of 13 facility licensed nurses have received training. As of 7/26/22, 3 out of 18 agency licensed nurses have received training. Monitoring: The Administrator and/ or designee will conduct random audits monthly times 3 months or until substantial compliance has been maintained to ensure the Health Disciplinary Action Reports published by the State of Michigan [NAME] department has been pulled and any facility professional staff employed and contracted with pending actions have been identified with appropriate follow up. The Director of Nursing and/ or designee will conduct random audits on 5 staff competencies weekly times 4 weeks, then monthly thereafter times 3 months or until substantial compliance has been maintained to ensure the necessary skills for administration of medications including controlled medications and identifying and reporting a medication error. The medical director was notified of these findings on 7/25/22. The pharmacist consultant was notified of these findings on 7/25/22. All findings will be forwarded to the QA committee and will provide further guidance as needed. The facility alleges that the immediacy with the deficient practice has been removed on July 26, 2022. Although the immediate jeopardy was removed on 7/26/22, the facility remained out of compliance at a scope of widespread and severity of likelihood of harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to 1). provide controlled substance oversight, 2). ensure facility nursing staff administering the medications were licensed and competent, and 3.) keep residents free from significant medication errors by following the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #20, #43, and #36) reviewed for medication administration. This deficient practice resulted in an immediate jeopardy when, beginning on 5/9/22, facility staff failed to provide proper administration of controlled substances and promptly notify the physician of medication errors. This deficient practice resulted in missed doses of controlled substances, additional doses of controlled substances, incorrect time for the administration of controlled substances and placed all residents residing in the facility at risk for serious harm, injury and/or death. Findings: Resident #21 (R21) Review of an Admission Record revealed R21 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 5/9/22 the [MEDICATION(S)] was administered as follows: *5/9/22 1 400 mg capsule at 8:30 AM *5/9/22 1 400 mg capsule at 12:00 PM *5/9/22 1 400 mg capsule at 1:00 PM *5/9/22 2 400 mg capsule at 7:20 PM Indicating R21 received an extra dose of [MEDICATION(S)] 400mg on that date. Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/7/22 the [MEDICATION(S)] was administered as follows: *7/7/22 1 400 mg capsule at 8:00 AM *7/7/22 1 400 mg capsule at 1:00 PM *7/7/22 1 400 mg capsule at 4:00 PM *7/7/22 2 400 mg capsule at 10:00 PM Indicating R21 received an extra dose of [MEDICATION(S)] 400mg by Unlicensed Staff B on that date. Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/8/22 the [MEDICATION(S)] was administered as follows: *7/8/22 1 400 mg capsule at 8:10 AM *7/8/22 2 400 mg capsule at 9:10 PM Indicating R21 did not receive the 1:00 PM dose of [MEDICATION(S)]. Review of R21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/6/22 the [MEDICATION(S)] 7.5/325 mg did not have a signature indicating which licensed nurse administered the medication for the dose administered at 8:00 AM, 1:00 PM, or 4:00 PM. Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/8/22 the [MEDICATION(S)] 7.5/325 mg was administered as follows: *7/8/22 1 tablet at 12:00 PM *7/8/22 1 tablet at 4:00 PM *7/8/22 1 tablet at 9:10 PM Indicating R21 did not receive the 7:30 AM dose of the medication. Review of R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/9/22 the [MEDICATION(S)] 7.5/325 mg was administered as follows: *7/9/22 1 tablet at 10:00 AM *7/9/22 1 tablet at 11:30 AM Indicating R21 received a dose of the narcotic medication 1.5 hours after the previous dose. Review of R21's Electronic Health Record revealed no documentation that the physician was notified of the medication errors at that time. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/2/22 the [MEDICATION(S)] was administered as follows: *6/2/22 1 tablet at 2:00 PM *6/2/22 1 tablet at 4:00 PM Indicating R30 received 2 doses of narcotic medication 2 hours apart by Unlicensed Staff B. Review of R30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's R21's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/7/22 the [MEDICATION(S)] was administered as follows: *7/7/22 1 tablet at 10:00 AM Indicating Unlicensed Staff B did not administer R30 his morning dose of [MEDICATION(S)] Review of R30's Electronic Health Record revealed no documentation that the physician was notified of the medication errors at that time. Resident #15 (R15) Review of an Admission Record revealed R15 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/2/22 the [MEDICATION(S)] was administered as follow: *7/2/22 1 tablet at 10:15 AM *7/2/22 1 tablet at 2:15 PM Indicating R15 received 2 doses of the controlled substance 4 hours apart and did not receive the 3rd dose. Review of R15's Electronic Health Record revealed no documentation that the physician was notified of the medication errors at that time. Resident #49 (R49) Review of an Admission Record revealed R49 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R49's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R49's Controlled Drug Receipt/Record/Disposition Form revealed that on 5/27/22 the [MEDICATION(S)] was administered as follows: *5/27/22 1 capsule at 7:00 AM *5/27/22 1 capsule at 12:00 PM Indicating the 3rd dose of [MEDICATION(S)] was not administered. Review of R49's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/10/22 the [MEDICATION(S)] was administered as follows: *6/10/22 1 capsule at 8:00 AM *6/10/22 1 capsule at 1:00 PM Indicating the 3rd dose of [MEDICATION(S)] was not administered. Review of R49's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R49's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/13/22 the [MEDICATION(S)] was administered as follow: *6/13/22 1 capsule at 7:30 AM *6/13/22 1 capsule at 6:00 PM Indicating the 2nd dose of [MEDICATION(S)] was administered late by Unlicensed Staff B. Review of R49's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/26/22 the [MEDICATION(S)] was administered as follows: *6/26/22 1 capsule at 7:00 AM *6/26/22 1 capsule at 12:30 PM Indicating the 3rd dose of [MEDICATION(S)] was not administered. Review of R49's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/1/22 the [MEDICATION(S)] was administered as follows: *7/1/22 1 capsule at 7:00 AM *7/1/22 1 capsule at 12:30 PM Indicating the 3rd dose of [MEDICATION(S)] was not administered. Review of R49's Electronic Health Record revealed no documentation that the physician was notified of the medication errors at that time. Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/7/22 the [MEDICATION(S)] was administered as follows: *7/7/22 1 capsule at 10:00 AM Indicating the morning dose of [MEDICATION(S)] was not administered by Unlicensed Staff B. Review of R5's Electronic Health Record revealed no documentation that the physician was notified of the medication error at that time. Resident #26 (R26) Review of an Admission Record revealed R26 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R26's Controlled Drug Receipt/Record/Disposition Form revealed that on 6/20/22 the [MEDICATION(S)] was administered as follows: *6/20/22 1 capsule on 6/20 at 7:20 PM Indicating the 7:30 AM dose and the 11:00 AM dose of [MEDICATION(S)] was not administered. During an interview on 7/25/22 at 11:05 AM, Nursing Home Administrator (NHA) reported that R26 was not on LOA (Leave of Absence) at the time the medication was documented as not given for the reason that the resident was not in facility. Review of R26's Electronic Health Record revealed no documentation that the physician was notified of the medication error or that the resident was not in the facility on 6/20/22. Resident #51 (R51) Review of an Admission Record revealed R51 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R51's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R51's Controlled Drug Receipt/Record/Disposition Form revealed that on 5/17/22 the [MEDICATION(S)] was administered as follows: *5/17/22 1 tablet at 12:00 AM *5/17/22 1 tablet at 9:00 AM *5/17/22 1 tablet at 12:30 PM *5/17/22 1 tablet at 5:00 PM Indicating R51 received an additional dose of [MEDICATION(S)] on 5/17/22 Review of R51's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/16/22 the [MEDICATION(S)] was administered as follows: *7/16/22 1 tablet at 12:00 AM *7/16/22 1 tablet at 4:00 PM Indicating R51 did not receive the 8:00 AM dose of [MEDICATION(S)] on 7/16/22 from Licensed Practical Nurse (LPN) H Review of R51's Electronic Health Record revealed no documentation that the physician was notified of the medication errors at that time. Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R25's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R25's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/17/22 the [MEDICATION(S)] was administered as follows: *7/17/22 1 tablet at 7:52 PM Indicating R25 did not receive a dose of [MEDICATION(S)] the morning of 7/17/22. Review of R25's Electronic Health Record revealed no documentation that the physician was notified of the medication error at that time. Resident #20 (R20) Review of an Admission Record revealed R20 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R20's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/17/22 the [MEDICATION(S)] was not administered. Review of R20's Electronic Health Record revealed no documentation that the physician was notified of the medication error at that time. Resident #43 (R43) Review of an Admission Record revealed R43 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R43's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R43's Controlled Drug Receipt/Record/Disposition Form revealed that on 7/19/22 the [MEDICATION(S)] was administered as follows: *7/19/22 1 tablet at 6:30 AM *7/19/22 1 tablet at 10:00 AM Indicating R43 received doses of [MEDICATION(S)] 3.5 hours apart. Review of R43's Medication Administration Record on 7/19/22 at 10:30 AM revealed there was no documentation that R43 had received the 8:00 AM dose of [MEDICATION(S)] (Indicating late controlled substance administration). Important to note that the MAR and observation indicated the [MEDICATION(S)] had not been administered as of 7/19/22 at 10:30 AM, review of the documentation on the Controlled Drug Receipt/Record/Disposition Form obtained on 7/19/22 at 2:48 PM revealed documentation that the [MEDICATION(S)] was administered on 7/19/22 at 10:00 AM causing inaccurate controlled substance administration/documentation. Review of R43's Electronic Health Record revealed no documentation that the physician was notified of the medication error at that time. Resident #36 (R36) Review of an Admission Record revealed R36 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R36's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4:00 PM, and 12:00 AM). Review of R36's Medication Administration Record on 7/19/22 at 10:30 AM there was no documentation that R36 had received the 8:00 AM dose of [MEDICATION(S)] (Indicating late/missed controlled substance administration). Review of R36's Electronic Health Record revealed no documentation that the physician was notified of the medication error at that time. During an observation on 07/19/22 at 10:33 AM, Licensed Practical Nurse (LPN) I had 2 preset medication cups setting on the top of her medication cart with multiple pills in each cup. LPN I then brought both medication cups into R43 and R36's room to administer the medication. (Note: the medications for R43 and R36 were administered outside of the nursing standard of practice of 1 hour before and 1 hour after the ordered time). During an interview on 7/21/22 at 2:03 PM, Nursing Home Administrator reported that she was not notified from the staffing agency nor Unlicensed Staff B that her nursing license was suspended as of 5/11/22. NHA reported that Unlicensed Staff B was immediately removed from the schedule and reported that her last date worked was 7/7/22. During an interview on 7/19/22 at 4:10 PM, Director of Nursing (DON) reported that LPN H had been hired on 6/9/22 and had orientation with the facility nursing staff. DON reported that LPN H would be receiving additional 1:1 orientation and education due to the ongoing medication errors identified during the survey. During an interview on 7/25/22 at 11:05 AM, Nursing Home Administrator reported that all resident's narcotic sheets were being reviewed for errors. No additional documentation regarding medication errors was produced prior to the survey exit on 7/26/22. On 7/25/22 the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that was identified on 7/25/22 due to the facility's failure to ensure controlled substances were administered according to standard nursing practice. A written plan for removal for the immediate jeopardy was received on 7/26/22 and the following was verified on 7/26/22: (Facility) is providing the following information to demonstrate that the immediacy of the cited deficiency F760 has been removed. Response to Cited Areas: On 7/25/2022, resident's #15, #30, #5, #49, #1, #43, #20, #25, #21 and #51 were interviewed and assessed (which included vital signs and pain assessment) by a facility nurse for adverse effects related to significant medication errors. There were no adverse effects identified. The facility completed a Medication Error Report on all 10 identified residents with medication errors. Other Residents at Potential Risk: An audit of all current resident narcotic logs from 7/1/22 to current was initiated on 7/25/22 by the nurse managers, to verify controlled substances were/are administered and documented to standards. There were 10 out of 66 additional residents identified at risk of a medication error. The facility will complete a Medication Error Report on any additional identified medication errors. Process Implemented to prevent further incidence: The Administrator and Regional Nurse Consultant have reviewed the Controlled Drugs, Administration of Drugs, and Medication Errors policies and deemed they meet clinical and regulatory standards. On 7/25/22, training was initiated with the DON and Nurse Managers by the Nurse Consultant on identifying, reporting and follow up on medication error. Nurse managers who have not received the education will be removed from the schedule until the education is completed. As of 7/26/22, 2 out of 3 Nurse Managers have received training. On 7/25/22, the facility-initiated education with the licensed nurses by a nurse manager on administration of Controlled Drugs, Administration of Drugs, and Medication Errors. Licensed nurses who have not received the education will be removed from the schedule until the education is completed. As of 7/26/22, 6 out of 13 facility licensed nurses have received training. As of 7/26/22, 3 out of 18 agency licensed nurses have received training. The consultant pharmacist was informed of the findings on 7/25/22. The pharmacist consultant will review monthly the controlled drugs shift to shift logs and medication administration records for concerns and report their findings to the facility for appropriate follow up. Monitoring: The Director of Nursing and/ or designee will conduct random audits of medication administration on three nurses weekly for 4 weeks, then monthly thereafter for 3 months or until sustained compliance has been achieved to ensure appropriate administration of medication, including controlled medications and medication error are identified and report as applicable. The medical director was notified of these findings on 7/25/2022 All findings will be forwarded to the QA committee and will provide further guidance as needed. The facility alleges that the immediacy with the deficient practice has been removed on July 26, 2022. Although the immediate jeopardy was removed on 7/26/22, the facility remained out of compliance at a scope of pattern and severity of likelihood of harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to implement the comprehensive Care Plan for four residents (Residents (R)6, R17, R7, R38), resulting in anxiety with self-injurious behavior, the potential for aspiration of liquid nutrition and the potential for infection from an ill-maintained assistive breathing device and the potential for all facility residents to not have their comprehensive Care Plans implemented preventing them from reaching their highest level of function. Findings: R 6 Review of R6's face sheet dated 7/19/22 revealed they are a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was not her own responsible party. On 07/18/22 at 10:50 AM, R6 was viewed in her room, she was staring blankly in a darkened room and sitting in her wheelchair. R6 had multiple sores on both sides of her face. They did not appear to be fresh, they were scabbed over and not bleeding. Blood was not observed on her hands, or bed sheets. R6 was asked what happened on face and she stated I'm not sure, maybe I dug at it with a screwdriver or something. On 07/18/22 at 12:20 PM, R6 was observed being assisted by staff D with her lunch tray after she put on her call light. On 7/19/22 at 11:30 AM, R6 was viewed in her room, laying in bed and awake. On 07/19/22 at 11:40 AM, an interview was completed with CNA (certified nursing assistant) C about R6's facial wounds. CNA C stated she has wounds that will heal up and then dig at them again. CNA C thought they put cream on them at times, but R6 often refuses. CNA C was not sure when the current wounds started. CNA C was also working on R6's hall the previous day. She could not recall if R6 had wounds at that time. On 07/19/22 at 11:42 AM an interview was completed with UM (unit manager) A. UM A stated, the last she knew the wounds on R6's face were healed. R6 has wounds intermittently on her face, it is anxiety related and R6 will dig and pick at her face. UM A stated interventions include activities such as giving her cardboard to tear or corn on the cob to pick at. The wound nurse practitioner will come in Thursdays for wound rounds and UM A rounds with them. R6 did not have any facial wounds as of last Thursday. Other interventions for R6 include topical creams, but they are not always tolerated. UM A stated that staff should put a skin note in if there was a new injury and she was not aware of a new injury or injuries to R6's face. On 07/19/22 at 04:10 PM, R6 was viewed in her wheelchair sitting in a darkened room with the door open. There were still no activities viewed in her room, she was viewed talking to herself and stated she was just talking to the pictures on the floor. On 07/20/22 at 09:16 AM, R6 was viewed in her darkened room, sitting in her wheelchair picking at her face. R6 said she just finished breakfast. A stuffed cat was viewed on the bed, the resident was not touching the cat. No other activities were viewed. On 07/20/22 at 09:29 AM an interview was completed with Activities Director (AD) E in reference to R6. AD E stated R6 is usually pleasant with staff, but never wants to come to group activities. AD E stated R6 likes tactile activities, like tearing cardboard and picking at corn cobs. Activities staff do involve R6 in some one on one activities with her roommate as well. AD E was asked what activities R6 has been provided this week. AD E stated she thought R6 was tearing up a tissue box at some point this week, but was unsure of any other activities. AD E stated no one has talked to her this week to reach out to R6 more with activities, but that she and 3 other activities staff round to get residents to group activities and offer individual activities. AD E stated R6 is usually in her chair in her room, she is very particular about having clutter or extra things in the room, so when bringing things they have to round back shortly to make sure she is done. AD E stated it is charted under tasks when staff round or do activities. It was discussed that not many activities or attempts to engage in activities are in R6's chart. AD E was informed R6 was recently doing some self injury behaviors again and staff had expressed that more activities would be explored. AD E reiterated that no one has reached out this week to do more things with R6, but will make sure the activities staff round more with her. On 07/20/22 at 11:52 AM, an interview was completed with UM A regarding R6. UM A stated she did not get a chance to talk to activities staff yesterday, but did talk to them now. UM A stated she personally did get R6 some cardboard to tear yesterday. Review of R6's care plan revealed a focus area with a last revised dated on 3/5/22 of an open lesion to R6's supra pubic regions and resident noted aggressively scratching that area when agitated. There is no note of facial [CONDITION(S)]. Interventions included: Activities providing extra activities for tactile stimulation as tolerated. Another focus area with a last revised date of 1/11/22 revealed a history of skin injuries with an intervention that included observe skin daily with care activities. Report any changes in coloration, integrity, etc to nurse. An additional care area with the last revised date of 3/14/20 related to psychosocial well-being included interventions such as: provide in room activities of choice, as able. R6's care plan also noted she needed assistance with ADL (activities of daily living), such as transfers from the bed to wheelchair, toileting and personal hygiene, thus staff should be regularly interacting with her. Review of R6's kardex revealed the following under the section Activities: provide her with materials for individual activities as desired. The resident likes the following independent activities: watching TV (talk shows), tearing cardboard, visiting with staff, special snacks and Provide in room activities of choice, as able. Review of R6's activities log revealed, limited activities were logged in the last 30 days. Review of R6's activity log for July revealed no activities offered to R6 on 7/2, 7/3, 7/4, 7/11, 7/13, 7/15, 7/16 and 7/17/22. Other days had 1-2 activities offered. On 7/20/22 there were 8 activities offered. Review of R6's skin assessment for 7/19/22 revealed 5 facial scabs measuring 1.4x0.7x0.1, 1x0.2x0.1, 1.5x0.5x0.1, 0.3x0.2x0.1 and 0.7x0.5x0.1 centimeters. Review of wound notes with encounter date of 7/14/22 revealed no active wounds. Past history of wounds are documented and included an abdominal wound, which had recently healed. There was a note from 12/9/2021 that referred to facial wounds due to R6 picking at her skin. Review of R6's progress notes revealed no recent mention of facial wounds prior to 7/19/22. A note on 7/19/22 at 12:04 PM by social services revealed: SS provided follow-up visit this morning. Resident was observed tearing cardboard and had a big smile on her face this morning. She told SS she was shredding cardboard which has been a preferred intervention of hers to avoid or minimize picking at her face. Resident noted that activities had just seen her and was bringing more cardboard for her to rip pieces from. Resident became frustrated when SS began asking her about picking at her face. To avoid more frustration, SS praised her for engaging in ripping cardboard and encouraged her to continue as this is something she voices enjoyment doing. Will continue to follow-up and offer support as needed or requested. A late entry general progress note was added on 7/20/22 and dated 7/19/22 at 10:54 AM: Resident provided with cardboard and cardstock for shredding by this nurse until able to be reviewed by activities director. Resident thankful for activity. An event note from 7/19/22 at 1:06 PM revealed: Nurse entered room and noticed 5 areas on residents face that were scabbed over, 2 areas noted on her left cheek, 1 on her nose, 1 on her chin and 1 on her right cheek. See skin obs for measurements. Resident states she picked at the skin on her face. Head to toe assessment completed, no additional self inflicted areas noted at this time. No c/o pain from resident. VS stable and at baseline. UM, DPOA, BCS and physician notified. Activities to assess for a tactile distraction for resident. A general progress note from 7/20/22 at 10:56 AM revealed: Discussed with Activities Director need to increase tactile activities for resident. Activities Director states she is aware and has provided items to her today and plans to assess further. A recreational services note on 7/20/22 at 12:10 PM revealed: Activities visited with Resident today to assess life enrichment options and preferences. Resident had pleasant affect and was sitting at her table waiting for lunch. Activities brought in multiple independent/tactile activities, per residents' preference. Resident initially refused most items in preference for cardboard to tear, but upon re-approach with basket to keep items in, accepted paper, cardboard, sensory putty, and coloring supplies. Resident refused offer to create a collage with ripped paper, both independently or with staff, as well as refused offer to go outside this afternoon. Historically, Resident has grown frustrated with keeping these items in her room for prolonged periods of time, so was reassured AD would follow up this afternoon. Resident expressed thankfulness at the end of today's visit. Activities will continue to monitor and encourage appropriate engagement. R17 Review of R17's face sheet dated 7/20/22 revealed they are a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 was not her own responsible party. Review of R17's orders in their electronic medical records revealed an active order with a start date of 06/04/21: Elevate HOB (head of bed) 30-45 degrees during all feeding and flushes. Review of R17's care plan revealed a focus area of tube feeding. Interventions included: Keep HOB elevated 45 degrees during and thirty minutes after tube feed. On 07/20/22 at 09:20 AM, R17 was viewed in bed with their tube feed running, the head of the bed was at slight angle, but the resident's feet were also up, so they appeared to be laying flat. At 9:25 AM, UM A was asked to come to R17's room and note if there were any concerns. UM A stated his bed was not in the right position and confirmed his tube feed was running. UM A stated his bed is tilted at about 15 degrees, but it should be 30-45 degrees. UM A put the tube feeding on hold and went to get another staff member to assist with repositioning the resident. R7 Review of the Minimum Data Set (MDS) dated [DATE] reflected R7 was admitted to the facility 11/21/07 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section K of this MDS titled Swallow/Nutrition Status revealed R7 received nutrition through a feeding tube. Review of the Doctor's Orders reflected directions for the administration of liquid nutrition through an enteral feeding. These directions included that the head of the bed was to be elevated at least 30 degrees during all feedings and flushes. Review of the Care Plan for R7 reflected the head of the bed was to be elevated 30 to 45 degrees during and 30 minutes after tube feedings. On 7/19/22 at 9:31 AM, R7 was observed in her bed with a tube feeding in progress by way of a pump at 70 cubic centimeters (cc) per hour. The head of the bed was observed to be raised approximately 30 degrees. However, the body of R7 was observed to be lower in the bed and with the Resident lying almost flat. On 7/20/22 at 9:15 AM, R7 was again observed to be positioned lower in the bed so that only the shoulders and head were against the head of the bed with the rest of the body flat. A tube feeding was in progress by way of a pump at 70 cc per hour. On 7/20/22 at 9:19 AM, Registered Nurse (RN) F was summoned to the room and asked if R7 was positioned correctly to be receiving nutrition through her feeding tube. RN F acknowledged that R7 was not positioned correctly to be receiving nutrition through her feeding tube. RN F suspended the infusion of liquid nutrition until the Resident could be moved to a position that prevented the risk aspiration of the liquid nutrition. R38 Review of the Minimum Data Set (MDS) dated [DATE] revealed R38 was admitted to the facility 6/17/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/18/22 at 10:49 AM, R38 was observed in bed wearing a nasal Continuous Positive Airway Pressure ([CONDITION(S)]) mask which was attached to an operating [CONDITION(S)] machine. The nasal [CONDITION(S)] mask appeared well used and was yellowing. R38 reported she did not know if her [CONDITION(S)] mask was ever cleaned. On 7/20/22 at 8:45 AM, R38 was observed in bed wearing the nasal [CONDITION(S)] mask. The [CONDITION(S)] mask appeared yellowing and soiled with debris encrusted on the inner side of the mask. Review of the Care Plan for R38 reflected a Care Plan focus topic of Resident has altered respiratory functioning and/or difficulty breathing (related to) Sleep Apnea. The altered respiratory Care Plan reflected an Intervention of Clean [CONDITION(S)]/[CONDITION(S)] mask weekly created on 1/9/22 and revised on 6/20/22. An additional Intervention reflected Licensed staff to assist with management of [CONDITION(S)] machine, initiated on 6/3/22. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMR Progress Notes from 4/23/22 to 7/19/22 did not reveal any documentation that the [CONDITION(S)] used by R38 had been cleaned or maintained weekly. On 7/20/22 at 1:48 PM, the Director of Nursing (DON) was informed of the soiled [CONDITION(S)] mask being used by R38. The DON was informed that no documentation was found that the [CONDITION(S)] being used by R38 was cleaned weekly as directed by the facility Care Plan. The DON was asked to provide any documentation regarding these concerns. As of survey exit no further documentation was provided by the facility.

This citation pertains to intake #: MI 341 Based on observation, interview, and record review, the facility failed to prevent facility acquired pressure ulcers and provide pressure ulcer preventative care consistent with professional standards of practice for 1 Resident (Resident #4) reviewed for the risk of and/or the development of pressure injuries, resulting in the development of an avoidable pressure ulcer and the potential for skin breakdown and overall deterioration in health status. Findings include: Review of the facility policy Skin Monitoring and Management-Pressure Ulcer adopted on 7/11/18 revealed, A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing . PREVENTION In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan .B. Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition. C. Reposition the resident. D. Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc.) . Review of the Fundamental of Nursing revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016) .A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominence's (WOCN, 2016). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition. Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R4, with a reference date of 7/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated R4 was severely cognitively impaired. Review of the Functional Status revealed that R4 required extensive 2 person physical assist for bed mobility, transferring, dressing, toileting, and personal hygiene. Review of R4's Care Plan revealed, (R4) has actual impairment to skin integrity r/t (related to) Stage 4 pressure sore to Sacrum. Risk factors/contributing dx (diagnosis) include MS ([CONDITION(S)]), spinal stenosis, [CONDITION(S)], expressive language disorder, wheelchair bound, decrease mobility, and multiple contractures. Date Initiated: 07/18/2021 .reposition with cares as resident allows revised 6/17/2022 .Resident needs pressure reduction interventions: alternating pressure mattress Date Initiated: 07/22/2021. (No intervention was noted for the frequency of repositioning on the Care Plan or Kardex). During an interview on 07/18/22 at 2:46 PM, Family Member (FM) G reported that R4 had recently been diagnosed with [CONDITION(S)] (antibiotic resistive infection). FM G reported that R4 had been diagnosed with a pressure ulcer while a resident at the facility and it had recently worsened. FM G reported that R4 was unable to reposition herself and relied on staff to provide care and ensure care planned interventions were in place to prevent the development and worsening of a pressure ulcer. During an observation on 07/19/22 at 7:47 AM, R4 was in bed on her back with no pressure reducing devices in place to offload pressure on R4's buttocks. During an observation on 07/19/22 at 8:25 AM, R4 was in bed on her back with no pressure reducing devices in place to offload pressure on R4's buttocks. During an observation on 07/19/22 at 9:43 AM, R4 was in bed on her back with no pressure reducing devices in place to offload pressure on R4's buttocks. During an observation on 07/19/22 at 10:53 AM, R4 was in bed on her back with no pressure reducing devices in place to offload pressure on R4's buttocks. During an observation and interview on 07/19/22 11:28 AM, R4 was in bed on her back with no pressure reducing devices in place to offload pressure on R4's buttocks. At that time Registered Nurse (RN) F was entering the room to provide wound care. RN F reported that R4 was to be repositioned at least every 2 hours to prevent the worsening of the pressure ulcer. R4 had stool in her brief and her coccyx/sacral wound had a measurable depth, was macerated around the edges, and had noted drainage. R4's wound was approximately the size of the diameter of a golf ball. Review of R4's Skin/Wound Evaluation dated 6/17/22 revealed, Wound evaluation completed. Resident wound type is Pressure. Wound location is Sacrum. Wound measurements are: Area - 0.9 cm2, Length - 1.6 cm, Width - 0.9 cm, Depth - 0.1 cm. Review of R4's Skin/Wound Evaluation dated 6/30/22 revealed, Sacrum Type of Skin change/Impairment:: Pressure - stage 4 Measurement(s):: 4 x 4.8 x 0.3cm. (Indicating the worsening of the facility acquired pressure ulcer). Review of the Wound Care Provider note dated 6/30/22 revealed, (name omitted) RN was present during the visit today requested I see patient to reassess the area that she has on her sacrum. She is on an APM (pressure reducing mattress) but it was turned off so it was completely flat . Review of R4's Skin/Wound Evaluation dated 7/7/22 revealed, Sacrum Type of Skin Change/Impairment:: Pressure - Stage 4 Measurement(s):: 3 x 3.6 x 0.3cm. Review of R4's Skin/Wound Evaluation dated 7/14/22 revealed, Sacrum Type of Skin Change/Impairment:: Pressure - stage 4 infection present Measurement(s):: 2.8 x 3.5 x 0.3cm (Indicating the worsening of the facility acquired pressure ulcer due to a new infection). Review of the Wound Care Provider note dated 7/14/22 revealed, (Licensed Practical Nurse/Wound Care Nurse LPN/WCN A) was present during the visit today request I see patient to reassess the area that she has on her sacrum. I spoke with (LPN/WCN A) earlier this week. She had the culture done on the sacrum on 7/7/2022 and it was sent to the nursing home on 7/12/2022. It showed heavy growth of Proteus Mirabilis, heavy growth Enterococcus, [CONDITION(S)], and [CONDITION(S)] pneumoniae. Her PCP (primary care provider) put her on Bactim DS (antibiotic) twice daily. I added [MEDICATION(S)] cream to the wound . During an interview on 7/20/22 at 2:20 PM, LPN/WCN A reported that the culture was obtained and the antibiotic started for R4 due to the significant and sudden worsening of the wound on her coccyx. LPN/WCN A reported that R4's sacral wound was nearly healed and then opened significantly.

This pertains to intake M 5723 and M 6630. Based on interview and record review, the facility failed to prevent neglect when systemic failures occured due to not following policies and procedures for new admissions, charting and documentation, and ordering medications and failed to provide necessary care and services including notifying the physician for missed treatment and medications for 2 residents (Resident #4 and Resident #10), resulting in residents not receiving medications, medical treatments or services including Activities of Daily Living (ADLs) and one resident readmitted back to the hospital 2 days after admission. Findings include: Review of a Policy titled Abuse and Neglect last revised on 10/14/20 revealed: The purpose of this policy/procedure is to articulate standards and/or processes for proper screening, training, prevention, identification, investigation protection and reporting relative to any form of abuse. It is the policy of this facility to provide professional care and services in an environment that is free from abuse, neglect, misappropriation of resident property, exploitation, and corporal punishment. Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of a policy titled Admissions adopted 7/11/18 revealed: It is the policy of this facility to have well defined guidelines for processing the Resident's entry into the nursing facility and that the Resident's rights are protected under federal and state laws. Licensed Nurse Procedure: .1. Welcome Resident and family to Facility and inquire about any immediate special needs. 2. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders. 3. Do a complete assessment of body systems and complete admission assessment and nursing notes. Include a through skin check. 4. Inform physician of admission and verify transfer and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order medications from pharmacy. 6. Confirm diet order, complete diet slip and sent to dietary.9. Initiate Resident Care Plan. 10. Communicate immediate Resident special needs to CNA's, dietary, therapies, social services, ect. 11. Note and initiate physician order. Initiate mediations and treatment sheets.13. Note advance-directive information. 14. Ensure that admission forms are completed per policy and baseline plan of care initiated. Review of a policy titled Charting and documentation adopted 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of a Guidelines for Medication Orders, Policy 2.1 revealed: Medications are dispensed by the Pharmacy only upon receipt of a clear, complete order, signed by an authorized licensed prescriber. facilities using an electronic order entry system and/or eMAR should refer to specific system. Resident #4 (R4) Review of a Face Sheet revealed R4 is an [AGE] year old female admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Discharge assessment dated [DATE] revealed R4 admitted to the facility on [DATE] and discharged on [DATE]. Section A2300 indicates R4 MDS Assessment Reference date is 1/16/22 and the resident was moderately cognitively impaired. In an interview on 2/1/22 at 1:20 p.m., Family Member (FM) A reported her mother (R4) admitted to the facility from the hospital on 1/14/22 around 3:30 p.m. and did not receive medications, oxygen, food, or water while at the facility. FM A reported she dropped off clothing for her mother around that time. The resident was cognitively intact until this incident. R4 was then admitted back to the hospital on 1/16/22. On 1/15/22 FM A reported she called the facility and complained to the nurse that her mother has not received any food, medications, or water and the facility did not connect R4 to 3 liters of oxygen. FM A reported she would call the facility and they would put her on hold and then hang up. FM A reported she talked to the nurse on 1/16/22 and insisted her mother (R4) goes back to the hospital after talking to R4 on the phone and noticed a change in her cognitive condition. The staff was reluctant to send R4 to the hospital and FM A reported she argued with the staff and insisted again that R4 goes to the hospital. They finally transferred the resident to the hospital and when she arrived, she was wearing the same clothes that she was admitted with on 1/14/22. When the resident arrived at the hospital, there was no discharge paperwork from the facility indicating who the resident was, so she was a [NAME] Doe for a few minutes. The resident was admitted to the hospital and FM A reported she was in a hepatic coma. Review of Hospital Records for R4 with an admitted [DATE] revealed Chief Complaint: Altered Mental Status pt (patient) present to ed (emergency department) c/o (complaints of) not feeling well. Pt coming from (Nursing Facility) and has been unable to take meds for 2 days. unable to take [MEDICATION(S)] . pt normal on 2L NC (nasal cannula) . Pt is confused currently, able to follow commands, pt is normally AXO 4 (alert and oriented x4) per facility. She was discharged to a skilled nursing facility as the caregiver has COVID and to get over the quarantine period, the patient was staying in a nursing facility. Unfortunately the nursing facility did not have any of her medications and therefore has not received any medication since discharge from the hospital on Friday (1/14/22). It is difficult to ascertain the timing of the symptoms, but the patient is altered, able to tell me her name. EKG (electrocardiogram) demonstrates sinus [CONDITION(S)] (fast heart rate) and elevated ammonia . Assessment/Plan: Altered mental status, Liver [CONDITION(S)] secondary to NASH (CMS/HCC), Hyperammonemia (metabolic disturbance characterized by an excess of ammonia in the blood). Review of an Internal Medicine History and Physical document dated 1/16/22 for R4 revealed: Patient presents from (Nursing Home) secondary to alteration of mental status. Reportedly the patient has not received her liver medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] since she was discharged from (Hospital) on 1/14/2022. Unfortunately it appears that as previously mentioned there was an interruption in pharmacological administration of which is the likely culprit as the patient's ammonia level was elevated. Outpatient medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Hepatic [CONDITION(S)]. Review of Hospital Discharge Therapy documentation dated 1/14/22 for R4 revealed she required some help with Activities of Daily Living (ADLs) and contact guard for toileting. At this time she demonstrated generalized weakness in upper extremities as well as requiring some continued assistance with activities of daily living. Review of the Electronic Medical Record revealed some of the Orders for R4 were documented to start on 1/15/22 at 2000 (8:00 p.m.) which included but not limited to [MEDICATION(S)] 550 milligram (mg) tablet twice a day for [CONDITION(S)], [MEDICATION(S)] 25 mg twice a day for high blood pressure, [MEDICATION(S)] 200 mg tablets- give 2 tablets by mouth every morning ad at bedtime for HF (heart failure), [MEDICATION(S)] 40 mg once a day for [CONDITION(S)], [MEDICATION(S)] solution 20 grams twice a day for [CONDITION(S)], and [MEDICATION(S)] 25 mg once a day for high blood pressure. All orders were dated to start on 1/15/22 and 1/16/22. Review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/15/22 doses of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and 3 liters of oxygen via nasal canula are documented as given. There is no documentation or resources available that verified [MEDICATION(S)] was available or on hand to administer to R4. The other two medications are verified they came from the Cubex (on site medication dispenser) log on 1/15/22 at 8:32 p.m. Review of the Cubex transactions list from 1/1/22 to 2/7/22 revealed on 1/15/22 at 8:32 p.m. R4 had [MEDICATION(S)] and [MEDICATION(S)] as the only medications removed from the Cubex by Registered Nurse (RN) C. Review of the EMR (Electronic Medical Record) revealed no documentation of when R4 arrived at the facility, no admission assessment, no documentation the physician was notified, no pharmacy notification of medication needs until 1/15/22, no care plans, no skin assessments, no meals documented, and no ADL's documented. Review of a Late Entry General Progress Note backdated for 1/15/22 at 9:22 a.m. and created on 1/16/22 at 9:28 a.m. for R4 revealed: Resident received morning medications by paper MAR from nurse. Nothing documented in the EMR indicating where these medications came from, if the physician verified orders or is aware of missed doses of medications or if the pharmacy was contacted. Review of a General Progress note dated 1/15/22 at 11:51 p.m. for R4 revealed: Res resting with eyes closed at this time, O2 (oxygen) on as ordered. Meds available in back up pulled and given at (bedtime). Pharmacy contacted and STAT (fast as possible) delivery of all other meds requested. No documentation indicating the physician was notified of missed doses of medications or an assessment of the resident. Review of a General Progress note dated 1/16/22 revealed R4 went to the hospital at approximately 9:20 a.m. Review of a Nursing Skilled Charting document for R4 dated 1/14/22 at 8:40 p.m. and locked on 1/15/22 at 7:45 p.m. revealed the resident was not assessed but her vital signs were documented. Review of the Task List for cares R4 received at the facility from 1/14/22 to 1/16/22 revealed the resident received no assistance with care and no meals were documented. In an interview on 2/3/22 at approximately 8:00 a.m., the Medical Records Clerk (MR) F reported she was caught up on any medical records needing to be scanned into the computer. When questioned if there were any records for R4 not scanned into the computer yet, MR F reported she was pretty sure all the records were in the computer and was going to make sure. About 30 minutes later MR F provided a soft file with a discharge summary/order from the hospital, a handwritten nursing admission assessment and a handwritten skilled charting document for R4. MR F reported the soft file was in the Administrator's office. During an interview on 2/3/22 at 10:22 a.m., RN D reported she took care of R4 on 1/15/22 during the day shift and did not verify the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was so they would not have to come out of the Covid unit to get medications out of the Cubex. In an interview on 2/3/22 at 10:45 a.m. The Director of Nursing (DON) reported RN E who worked the night of 1/14/22 did not do an initial assessment for R4 when she admitted to the facility. The facility was informed by the Attorney Generals (AG) Office on 1/20/22 that there was a concern regarding R4s care and they were instructed to freeze the electronic medical record for R4. So no documentation was to be added, removed, or altered at that point. When they became aware there was a concern with R4's care, the DON reported she had an assessment printed out and had the nurses fill them out by hand as a late entry, then put a file together to be put in the Administrator's office. The DON reported R4 did not get any medications on Friday 1/14/22 but reported RN D did put the medications in the computer that day. The DON reported once they were aware of the allegation, they reported it to the State Agency (SA). The DON confirmed there was a tackle box on the COVID unit with daily medications for the new admissions so they would not have to go out to the Cubex that was off of the COVID unit to get medications for the residents. The DON later provided a list of the medications that were in the tackle box designated to the COVID unit, but the list only included medications that were common to treat COVID, not regular routine medications or any medications that were given to R4. The DON then reported she could not exactly verify where the medications that the nurse signed as given on the hospital discharge orders fro R4 were obtained from. In an interview on 2/3/22 at 11:00, the Nursing Home Administrator (NHA) reported that the AG reached out to them on 1/20/22 and told her of the concern reported to their office, and so the NHA reported to the SA that there is an allegation of neglect. The AG office told them to not put any more documents into the computer for R4 because the records are being sequestered. That is why there was a soft file with handwritten assessments and hospital discharge medication list in her office signed by the nurses who were on duty when R4 was in the building. In an interview on 2/3/22 at 11:43 a.m. the DON still could not verify where the medications that were documented as given to R4 during her stay came from. During an Interview and Record review on 2/7/22 at 11:38 a.m., Pharmacist (PM) B revealed on 1/15/22 a New Admit place holder information was sent to them via EMR at the Nursing Facility. At 8:32 p.m., the nurse called the pharmacy for STAT medications and again at 9:32 p.m. No medications were delivered the night of 1/15/22 to the facility. [MEDICATION(S)] and [MEDICATION(S)] was delivered to the facility on [DATE] at 8:40 a.m. PM B reported they had no record of R4 being charged for any medications received by the facility while she was there. If she did receive medications, she would have been charged for them or should have been. The pharmacy receives the information when a resident gets medications from the Cubex. PM B reported if the facility used the old tackle box approach to providing medications, then there should be a slip that would be written out with the residents' information and sent to the pharmacy for a charge. At the time of this interview, there were no medications charged to the resident or any proof provided to the Pharmacy that this resident received medications to be charged. In an interview on 2/7/22 at 4:15 p.m., Licensed Practical Nurse (LPN) M reported that she did not complete admission documentation for R4 who arrived to the facility on [DATE] because she was already admitting another resident who arrived 10 minutes before R4 arrived at the facility. LPN M reported she worked the day shift that day and started at 6:00 a.m. and worked until 9:30 p.m. to complete her other two admissions and their documentation. LPN M reported RN E worked the second shift this day and reported to him that R4 just recently arrived to the facility. Then about an hour later another new admission came in to the facility. LPN M reported R4 arrived around dinner time, and she just helped get her get settled into the room and made sure she had a meal tray and she was safe. There is no documentation in the EMR that this resident arrived or received services. In an interview on 2/8/22 at 8:49 a.m., RN D reported she did not get information during report the morning of 1/15/22 that R4 was in the facility. She became aware once she passed medications to her roommate and noticed R4 was in the room too. RN D reported her name was not on the report sheet or on the census list. RN D reported she filled out an assessment for R4 after the resident had discharged from the facility and signed it as a late entry for 1/20/22. This document was not part of the residents' medical records and was filled out by hand and put into a soft file in the Administrator's office. RN D reported the assessment she filled out reflected the date of 1/15/22 when she took care of her. RN D reported she only filled out part B and down and someone else completed the top portion. RN D reported that RN E told her he was going to come back to finish the admission documentation for R4 on 1/15/22. RN D reported the admission packet was on the desk for R4 and when she opened it, she was able to see what medications the resident needed. When queried about how R4 got her medications and why they were not charted in the EMR, RN D changed her story from earlier when she reported she got the medications out of the special tackle box that was for the COVID unit. She said she got the medications out of the Cubex. RN D could not explain why the medications she gave R4 did not show up in the Cubex log as a medication dispensed in R4s name. When queried why the medications were not documented in the EMAR, RN D reported is was because the timing would be off for the resident's next dose. So she signed the paper hospital medication discharge orders for R4 that she gave her [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] sulfate, [MEDICATION(S)], [MEDICATION(S)], loratadine, [MEDICATION(S)], oxygen, [MEDICATION(S)], and [MEDICATION(S)] at 9:30 a.m. on 1/15/22. When queried about the [MEDICATION(S)], RN D reported she took the [MEDICATION(S)] from another resident to give to R4 None of these medications showed up as dispensed from the Cubex for R4, no documentation provided by the pharmacy to prove these medications were given, or any other paper trail indicating the resident received these medications from RN D. In an interview on 2/8/22 at 11:48 a.m., the DON reported the nurse did get medications out of the Cubex for R4 and got the [MEDICATION(S)] from another resident by borrowing it. The facility replaced the medication taken from the other resident. The DON reported there should be a record of R4 in the Cubex if medications were taken out of it for her. The DON reported RN D told her 3 times that she pulled R4s medication from the Cubex. The DON did not know why the nurse took [MEDICATION(S)] from another resident when the [MEDICATION(S)] is also in the Cubex. The DON reported she is not involved in the investigation because the facility is trying to protect her since she is a witness per the AG. The DON did not know who the resident was that the medication was taken from. During an interview and record review on 2/9/22 at 11:00 a.m., RN E reported he worked the night of 1/14/22 and R4 was already in the building but he got another admission about an hour later. He introduced himself to the resident and did a quick assessment and made sure she had a call light but did not document anything in the computer. Could not recall if she had her oxygen in place or if she got a meal. Could not recall if he called the physician or left a message for the physician. RN E reported that night was busy and had another resident that occupied much of his time, and it was just a busy night. RN E reported the DON and the NHA had him fill out a handwritten assessment around 1/21/22 for R4 even though the date on one document showed 1/15/22, but verified it was not filled out until long after she was discharged and filled out what he could remember. These documents are not in the EMR and are in the soft file in the NHAs office. RN E reported he did not chart much that night because it was busy. In an interview on 2/15/22 at 12:00 p.m., RN C reported she worked the second shift on 1/15/22 and took care of R4 that day. RN C was not sure if R4 received medications earlier that day but was informed that the resident's daughter had called with concerns that R4 had not received any medication since she was admitted to the facility on [DATE]. RN C reviewed the chart and it looked like she was admitted that day (1/15/22) and was told that RN E was going to complete the admission documentation for the resident. RN E was there this night and thought he was completing the paperwork. RN C reported if the medications on the EMAR were documented as given, then she gave the medications. The medications documented are [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Two of the medications were shown to be dispensed from the Cubex but not the [MEDICATION(S)]. No other medications were documented as given and no documentation indicating the physician was notified. In an interview on 2/16/22 at 9:22 a.m., MDS Coordinator LPN N reported she completed the MDS assessment, and another Registered Nurse signed off on it. She reported she gathers information about the residents based on the information put into the computer. She reported the census line on this day still shows R4 admitted to the facility on [DATE] and not 1/14/22. LPN N reported she utilizes the admission nursing assessment as well to assist in filling out the MDS assessment while other disciplines will fill out their portions of the assessments. LPN N reported section A and G are a couple of the areas she fills out among other sections, but the social workers fill out section C for cognition. Review of several witness statements provided by the facility revealed a lack of documentation in R4's EMR backing up services and goods provided to the resident. There is no paper trail of events, assessments, physician contact, pharmacy contact, medication administration, pharmacy receipt and/or charges for medications or full physical assessment while R4 resided in the building. Resident #10 (R10) Review of the MDS dated [DATE] for R10 revealed she admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She is severely cognitively impaired and requires extensive assistance of 2 staff for ADL's. Review of the January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure ulcer dressing changes to the sacral wound was to be done twice a day and discontinued on 1/13/22, and missed 9 treatments. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order for a sacral wound dressing to be cleansed with Dakins solution, pack wound bed with 4x4s, apply periguard, xeroform, and cover with an ABD dressing started 1/13/22 missed 6 treatments. An order to check the PEG tube placement missed 12 verifications. Orders to monitor and maintain the foley catheter missed 12 treatments. No orders to change foley catheter. Order for Prevalon boots to the bilateral lower extremities twice a day missed 10 treatments and no follow up documentation or physician notification noted. Review of an Incident Report titled Medication Error for R10 dated 1/7/22 revealed : Medication not given per scheduled date and time 1/7/2021 @ 0730: [MEDICATION(S)] 5 mg, [MEDICATION(S)] DR 30 mg, Magnesium Ox 400 mg, Oxybutinin 5 mg, Vitamin D3, Zinc [MEDICATION(S)] 50 mg. 1/5/22 at 2000: [MEDICATION(S)] 5mg. No statements obtained from the incident from staff. No witnesses found. A copy of the packets these medications were attached to the report. The MAR for January 2022 revealed the medications were given. No further details to the investigation provided and the NHA reported this was all there was. In an interview on 2/14/22 at 10:25 a.m., the DON reported a State Agency staff member came to the facility to fill in for staffing. The facility found two packets of medications at the bottom of the medication cart that were not given to R10. (Indicated they found more residents that did not receive medications.) The facility tried to call the agency nurses who did not call back. So they assessed the resident and completed an incident form. During an observation and an interview on 2/2/22 at 2:05 p.m., R10 was in her room and the CNA finished cleaning her up and said her brief was soaked. Her dressing on her sacrum was heavily soaked with urine and barely attached to the skin. At this time LPN G entered the room to complete a dressing change. CNA O reported the therapist changed the residents brief about a half hour before lunch and alerted the nurse the foley catheter may not be working which is why her brief was soaked. The tubing of the catheter had cottage cheese like debri floating in the tubing. In an interview on 2/2/22 at 2:40 p.m., LPN G reported she had about 27 residents this day to care for and remembered the therapist came to tell her they changed the resident and reported the catheter may not be working but she did not have a chance to check on the residents catheter. Review of a Nurse Practitioner Progress Note dated 1/31/22 revealed: Patient seen for evaluation and management of multiple complex chronic medical problems that require frequent monitoring to maintain stability and prevent further decline. (R10) seen today for evaluation of Sacral /coccyx ulcer. Patient is bed bound dependent on staff for all ADL. She has a chronic sacral wound that is not improving as expected, although it has been without deterioration and infection.

This citation pertains to intake M 5723 and M 6630. Based on interview and record review, the facility failed to follow policies and procedures for neglect, admissions, charting, and medications, for 2 (Resident #4 and Resident #10) resulting in gross negligence of residents not documented as receiving medications, treatments, services including Activities of Daily Living (ADLs) and one resident readmitted back to the hospital 2 days after admission. Findings include: Review of a Policy titled Abuse and Neglect last revised on 10/14/20 revealed: The purpose of this policy/procedure is to articulate standards and/or processes for proper screening, training, prevention, identification, investigation protection and reporting relative to any form of abuse. It is the policy of this facility to provide professional care and services in an environment that is free from abuse, neglect, misappropriation of resident property, exploitation, and corporal punishment. Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of a policy titled Admissions adopted 7/11/18 revealed: It is the policy of this facility to have well defined guidelines for processing the Resident's entry into the nursing facility and that the Resident's rights are protected under federal and state laws. Licensed Nurse Procedure: .1. Welcome Resident and family to Facility and inquire about any immediate special needs. 2. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders. 3. Do a complete assessment of body systems and complete admission assessment and nursing notes. Include a through skin check. 4. Inform physician of admission and verify transfer and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order medications from pharmacy. 6. Confirm diet order, complete diet slip and sent to dietary.9. Initiate Resident Care Plan. 10. Communicate immediate Resident special needs to CNA's, dietary, therapies, social services, ect. 11. Note and initiate physician order. Initiate mediations and treatment sheets.13. Note advance-directive information. 14. Ensure that admission forms are completed per policy and baseline plan of care initiated. Review of a policy titled Charting and documentation adopted 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of a Guidelines for Medication Orders, Policy 2.1 revealed: Medications are dispensed by the Pharmacy only upon receipt of a clear, complete order, signed by an authorized licensed prescriber. facilities using an electronic order entry system and/or eMAR should refer to specific system. Resident #4 (R4) Review of a Face Sheet revealed R4 is an [AGE] year old female admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Discharge assessment dated [DATE] revealed R4 admitted to the facility on [DATE] and discharged on [DATE]. Section A2300 indicates R4 MDS Assessment Reference date is 1/16/22 and the resident was moderately cognitively impaired. In an interview on 2/1/22 at 1:20 p.m., Family Member (FM) A reported her mother (R4) admitted to the facility from the hospital on 1/14/22 around 3:30 p.m. and did not receive medications, oxygen, food, or water while at the facility. FM A reported she dropped off clothing for her mother around that time. The resident was cognitively intact until this incident. R4 was then admitted back to the hospital on 1/16/22. On 1/15/22 FM A reported she called the facility and complained to the nurse that her mother has not received any food, medications, or water and the facility did not connect R4 to 3 liters of oxygen. FM A reported would call the facility and they would put her on hold and then hang up. FM A reported she talked to the nurse on 1/16/22 and insisted her mother (R4) goes back to the hospital after talking to R4 on the phone and noticed a change in her cognitive condition. The staff was reluctant to send R4 to the hospital and FM A reported she argued with the staff and insisted again that R4 goes to the hospital. They finally transferred the resident to the hospital and when she arrived, she was wearing the same clothes that she was admitted with on 1/14/22. When the resident arrived at the hospital, there was no discharge paperwork from the facility indicating who the resident was, so she was a [NAME] Doe for a few minutes. The resident was admitted to the hospital and FM A reported she was in a hepatic coma. Review of Hospital Records for R4 with an admitted [DATE] revealed Chief Complaint: Altered Mental Status pt (patient) present to ed (emergency department) c/o (complaints of) not feeling well. Pt coming from (Nursing Facility) and has been unable to take meds for 2 days. unable to take [MEDICATION(S)] . pt normal on 2L NC (nasal cannula) . Pt is confused currently, able to follow commands, pt is normally AXO 4 (alert and oriented x4) per facility. She was discharged to a skilled nursing facility as the caregiver has COVID and to get over the quarantine period, the patient was staying in a nursing facility. Unfortunately the nursing facility did not have any of her medications and therefore has not received any medication since discharge from the hospital on Friday (1/14/22). It is difficult to ascertain the timing of the symptoms, but the patient is altered, able to tell me her name. EKG (electrocardiogram) demonstrates sinus [CONDITION(S)] (fast heart rate) and elevated ammonia . Assessment/Plan: Altered mental status, Liver [CONDITION(S)] secondary to NASH (CMS/HCC), Hyperammonemia (metabolic disturbance characterized by an excess of ammonia in the blood). Review of an Internal Medicine History and Physical document dated 1/16/22 for R4 revealed: Patient presents from (Nursing Home) secondary to alteration of mental status. Reportedly the patient has not received her liver medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] since she was discharged from (Hospital) on 1/14/2022. Unfortunately it appears that as previously mentioned there was an interruption in pharmacological administration of which is the likely culprit as the patient's ammonia level was elevated. Outpatient medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Hepatic [CONDITION(S)]. Review of Hospital Discharge Therapy documentation dated 1/14/22 for R4 revealed she required some help with Activities of Daily Living (ADLs) and contact guard for toileting. At this time she demonstrated generalized weakness in upper extremities as well as requiring some continued assistance with activities of daily living. Review of the Electronic Medical Record revealed some of the Orders for R4 were documented to start on 1/15/22 at 2000 (8:00 p.m.) which included but not limited to [MEDICATION(S)] 550 milligram (mg) tablet twice a day for [CONDITION(S)], [MEDICATION(S)] 25 mg twice a day for high blood pressure, [MEDICATION(S)] 200 mg tablets- give 2 tablets by mouth every morning ad at bedtime for HF (heart failure), [MEDICATION(S)] 40 mg once a day for [CONDITION(S)], [MEDICATION(S)] solution 20 grams twice a day for [CONDITION(S)], and [MEDICATION(S)] 25 mg once a day for high blood pressure. All orders were dated to start on 1/15/22 and 1/16/22. Review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/15/22 doses of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and 3 liters of oxygen via nasal canula are documented as given. There is no documentation or resources available that verified [MEDICATION(S)] was available or on hand to administer to R4. The other two medications are verified they came from the Cubex (on site medication dispenser) log on 1/15/22 at 8:32 p.m. Review of the Cubex transactions list from 1/1/22 to 2/7/22 revealed on 1/15/22 at 8:32 p.m. R4 had [MEDICATION(S)] and [MEDICATION(S)] as the only medications removed from the Cubex by Registered Nurse (RN) C. Review of the EMR (Electronic Medical Record) revealed no documentation of when R4 arrived at the facility, no admission assessment, no documentation the physician was notified, no pharmacy notification of medication needs until 1/15/22, no care plans, no skin assessments, no meals documented, and no ADL's documented. Review of a Late Entry General Progress Note backdated for 1/15/22 at 9:22 a.m. and created on 1/16/22 at 9:28 a.m. for R4 revealed: Resident received morning medications by paper MAR from nurse. Nothing documented in the EMR indicating where these medications came from, if the physician verified orders or is aware of missed doses of medications or if the pharmacy was contacted. Review of a General Progress note dated 1/15/22 at 11:51 p.m. for R4 revealed: Res resting with eyes closed at this time, O2 (oxygen) on as ordered. Meds available in back up pulled and given at (bedtime). Pharmacy contacted and STAT (fast as possible) delivery of all other meds requested. No documentation indicating the physician was notified of missed doses of medications or an assessment of the resident. Review of a General Progress note dated 1/16/22 revealed R4 went to the hospital at approximately 9:20 a.m. Review of a Nursing Skilled Charting document for R4 dated 1/14/22 at 8:40 p.m. and locked on 1/15/22 at 7:45 p.m. revealed the resident was not assessed but her vital signs were documented. Review of the Task List for cares R4 received at the facility from 1/14/22 to 1/16/22 revealed the resident received no assistance with care and no meals were documented. In an interview on 2/3/22 at approximately 8:00 a.m., the Medical Records Clerk (MR) F reported she was caught up on any medical records needing to be scanned into the computer. When questioned if there were any records for R4 not scanned into the computer yet, MR F reported she was pretty sure all the records were in the computer and was going to make sure. About 30 minutes later MR F provided a soft file with a discharge summary/order from the hospital, a handwritten nursing admission assessment and a handwritten skilled charting document for R4. MR F reported the soft file was in the Administrator's office. During an interview on 2/3/22 at 10:22 a.m., RN D reported she took care of R4 on 1/15/22 during the day shift and did not verify the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was so they would not have to come out of the Covid unit to get medications out of the Cubex. In an interview on 2/3/22 at 10:45 a.m. The Director of Nursing (DON) reported RN E who worked the night of 1/14/22 did not do an initial assessment for R4 when she admitted to the facility. The facility was informed by the Attorney Generals (AG) Office on 1/20/22 that there was a concern regarding R4s care and they were instructed to freeze the electronic medical record for R4. So no documentation was to be added, removed, or altered at that point. When they became aware there was a concern with R4's care, the DON reported she had an assessment printed out and had the nurses fill them out by hand as a late entry, then put a file together to be put in the Administrator's office. The DON reported R4 did not get any medications on Friday 1/14/22 but reported RN D did put the medications in the computer that day. The DON reported once they were aware of the allegation, they reported it to the State Agency (SA). The DON confirmed there was a tackle box on the COVID unit with daily medications for the new admissions so they would not have to go out to the Cubex that was off of the COVID unit to get medications for the residents. The DON later provided a list of the medications that were in the tackle box designated to the COVID unit, but the list only included medications that were common to treat COVID, not regular routine medications or any medications that were given to R4. The DON then reported she could not exactly verify where the medications that the nurse signed as given on the hospital discharge orders fro R4 were obtained from. In an interview on 2/3/22 at 11:00, the Nursing Home Administrator (NHA) reported that the AG reached out to them on 1/20/22 and told her of the concern reported to their office, and so the NHA reported to the SA that there is an allegation of neglect. The AG office told them to not put any more documents into the computer for R4 because the records are being sequestered. That is why there was a soft file with handwritten assessments and hospital discharge medication list in her office signed by the nurses who were on duty when R4 was in the building. In an interview on 2/3/22 at 11:43 a.m. the DON still could not verify where the medications that were documented as given to R4 during her stay came from. During an Interview and Record review on 2/7/22 at 11:38 a.m., Pharmacist (PM) B revealed on 1/15/22 a New Admit place holder information was sent to them via EMR at the Nursing Facility. At 8:32 p.m., the nurse called the pharmacy for STAT medications and again at 9:32 p.m. No medications were delivered the night of 1/15/22 to the facility. [MEDICATION(S)] and [MEDICATION(S)] was delivered to the facility on [DATE] at 8:40 a.m. PM B reported they had no record of R4 being charged for any medications received by the facility while she was there. If she did receive medications, she would have been charged for them or should have been. The pharmacy receives the information when a resident gets medications from the Cubex. PM B reported if the facility used the old tackle box approach to providing medications, then there should be a slip that would be written out with the residents' information and sent to the pharmacy for a charge. At the time of this interview, there were no medications charged to the resident or any proof provided to the Pharmacy that this resident received medications to be charged. In an interview on 2/7/22 at 4:15 p.m., Licensed Practical Nurse (LPN) M reported that she did not complete admission documentation for R4 who arrived to the facility on [DATE] because she was already admitting another resident who arrived 10 minutes before R4 arrived at the facility. LPN M reported she worked the day shift that day and started at 6:00 a.m. and worked until 9:30 p.m. to complete her other two admissions and their documentation. LPN M reported RN E worked the second shift this day and reported to him that R4 just recently arrived to the facility. Then about an hour later another new admission came in to the facility. LPN M reported R4 arrived around dinner time, and she just helped get her get settled into the room and made sure she had a meal tray and she was safe. There is no documentation in the EMR that this resident arrived or received services. In an interview on 2/8/22 at 8:49 a.m., RN D reported she did not get information during report the morning of 1/15/22 that R4 was in the facility. She became aware once she passed medications to her roommate and noticed R4 was in the room too. RN D reported her name was not on the report sheet or on the census list. RN D reported she filled out an assessment for R4 after the resident had discharged from the facility and signed it as a late entry for 1/20/22. This document was not part of the residents' medical records and was filled out by hand and put into a soft file in the Administrator's office. RN D reported the assessment she filled out reflected the date of 1/15/22 when she took care of her. RN D reported she only filled out part B and down and someone else completed the top portion. RN D reported that RN E told her he was going to come back to finish the admission documentation for R4 on 1/15/22. RN D reported the admission packet was on the desk for R4 and when she opened it, she was able to see what medications the resident needed. When queried about how R4 got her medications and why they were not charted in the EMR, RN D changed her story from earlier when she reported she got the medications out of the special tackle box that was for the COVID unit. She said she got the medications out of the Cubex. RN D could not explain why the medications she gave R4 did not show up in the Cubex log as a medication dispensed in R4s name. When queried why the medications were not documented in the EMAR, RN D reported is was because the timing would be off for the resident's next dose. So she signed the paper hospital medication discharge orders for R4 that she gave her [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] sulfate, [MEDICATION(S)], [MEDICATION(S)], loratadine, [MEDICATION(S)], oxygen, [MEDICATION(S)], and [MEDICATION(S)] at 9:30 a.m. on 1/15/22. When queried about the [MEDICATION(S)], RN D reported she took the [MEDICATION(S)] from another resident to give to R4 None of these medications showed up as dispensed from the Cubex for R4, no documentation provided by the pharmacy to prove these medications were given, or any other paper trail indicating the resident received these medications from RN D. In an interview on 2/8/22 at 11:48 a.m., the DON reported the nurse did get medications out of the Cubex for R4 and got the [MEDICATION(S)] from another resident by borrowing it. The facility replaced the medication taken from the other resident. The DON reported there should be a record of R4 in the Cubex if medications were taken out of it for her. The DON reported RN D told her 3 times that she pulled R4s medication from the Cubex. The DON did not know why the nurse took [MEDICATION(S)] from another resident when the [MEDICATION(S)] is also in the Cubex. The DON reported she is not involved in the investigation because the facility is trying to protect her since she is a witness per the AG. The DON did not know who the resident was that the medication was taken from. During an interview and record review on 2/9/22 at 11:00 a.m., RN E reported he worked the night of 1/14/22 and R4 was already in the building but he got another admission about an hour later. He introduced himself to the resident and did a quick assessment and made sure she had a call light but did not document anything in the computer. Could not recall if she had her oxygen in place or if she got a meal. Could not recall if he called the physician or left a message for the physician. RN E reported that night was busy and had another resident that occupied much of his time, and it was just a busy night. RN E reported the DON and the NHA had him fill out a handwritten assessment around 1/21/22 for R4 even though the date on one document showed 1/15/22, but verified it was not filled out until long after she was discharged and filled out what he could remember. These documents are not in the EMR and are in the soft file in the NHAs office. RN E reported he did not chart much that night because it was busy. In an interview on 2/15/22 at 12:00 p.m., RN C reported she worked the second shift on 1/15/22 and took care of R4 that day. RN C was not sure if R4 received medications earlier that day but was informed that the resident's daughter had called with concerns that R4 had not received any medication since she was admitted to the facility on [DATE]. RN C reviewed the chart and it looked like she was admitted that day (1/15/22) and was told that RN E was going to complete the admission documentation for the resident. RN E was there this night and thought he was completing the paperwork. RN C reported if the medications on the EMAR were documented as given, then she gave the medications. The medications documented are [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Two of the medications were shown to be dispensed from the Cubex but not the [MEDICATION(S)]. No other medications were documented as given and no documentation indicating the physician was notified. In an interview on 2/16/22 at 9:22 a.m., MDS Coordinator LPN N reported she completed the MDS assessment, and another Registered Nurse signed off on it. She reported she gathers information about the residents based on the information put into the computer. She reported the census line on this day still shows R4 admitted to the facility on [DATE] and not 1/14/22. LPN N reported she utilizes the admission nursing assessment as well to assist in filling out the MDS assessment while other disciplines will fill out their portions of the assessments. LPN N reported section A and G are a couple of the areas she fills out among other sections, but the social workers fill out section C for cognition. Review of several witness statements provided by the facility revealed a lack of documentation in R4's EMR backing up services and goods provided to the resident. There is no paper trail of events, assessments, physician contact, pharmacy contact, medication administration, pharmacy receipt and/or charges for medications or full physical assessment while R4 resided in the building.

This citation pertains to intake M 5723 and M 630. The facility failed to follow policies and procedures for a new admission and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of a policy titled Admissions adopted 7/11/18 revealed: It is the policy of this facility to have well defined guidelines for processing the Resident's entry into the nursing facility and that the Resident's rights are protected under federal and state laws. Licensed Nurse Procedure: .1. Welcome Resident and family to Facility and inquire about any immediate special needs. 2. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders. 3. Do a complete assessment of body systems and complete admission assessment and nursing notes. Include a through skin check. 4. Inform physician of admission and verify transfer and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order medications from pharmacy. 6. Confirm diet order, complete diet slip and sent to dietary.9. Initiate Resident Care Plan. 10. Communicate immediate Resident special needs to CNA's, dietary, therapies, social services, ect. 11. Note and initiate physician order. Initiate mediations and treatment sheets.13. Note advance-directive information. 14. Ensure that admission forms are completed per policy and baseline plan of care initiated. Review of a policy titled Charting and documentation adopted 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of a Guidelines for Medication Orders, Policy 2.1 revealed: Medications are dispensed by the Pharmacy only upon receipt of a clear, complete order, signed by an authorized licensed prescriber. facilities using an electronic order entry system and/or eMAR should refer to specific system. Resident #4 (R4) Review of a Face Sheet revealed R4 is an [AGE] year old female admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Discharge assessment dated [DATE] revealed R4 admitted to the facility on [DATE] and discharged on [DATE]. Section A2300 indicates R4 MDS Assessment Reference date is 1/16/22 and the resident was moderately cognitively impaired. In an interview on 2/1/22 at 1:20 p.m., Family Member (FM) A reported her mother (R4) admitted to the facility from the hospital on 1/14/22 around 3:30 p.m. and did not receive medications, oxygen, food, or water while at the facility. FM A reported she dropped off clothing for her mother around that time. The resident was cognitively intact until this incident. R4 was then admitted back to the hospital on 1/16/22. On 1/15/22 FM A reported she called the facility and complained to the nurse that her mother has not received any food, medications, or water and the facility did not connect R4 to 3 liters of oxygen. FM A reported would call the facility and they would put her on hold and then hang up. FM A reported she talked to the nurse on 1/16/22 and insisted her mother (R4) goes back to the hospital after talking to R4 on the phone and noticed a change in her cognitive condition. The staff was reluctant to send R4 to the hospital and FM A reported she argued with the staff and insisted again that R4 goes to the hospital. They finally transferred the resident to the hospital and when she arrived, she was wearing the same clothes that she was admitted with on 1/14/22. When the resident arrived at the hospital, there was no discharge paperwork from the facility indicating who the resident was, so she was a [NAME] Doe for a few minutes. The resident was admitted to the hospital and FM A reported she was in a hepatic coma. Review of Hospital Records for R4 with an admitted [DATE] revealed Chief Complaint: Altered Mental Status pt (patient) present to ed (emergency department) c/o (complaints of) not feeling well. Pt coming from (Nursing Facility) and has been unable to take meds for 2 days. unable to take [MEDICATION(S)] . pt normal on 2L NC (nasal cannula) . Pt is confused currently, able to follow commands, pt is normally AXO 4 (alert and oriented x4) per facility. She was discharged to a skilled nursing facility as the caregiver has COVID and to get over the quarantine period, the patient was staying in a nursing facility. Unfortunately the nursing facility did not have any of her medications and therefore has not received any medication since discharge from the hospital on Friday (1/14/22). It is difficult to ascertain the timing of the symptoms, but the patient is altered, able to tell me her name. EKG (electrocardiogram) demonstrates sinus [CONDITION(S)] (fast heart rate) and elevated ammonia . Assessment/Plan: Altered mental status, Liver [CONDITION(S)] secondary to NASH (CMS/HCC), Hyperammonemia (metabolic disturbance characterized by an excess of ammonia in the blood). Review of an Internal Medicine History and Physical document dated 1/16/22 for R4 revealed: Patient presents from (Nursing Home) secondary to alteration of mental status. Reportedly the patient has not received her liver medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] since she was discharged from (Hospital) on 1/14/2022. Unfortunately it appears that as previously mentioned there was an interruption in pharmacological administration of which is the likely culprit as the patient's ammonia level was elevated. Outpatient medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Hepatic [CONDITION(S)]. Review of Hospital Discharge Therapy documentation dated 1/14/22 for R4 revealed she required some help with Activities of Daily Living (ADLs) and contact guard for toileting. At this time she demonstrated generalized weakness in upper extremities as well as requiring some continued assistance with activities of daily living. Review of the Electronic Medical Record revealed some of the Orders for R4 were documented to start on 1/15/22 at 2000 (8:00 p.m.) which included but not limited to [MEDICATION(S)] 550 milligram (mg) tablet twice a day for [CONDITION(S)], [MEDICATION(S)] 25 mg twice a day for high blood pressure, [MEDICATION(S)] 200 mg tablets- give 2 tablets by mouth every morning ad at bedtime for HF (heart failure), [MEDICATION(S)] 40 mg once a day for [CONDITION(S)], [MEDICATION(S)] solution 20 grams twice a day for [CONDITION(S)], and [MEDICATION(S)] 25 mg once a day for high blood pressure. All orders were dated to start on 1/15/22 and 1/16/22. Review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/15/22 doses of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and 3 liters of oxygen via nasal canula are documented as given. There is no documentation or resources available that verified [MEDICATION(S)] was available or on hand to administer to R4. The other two medications are verified they came from the Cubex (on site medication dispenser) log on 1/15/22 at 8:32 p.m. Review of the Cubex transactions list from 1/1/22 to 2/7/22 revealed on 1/15/22 at 8:32 p.m. R4 had [MEDICATION(S)] and [MEDICATION(S)] as the only medications removed from the Cubex by Registered Nurse (RN) C. Review of the EMR (Electronic Medical Record) revealed no documentation of when R4 arrived at the facility, no admission assessment, no documentation the physician was notified, no pharmacy notification of medication needs until 1/15/22, no care plans, no skin assessments, no meals documented, and no ADL's documented. Review of a Late Entry General Progress Note backdated for 1/15/22 at 9:22 a.m. and created on 1/16/22 at 9:28 a.m. for R4 revealed: Resident received morning medications by paper MAR from nurse. Nothing documented in the EMR indicating where these medications came from, if the physician verified orders or is aware of missed doses of medications or if the pharmacy was contacted. Review of a General Progress note dated 1/15/22 at 11:51 p.m. for R4 revealed: Res resting with eyes closed at this time, O2 (oxygen) on as ordered. Meds available in back up pulled and given at (bedtime). Pharmacy contacted and STAT (fast as possible) delivery of all other meds requested. No documentation indicating the physician was notified of missed doses of medications or an assessment of the resident. Review of a General Progress note dated 1/16/22 revealed R4 went to the hospital at approximately 9:20 a.m. Review of a Nursing Skilled Charting document for R4 dated 1/14/22 at 8:40 p.m. and locked on 1/15/22 at 7:45 p.m. revealed the resident was not assessed but her vital signs were documented. Review of the Task List for cares R4 received at the facility from 1/14/22 to 1/16/22 revealed the resident received no assistance with care and no meals were documented. In an interview on 2/3/22 at approximately 8:00 a.m., the Medical Records Clerk (MR) F reported she was caught up on any medical records needing to be scanned into the computer. When questioned if there were any records for R4 not scanned into the computer yet, MR F reported she was pretty sure all the records were in the computer and was going to make sure. About 30 minutes later MR F provided a soft file with a discharge summary/order from the hospital, a handwritten nursing admission assessment and a handwritten skilled charting document for R4. MR F reported the soft file was in the Administrator's office. During an interview on 2/3/22 at 10:22 a.m., RN D reported she took care of R4 on 1/15/22 during the day shift and did not verify the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was so they would not have to come out of the Covid unit to get medications out of the Cubex. In an interview on 2/3/22 at 10:45 a.m. The Director of Nursing (DON) reported RN E who worked the night of 1/14/22 did not do an initial assessment for R4 when she admitted to the facility. The facility was informed by the Attorney Generals (AG) Office on 1/20/22 that there was a concern regarding R4s care and they were instructed to freeze the electronic medical record for R4. So no documentation was to be added, removed, or altered at that point. When they became aware there was a concern with R4's care, the DON reported she had an assessment printed out and had the nurses fill them out by hand as a late entry, then put a file together to be put in the Administrator's office. The DON reported R4 did not get any medications on Friday 1/14/22 but reported RN D did put the medications in the computer that day. The DON reported once they were aware of the allegation, they reported it to the State Agency (SA). The DON confirmed there was a tackle box on the COVID unit with daily medications for the new admissions so they would not have to go out to the Cubex that was off of the COVID unit to get medications for the residents. The DON later provided a list of the medications that were in the tackle box designated to the COVID unit, but the list only included medications that were common to treat COVID, not regular routine medications or any medications that were given to R4. The DON then reported she could not exactly verify where the medications that the nurse signed as given on the hospital discharge orders fro R4 were obtained from. In an interview on 2/3/22 at 11:00, the Nursing Home Administrator (NHA) reported that the AG reached out to them on 1/20/22 and told her of the concern reported to their office, and so the NHA reported to the SA that there is an allegation of neglect. The AG office told them to not put any more documents into the computer for R4 because the records are being sequestered. That is why there was a soft file with handwritten assessments and hospital discharge medication list in her office signed by the nurses who were on duty when R4 was in the building. In an interview on 2/3/22 at 11:43 a.m. the DON still could not verify where the medications that were documented as given to R4 during her stay came from. During an Interview and Record review on 2/7/22 at 11:38 a.m., Pharmacist (PM) B revealed on 1/15/22 a New Admit place holder information was sent to them via EMR at the Nursing Facility. At 8:32 p.m., the nurse called the pharmacy for STAT medications and again at 9:32 p.m. No medications were delivered the night of 1/15/22 to the facility. [MEDICATION(S)] and [MEDICATION(S)] was delivered to the facility on [DATE] at 8:40 a.m. PM B reported they had no record of R4 being charged for any medications received by the facility while she was there. If she did receive medications, she would have been charged for them or should have been. The pharmacy receives the information when a resident gets medications from the Cubex. PM B reported if the facility used the old tackle box approach to providing medications, then there should be a slip that would be written out with the residents' information and sent to the pharmacy for a charge. At the time of this interview, there were no medications charged to the resident or any proof provided to the Pharmacy that this resident received medications to be charged. In an interview on 2/7/22 at 4:15 p.m., Licensed Practical Nurse (LPN) M reported that she did not complete admission documentation for R4 who arrived to the facility on [DATE] because she was already admitting another resident who arrived 10 minutes before R4 arrived at the facility. LPN M reported she worked the day shift that day and started at 6:00 a.m. and worked until 9:30 p.m. to complete her other two admissions and their documentation. LPN M reported RN E worked the second shift this day and reported to him that R4 just recently arrived to the facility. Then about an hour later another new admission came in to the facility. LPN M reported R4 arrived around dinner time, and she just helped get her get settled into the room and made sure she had a meal tray and she was safe. There is no documentation in the EMR that this resident arrived or received services. In an interview on 2/8/22 at 8:49 a.m., RN D reported she did not get information during report the morning of 1/15/22 that R4 was in the facility. She became aware once she passed medications to her roommate and noticed R4 was in the room too. RN D reported her name was not on the report sheet or on the census list. RN D reported she filled out an assessment for R4 after the resident had discharged from the facility and signed it as a late entry for 1/20/22. This document was not part of the residents' medical records and was filled out by hand and put into a soft file in the Administrator's office. RN D reported the assessment she filled out reflected the date of 1/15/22 when she took care of her. RN D reported she only filled out part B and down and someone else completed the top portion. RN D reported that RN E told her he was going to come back to finish the admission documentation for R4 on 1/15/22. RN D reported the admission packet was on the desk for R4 and when she opened it, she was able to see what medications the resident needed. When queried about how R4 got her medications and why they were not charted in the EMR, RN D changed her story from earlier when she reported she got the medications out of the special tackle box that was for the COVID unit. She said she got the medications out of the Cubex. RN D could not explain why the medications she gave R4 did not show up in the Cubex log as a medication dispensed in R4s name. When queried why the medications were not documented in the EMAR, RN D reported is was because the timing would be off for the resident's next dose. So she signed the paper hospital medication discharge orders for R4 that she gave her [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] sulfate, [MEDICATION(S)], [MEDICATION(S)], loratadine, [MEDICATION(S)], oxygen, [MEDICATION(S)], and [MEDICATION(S)] at 9:30 a.m. on 1/15/22. When queried about the [MEDICATION(S)], RN D reported she took the [MEDICATION(S)] from another resident to give to R4 None of these medications showed up as dispensed from the Cubex for R4, no documentation provided by the pharmacy to prove these medications were given, or any other paper trail indicating the resident received these medications from RN D. In an interview on 2/8/22 at 11:48 a.m., the DON reported the nurse did get medications out of the Cubex for R4 and got the [MEDICATION(S)] from another resident by borrowing it. The facility replaced the medication taken from the other resident. The DON reported there should be a record of R4 in the Cubex if medications were taken out of it for her. The DON reported RN D told her 3 times that she pulled R4s medication from the Cubex. The DON did not know why the nurse took [MEDICATION(S)] from another resident when the [MEDICATION(S)] is also in the Cubex. The DON reported she is not involved in the investigation because the facility is trying to protect her since she is a witness per the AG. The DON did not know who the resident was that the medication was taken from. During an interview and record review on 2/9/22 at 11:00 a.m., RN E reported he worked the night of 1/14/22 and R4 was already in the building but he got another admission about an hour later. He introduced himself to the resident and did a quick assessment and made sure she had a call light but did not document anything in the computer. Could not recall if she had her oxygen in place or if she got a meal. Could not recall if he called the physician or left a message for the physician. RN E reported that night was busy and had another resident that occupied much of his time, and it was just a busy night. RN E reported the DON and the NHA had him fill out a handwritten assessment around 1/21/22 for R4 even though the date on one document showed 1/15/22, but verified it was not filled out until long after she was discharged and filled out what he could remember. These documents are not in the EMR and are in the soft file in the NHAs office. RN E reported he did not chart much that night because it was busy. In an interview on 2/15/22 at 12:00 p.m., RN C reported she worked the second shift on 1/15/22 and took care of R4 that day. RN C was not sure if R4 received medications earlier that day but was informed that the resident's daughter had called with concerns that R4 had not received any medication since she was admitted to the facility on [DATE]. RN C reviewed the chart and it looked like she was admitted that day (1/15/22) and was told that RN E was going to complete the admission documentation for the resident. RN E was there this night and thought he was completing the paperwork. RN C reported if the medications on the EMAR were documented as given, then she gave the medications. The medications documented are [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Two of the medications were shown to be dispensed from the Cubex but not the [MEDICATION(S)]. No other medications were documented as given and no documentation indicating the physician was notified. In an interview on 2/16/22 at 9:22 a.m., MDS Coordinator LPN N reported she completed the MDS assessment, and another Registered Nurse signed off on it. She reported she gathers information about the residents based on the information put into the computer. She reported the census line on this day still shows R4 admitted to the facility on [DATE] and not 1/14/22. LPN N reported she utilizes the admission nursing assessment as well to assist in filling out the MDS assessment while other disciplines will fill out their portions of the assessments. LPN N reported section A and G are a couple of the areas she fills out among other sections, but the social workers fill out section C for cognition. Review of several witness statements provided by the facility revealed a lack of documentation in R4's EMR backing up services and goods provided to the resident. There is no paper trail of events, assessments, physician contact, pharmacy contact, medication administration, pharmacy receipt and/or charges for medications or full physical assessment while R4 resided in the building.

This citation pertains to intake M 5723 and M 630. Based on observation, interview and record review, the facility failed to follow policies and procedures for medication orders, obtain physician orders timely, provide and administer medications, and ensure a sufficient process for ordering medications to meet the needs for 1 (Resident #4), resulting in the Resident #4's admission to the hospital. Findings include: Review of a Guidelines for Medication Orders, Policy 2.1 revealed: Medications are dispensed by the Pharmacy only upon receipt of a clear, complete order, signed by an authorized licensed prescriber. facilities using an electronic order entry system and/or eMAR should refer to specific system. Review of a Medication Ordering and Receipt Policy 3.4-Delivery and Receipt of Medications revealed: The pharmacy will deliver Cycle Fill medications on a predetermined schedule. Nursing staff at the facility are responsible for verifying the accuracy of the delivery and notifying the pharmacy of any discrepancies within 4 hours of delivery.2. Orders received by the pharmacy before the designated fax cut-off time will be sent on the Facility's regular scheduled delivery. 3. Orders received by the pharmacy after the designated fax cut-off time and required the same night, must be called to the pharmacy and requested for same day delivery. Review of a policy titled Admissions adopted 7/11/18 revealed: It is the policy of this facility to have well defined guidelines for processing the Resident's entry into the nursing facility and that the Resident's rights are protected under federal and state laws. 2. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders. 5. Order medications from pharmacy. 6. Confirm diet order, complete diet slip and sent to dietary. 11. Note and initiate physician order. Initiate mediations and treatment sheets. Review of a policy titled Charting and documentation adopted 7/11/18 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #4 (R4) Review of a Face Sheet revealed R4 is an [AGE] year old female admitted to the facility on [DATE] with pertinent diagnoses of cardiac arrythmia, acute and chronic respiratory disease, and heart failure. Review of the Minimum Data Set (MDS) Discharge assessment dated [DATE] revealed R4 admitted to the facility on [DATE] and discharged on [DATE]. Section A2300 indicates R4 MDS Assessment Reference date is 1/16/22 and the resident was moderately cognitively impaired. In an interview on 2/1/22 at 1:20 p.m., Family Member (FM) A reported her mother (R4) admitted to the facility from the hospital on 1/14/22 around 3:30 p.m. and did not receive medications, oxygen, food, or water while at the facility. FM A reported she dropped off clothing for her mother around that time. The resident was cognitively intact until this incident. R4 was then admitted back to the hospital on 1/16/22. On 1/15/22 FM A reported she called the facility and complained to the nurse that her mother has not received any food, medications, or water and the facility did not connect R4 to 3 liters of oxygen. She would call the facility and they would put her on hold and then hang up. FM A reported she talked to the nurse and insisted her mother (R4) goes back to the hospital after talking to R4 on the phone and noticed a change in her cognitive condition. The staff was reluctant to send R4 to the hospital and FM A reported she argued with the staff and insisted again that R4 goes to the hospital. They finally transferred the resident to the hospital and when she arrived, she had the same clothes on that she was admitted to the Nursing Home on 1/14/22. When the resident arrived at the hospital, there was no discharge paperwork from the facility indicating who the resident was, so she was a [NAME] Doe for a few minutes. The resident was admitted to the hospital and FM A reported she was in a hepatic coma. Review of Hospital Records for R4 with an admitted [DATE] revealed Chief Complaint: Altered Mental Status (pt (patient) present to ed (emergency department) c/o (complaints of) not feeling well. Pt coming from (Nursing Facility) and has been unable to take meds for 2 days. unable to take [MEDICATION(S)] . pt normal on 2L NC (nasal cannula), BS (blood sugar) 138. Pt is confused currently, able to follow commands, pt is normally AXO 4 (alert and oriented x4) per facility. She was discharged to a skilled nursing facility as the caregiver has COVID and to get over the quarantine period, the patient was staying in a nursing facility. Unfortunately the nursing facility did not have any of her medications and therefore has not received any medication since discharge from the hospital on Friday. It is difficult to ascertain the timing of the symptoms, but the patient is altered, able to tell me her name. EKG (electrocardiogram) demonstrates sinus [CONDITION(S)] (fast heart rate) and elevated ammonia . Assessment/Plan: Altered mental status, Liver [CONDITION(S)] secondary to NASH (CMS/HCC), Hyperammonemia (metabolic disturbance characterized by an excess of ammonia in the blood). Review of an Internal Medicine History and Physical dated 1/16/22 for R4 revealed: Patient presents from (Nursing Home) secondary to alteration of mental status. Reportedly the patient has not received her liver medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] since she was discharged from (Hospital) on 1/14/2022. Unfortunately it appears that as previously mentioned there was an interruption in pharmacological administration of which is the likely culprit as the patient's ammonia level was elevated. Outpatient medications: . oxygen 3 liters nasal canula . 1. Hepatic [CONDITION(S)]. Review of the Electronic Medical Record revealed some of the Orders for R4 were documented to start on 1/15/22 at 2000 (8:00 p.m.) which included but not limited to [MEDICATION(S)] 550 milligram (mg) tablet twice a day for [CONDITION(S)], [MEDICATION(S)] 25 mg twice a day for high blood pressure, [MEDICATION(S)] 200 mg tablets- give 2 tablets by mouth every morning and at bedtime for HF (heart failure), [MEDICATION(S)] 40 mg once a day for [CONDITION(S)], [MEDICATION(S)] solution 20 grams twice a day for [CONDITION(S)], and [MEDICATION(S)] 25 mg once a day for high blood pressure. Orders were dated for 1/15/22 and 1/16/22. Review of the Electronic Medication Administration Record (EMAR) revealed no medications were given to R4 on 1/14/22 and on 1/15/22 she received evening doses of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], 3 liters of oxygen via nasal canula. There is no documentation or resource that verified [MEDICATION(S)] was available or on hand to give to the resident but is signed as given to her. The other two medications are documented they came from the Cubex (on site medication dispenser) on 1/15/22 at 8:32 p.m. Review of the EMR revealed no documentation of when the R4 arrived at the facility, no admission assessment, no documentation the physician was notified, no care plans, no skin assessments, no meals documented, and no ADL's documented. Review of a Late Entry General Progress Note backdated 1/15/22 and created on 1/16/22 at 9:28 a.m. for R4 revealed: Resident received morning medications by paper MAR from nurse. Nothing documented in the EMR indicating the resident received these medications or where they came from. Review of a General Progress note dated 1/15/22 at 11:51 p.m. for R4 revealed: Res resting with eyes closed at this time, O2 (oxygen) on as ordered. Meds available in back up pulled and given at (bedtime). Pharmacy contacted and STAT (fast as possible) delivery of all other meds requested. Review of a Nursing Skilled Charting document for R4 dated 1/14/22 at 8:40 p.m. and locked on 1/15/22 at 7:45 p.m. revealed the resident had her vitals documented but was not assessed for ADL's. Review of the Cubex transactions list from 1/1/22 to 2/7/22 revealed on 1/15/22 at 8:32 p.m. R4 had [MEDICATION(S)] and [MEDICATION(S)] as the only medications removed from the Cubex by Registered Nurse (RN) C. In an interview on 2/3/22 at approximately 8:00 a.m., the Medical Records Clerk (MR) F reported she was caught up on any medical records needing to be scanned into the computer. When questioned if there were any records for R4 not scanned into the computer yet, MR F reported she was pretty sure all the records were in the computer and was going to make sure. About 30 minutes later MR F provided a soft file with a discharge summary/order from the hospital, a preprinted handwritten nursing admission assessment and a preprinted handwritten skilled charting documentation for R4. MR F reported the soft file was in the administrator's office. During an interview on 2/3/22 at 10:22 a.m., RN D reported she took care of R4 on 1/15/22 during the day shift and did not verify the admission orders with the physician. RN D reported she got medications for R4 from the tackle box that had medications for the residents on the COVID unit so they would not have to come out of the unit to go to the Cubex to get medications. During an interview and record review on 2/3/22 at 10:45 a.m. The Director of Nursing (DON) reported RN E did not do an initial assessment for R4 when she admitted to the facility on [DATE]. The facility was informed by the Attorney Generals (AG) Office on 1/20/22 that there was a concern regarding R4s care and instructed to freeze the electronic medical record for R4. So no documentation was to be added, removed, or altered at that point. When they became aware there was a concern, she had an assessment printed out and had the nurses fill them out as a late entry and put a file together to be put in the administrator's office. The DON reported R4 did not get any medications on Friday 1/14/22 but reported RN D put the medications in the computer that day. The DON reported once they were aware of the allegation, they reported it to the State Agency (SA). The DON later provided a list of medications that were in the tackle box designated to the COVID unit, but the list only included medications that were common to treat COVID, not regular routine medications or any medications that were given to R4. The DON then reported she could not exactly verify where the medications that the nurse signed on the hospital discharge orders summary as given to R4 were obtained from. In an interview on 2/3/22 at 11:00, the Nursing Home Administrator (NHA) reported that the AG reached out to them on 1/20/22 and told her of the concern reported to their office, and so the NHA reported to the SA that there is an allegation of neglect. The AG office told them to not put any more documents into the computer for R4 because the records are being sequestered. In an interview on 2/3/22 at 11:43 a.m. the DON still could not verify where the medications that were documented as given to R4 during her stay came from. During an Interview and Record review on 2/7/22 at 11:38 a.m., Pharmacist (PM) B revealed on 1/15/22 a New Admit place holder information was sent to them via EMR at the Nursing Facility. At 8:32 p.m., the nurse called the pharmacy for STAT medications and again at 9:32 p.m. No medications were delivered the night of 1/15/22 to the facility. [MEDICATION(S)] and [MEDICATION(S)] was delivered to the facility on [DATE] at 8:40 a.m. PM B reported they had no record of R4 being charged for any medications at the facility while she was there. If she did receive medications, she would have been charged for them or should have been. The pharmacy receives the information when a resident gets medication. PM B reported if the facility used the old tackle box approach to providing medications, then there should be a slip that would be written out with the residents' information and sent to the pharmacy for a charge. At the time of this interview, there were no medications charged to the resident or any proof provided to the Pharmacy that this resident received medications to be charged. In an interview on 2/7/22 at 4:15 p.m., Licensed Practical Nurse (LPN) M reported that she did not admit R4 to the facility on [DATE] because she was already admitting another resident when R4 arrived at the facility. LPN M reported she worked the day shift and started at 6:00 a.m. and worked until 9:30 p.m. to complete her other admission and documentation. LPN M reported RN E worked the second shift this day and reported to him of R4 admitting to the facility and about an hour later another new admission came to the facility. LPN M reported R4 arrived around dinner time, and she just helped get her settled into the room and made sure she had a meal tray and was safe. In an interview on 2/8/22 at 8:49 a.m., RN D reported she did not get in report that R4 was in the facility and became aware once she passed medications to her roommate and noticed R4 was in the room too. RN D reported her name was not on the report sheet or census either. RN D reported she filled out an assessment for R4 after the resident had discharged from the facility and signed it as a late entry for 1/20/22. This document was not part of the residents' medical records and was filled out by hand and put into a soft file in the administrator's office. RN D reported the assessment she did reflected the date of 1/15/22 when she took care of her. RN D reported she only filled out part B and down. RN D reported that RN E was going to come back to finish the admission documentation. RN D reported the admission packet was on the desk for R4 and she opened it to find out what medications the resident was on. When queried about how R4 got her medications and why they were not charted in the electronic medical record, RN D changed her story from earlier when she reported she got the medications out of the special tackle box that was for the COVID unit. She said she got the medications out of the Cubex. RN D could not explain why the medications she gave R4 did not show up in the Cubex log as a medication dispensed in R4s name. When queried why the medications were not documented in the computer MAR, RN D reported is was because the timing would be off for the resident's next dose. So she signed the paper hospital medication discharge orders for R4 that she gave her [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] sulfate, [MEDICATION(S)], [MEDICATION(S)], loratadine, [MEDICATION(S)], oxygen, [MEDICATION(S)], and [MEDICATION(S)] at 9:30 a.m. on 1/15/22. When queried about the [MEDICATION(S)], RN D reported she took the [MEDICATION(S)] from another resident to give to R4. None of these medications showed up as dispensed from the Cubex for R4, provided by the pharmacy, or any other paper trail indicating the resident received these medications from RN D. In an interview on 2/8/22 at 11:48 a.m., the DON reported the nurse did get medications out of the Cubex for R4 and got the [MEDICATION(S)] from another resident by borrowing it. The facility replaced the medication taken from the other resident. The DON reported there should be a record of R4 in the Cubex if medications were taken out of it for her. The DON reported RN D told her 3 times that she pulled R4s medication from the Cubex. The DON did not know why the nurse took [MEDICATION(S)] from another resident when the [MEDICATION(S)] is also in the Cubex. The DON reported she is not involved in the investigation because the facility is trying to protect her since she is a witness per the AG. The DON did not know who the resident was that the medication was taken from. During an interview and record review on 2/9/22 at 11:00 a.m., RN E reported he worked the night of 1/14/22 and R4 was already in the building but he got another admission about an hour later. He introduced himself to the resident and did a quick assessment and made sure she had a call light but did not document anything in the computer. Could not recall if she had her oxygen in place or if she got a meal. Could not recall if he called the physician or left a message for the physician. RN E reported that night was busy and had another resident that occupied much of his time, and it was just a busy night. RN E reported the DON and the NHA had him fill out a handwritten assessment around 1/21/22 for R4 even though the date on one document showed 1/15/22, but verified it was not filled out until long after she was discharged and filled out what he could remember. These documents are not in the EMR and in the soft file in the NHAs office. RN E reported he did not chart much that night because it was busy. In an interview on 2/15/22 at 12:00 p.m., RN C reported she worked the second shift on 1/15/22 and took care of R4 that day. RN C was not sure if R4 received medications earlier that day but was informed that the resident's daughter had called with concerns R4 had not received any medication since she was admitted to the facility. RN C reviewed the chart and it looked like she was admitted that day (1/15/22) and was told that RN E was going to complete the admission documentation for the resident. RN E was there this night and thought he was completing the paperwork. RN C reported if the medications on the MAR were documented as given, then she gave the medications. The medications documented are [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Two of the medications were shown to be dispensed from the Cubex but not the [MEDICATION(S)]. No other medications were documented as given. Review of several witness statements provided by the facility revealed a lack of documentation in R4's EMR backing up services and goods provided to the resident. There is no paper trail of events, assessments, physician contact, pharmacy contact, medication administration, pharmacy receipt and/or charges for medications or full physical assessment while R4 resided in the building.

This citation refers to MI 429: Based on observation, interview and record review the facility failed to provide adequate nutrition monitoring and interventions for 3 residents (R6, R10, R11) of 7 residents reviewed for nutrition/hydration resulting in an Immediate Jeopardy (IJ) that began on 12/13/2021 when R6 experienced a significant weight loss and the facility failed to implement identified interventions to prevent weight loss and R6 continued to lose weight. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. Findings include: Review of facility policy with the subject Weight Management with adopted date 9/11/20 revealed weight loss is defined as: significant weight loss (5% in one (1) month, 7.5% in three (3) months, oR10% in six (6) months) . should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the cause(s) of weight loss .once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed. The procedure includes the resident being weighed monthly and as needed .Monthly weights are to be completed by the 7th day of each month and reviewed by the Nutrition Committee within a reasonable period of time thereafter .any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of the weight gain/loss and the intervention(s) required .any resident meeting the criteria for weight loss .will be weighed weekly, with the weight entered in the resident's medical record . Review of the facility policy with the subject Nutrition Monitoring & Management Program with the adopted date of 7/11/18 revealed a purpose: To provide care and services including .defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice .monitoring and evaluating the resident's response or lack of response to the interventions . Dietary evaluations are assessed on admission and at least quarterly thereafter, and following a change in condition. R6 Review of R6's face sheet revealed she had originally admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's kardex revealed under food/fluids: 1:1 feeding assistance at all meals . check mouth after meal for pocketed foods and debris . instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly . There is a conflicting entry in the kardex, which stated R6 is able to eat independently. Under the section special needs weight is noted to be taken weekly as well as monthly. Review of R6's care plan revealed under the focus ADL (activities of daily living) self-care deficit r/t (related to) weakness, confusion, impaired balance, limited mobility an intervention that states The resident is able to: eat independently with an initiation date of 4/27/20. Under the focus area: [R6] has a Nutritional status risk AEB (as evidenced by) Dx (diagnosis) of .dementia . dysphagia w/ need for altered textured diet/fluids in place; chronic variable po (by mouth) intake; h/o (history of) wt (weight) fluctuations; and advanced age with interventions that included: 1:1 feeding assistance at all meals with an initiated date of 12/7/21, Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of dysphagia ., review routine weights, and weigh resident per facility protocol . Under the focus area has a swallowing problem r/t (related to) dysphagia, poor dentition interventions included: check mouth after meal for pocketed food and debris ., instruct, assist and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly, and Monitor for .choking . Review of physician note from 11/22/21 revealed R6 was being seen for a complaint of weight loss. Lab work, dietary evaluation and weekly weight checks to further monitor weight loss were ordered. On 12/16/21 at approximately 8:35 AM, no staff other than a housekeeper were observed on the 400 hall or in resident rooms and residents were eating breakfast. R6 was observed in her room, not being assisted with her meal. One of her roommates had completely finished their meal at this time, and the other roommate was about half complete in consuming her meal. R6 was viewed to have her food untouched and had a glass of clear red honey thick liquid to her mouth with her eyes closed. R6 was approached and appeared to be asleep with the glass to her mouth, she did not respond to verbal attempts to get her attention for about a minute. R6's shoulder was rubbed when speaking to her and she slowly opened her eyes, but kept the glass to her lips briefly and then slowly lowered it. R6 continued to not respond verbally and looked around the room with confusion, not making eye contact. A discussion was completed with R6's roommate, who stated that usually someone will come help R6 at with her meal, but they don't usually assist her until later, so someone may come back to help her. Conversation was attempted again with R6 and she was not communicative and did not make eye contact. Upon exiting the room and walking the hall again, no staff other than housekeeping was viewed on the hall or in resident rooms. R6 was watched from the hall consuming her breakfast. She took a limited amount of very small bites, moving very slowly. At approximately 8:47 AM, a CNA (certified nursing assistant) entered the hall and appeared to have gotten additional food from the kitchen for a resident and delivered it to their rooms. At 8:52 AM, CNA X entered the room of R10. At 8:55 AM CNA X exited R10's room with their meal tray and then went into R11's room. At 8:58 AM, CNA X exited R11's room with their meal tray and then entered the room of R6. CNA X was viewed to briefly check on R6 and walked away as she was viewed to be very slowly feeding herself. CNA X was in the room with R6 for approximately 2 minutes. CNA X was asked if she was the only aide assigned to the hall that morning and she stated yes, I am the only one on the hall, it's like this every day. CNA X was asked if anyone on the hall needed feeding assistance and she said at least 3 and pointed to the rooms of R6, R10 and R11. CNA X was asked specifically about R6 and her needs. CNA X stated she seems to be doing good now, but you have to keep checking on her to make sure she's not choking, but she is doing good on her own today. CNA X was asked how she managed to assist 3 residents at once who needed feeding assistance and she stated that she just has to keep going back and forth between them. On 12/16/21 at 10:50 AM, an interview was completed with Dietician Y regarding R6's nutritional status. Dietician Y stated R6 has had weight loss recently and overall a decline and had a downgrade in her swallowing ability. The dietary plan was to add supplements to meals as well as provide feeding assistance to R6. Dietician Y stated R6 can feed herself at times, but that staff usually need to initiate feeding and provide encouragement. The food acceptance logs for R6 were reviewed with Dietician Y and she stated it appears R6's acceptance increases when she has staff assistance. Dietician Y agreed there were some holes in the food acceptance documentation and stated she would expect each meal to be documented. Dietician Ys stated R6 was placed on weekly weights as of 11/23/21, this was discontinued for some reason, but reordered on 12/6/21. Weekly weights were ordered to be completed on Mondays for 4 weeks. Dietician Y stated she is also completing weekly dietary evaluations of R6 due to the significant weight loss, which would include reviewing her intake and weights. Dietician Y was asked how she completed her review of R6 on 12/14/21 (a Tuesday) if R6's weekly weight was missed on 12/13/21 (Monday). Dietician Y stated it does appear R6 needed another weight to be completed. Dietician Y was informed missing the weekly weight was concerning and also informed R6 was not viewed to be getting assistance with her breakfast meal. On 12/16/21 at 12:08 PM, lunch meal trays were observed to begin to be delivered to the 400 hall. R6 was viewed to be asleep in bed. There were between 2 to 3 CNA staff on the hall at various times delivering the meal trays to resident in their rooms. At 12:13 PM a CNA entered R6's room to deliver her tray. They elevated R6 in bed, set up her meal and then exited the room by 12:17 PM without assisting the resident to begin eating. At 12:21 PM, R6 had yet to take a bit and the surveyor entered the room. R6 was asked how she was today and how her meal was. R6 stared blankly at the surveyor and then slowly took one small bite of ice cream. Upon exiting R6's room at 12:23 PM, it was viewed that no staff were in the hall and a nurse was completing medication pass. There were 2 staff in the dining room area and 1 staff was assisting a resident with their meal. At 12:28 PM, Nurse Z returned to the hall. R6 was not eating any further bites of food. At 12:31 PM Nurse Z entered R6's room with medications and asked R6 if she needed help. At this time the resident took one more very slow bite of ice cream. Nurse Z appeared to be looking for another staff member and came across CNA X briefly exiting the dining room, Nurse Z asked CNA X to assist R6 with lunch. CNA X stated she could not because she was assisting residents in the dining room and was overheard saying she [R6] did not do great at breakfast. Nurse Z then left the hall and there were not any nursing staff on the hall for about 3 minutes. Nurse Z then returned to the hall and to R6's room and began to assist her with eating at approximately 12:35 PM. On 12/16/21 at 12:03 PM, an email request was made to the director of nursing (DON) and nursing home administrator (NHA) requesting the staff covering the 400 hall for the morning of 12/16/21, since the schedule appeared to be unclear. The DON responded by email on 12/16/21 at 12:08 PM that 2 CNAs and one nurse were assigned to the hall for that shift. During a follow up interview on 12/16/21 at 3:20 PM, the DON and NHA were informed of the lack of staff viewed on the hall during meal service that day, which was concerning with there being at least 3 identified residents who required 1:1 assistance with meals due to choking hazards and/or weight loss. The DON and NHA were informed of the extensive concerns rising to a level of immediate jeopardy with R6's weight loss and lack of interventions being implemented. On 12/17/21 at 9:05 AM, R6 was viewed being transported to the dining room in her wheelchair by staff. She was viewed to be attached to a bag of IV fluids and was smiling and making eye contact. On 12/17/21 at 9:55 AM, Unit Manager (UM) Z was observed feeding R6 in the main dining room. R6 had an IV in her arm. The Surveyor asked R6 how her food tasted, and she responded, I do not know. R6's had she eyes wide open and was watching UM Z. When the spoon came to her mouth, she opened it without cueing. On 12/21/21 at 9:00 AM, UM Z was observed feeding R6 in the main dining room. R6 did not have an IV running. UM Z was giving R6 spoonfuls of thickened cranberry juice. R6 had her eyes open and did not need verbal cues to open her mouth when the spoon reached her lips. The Surveyor asked R6 how her food tasted, and she responded good. Review of R6's weights revealed the following weights in the last approximately 3 months: 9/2/21 127.6 pounds, 10/1/21 125.6 pounds, 11/17/21 116.6 pounds, 12/1/21 109.0 pounds, 12/6/21 109.0 pounds, 12/16/21 106.3 pounds, 12/20/21 105.1 pounds. Between 10/1/21 and 11/17/21 (1 month) sustained a 7.1 % weight loss. Between 11/17/21 and 12/1/21 (2 weeks) R6 sustained another 6.5% weight loss. Between 9/2/21 and 12/1/21 (3 months) R6 sustained a 14.5% weight loss. The monthly weight in November was completed late during a time period where R6 sustained a significant weight loss and weekly weights were missed the week of 11/29/21 and 12/13/21 where R6 continued to lose weight. Review of R6 progress notes revealed no dietary progress notes from 5/17/21 until 11/18/21. A nutrition progress note from 11/18/21 revealed: Resident triggered a 8.6% significant wt loss x 1.5mo with her CBW (current body weight) at 117# (11/17) and BMI 22.0. Wt hx reviewed: 126# (10/1), 127# (8/3), and 125# (5/2) . Meal intake reviewed which remains fair, consuming 60% on average over a 14-day lookback period. She is supplemented with House Shake . Will increase her supplement to TID to support wt maintenance. MD notified of significant wt loss as well. A nutrition progress note for R11/23/21 revealed: Weekly Review: Resident's meal intake remains fair, consuming 56% on average over the past week. She is provided with House Shake supplement TID (three times a day) (200kcals, 6g pro each) for increased kcal and nutrient intake. Noted orders for weekly wts to monitor trends. Will continue with all other nutrition interventions in place and continue to monitor resident weekly and PRN for changes A nutrition progress note for R11/30/21 revealed: Weekly Review: Resident's meal intake remains fair, consuming 55% on average over the past week. She continues to have good acceptance of her House Shake supplement provided TID (200kcals, 6g pro each) for increased kcal and nutrient intake. Goal po (by mouth) intake is >60% average and prevent ongoing wt loss. Will continue with current nutrition interventions in place and monitor resident weekly and PRN (as needed) for changes. A nutrition progress note from 12/2/21 revealed Resident's weight obtained and is triggering a 7.6% significant wt loss x2wk. Her CBW (current body weight) is 109# (12/1) and BMI 20.6. Wt hx reviewed: 117# (11/17), 128# (9/2) and 123# (6/3). Recommend Enhanced foods to maximize kcal intake. Will continue with all other nutrition interventions in place and continue to monitor trends weekly x4wks and PRN (as needed) for further changes. If decline continues, resident may benefit from alternative means of nutrition vs. comfort care. A behavior progress note from 12/7/21 revealed Note Text: Resident alert with confusion. Not engaged with staff today. Resisted am cares and refused medications this morning. Resident is now a 'feed' due to poor intake, as seen by recent weight loss. Noted drooling and coughing while feeding in up right position of 45+ degrees. Speech therapist in with resident and downgrading fluids to honey thick. Provider notified. Resident staying in bed today per her choice. A nutrition note for 12/7/21 revealed: Resident's diet has been downgraded to Honey-thickened liquids with recommendations for 1:1 feeding assistance at all meals per SLP (speech-language pathology). Supplement updated to Nutritional Treat TID (3 times a day) (300kcals, 11g pro each) in place of House Shakes for appropriate consistency and increased kcal intake. A nutrition note from 12/14/21 revealed: Resident's meal intake remains fair/poor, consuming only 35% on average over the past week. She is accepting of most supplements and fluids throughout the day. She is provided with Nutritional Treat TID (300kcals, 11g pro each) for increased kcal and nutrient intake. Supplement updated from House Shake d/t downgrade to HTL (honey thick liquids). Noted referral for hospice care in place. PO (by mouth) intake anticipated to remain variable given overall decline. Will continue to monitor weekly and PRN (as needed) for further changes. A general progress note from 12/16/21 revealed: A hydration assessment was completed on this resident. She presented with dry [MEDICATION(S)] membranes. Her skin turgor is poor and tenting . Physician on-call [name of physician] notified. Order received for one liter of NS (normal saline) to be ran @ 100cc/hr. IV started in resident's left forearm. Site is patent and is infusing well. Review of R6's meal intake records for the last 30 days (from 11/17-12/16/21) revealed 11 days when only 2 meals were charted and 6 days when only 1 meal was charted. The entries did not indicate what meal was being charted. Approximately 37 of the meals charted stated the resident was independent with eating with no staff oversight or help at any time (8 of those meals were after 12/7/21 even though she was care planned for 1:1 assistance at that time and 2 meals were charted for 12/16/21- one at 1:46 PM with 25% eaten and one at 1:47 PM with 75% eaten. Both were coded as the resident being totally dependent on staff). R10 Review of R10's face sheet revealed he originally admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's kardex revealed under food/fluids: 1:1 feeding assistance at all meals as resident allows .check mouth after meals for pocketed food and debris .instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew eat bite thoroughly . Review of R10's care plan revealed a focus area of ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, [CONDITION(S)], Impaired balance, Limited Mobility, Limited ROM (range of motion), Stroke) interventions include: EATING: 1:1 feeding assistance at all meals as resident allows. Under focus area [R10] has a potential for swallowing problems r/t Dysphagia interventions include: Alternate small bites and sips . check mouth after meals for pocketed food and debris . instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew eat bite thoroughly . Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Report to nurse and/or MD and adjust plan of care as indicated. Review of R10's progress notes for R10/3/21 revealed: .Resident prefers being fed his meals as he struggles to keep food on his utensil. Assisted with lunch today, he ate 100%. Will notify UM (unit manager) and SLP (Speech-Language Pathology) for possible evaluation. R11 Review of R11's face sheet revealed she was initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's kardex revealed under Food/fluids: Assist resident to consume food/fluids as resident allows; encourage self-feeding .The resident requires extensive assistance by 1 staff to eat Review of R11's care plan revealed a focus area ADL self-care performance deficit r/t Confusion, Fatigue, Impaired balance, Limited Mobility with interventions including EATING: The resident requires extensive assistance by 1 staff to eat . Under the focus area Nutritional status risk AEB (as evidenced by) dx (diagnosis) of .cognitive communication deficit .h/o (history of) dysphagia; self-feeding deficits r/t (related to) [CONDITION(S)] and tremors; need for feeding assistance and adaptive equipment . interventions include assist resident to consume food/fluids as resident allows . Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Report to nurse and/or MD and adjust plan of care as indicated. Review of R11's progress notes for R10/8/21 revealed: CNA reported to the the (sic) writer that resident has been noted holding food in her mouth, appetite has decreased . On 12/16/21 at 3:20 PM, the NHA was informed of an Immediate (IJ) related to F 600 that began on 12/13/21 when the facility failed to assist R6 (who weighs 109 pounds) with nutritional needs per the plan of care and doctor's orders which include: performing weekly weights, providing 1:1 assistance or supervision for choking risk (dysphagia) and nutritional needs; monitoring food intake and monitoring nutritional and hydration status timely per standards of practice. The identified risk of serious injury, serious harm, serious impairment or death was evidenced by: R6 had a 14.5% weight loss in 3 months and a 6.5% weight loss in the last 2 weeks. Surveyor observations revealed no or little assistance or supervision for R6 who could not eat on her own. R6 is likely to incur further weight loss, functional decline, serious harm and/or hastened death if weight loss continues without monitoring and interventions to prevent weight loss in place. The need for immediate action was: The facility interdisciplinary team must immediately review and monitor R6 for her significant weight loss and decline, and ensure that all residents at risk for nutrition and/or hydration are assessed to ensure nutrition and hydration needs are being met per plan of care, doctor's orders, and standards of practice. On 12/17/2021, the facility plan to remove the Immediate Jeopardy was accepted and the state survey agency began to validate the removal plan which included: [Name of facility] is providing the following information to demonstrate that the immediacy of the cited deficiency F692 has been removed. 1. Response to Cited Areas: - Resident 6 had a current weight obtained. The physician has assessed the resident, a nutrition assessment has been completed and plan of care has been reviewed to ensure appropriate interventions are in place. - A review has been completed on current residents to ensure a current weight is documented. - A review of current residents that need supervision or 1:1 assistance with feeding have been reviewed to ensure nutritional needs are met and proper assistance is provided. - A review of current resident's nutrition acceptance record has been reviewed to ensure no significant changes in nutritional status. - Residents that have been identified as having an altercation in hydration or nutritional status have been reviewed to ensure appropriate interventions and monitoring is in place. 2. Other Residents at Potential Risk: - On December 16th, 2021, an audit was completed on the 81 residents residing in the facility to identify which residents are at risk for hydration and/or nutritional interventions and monitoring. - 10 residents have been identified as at risk for alterations in hydration or nutritional status and have had a nutritional assessment completed along with a plan of care review and update as needed. 3. Process Implemented to prevent further incidence: - On December 16th, 2021, 22 out of 67 nursing staff members have been educated on the nutrition monitoring and management program with special attention to: o Weekly weight process o Providing proper assistance with oral intake o Documenting intake o Notification of changes in nutritional status timely - On December 16th, 2021, 1 out of 1 registered dietician has been educated on the nutrition monitoring and management program. - Any staff member that has not been educated will be educated prior to the start of their shift. 4. Monitoring: - The DON/designee will complete 5 random audits on residents, weekly times 4 weeks and then monthly thereafter times 3 months or until substantial compliance has been maintained to ensure the nutrition monitoring and management program is being followed including appropriate nutritional interventions, weekly weights, intake documentation and proper assistance being provided during meals, as applicable The facility alleges that the immediacy with the deficient practice has been removed on December 16th, 2021. Although the Immediate Jeopardy was removed on 12/16/2021, the facility remained out of compliance with a scope of pattern and severity of actual harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency.

This citation refers to MI 429: This citation has two deficient practice statements DPS #1 Based on observation, interview and record review the facility failed to provide adequate staff for weight monitoring, feeding assistance and supervision for 3 residents (R6, R10, and R11), resulting in significant weight loss for R6 and the potential for future weight loss, as well as the potential for choking, aspiration, and serious injury due to lack of supervision and meal assistance for R6, R10 and R11. Findings include: Review of facility policy with the subject Weight Management with adopted date 9/11/20 revealed weight loss is defined as: significant weight loss (5% in one (1) month, 7.5% in three (3) months, oR10% in six (6) months) . should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the cause(s) of weight loss .once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed. The procedure includes the resident being weighed monthly and as needed .Monthly weights are to be completed by the 7th day of each month and reviewed by the Nutrition Committee within a reasonable period of time thereafter .any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of the weight gain/loss and the intervention(s) required .any resident meeting the criteria for weight loss .will be weighed weekly, with the weight entered in the resident's medical record . Review of the facility policy with the subject Nutrition Monitoring & Management Program with the adopted date of 7/11/18 revealed a purpose: To provide care and services including .defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice .monitoring and evaluating the resident's response or lack of response to the interventions . Dietary evaluations are assessed on admission and at least quarterly thereafter, and following a change in condition. R6 Review of R6's face sheet revealed she had originally admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's kardex revealed under food/fluids: 1:1 feeding assistance at all meals . check mouth after meal for pocketed foods and debris . instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly . There is a conflicting entry in the kardex, which stated R6 is able to eat independently. Under the section special needs weight is noted to be taken weekly as well as monthly. Review of R6's care plan revealed under the focus ADL (activities of daily living) self-care deficit r/t (related to) weakness, confusion, impaired balance, limited mobility an intervention that states The resident is able to: eat independently with an initiation date of 4/27/20. Under the focus area: [R6] has a Nutritional status risk AEB (as evidenced by) Dx (diagnosis) of .dementia . dysphagia w/ need for altered textured diet/fluids in place; chronic variable po (by mouth) intake; h/o (history of) wt (weight) fluctuations; and advanced age with interventions that included: 1:1 feeding assistance at all meals with an initiated date of 12/7/21, Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of dysphagia ., review routine weights, and weigh resident per facility protocol . Under the focus area has a swallowing problem r/t (related to) dysphagia, poor dentition interventions included: check mouth after meal for pocketed food and debris ., instruct, assist and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly, and Monitor for .choking . Review of physician note from 11/22/21 revealed R6 was being seen for a complaint of weight loss. Lab work, dietary evaluation and weekly weight checks to further monitor weight loss were ordered. On 12/16/21 at approximately 8:35 AM, no staff other than a housekeeper were observed on the 400 hall or in resident rooms and residents were eating breakfast. R6 was observed in her room, not being assisted with her meal. One of her roommates had completely finished their meal at this time, and the other roommate was about half complete in consuming her meal. R6 was viewed to have her food untouched and had a glass of clear red honey thick liquid to her mouth with her eyes closed. R6 was approached and appeared to be asleep with the glass to her mouth, she did not respond to verbal attempts to get her attention for about a minute. R6's shoulder was rubbed when speaking to her and she slowly opened her eyes, but kept the glass to her lips briefly and then slowly lowered it. R6 continued to not respond verbally and looked around the room with confusion, not making eye contact. A discussion was completed with R6's roommate, who stated that usually someone will come help R6 at with her meal, but they don't usually assist her until later, so someone may come back to help her. Conversation was attempted again with R6 and she was not communicative and did not make eye contact. Upon exiting the room and walking the hall again, no staff other than housekeeping was viewed on the hall or in resident rooms. R6 was watched from the hall consuming her breakfast. She took a limited amount of very small bites, moving very slowly. At approximately 8:47 AM, a CNA (certified nursing assistant) entered the hall and appeared to have gotten additional food from the kitchen for a resident and delivered it to their rooms. At 8:52 AM CNA X entered the room of R10. At 8:55 AM CNA X exited R10's room with their meal tray and then went into R11's room. At 8:58 AM CNA X exited R11's room with their meal tray and then entered the room of R6. CNA X was viewed to briefly check on R6 and walked away as she was viewed to be very slowly feeding herself. CNA X was in the room with R6 for approximately 2 minutes. CNA X was asked if she was the only aide assigned to the hall the morning and she stated yes, I am the only one on the hall, it's like this every day. CNA X was asked if anyone on the hall needed feeding assistance and she said at least 3 and pointed to the rooms of R6, R10 and R11. CNA X was asked specifically about R6 and her needs. CNA X stated she seems to be doing good now, but you have to keep checking on her to make sure she's not choking, but she is doing good on her own today. CNA X was asked how she managed to assist 3 residents at once who needed feeding assistance and she stated that she just has to keep going back and forth between them. On 12/16/21 at 10:50 AM, an interview was completed with Dietician Y regarding R6's nutritional status. Dietician Y stated R6 has had weight loss recently and overall a decline and had a downgrade in her swallowing ability. The dietary plan was to add supplements to meals as well as provide feeding assistance to R6. Dietician Y stated R6 can feed herself at times, but that staff usually need to initiate feeding and provide encouragement. The food acceptance logs for R6 were reviewed with Dietician Y and she stated it appears R6's acceptance increases when she has staff assistance. Dietician Y agreed there were some holes in the food acceptance documentation and stated she would expect each meal to be documented. Dietician Ys stated R6 was placed on weekly weights as of 11/23/21, this was discontinued for some reason, but reordered on 12/6/21. Weekly weights were ordered to be completed on Mondays for 4 weeks. Dietician Y stated she is also completing weekly dietary evaluations of R6 due to the significant weight loss, which would include reviewing her intake and weights. Dietician Y was asked how she completed her review of R6 on 12/14/21 (a Tuesday) if R6's weekly weight was missed on 12/13/21 (Monday). Dietician Y stated it does appear R6 needed another weight to be completed. Dietician Y was informed missing the weekly weight was concerning and also informed R6 was not viewed to be getting assistance with her breakfast meal. On 12/16/21 at 12:08 PM, lunch meal trays were observed to begin to be delivered to the 400 hall. R6 was viewed to be asleep in bed. There were between 2-3 CNA staff on the hall at various times delivering the meal trays to resident in their rooms. At 12:13 PM a CNA entered R6's room to deliver her tray. They elevated R6 in bed, set up her meal and then exited the room by 12:17 PM without assisting the resident to begin eating. At 12:21 PM, R6 had yet to take a bit and the surveyor entered the room. R6 was asked how she was today and how her meal was. R6 stared blankly at the surveyor and then slowly took one small bite of ice cream. Upon exiting R6's room at 12:23 PM, it was viewed that no staff were in the hall and a nurse was completing medication pass. There was 2 staff in the dining room area and 1 staff was assisting a resident with their meal. At 12:28 PM, Nurse Z returned to the hall. R6 was not eating any further bites of food. At 12:31 PM Nurse Z entered R6's room with medications and asked R6 if she needed help, at this time the resident took one more very slow bite of ice cream. Nurse Z appeared to be looking for another staff member and came across CNA X briefly exiting the dining room, Nurse Z asked CNA X to assist R6 with lunch. CNA X stated she could not because she was assisting residents in the dining room and was overheard saying she [R6] did not do great at breakfast. Nurse Z then left the hall and there was no nursing staff on the hall for about 3 minutes. Nurse Z then returned to the hall and to R6's room and began to assist her with eating at approximately 12:35 PM. On 12/16/21 at 12:03 PM email request was made to the director of nursing (DON) and nursing home administrator (NHA) requesting the staff covering the 400 hall for the morning of 12/16/21, since the schedule appeared to be unclear. The DON responded by email on 12/16/21 at 12:08 PM that 2 CNAs and one nurse were assigned to the hall for that shift. During a follow up interview on 12/16/21 at 3:20 PM, the DON and NHA were informed of the lack of staff viewed on the hall during meal service that day, which was concerning with there being at least 3 identified residents who required 1:1 assistance with meals due to choking hazards and/or weight loss. The DON and NHA were informed of the extensive concerns rising to a level of immediate jeopardy with R6's weight loss and lack of interventions being implemented. On 12/17/21 at 9:05 AM, R6 was viewed being transported to the dining room in her wheelchair by staff. She was viewed to be attached to a bag of IV fluids and was smiling and making eye contact. On 12/17/21 at 9:55 AM Unit Manager (UM) Z was observed feeding R6 in the main dining room. R6 had an IV in her arm. The Surveyor asked R6 how her food tasted, and she responded, I do not know. R6's had she eyes wide open and was watching UM Z. When the spoon came to her mouth, she opened it without cueing. On 12/21/21 at 9:00 AM UM Z was observed feeding R6 in the main dining room. R6 did not have an IV running. UM Z was giving R6 spoonfuls of thickened cranberry juice. R6 had her eyes open and did not need verbal cues to open her mouth when the spoon reached her lips. The Surveyor asked R6 how her food tasted, and she responded good. Review of R6's weights revealed the following weights in the last approximately 3 months: 9/2/21 127.6 pounds, 10/1/21 125.6 pounds, 11/17/21 116.6 pounds, 12/1/21 109.0 pounds, 12/6/21 109.0 pounds, 12/16/21 106.3 pounds, 12/20/21 105.1 pounds. Between 10/1/21 and 11/17/21 (1 month) sustained a 7.1 % weight loss. Between 11/17/21 and 12/1/21 (2 weeks) R6 sustained another 6.5% weight loss. Between 9/2/21 and 12/1/21 (3 months) R6 sustained a 14.5% weight loss. The monthly weight in November was completed late during a time period where R6 sustained a significant weight loss and weekly weights were missed the week of 11/29/21 and 12/13/21 where R6 continued to lose weight. Review of R6 progress notes revealed no dietary progress notes from 5/17/21 until 11/18/21. A nutrition progress note from 11/18/21 revealed: Resident triggered a 8.6% significant wt loss x 1.5mo with her CBW (current body weight) at 117# (11/17) and BMI 22.0. Wt hx reviewed: 126# (10/1), 127# (8/3), and 125# (5/2) . Meal intake reviewed which remains fair, consuming 60% on average over a 14-day lookback period. She is supplemented with House Shake . Will increase her supplement to TID to support wt maintenance. MD notified of significant wt loss as well. A nutrition progress note for R11/23/21 revealed: Weekly Review: Resident's meal intake remains fair, consuming 56% on average over the past week. She is provided with House Shake supplement TID (three times a day) (200kcals, 6g pro each) for increased kcal and nutrient intake. Noted orders for weekly wts to monitor trends. Will continue with all other nutrition interventions in place and continue to monitor resident weekly and PRN for changes A nutrition progress note for R11/30/21 revealed: Weekly Review: Resident's meal intake remains fair, consuming 55% on average over the past week. She continues to have good acceptance of her House Shake supplement provided TID (200kcals, 6g pro each) for increased kcal and nutrient intake. Goal po (by mouth) intake is >60% average and prevent ongoing wt loss. Will continue with current nutrition interventions in place and monitor resident weekly and PRN (as needed) for changes. A nutrition progress note from 12/2/21 revealed Resident's weight obtained and is triggering a 7.6% significant wt loss x2wk. Her CBW (current body weight) is 109# (12/1) and BMI 20.6. Wt hx reviewed: 117# (11/17), 128# (9/2) and 123# (6/3). Recommend Enhanced foods to maximize kcal intake. Will continue with all other nutrition interventions in place and continue to monitor trends weekly x4wks and PRN (as needed) for further changes. If decline continues, resident may benefit from alternative means of nutrition vs. comfort care. A behavior progress note from 12/7/21 revealed Note Text: Resident alert with confusion. Not engaged with staff today. Resisted am cares and refused medications this morning. Resident is now a 'feed' due to poor intake, as seen by recent weight loss. Noted drooling and coughing while feeding in up right position of 45+ degrees. Speech therapist in with resident and downgrading fluids to honey thick. Provider notified. Resident staying in bed today per her choice. A nutrition note for 12/7/21 revealed: Resident's diet has been downgraded to Honey-thickened liquids with recommendations for 1:1 feeding assistance at all meals per SLP (speech-language pathology). Supplement updated to Nutritional Treat TID (3 times a day) (300kcals, 11g pro each) in place of House Shakes for appropriate consistency and increased kcal intake. A nutrition note from 12/14/21 revealed: Resident's meal intake remains fair/poor, consuming only 35% on average over the past week. She is accepting of most supplements and fluids throughout the day. She is provided with Nutritional Treat TID (300kcals, 11g pro each) for increased kcal and nutrient intake. Supplement updated from House Shake d/t downgrade to HTL (honey thick liquids). Noted referral for hospice care in place. PO (by mouth) intake anticipated to remain variable given overall decline. Will continue to monitor weekly and PRN (as needed) for further changes. A general progress note from 12/16/21 revealed: A hydration assessment was completed on this resident. She presented with dry [MEDICATION(S)] membranes. Her skin turgor is poor and tenting . Physician on-call [name of physician] notified. Order received for one liter of NS (normal saline) to be ran @ 100cc/hr. IV started in resident's left forearm. Site is patent and is infusing well. Review of R6's meal intake records for the last 30 days (from 11/17-12/16/21) revealed 11 days when only 2 meals were charted and 6 days when only 1 meal was charted. The entries did not indicate what meal was being charted. Approximately 37 of the meals charted stated the resident was independent with eating with no staff oversight or help at any time, 8 of those meals were after 12/7/21 even though she was care planned for 1:1 assistance at that time. 2 meals were charted for 12/16/21, one at 1:46 PM with 25% eaten and one at 1:47 PM with 75% eaten. Both were coded as the resident being totally dependent on staff. R10 Review of R10's face sheet revealed he originally admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's kardex revealed under food/fluids: 1:1 feeding assistance at all meals as resident allows .check mouth after meals for pocketed food and debris .instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew eat bite thoroughly . Review of R10's care plan revealed a focus area of ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, [CONDITION(S)], Impaired balance, Limited Mobility, Limited ROM (range of motion), Stroke) interventions include: EATING: 1:1 feeding assistance at all meals as resident allows. Under focus area [R10] has a potential for swallowing problems r/t Dysphagia interventions include: Alternate small bites and sips . check mouth after meals for pocketed food and debris . instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew eat bite thoroughly . Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Report to nurse and/or MD and adjust plan of care as indicated. Review of R10's progress notes for R10/3/21 revealed: .Resident prefers being fed his meals as he struggles to keep food on his utensil. Assisted with lunch today, he ate 100%. Will notify UM (unit manager) and SLP (Speech-Language Pathology) for possible evaluation. R11 Review of R11's face sheet revealed she was initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's kardex revealed under Food/fluids: Assist resident to consume food/fluids as resident allows; encourage self-feeding .The resident requires extensive assistance by 1 staff to eat Review of R11's care plan revealed a focus area ADL self-care performance deficit r/t Confusion, Fatigue, Impaired balance, Limited Mobility with interventions including EATING: The resident requires extensive assistance by 1 staff to eat . Under the focus area Nutritional status risk AEB (as evidenced by) dx (diagnosis) of .cognitive communication deficit .h/o (history of) dysphagia; self-feeding deficits r/t (related to) [CONDITION(S)] and tremors; need for feeding assistance and adaptive equipment . interventions include assist resident to consume food/fluids as resident allows . Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Report to nurse and/or MD and adjust plan of care as indicated. Review of R11's progress notes for R10/8/21 revealed: CNA reported to the the (sic) writer that resident has been noted holding food in her mouth, appetite has decreased . DPS #2 Based on observation interview and record review the facility failed to provide adequate staffing for 1 Resident (R8) to provided timely repositioning and incontinence care, resulting in R8 not being repositioned in over 2 hours and left soiled for over 4 hours. Findings include: Review of R8's face sheet dated 12/16/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 was his own responsibility party. Review of R8's Brief Interview of Mental Status (BIMS) score dated 11/18/21 revealed he scored 15/15 (normal cognition). On 12/17/21 at 9:55 AM, R8 was observed eating in bed. The head of his bed was elevated about 20 to 30 degrees. R8 was dropping a lot of his food in bed. His body was covered with a sheet. R8 said he had not been provided any care yet this morning. He was feeding himself. On 12/17/21 at 10:09 AM, CNA AA said she was assigned to R8 today and started work at 6:00 AM. CNA AA said the only care she had provided for R8 this morning was to reposition him around 6:00 AM. CNA AA said she was also responsible for residents on another hall. CNA AA said she was caring for 11 residents and was on a split hall. CNA AA said there was one on other CNA working with her that morning. During an interview with Unit Manager Z on 12/17/21 at 10:15 AM, she confirmed CNA AA was assigned to R8. CNA AA was assigned to care for 11 residents on the unit and 6 of the residents on the unit were care planned to need 2 people for care. The other CNA on the unit this morning was CNA X. During an interview with CNA X on 12/17/21 at 10:18 AM, CNA X said she had not provided any care for R8 this morning. R8 was observed in bed on 12/17/21 at 10:20 AM, CNA AA and Unit Manager Z rolled R8 in bed to remove his saturated brief and sheet. .

This citation refers to MI 948. Based on interview and record review, the facility failed to prevent, assess, and monitor pressure ulcers for 2 of 3 residents (R7 and 8), resulting in R7and R8 developing pressure ulcers and R7's and R8's pressure ulcers not being timely assessed and monitored and the potential for the facility not being aware of a worsening of R7's and R8's pressure ulcers and wounds, should it occur, and a delay in the implementation of new interventions, if warranted, in a timely manner. Findings include: A review of R7's Admission Record, dated 12/15/21, revealed R7 was an 87 -year-old resident admitted to the facility on [DATE]. In addition, R7's Admission Record revealed R7 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/21/21, revealed R7 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed R7 had short-term and long-term memory problems. In addition, R7's MDS revealed R7 had moderately impaired cognitive decision-making skills. R7's MDS also revealed R7 did not have any pressure ulcers or sores. A review of R7's impaired skin integrity care plan, revised 1/25/21, revealed R7 had impaired skin integrity related to decreased mobility, resistance to repositioning, incontinence of bowel and bladder (Date Initiated: 09/02/2020). R7's impaired skin integrity care plan also revealed an intervention of Elevate heels off bed surface while at rest in bed (Date Initiated: 10/26/2020). A review of R7's Skin & Wound Evaluations, dated 11/10/21 to 12/16/21, revealed the following: - Left heel- Stage 3 pressure ulcer (involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present). - 11/11/21= 4.1 cm (centimeters) x (by) 3.6 cm (length by width). Area= 11 cm2 (centimeters squared). - 11/18/21= 2.8 cm x 1.8 cm x 0.2 cm (length by width by depth). Area= 3.9 cm2. - 12/2/21= 0.9 cm x 0.3 cm x 0.1 cm. Area= 0.2 cm2. This measurement was done 14 days after the previous one. - 12/16/21= No open area. This measurement was done 14 days after the previous one. - Right heel- unstageable pressure ulcer (Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). -11/11/21= 3.2 cm x 2.6 cm. Area= 6.1 cm2. - 11/18/21 at 8:57 AM= 2.4 cm x 0.8 cm. Area= 1.2 cm2. - 11/18/21 at 8:59 AM= 2 cm x 1.2 cm. Area= 1.9 cm2. - 12/2/21= 0.6 cm x 0.4 cm x 0.2 cm. Area= 0.1 cm2. This measurement was done 14 days after the previous one. - 12/16/21= 1.1 cm x 0.7 cm. Area= 0.6 cm2. This measurement was done 14 days after the previous one. A review of R7's progress notes, dated 11/1/21 to 12/16/21, revealed the above mentioned measurements were also in the progress notes. In addition to the following note and measurement: - General Progress Note, dated 11/12/21, revealed, observed resident to have bilateral heels elevated up on pillows , heels had lotion on them, they were cracked open and tender to the touch left heel measured at - 5.3 cm x 4.4 cm x .2 cm deep, right heel measured at 5.6 cm x 4.3 cm x 1.4 cm deep, no drainage present, surrounding tissue dry and cracked, 70% pink, 30% eschar, treatment started, notifications completed, wound care to follow weekly on wound rounds, encourage resident to use heel bridge, and will have his bed length extended to help prevent his heels from resting on the foot board. A review of R7's Skin Observation Tools, dated 10/11/21 to 11/10/21, failed to reveal any skin alterations or wounds. R7's Skin Observation Tools revealed R7 had normal appearing skin and no new alterations in skin integrity including open areas of any type. During an interview on 12/15/21 at 2:45 PM, R7 stated he developed sores on his heels because they were laying on the bed. He stated when the staff were made aware of his pressure sores, they put them up on pillows. They keep them up on pillows now. During an interview on 12/16/21 at 11:10 AM, Registered Nurse Unit Manager (UM) N stated on 11/10/21, a nursing assistant filled out a skin alert note. She stated she (UM N) evaluated R7's wound and did measurements on 11/10/21. She stated R7 had wounds on his right heel and left heel (one each). UM N stated R7 was non-compliant with positioning, including being boosted up in be when he slides down towards the foot board. UM N stated she asked R7 if he knew how he developed the pressure ulcers on each heel. He told her he did not. UM N stated R7 probably developed the bilateral heel pressure ulcers because he would slide down in bed, refuse to be boosted/pulled up in bed, and his feet would rest on the foot boards. UM N stated on 11/10/21, she completed a Focused Incident Review for New or Worsened Pressure Ulcer/Injury form for R7's bilateral heel pressure ulcers and R7's wound measurements were 5.3 cm x 4.4 cm x 0.2 cm (left heel) and 5.6 cm x 4.3 cm x 1.4 cm (right heel). UM N stated that she locked (completed) R7's Focused Incident Review for New or Worsened Pressure Ulcer/Injury form on 11/12/21 and on that date the progress note was entered with the measurements she did. During an interview on 12/16/21 at 11:10 AM, UM N stated on 11/11/21, the wound team looked at R7's wounds and initiated treatments. However, prior to the wound team evaluating R7's pressure ulcers on 11/11/21, UM N stated she had initiated a heel bridge (a pillow-like object) to lift R7's heels off the bed and obtained a bed extension piece to extend R7's bed another three inches in length. UM N stated she obtained the bed extension piece because R7 refused to be boosted up in bed when he slides down and the extension will give him more feet room. She stated the bed extension piece was not a result of R7 being too tall for the bed. UM N also stated residents with pressure ulcers are assessed and measurements are done weekly. During an interview on 12/16/21 at 11:10 AM, UM N stated all of R7's wound measurements were in his progress notes and that there were not any other wound measurements anywhere else in his medical record. A review of the facility's Documentation of Wounds policy and procedure, revised on 2/1/21, revealed, 1. Wound assessments are documented upon admission, weekly, and as needed . 4. Additional documentation shall include, but is not limited to: a. Date and time of wound management treatments b. Weekly progress towards healing and/or effectiveness of current intervention . Review of R8's face sheet dated 12/16/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 was his own responsibility party. Review of R8's Brief Interview of Mental Status (BIMS) score dated 11/18/21 revealed he scored 15/15 (normal cognition). Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . When R8 returned to the facility he complained of persistent pain and a repeat x-ray showed an addition femur fracture. He returned to the hospital for a revision of his Open Reduction Internal Fixation (ORIF), surgical repair of the right femur. Under Assessment/Plan revealed, Change [MEDICATION(S)] to 5/325 TID (narcotic pain medication three times a day) as patients pain is not well controlled. He has mental illness and is not remembering to ask for pain medication. After skin revealed, Inspection and palpation (touch): warm and dry. No indication of skin break down. After musculoskeletal revealed, Right leg swelling greater than left leg. Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient recently had a right femur fracture. He is motivated, cooperative and is making good progress with therapy. He denies any pain, has no acute concerns. He is eating and sleeping well. Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient had a dressing on and he had a recent [CONDITION(S)]. Incision is very well approximated. Sutures are still in place. The patient thinks that his pain is much better than before. After plan revealed, 1. encourage pt (patient) to limit his time in chair to 2 hours. 2. Pain in right hip joint- externally rotated. Patient instructions. Continue current treatment. Review of R8's physician note dated 12/6/21 at 2:10 PM revealed, R8 is seen today for evaluation of the patient for complaints of pain. He had a femur fracture. The patient has less pain when he is in bed. His leg is still externally rotated. We are attempting to procure specialized shoes that he is able to maintain his right lower extremity in an anatomical position. At this time, I would like to start him on [MEDICATION(S)] patch in an effort to reduce the effect of narcotic pain medicine and also start him on muscle relaxant in an effort to improve PT and OT to work with the patient. His lower extremity [CONDITION(S)] is much improved. He is alert, awake, confused, in no acute distress. He denies any acute problem. He is painful when he is able to bear weight. No mention of pressure ulcer on right lower extremity. Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . I have been asked to evaluate the patient for increased pain and discomfort. Patient has a history of right femur fracture and is currently on [MEDICATION(S)] 3-325 TID (narcotic pain medication 3 times a day). Patient is seen lying in bed. He denies any current pain. He denies hip pain however does mention that he experiences occasional pain in his right knee. He denies knee pain at this moment. Nursing reports that the patient was exhibiting pain this morning during care and repositioning however, nurse says he has just receive a pain pill prior to care and it may not have taken affect at that time. Nursing also mentions that the patients right hip pain is well controlled with a [MEDICATION(S)] patch and is requesting a [MEDICATION(S)] patch for the patients right knee. Review of R8's Skin & Wound Evaluation dated 12/2/21 at 9:17 AM revealed, he had a new unstageable ulcer on his right lateral malleolus that measured 7.3 cm x 4.1 cm x 2.5 cm and was 0.1 cm deep. Review of a pressure ulcer report for R8 dated 11/27/21 at 10:05 AM revealed, Therapist reported to this nurse, an open area on the outer right ankle area. 4.5 cm in length 5.5 cm in width. Some serosanguino (sp) drainage (fluid containing blood) drainage noted on linen. Right leg is externally rotated with no tolerance of correcting this position. Resident was unaware of open area on right ankle. After notes revealed, 11/29/21 Wound nurse to examine to determine if pressure related. 12/10/21 Root Cause: Related to resident having recent surgery with external rotation noted. Bed and wheelchair checked for any sharp surfaces and none noted. [CONDITION(S)] to lower leg noted to be contributing factor. Wound team following. Boot and positioning in devices in place. Ordered positioning device for positioning. Therapy to assess for any further positioning recommendations. Review of R8's care plan revealed a care plan for actual impairment to skin integrity related to current break in skin integrity, multiple incision sites to his right lower extremity and pressure injury to his right lateral ankle. Date initiated was 10/26/21 and last revision was on 12/2/21. Interventions included, 12/17/21 position pillow to be place mid back when lying on side. 12/2/21 Prevalon boot with outer wedge to right foot when in bed as tolerated, 12/17/21 resident needs pressure reduction interventions: positioning pillow between knees when side lying and while turning resident. Review of R8's care plan for limited physical mobility related to weakness and history of right fibula fracture date initiated 5/28/19 and last revision on 12/16/21 revealed, 9/17/21 The resident is NON WEIGHT BEARING TO RLE (right lower extremity) and FULL WEIGHT BEARING to LLE (left lower extremity). 10/28/21 Bed Mobility: resident requires assistance of one staff member. (All observations 12/17/21 to 12/21/21 R8 required the assistance of 2 staff for bed mobility). 12/22/20 Locomotion: The resident uses a two wheeled walker for locomotion (R8 was not able to stand and was not able to bear weight on his right leg). Review of R8's care plan for chronic pain dated initiated 1/14/21 and revision on 11/12/21 revealed, 5/29/19 Administer [MEDICATION(S)] per physician orders. Anticipate and treat before, during, and after treatment tat may cause increased pain or discomfort. Review of R8's Kardex dated 12/19/21 revealed he required assistance of one person for bed mobility. However, all observations of care for R8 from 12/17/21 to 12/21/21 R8's had 2 people assisting him with movement in bed as his right leg was very painful and he was not able to move his right leg without assistance. R8 also required physical assistance to roll and two people to pull him up in bed. Review of R8's IDT (interdisciplinary note) dated 12/20/21 revealed, Heal suspension boot discontinued, AMP (alternating pressure mattress) in place now. Care plan did not reflect these changes. Review of R8's wound timeline provided by the facility revealed the following measurements: 11/27/21 - 4.5 cm x 5 x 5 cm 12/2/21 - 7.3 cm x 4.1 cm x 2.5 cm 12/9/21 3.2 cm x 2.5 cm x 1.7 cm 12/17/21 2.8 cm x 3.2 cm x UTD (undermined depth). The last Skin & Wound evaluation located in R8's record and provided by the facility was dated 12/9/21 and revealed a facility acquired, unstageable pressure ulcer on R8's right lateral malleolus that measured 3.2 cm x 2.5 cm x 1.7 cm and was 0.2 depth. Assessments did not indicate any drainage. On 12/17/21 at 9:55 AM, R8 was observed eating in bed. The head of his bed was elevated about 20 to 30 degrees. R8 was dropping a lot of his food in bed. His body was covered with a sheet. R8 said he had not been provided any care yet this morning. He was feeding himself. On 12/17/21 at 10:09 AM CNA AA said she was assigned to R8 today and started work at 6:00 AM. CNA AA said the only care she had provided for R8 this morning was to reposition him around 6:00 AM. CNA AA said she was also responsible for residents on another hall. CNA AA said she was caring for 11 residents and was on a split hall. CNA AA said there was one on other CNA working with her that morning. During an interview with Unit Manager Z on 12/17/21 at 10:15 AM, she confirmed CNA AA was assigned to R8. CNA AA was assigned to care for 11 residents on the unit and 6 of the residents on the unit were care planned to need 2 people for care. The other CNA on the unit this morning was CNA X. During an interview with CNA X on 12/17/21 at 10:18 AM, CNA X said she had not provided any care for R8 this morning. R8 was observed in bed on 12/17/21 at 10:20 AM, R8 had a dressing on his right hip over his surgical incision with no date or initials, he had a [MEDICATION(S)] patch on his right thigh and a dressing on his right lower leg just above his malleolus with no date or initials. The dressings did not have any drainage showing through. Unit Manager Z removed the dressing on his right hip and the incision under the dressing had red areas on the boarder and an indentation about approximately .5 cm in length at the distal end of the incision. No dressing was placed back over R8's incision on his right hip. No drainage was observed on the dressing that was removed. CNA AA and Unit Manager Z rolled R8 in bed to remove his saturated brief and sheet. R8 grimaced and hit his fisted hands on the mattress with movement. R8 did not yell out in pain or ask staff to stop moving him. Urine had soak through to his sheet. R8 did yell out in pain at times when staff were moving his right leg to provide care and positioning. During care R 10 said his pain was at 10 on a 1-10 scale when he was asked. When pulling back the boot on R8's foot a 1-inch indentation was noted in his skin below the top of the boot. The boot was fastened with a Velcro strap (1 inch pitting [CONDITION(S)]). When CNA AA and the unit manager rolled R8 in bed they did not support his right leg. R8 indicated his pain was in his right leg. CNA AA said when she came in at 6:00 AM R8 was positioned toward his right side, and she moved the pillow to allow him to be on his back for breakfast. CNA AA and Unit Manager Z placed wedge cushion under R8's right hip and kept the boot fastened on his right foot. On 10/17/21 at approximately 11:00 AM, Physical Therapist Assistant (PTA) BB came in to provided care for R8. Unit Manager Z was still in the room. The Surveyor asked PTA BB if anything could be done to decrease pain in the right leg during movement, how she would instruct staff to do pressure relief in bed and if R8's circulation was being impaired by the boot on his right leg. PTA BB confirmed the boot was causing the indentation on the right foot and need to be replaced by some other device to provide pressure relief and positioning. PTA BB said they had a device on order, but it had not arrived. PTA BB removed the boot and placed a pillow under R8 calf. PTA BB demonstrated and instructed Unit Manager Z to use a pillow between R8's legs when rolling him (log roll). PTA BB instructed Unit Manager Z to place the pillow or wedge behind R8's back (not his hip) when positioning him to his side. (avoid bony areas with positioning devices). R8 complained of less pain with this movement than he did during the observation at 10:20 AM. R8 was able to let staff know he had less pain when he was log rolled in bed and his right leg was supported but he still had a lot of pain with movement. On 12/17/21 at 11:25 AM the Surveyor emailed the Director of Nursing (DON) to inform her R8's boot on his right foot caused 1 inch pitting [CONDITION(S)], he was complaining of pain at a 10 on 1-10 scale with movement, staff were having difficulty with providing pressure relief due to pillows placed over bony areas, resident was left soaked in urine for over 4 hours and was not provided any pressure relief for 3 hours. Around noon on 12/17/21 the DON acknowledged receiving the email about R8 and said she would address the issues. The DON did not respond to this email or provide any different information. On 12/21/21 at 8:47 AM R8 was observed up in a wheelchair in the main dining room on his unit. R8's left foot was on a foot pedal and his right foot was on the floor. R8 had gripper socks on both feet. R8's dressing on his right lower leg was visibly soiled. R8 said he had been up in his wheelchair since around 6 or 7 this morning. R8 said his right knee and ankle hurt. R8 was served breakfast at 8:51 AM. On 12/21/21 at 9:17 AM, PTA BB came in the Main Dining room and removed R8's right leg rest from his chair. When PTA BB moved R8's leg to remove the leg rest she grabbed his leg with her bare hand right over his dressing on the right lower leg that was visible soiled. PTA BB returned to put a leg rest back on R8's wheelchair at 9:29 AM and R8's said it this leg rest felt better. R8's pushed his wheelchair with both arms to the door of the main dining room than requested assistance to get out the door and back to his room. PTA BB was planning on doing therapy at this time but R8 reported his pain was 10 out of 1 - 10. PTA BB checked with LPN CC to see if R8 could get anything for pain. LPN CC said R8 had [MEDICATION(S)] at 8:08 AM and had his [MEDICATION(S)] patch so he did not have any thing else she could give at this time. LPN CC said R8's nurse would need to contact the doctor. On 12/21/21 at 10:21 AM, the Director of Nursing (DON) informed staff she had contacted R8's doctor and he now had a order for prn (as need) [MEDICATION(S)] and they could give it now. On 12/21/21 at approximately 11:00 AM CNA B and CNA DD used an electronic lift to put R8 back in bed. R8 grimaced with pain during the transfer. He made fists with both hands and shook his arms but did not yell out in pain or complain during the transfer. He again reported a 10 with pain during movement but reported his pain was 5 when he was not moving in bed. On 12/21/21 at 11: 35 AM LPN EE said she put the dressing on R8's right ankle at 7:15 AM this morning. LPN EE showed where she had written with a light ink pen the date, time and her initials. The dressing was saturated all the way through. There was a large letter C shape in the bloody drainage of the dressing she removed. The wound was facing the mattress so the Surveyor was not able to see the wound. R8 was having too much pain to change his position to allow the Surveyor to view his ankle wound. The Surveyor pointed out that R8 had a dressing over his right hip incision with no date, time or initials. LPN EE said she did not know anything about that dressing. A few minutes later Unit Manager Z arrive at R8's room and said the dressing should not be on R8's right hip. LPN EE removed the dressing on R8's right hip and a ½ saturated area was noted on the dressing. The distal area of the incision that had an indentation in it when the undated dressing was removed on 12/17/21 at 10:20 AM. Unit Manager Z was not able to locate any documentation that showed when R8's incision on his right hip started draining, or when the wound on his right ankle started having drainage. Unit Manager Z said she would get new orders for a dressing over R8's right hip. During an interview with the DON on 12/20/21 around noon, the DON was not aware R8's incision on his right hip was draining, she was not aware the dressing on his right ankle was saturated. The DON was asked for all documentation on R8's wounds. Upon exit on 12/21/21 the facility did not provide any documentation that showed they were aware the right hip wound was draining, they had no documentation of who put the dressing on the right hip, they had no full assessment documented or notes on the full condition of R8's right ankle since 12/9/21. None of the documents located from 12/9/21 or after indicated the wound on R8's right ankle was draining.

This citation refers to MI 948, MI 429, and MI 983. Based on interview and record review, the facility failed to implement and operationalize care plans for 5 residents (R6, R7, R8, R10, and R11), resulting in R7 and R8 developing pressure ulcers and the potential for the development of serious complications (e.g. infection, declining health status) from the pressure ulcers,and resulting in R6 having significant weight loss and R6, R10, R11 being at risk for future weight loss and choking hazards due to lack of feeding support. R8 having poor pain control and poor tolerance to activity due to pain. Findings include: R7 A review of R7's Admission Record, dated 12/15/21, revealed R7 was an 87 -year-old resident admitted to the facility on [DATE]. In addition, R7's Admission Record revealed R7 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/21/21, revealed R7 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed R7 had short-term and long-term memory problems. In addition, R7's MDS revealed R7 had moderately impaired cognitive decision-making skills. R7's MDS also revealed R7 did not have any pressure ulcers or sores. A review of R7's impaired skin integrity care plan, revised 1/25/21, revealed R7 had impaired skin integrity related to decreased mobility, resistance to repositioning, incontinence of bowel and bladder (Date Initiated: 09/02/2020). R7's impaired skin integrity care plan also revealed an intervention of Elevate heels off bed surface while at rest in bed (Date Initiated: 10/26/2020). A review of R7's Skin & Wound Evaluations, dated 11/11/21, revealed the following: - Left heel- Stage 3 pressure ulcer (involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present). - 11/11/21= 4.1 cm (centimeters) x (by) 3.6 cm (length by width). Area= 11 cm2 (centimeters squared). - Right heel- unstageable pressure ulcer (Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). -11/11/21= 3.2 cm x 2.6 cm. Area= 6.1 cm2. A review of R7's General Progress Note, dated 11/12/21, revealed, observed resident to have bilateral heels elevated up on pillows , heels had lotion on them, they were cracked open and tender to the touch left heel measured at - 5.3 cm x 4.4 cm x .2 cm deep, right heel measured at 5.6 cm x 4.3 cm x 1.4 cm deep, no drainage present, surrounding tissue dry and cracked, 70% pink, 30% eschar, treatment started, notifications completed, wound care to follow weekly on wound rounds, encourage resident to use heel bridge, and will have his bed length extended to help prevent his heels from resting on the foot board. A review of R7's Skin Observation Tools, dated 10/11/21 to 11/10/21, failed to reveal any skin alterations or wounds. R7's Skin Observation Tools revealed R7 had normal appearing skin and no new alterations in skin integrity including open areas of any type. During an interview on 12/15/21 at 2:45 PM, R7 stated he developed sores on his heels because they were laying on the bed. He stated when the staff were made aware of his pressure sores, they put them up on pillows. They keep them up on pillows now. During an interview on 12/16/21 at 11:10 AM, Registered Nurse Unit Manager (UM) N stated on 11/10/21, a nursing assistant filled out a skin alert note. She stated she (UM N) evaluated R7's wound and did measurements on 11/10/21. She stated R7 had wounds on his right heel and left heel (one each). UM N stated R7 was non-compliant with positioning, including being boosted up in bed when he slides down towards the foot board. UM N stated she asked R7 if he knew how he developed the pressure ulcers on each heel. He told her he did not. UM N stated R7 probably developed the bilateral heel pressure ulcers because he would slide down in bed, refused to be boosted/pulled up in bed, and his feet would rest on the foot boards. UM N stated on 11/10/21, she completed a Focused Incident Review for New or Worsened Pressure Ulcer/Injury form for R7's bilateral heel pressure ulcers and R7's wound measurements were 5.3 cm x 4.4 cm x 0.2 cm (left heel) and 5.6 cm x 4.3 cm x 1.4 cm (right heel). UM N stated that she locked (completed) R7's Focused Incident Review for New or Worsened Pressure Ulcer/Injury form on 11/12/21 and on that date the progress note was entered with the measurements she did. Review of facility policy with the subject Weight Management with adopted date 9/11/20 revealed weight loss is defined as: significant weight loss (5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months) . should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the cause(s) of weight loss .once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed. The procedure includes the resident being weighed monthly and as needed .Monthly weights are to be completed by the 7th day of each month and reviewed by the Nutrition Committee within a reasonable period of time thereafter .any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of the weight gain/loss and the intervention(s) required .any resident meeting the criteria for weight loss .will be weighed weekly, with the weight entered in the resident's medical record . Review of the facility policy with the subject Nutrition Monitoring & Management Program with the adopted date of 7/11/18 revealed a purpose: To provide care and services including .defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice .monitoring and evaluating the resident's response or lack of response to the interventions . Dietary evaluations are assessed on admission and at least quarterly thereafter, and following a change in condition. R6 Review of R6's face sheet revealed she had originally admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's kardex revealed under food/fluids: 1:1 feeding assistance at all meals . check mouth after meal for pocketed foods and debris . instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly . There is a conflicting entry in the kardex, which stated R 6 is able to eat independently. Under the section special needs weight is noted to be taken weekly as well as monthly. Review of R6's care plan revealed under the focus ADL (activities of daily living) self-care deficit r/t (related to) weakness, confusion, impaired balance, limited mobility an intervention that states The resident is able to: eat independently with an initiation date of 4/27/20. Under the focus area: [R6] has a Nutritional status risk AEB (as evidenced by) Dx (diagnosis) of .dementia . dysphagia w/ need for altered textured diet/fluids in place; chronic variable po (by mouth) intake; h/o (history of) wt (weight) fluctuations; and advanced age with interventions that included: 1:1 feeding assistance at all meals with an initiated date of 12/7/21, Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of dysphagia ., review routine weights, and weigh resident per facility protocol . Under the focus area has a swallowing problem r/t (related to) dysphagia, poor dentition interventions included: check mouth after meal for pocketed food and debris ., instruct, assist and/or encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly, and Monitor for .choking . Review of physician note from 11/22/21 revealed R6 was being seen for a complaint of weight loss. Lab work, dietary evaluation and weekly weight checks to further monitor weight loss were ordered. On 12/16/21 at approximately 8:35 AM, no staff other than a housekeeper were observed on the 400 hall or in resident rooms and residents were eating breakfast. R6 was observed in her room, not being assisted with her meal. One of her roommates had completely finished their meal at this time and the other roommate was about half complete in consuming her meal. R6 was viewed to have her food untouched and had a glass of clear red honey thick liquid to her mouth with her eyes closed. R6 was approached and appeared to be asleep with the glass to her mouth. She did not respond to verbal attempts to get her attention for about a minute. R6's shoulder was rubbed when speaking to her and she slowly opened her eyes, but kept the glass to her lips briefly and then slowly lowered it. R6 continued to not respond verbally and looked around the room with confusion, not making eye contact. A discussion was completed with R6's roommate, who stated that usually someone will come help R6 at with her meal, but they don't usually assist her until later, so someone may come back to help her. Conversation was attempted again with R 6 and she was not communicative and did not make eye contact. Upon exiting the room and walking the hall again, no staff other than housekeeping was viewed on the hall or in resident rooms. R6 was watched from the hall consuming her breakfast. She took a limited amount of very small bites, moving very slowly. At approximately 8:47 AM, a CNA (certified nursing assistant) entered the hall and appeared to have gotten additional food from the kitchen for a resident and delivered it to their rooms. At 8:52 AM CNA X entered the room of R 10. At 8:55 AM CNA X exited R10's room with their meal tray and then went into R 11's room. At 8:58 AM CNA X exited R11's room with their meal tray and then entered the room of R 6. CNA X was viewed to briefly check on R6 and walked away as she was viewed to be very slowly feeding herself. CNA X was in the room with R6 for approximately 2 minutes. CNA X was asked if she was the only aide assigned to the hall that morning and she stated yes, I am the only one on the hall, it's like this every day. CNA X was asked if anyone on the hall needed feeding assistance and she said at least 3 and pointed to the rooms of R6, R10, and R11. CNA X was asked specifically about R6 and her needs. CNA X stated she seems to be doing good now, but you have to keep checking on her to make sure she's not choking. But she is doing good on her own today. CNA X was asked how she managed to assist 3 residents at once who needed feeding assistance and she stated that she just has to keep going back and forth between them. On 12/16/21 at 10:50 AM, an interview was completed with Dietician Y regarding R6's nutritional status. Dietician Y stated R6 has had weight loss recently and overall a decline and had a downgrade in her swallowing ability. The dietary plan was to add supplements to meals as well as provide feeding assistance to R6. Dietician Y stated R6 can feed herself at times, but that staff usually need to initiate feeding and provide encouragement. The food acceptance logs for R6 were reviewed with Dietician Y and she stated it appears R6's acceptance increases when she has staff assistance. Dietician Y agreed there were some holes in the food acceptance documentation and stated she would expect each meal to be documented. Dietician Ys stated R6 was placed on weekly weights as of 11/23/21, this was discontinued for some reason, but reordered on 12/6/21. Weekly weights were ordered to be completed on Mondays for 4 weeks. Dietician Y stated she is also completing weekly dietary evaluations of R 6 due to the significant weight loss, which would include reviewing her intake and weights. Dietician Y was asked how she completed her review of R6 on 12/14/21 (a Tuesday) if R6's weekly weight was missed on 12/13/21 (Monday). Dietician Y stated it does appear R6 needed another weight to be completed. Dietician Y was informed missing the weekly weight was concerning and also informed R6 was not viewed to be getting assistance with her breakfast meal. On 12/16/21 at 12:08 PM, lunch meal trays were observed to begin to be delivered to the 400 hall. R6 was viewed to be asleep in bed. There were between 2 to 3 CNA staff on the hall at various times delivering the meal trays to residents in their rooms. At 12:13 PM a CNA entered R6's room to deliver her tray. They elevated R 6 in bed, set up her meal and then exited the room by 12:17 PM without assisting the resident to begin eating. At 12:21 PM, R6 had yet to take a bit and the surveyor entered the room. R6 was asked how she was today and how her meal was. R6 stared blankly at the surveyor and then slowly took one small bite of ice cream. Upon exiting R6's room at 12:23 PM, it was viewed that no staff were in the hall and a nurse was completing medication pass. There were 2 staff in the dining room area and 1 staff was assisting a resident with their meal. At 12:28 PM, Nurse Z returned to the hall. R6 was not eating any further bites of food. At 12:31 PM Nurse Z entered R6's room with medications and asked R6 if she needed help. At this time the resident took one more very slow bite of ice cream. Nurse Z appeared to be looking for another staff member and came across CNA X briefly exiting the dining room, Nurse Z asked CNA X to assist R6 with lunch. CNA X stated she could not because she was assisting residents in the dining room and was overheard saying she [R6] did not do great at breakfast. Nurse Z then left the hall and there was not any nursing staff on the hall for about 3 minutes. Nurse Z then returned to the hall and to R6's room and began to assist her with eating at approximately 12:35 PM. On 12/16/21 at 12:03 PM, an email request was made to the director of nursing (DON) and nursing home administrator (NHA) requesting the staff covering the 400 hall for the morning of 12/16/21, since the schedule appeared to be unclear. The DON responded by email on 12/16/21 at 12:08 PM that 2 CNAs and one nurse were assigned to the hall for that shift. During a follow up interview on 12/16/21 at 3:20 PM, the DON and NHA were informed of the lack of staff viewed on the hall during meal service that day, which was concerning with there being at least 3 identified residents who required 1:1 assistance with meals due to choking hazards and/or weight loss. The DON and NHA were informed of the extensive concerns rising to a level of immediate jeopardy with R6's weight loss and lack of interventions being implemented. On 12/17/21 at 9:05 AM, R6 was viewed being transported to the dining room in her wheelchair by staff. She was viewed to be attached to a bag of IV fluids and was smiling and making eye contact. On 12/17/21 at 9:55 AM Unit Manager (UM) Z was observed feeding R6 in the main dining room. R6 had an IV in her arm. The Surveyor asked R6 how her food tasted, and she responded, I do not know. R6's had her eyes wide open and was watching UM Z. When the spoon came to her mouth, she opened it without cueing. On 12/21/21 at 9:00 AM, UM Z was observed feeding R6 in the main dining room. R6 did not have an IV running. UM Z was giving R6 spoonfuls of thickened cranberry juice. R6 had her eyes open and did not need verbal cues to open her mouth when the spoon reached her lips. The Surveyor asked R6 how her food tasted, and she responded good. Review of R6's weights revealed the following weights in the last approximately 3 months: 9/2/21 127.6 pounds, 10/1/21 125.6 pounds, 11/17/21 116.6 pounds, 12/1/21 109.0 pounds, 12/6/21 109.0 pounds, 12/16/21 106.3 pounds, 12/20/21 105.1 pounds. Between 10/1/21 and 11/17/21 (1 month) sustained a 7.1 % weight loss. Between 11/17/21 and 12/1/21 (2 weeks) R6 sustained another 6.5% weight loss. Between 9/2/21 and 12/1/21 (3 months) R6 sustained a 14.5% weight loss. The monthly weight in November was completed late during a time period where R6 sustained a significant weight loss and weekly weights were missed the week of 11/29/21 and 12/13/21 where R6 continued to lose weight. Review of R6's progress notes revealed no dietary progress notes from 5/17/21 until 11/18/21. A nutrition progress note from 11/18/21 revealed: Resident triggered a 8.6% significant wt loss x1.5mo with her CBW (current body weight) at 117# (11/17) and BMI 22.0. Wt hx reviewed: 126# (10/1), 127# (8/3), and 125# (5/2) . Meal intake reviewed which remains fair, consuming 60% on average over a 14-day lookback period. She is supplemented with House Shake . Will increase her supplement to TID to support wt maintenance. MD notified of significant wt loss as well. A nutrition progress note for 11/23/21 revealed: Weekly Review: Resident's meal intake remains fair, consuming 56% on average over the past week. She is provided with House Shake supplement TID (three times a day) (200kcals, 6g pro each) for increased kcal and nutrient intake. Noted orders for weekly wts to monitor trends. Will continue with all other nutrition interventions in place and continue to monitor resident weekly and PRN for changes A nutrition progress note for 11/30/21 revealed: Weekly Review: Resident's meal intake remains fair, consuming 55% on average over the past week. She continues to have good acceptance of her House Shake supplement provided TID (200kcals, 6g pro each) for increased kcal and nutrient intake. Goal po (by mouth) intake is >60% average and prevent ongoing wt loss. Will continue with current nutrition interventions in place and monitor resident weekly and PRN (as needed) for changes. A nutrition progress note from 12/2/21 revealed Resident's weight obtained and is triggering a 7.6% significant wt loss x2wk. Her CBW (current body weight) is 109# (12/1) and BMI 20.6. Wt hx reviewed: 117# (11/17), 128# (9/2) and 123# (6/3). Recommend Enhanced foods to maximize kcal intake. Will continue with all other nutrition interventions in place and continue to monitor trends weekly x4wks and PRN (as needed) for further changes. If decline continues, resident may benefit from alternative means of nutrition vs. comfort care. A behavior progress note from 12/7/21 revealed Note Text: Resident alert with confusion. Not engaged with staff today. Resisted am cares and refused medications this morning. Resident is now a 'feed' due to poor intake, as seen by recent weight loss. Noted drooling and coughing while feeding in up right position of 45+ degrees. Speech therapist in with resident and downgrading fluids to honey thick. Provider notified. Resident staying in bed today per her choice. A nutrition note for 12/7/21 revealed: Resident's diet has been downgraded to Honey-thickened liquids with recommendations for 1:1 feeding assistance at all meals per SLP (speech-language pathology). Supplement updated to Nutritional Treat TID (3 times a day) (300kcals, 11g pro each) in place of House Shakes for appropriate consistency and increased kcal intake. A nutrition note from 12/14/21 revealed: Resident's meal intake remains fair/poor, consuming only 35% on average over the past week. She is accepting of most supplements and fluids throughout the day. She is provided with Nutritional Treat TID (300kcals, 11g pro each) for increased kcal and nutrient intake. Supplement updated from House Shake d/t downgrade to HTL (honey thick liquids). Noted referral for hospice care in place. PO (by mouth) intake anticipated to remain variable given overall decline. Will continue to monitor weekly and PRN (as needed) for further changes. A general progress note from 12/16/21 revealed: A hydration assessment was completed on this resident. She presented with dry [MEDICATION(S)] membranes. Her skin turgor is poor and tenting . Physician on-call [name of physician] notified. Order received for one liter of NS (normal saline) to be ran @ 100cc/hr. IV started in resident's left forearm. Site is patent and is infusing well. Review of R6's meal intake records for the last 30 days (from 11/17/21 to 12/16/21) revealed 11 days when only 2 meals were charted and 6 days when only 1 meal was charted. The entries did not indicate what meal was being charted. Approximately 37 of the meals charted stated the resident was independent with eating with no staff oversight or help at any time (8 of those meals were after 12/7/21 even though she was care planned for 1:1 assistance at that time and 2 meals were charted for 12/16/21- one at 1:46 PM with 25% eaten and one at 1:47 PM- with 75% eaten. Both were coded as the resident being totally dependent on staff). R10 Review of R10's face sheet revealed he originally admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's kardex revealed under food/fluids: 1:1 feeding assistance at all meals as resident allows .check mouth after meals for pocketed food and debris .instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew eat bite thoroughly . Review of R10's care plan revealed a focus area of ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, [CONDITION(S)], Impaired balance, Limited Mobility, Limited ROM (range of motion), Stroke) interventions include: EATING: 1:1 feeding assistance at all meals as resident allows. Under focus area [R 10] has a potential for swallowing problems r/t Dysphagia interventions include: Alternate small bites and sips . check mouth after meals for pocketed food and debris . instruct, assist, and/or encourage resident to eat in an upright position, to eat slowly, and to chew eat bite thoroughly . Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Report to nurse and/or MD and adjust plan of care as indicated. Review of R10's progress notes for 10/3/21 revealed: .Resident prefers being fed his meals as he struggles to keep food on his utensil. Assisted with lunch today, he ate 100%. Will notify UM (unit manager) and SLP (Speech-Language Pathology) for possible evaluation. R11 Review of R11's face sheet revealed she was initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's kardex revealed under Food/fluids: Assist resident to consume food/fluids as resident allows; encourage self-feeding .The resident requires extensive assistance by 1 staff to eat Review of R11's care plan revealed a focus area ADL self-care performance deficit r/t Confusion, Fatigue, Impaired balance, Limited Mobility with interventions including EATING: The resident requires extensive assistance by 1 staff to eat . Under the focus area Nutritional status risk AEB (as evidenced by) dx (diagnosis) of .cognitive communication deficit .h/o (history of) dysphagia; self-feeding deficits r/t (related to) [CONDITION(S)] and tremors; need for feeding assistance and adaptive equipment . interventions include assist resident to consume food/fluids as resident allows . Monitor/document/report PRN (as needed) and s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Report to nurse and/or MD and adjust plan of care as indicated. Review of R11's progress notes for 10/8/21 revealed: CNA reported to the the (sic) writer that resident has been noted holding food in her mouth, appetite has decreased . Review of R8's face sheet dated 12/16/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 was his own responsibility party. Review of R8's Brief Interview of Mental Status (BIMS) score dated 11/18/21 revealed he scored 15/15 (normal cognition). Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . When R 8 returned to the facility he complained of persistent pain and a repeat x-ray showed an addition femur fracture. He returned to the hospital for a revision of his Open Reduction Internal Fixation (ORIF), surgical repair of the right femur. Under Assessment/Plan revealed, Change [MEDICATION(S)] to 5/325 TID (narcotic pain medication three times a day) as patients pain is not well controlled. He has mental illness and is not remembering to ask for pain medication. After skin revealed, Inspection and palpation (touch): warm and dry. No indication of skin break down. After musculoskeletal revealed, Right leg swelling greater than left leg. Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient recently had a right femur fracture. He is motivated, cooperative and is making good progress with therapy. He denies any pain, has no acute concerns. He is eating and sleeping well. Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient had a dressing on and he had a recent [CONDITION(S)]. Incision is very well approximated. Sutures are still in place. The patient thinks that his pain is much better than before. After plan revealed, 1. encourage pt (patient) to limit his time in chair to 2 hours. 2. Pain in right hip joint- externally rotated. Patient instructions. Continue current treatment. Review of R8's physician note dated 12/6/21 at 2:10 PM revealed, R8 is seen today for evaluation of the patient for complaints of pain. He had a femur fracture. The patient has less pain when he is in bed. His leg is still externally rotated. We are attempting to procure specialized shoes that he is able to maintain his right lower extremity in an anatomical position. At this time, I would like to start him on [MEDICATION(S)] patch in an effort to reduce the effect of narcotic pain medicine and also start him on muscle relaxant in an effort to improve PT and OT to work with the patient. His lower extremity [CONDITION(S)] is much improved. He is alert, awake, confused, in no acute distress. He denies any acute problem. He is painful when he is able to bear weight. No mention of pressure ulcer on right lower extremity. Review of R8's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . I have been asked to evaluate the patient for increased pain and discomfort. Patient has a history of right femur fracture and is currently on [MEDICATION(S)] 3-325 TID (narcotic pain medication 3 times a day). Patient is seen lying in bed. He denies any current pain. He denies hip pain however does mention that he experiences occasional pain in his right knee. He denies knee pain at this moment. Nursing reports that the patient was exhibiting pain this morning during care and repositioning however, nurse says he has just receive a pain pill prior to care and it may not have taken affect at that time. Nursing also mentions that the patients right hip pain is well controlled with a [MEDICATION(S)] patch and is requesting a [MEDICATION(S)] patch for the patients right knee. Review of R8's Skin & Wound Evaluation dated 12/2/21 at 9:17 AM revealed, he had a new unstageable ulcer on his right lateral malleolus that measured 7.3 cm x 4.1 cm x 2.5 cm and was 0.1 cm deep. Review of a pressure ulcer report for R8 dated 11/27/21 at 10:05 AM revealed, Therapist reported to this nurse, an open area on the outer right ankle area. 4.5 cm in length 5.5 cm in width. Some serosanguino (sp) drainage (fluid containing blood) drainage noted on linen. Right leg is externally rotated with no tolerance of correcting this position. Resident was unaware of open area on right ankle. After notes revealed, 11/29/21 Wound nurse to examine to determine if pressure related. 12/10/21 Root Cause: Related to resident having recent surger with external rotation noted. Bed and wheelchair checked for any sharp surfaces and none noted. [CONDITION(S)] to lower leg noted to be contributing factor. Wound team following. Boot and positioning in devices in place. Ordered positioning device for positioning. Therapy to assess for any further positioning recommendations. Review of R8's care plan revealed a care plan for actual impairment to skin integrity related to current break in skin integrity, multiple incision sites to his right lower extremity and pressure injury to his right lateral ankle. Date initiated was 10/26/21 and last revision was on 12/2/21. Interventions included, 12/17/21 position pillow to be place mid back when lying on side. 12/2/21 Prevalon boot with outer wedge to right foot when in bed as tolerated, 12/17/21 resident needs pressure reduction interventions: positioning pillow between knees when side lying and while turning resident. Review of R8's care plan for limited physical mobility related to weakness and history of right fibula fracture date initiated 5/28/19 and last revision on 12/16/21 revealed, 9/17/21 The resident is NON WEIGHT BEARING TO RLE (right lower extremity) and FULL WEIGHT BEARING to LLE (left lower extremity). 10/28/21 Bed Mobility: resident requires assistance of one staff member. (All observations 12/17/21 to 12/21/21 R 8 required the assistance of 2 staff for bed mobility). 12/22/20 Locomotion: The resident uses a two wheeled walker for locomotion (R 8 was not able to stand and was not able to bear weight on his right leg). Review of R8's care plan for chronic pain dated initiated 1/14/21 and revision on 11/12/21 revealed, 5/29/19 Administer [MEDICATION(S)] per physician orders. Anticipate and treat before, during, and after treatment tat may cause increased pain or discomfort. Review of R8's Kardex dated 12/19/21 revealed he required assistance of one person for bed mobility. However, all observations of care for R8 from 12/17/21 to 12/21/21 R8's had 2 people assisting him with movement in bed as his right leg was very painful and he was not able to move his right leg without assistance. R8 also required physical assistance to roll and two people to pull him up in bed. Review of R8's IDT (interdisciplinary note) dated 12/20/21 revealed, Heal suspension boot discontinued, AMP (alternating pressure mattress) in place now. Care plan did not reflect these changes. Review of R8's wound timeline provided by the facility revealed the following measurements: 11/27/21 - 4.5 cm x 5 x 5 cm 12/2/21 - 7.3 cm x 4.1 cm x 2.5 cm 12/9/21 3.2 cm x 2.5 cm x 1.7 cm 12/17/21 2.8 cm x 3.2 cm x UTD (undermined depth). The last Skin & Wound evaluation located in R8's record and provided by the facility was dated 12/9/21 and revealed a facility acquired, unstageable pressure ulcer on R8's right lateral malleolus that measured 3.2 cm x 2.5 cm x 1.7 cm and was 0.2 depth. Assessment [TRUNCATED]

This Citation pertains to Intake Number MI 984. Based on observation, interview and record review the facility failed to assess and monitor for infections for 2 residents (Resident #3 and Resident #4) reviewed for infections. The deficient practice resulted in allowing Resident #3's urinary tract infection [MEDICAL CONDITION] to go unassessed and unmonitored and a suspected UTI for Resident #4 to go unassessed and unmonitored. Resident #4 subsequently transferred to the emergency department. Findings include: The facility provided a copy of the Alert Charting Process (undated) for review. The process reflected that for all infections staff will monitor residents each shift for the duration of the infection. The monitoring would include, Assessment of the system affected by the infection, symptoms related to the infection, vital signs, tolerance of antibiotic therapy. Resident #4: Review of the Face Sheet and Minimum Data Set (MDS) note, dated 7/22/19, revealed Resident #4 was an eighty-nine year old who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 required the assistance of 1-2 staff for all activities of daily living. The Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents Resident #4 had severe cognitive impairment. Resident #4 transferred to the hospital on [DATE] and did not return to the facility. According to the incident report dated 8/20/19 at 5:45 AM, the staff observed Resident #4 on the floor next to his bed. He was unable to state why the fall occurred. There were no injuries noted. The incident report did not identify an immediate intervention to prevent reoccurrence of falls. According to the nursing note on 8/20/19 at 9:57 AM the staff suspected a urinary tract infection [MEDICAL CONDITION] due to the recent fall, increased confusion and foul-smelling urine. According to the note 8/21/19 at 5:17 PM, the urine was collected and sent to the lab (over 31 hours after the UTI was suspected). The laboratory report with a collection dated of 8/21/19 at 1:40 AM, a received date of 8/22/19 and report date of 8/25/19 reflected that Resident #4's results reflected positive results for a urinary tract infection. According to the incident report dated 8/22/19 at 4:07 PM, staff witnessed resident attempt to self-transfer into a chair in the dining room and fell to the floor. He was unable to state why the fall occurred. There were no injuries noted. The incident report did not identify an immediate intervention to prevent reoccurrence of falls. The progress notes from 8/20/19 - 8/23/19 did not reflect 72-hour alert charting each shift according to the facility process for the suspected UTI. Review of the temperature log for Resident #4 reflected: 8/20/19 at 1:30 PM 97.5 degrees 8/21/19 at 1:30 PM 97.1 degrees No temperature taken/recorded on 8/22/19 8/23/19 at 1:26 PM 100.2 degrees 8/23/19 at 1:55 PM 100.2 degrees According to the food acceptance record on 8/22/19, Resident #4 refused dinner, refused his breakfast on 8/23/19 and refused his lunch on 8/23/19. The progress note dated 8/23/19 at 1:57 PM reflected that staff was unable to wake resident for lunch and that the resident presented really tired. The resident only responded to painful stimuli and the Physician's Assistant was notified. The vitals reflected blood pressure 97/50, pulse rate 97, respiratory rate 24, temperature 100.2 degrees axillary, and oxygen saturation of 95%. The nurse started an IV, called a verbal report to the hospital and the resident was transferred to the ED at approximately 2:00 PM via ambulance. The Physician Assistant note, dated 8/23/19 (untimed), reflected, Patient was seen for acute change in condition. Patient was found by nursing staff to be virtually nonresponsive, heavy breathing, difficult to arouse, eyes open but reported to me patient sleeps that way, patient with recent increased confusion, prompted UA (urinalysis) which appears grossly positive, LG (low grade) temp noted today as well, mild [MEDICAL CONDITION] and [MEDICAL CONDITION] well, ROS (review of systems) cannot be obtained as patient not participating dt (due to) lethargy .MM (mucus membranes) very dry, tongue is fissured .VS (vital signs) show sx (signs) of volume depletion .felt better to send to ED (emergency department) . The note was electronically signed 8/25/19 at 10:27 PM. During an interview and record review on 1/15/19 the DON, Registered Nurse, Unit Manager (RN, UM) H and RN, UM E answered questions related Resident #4. When asked if staff should assess and monitor residents when they suspect a UTI, the DON stated, Yes. The DON reviewed the progress notes (8/20/19 - 8/23/19) and was unable to find the monitoring for the suspected UTI. According to the ED note, dated 8/23/19, Resident #4 was admitted to the hospital for septic shock (a widespread infection causing organ failure and dangerously low blood pressure). Resident #4 did not return to the facility after the hospitalization . Resident #3: Review of the Face Sheet, dated 1/14/20, revealed Resident #3 was a sixty-six-year-old who was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3 required the assistance of 1-2 staff for all activities of daily living. The 1/8/20 admission assessment reflected that Resident #3 was confused and had poor memory. The progress note, dated 1/9/20, reflected that Resident #3 admitted from the hospital with a UTI and will continue with antibiotic treatment. Review of the temperature log for Resident #3 reflected: 1/9/20 at 7:45 PM 97.8 degrees No temperature taken or recorded for 1/10/20 1/11/20 at 11:48 AM 97.2 degrees 1/11/20 at 7:45 PM 98.3 degrees No temperature taken or recorded for 1/12/20 1/13/20 at 3:55 PM 98.3 degrees No temperature taken or recorded for 1/14/20 Review of [MEDICAL CONDITION] screenings reflected: 1/9/20 at 2:02 AM and 10:30 AM with vitals dated 1/8/20 at 4:56 PM 1/10/20 at 12:17 AM with vitals dated 1/9/20 at 7:45 PM 1/11/20 at 11:55 PM with vitals dated 1/11/20 at 11:49 AM [MEDICAL CONDITION] screening assessment for 1/12/20 1/13/20 at 12:18 AM with vitals dated 1/11/20 at 7:45 PM 1/14/20 at 1:40 AM with vitals dated 1/13/20 at 3:55 PM 1/15/20 at 12:49 AM with vitals dated 1/13/20 at 3:55 PM During an interview and record review on 1/15/19 the DON, Registered Nurse, Unit Manager (RN, UM) H and RN, UM E answered questions related Resident #3. The DON was unaware that the staff were not obtaining a set of vital signs with [MEDICAL CONDITION] assessment screening and had not completed one on 1/12/20. The DON stated that she expects the staff to obtain a set of vital signs at the time of each assessment and continue assessments 72 hours after the completion of the antibiotics. There were no further documents presented for review prior to the exit of this survey.

This citation pertains to intake MI- 3 Past Non-compliance was verified for this citation. Plan identified below. Based on interview and record review, the facility failed to conduct a complete physical exam after an unwitnessed fall for one resident (Resident #1) of 4 residents reviewed for quality of care, resulting in a delay in treatment of [REDACTED]. Findings include: Review of a facility Fall policy adopted 7/11/2018 reflected It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. The policy specifies 1. The resident will not be moved until a nurse evaluates the resident's condition. 2. Check resident for any abnormalities. 3. Obtain vital signs. 4. Complete Range of Motion (ROM) to unaffected extremities only without overt signs of fracture. 5. Initiate neurological checks for any fall where a resident hit his/her head or for any unwitnessed fall. 6. Evaluate for cause of fall, e.g. wet floor, obstructed pathway etc. 7. Make resident as comfortable as condition from fall permits. 8. Notify the physician for further orders and follow instructions (All falls must be reported to the physician). 9. Notify family or responsible party. 10. Document all appropriate information in the medical record. 11. Note (the fall) on 24-Hour Report. Resident #1 According to a facility Admission Record dated 12/26/19 Resident #1 admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment dated [DATE] reflected Resident #1 was cognitively impaired with periods of disorganized thinking and inattention. Resident #1 required supervision and set up help only with bed mobility, transfers, ambulation and toilet use. Review of a Care Plan revised on 7/11/2019 reflected Resident #1 was At risk for falls due to impaired balance/poor coordination, unsteady gait, history of falls, poor safety awareness, impulsiveness, confusion, weakness, pain, high blood pressure, [MEDICAL CONDITION], medications and impaired vision ([MEDICAL CONDITION]). Interventions on the care plan included Report development of pain, bruises, changes in mental status, ADL function, appetite or neurological status per facility guidelines post fall (implemented on 7/17/17) and 15-minute checks (implemented on 5/6/17). Review of a General Progress Note dated 11/12/2019 at 2200 (10:00 PM) indicated Licensed Practical Nurse (LPN) E documented Resident observed in front of bathroom door wrapped in a blanket. Neurological assessment WNL (within normal limits) for resident, no c/o (complaint of) pain at time of fall, BP (blood pressure) 146/77, HR (heart rate) 89, O2 (oxygen saturation) 91% RA (Room Air), T (Temperature) 97.3, RR (Respiratory Rate) 18. Staff assisted resident into wheelchair. Patient was unable to explain how the fall happened. Dr. notified, unit manager notified, son notified via telephone. 15- minute checks and neurological checks initiated by staff. Resident refused vital signs and became combative with CENA (nurse aide). Redirection given by nurse. Patient in wheelchair at this time. No further complaints. Continue 15-minute checks. Call light placed within reach. Review of a (Facility) Nursing Post Fall assessment dated [DATE] reflected LPN E documented Resident #1 had poor safety judgement and had no pain during ROM or ambulation. The New intervention added to the plan of care was 15-minute checks until discharge. Review of a General Progress Note dated 11/13/2019 at 7:02 AM reflected LPN A documented Nurse entered resident's room, resident was sitting in her w/c (wheelchair), nurse redressed BLE (bilateral lower extremity), resident was c/o pain in her right leg, stated she could not stand on it when nurse was trying to take her to the restroom, resident's pants were removed and nurse noted that resident right hip was severely deformed, [MEDICAL CONDITION], and bruised. Transferred to (hospital emergency department) for possible fractured right hip. Family, unit manager, and doctor notified. During an interview on 12/26/19 at 11:10 AM, LPN A said when she started her shift at 6:00 AM on 11/13/19, LPN E reported Resident #1 had a fall without injury the night before. LPN A said Resident #1 was the first patient she cared for that morning because Registered Nurse (RN) K observed Resident #1 needed her bilateral leg dressings changed. LPN A reported that Resident #1 complained of pain and was unable to lift her leg during the dressing change or attempt to stand to use the toilet. LPN A said she cut away Resident #1's right pant leg and observed swelling, deformity and significant bruising. LPN A then followed facility protocol to notify the physician who ordered Resident #1 transferred to the hospital for evaluation of a possible fracture. During a telephone interview on 12/26/2019 at 12:40 PM, LPN E said another nurse (Registered Nurse (RN) H) discovered Resident #1 on the floor and summoned help from the nurse aides on duty then left Resident #1 to tell her that the resident had fallen. LPN E said that when she got to Resident #1's room, she was sitting in her wheelchair. LPN E said she started neurological checks but did not perform a range of motion assessment and did not call the physician to report that Resident #1 refused to be assessed. LPN E said she did not ambulate Resident #1 and was not told by nurse aides Resident #1 had been assisted to the bathroom or had any difficulty with standing or toileting which she assumed had been done overnight. Review of a hospital CT Scan dated 11/13/19 at 9:06 AM reflected Resident #1 had a CT Pelvis without contrast. The report revealed There is a subtle impaction subcapital fracture deformity of the proximal right femoral neck. Minimal surrounding hematoma is seen. On 12/26/2019 the state agency verified the following interventions were put into place and were effective to remove the non-compliance: 1. On 11/13/19 the Interdisciplinary Team (IDT) started an investigation to review the circumstances surrounding Resident #1's unwitnessed fall and subsequent [DIAGNOSES REDACTED]. 2. On 11/13/19 Education for nurses on fall policy and completing full nursing assessment before moving resident from floor. 3. On 11/13/19 Education provided to nurse aides to inform nurse immediately for resident fall and not to remove from floor until fully cleared by nurse. 4. On 11/13/19 Like residents were interviewed, evaluated, care plans were reviewed and new fall risk assessment completed as needed. 5. On 11/13/19 nursing assignments were reviewed and changed to accommodate room changes during construction as needed. 6. On 11/14/19 Education to nurses and nurse aides continued. 7. On 11/14/19 full/large backboards were ordered to assist in transfer of fallen resident as appropriate. 8. On 11/29/19 facility Quality Assurance team developed a new fall event audit tool with audits to be ongoing. On 12/26/19 the state agency reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 11/29/2019.

Based on observation, interviews, and record review, the facility failed to 1) prevent the development of two pressure ulcers for 1 resident (Resident#59), 2) do complete nursing and pressure ulcer/skin assessments and implement care planned interventions, and initiate treatments in a timely manner for 1 resident (Resident #59) of 2 residents reviewed for pressure ulcers, resulting in pain and discomfort, medical care with wound treatment. Findings include: Resident #59 Review of Resident #59's Admission Record, dated 5/3/19, revealed Resident #59 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #59's Minimum Data Set (MDS, resident assessment) dated 3/26/19 revealed resident had a Brief Interview of Mental Status (BIMS) score of 99 (unable to complete test that checks for cognition.) Resident was Non-ambulatory and required extensive staff assistance with Activities of Daily Living (ADL's). During the Confidential Group meeting on 5/1/19 at about 2:30 PM, R#59's spouse entered the Confidential Group interview and stated he had a complaint/grievance on how the facility treated his wife's facility acquired pressure ulcers. Stated it was not right and it should not have happened, and it needed to be investigated. Review of Resident #59's Skin care plan, print date of 12/20/18 reflected that, The resident has the potential for impairment to skin integrity of the r/t fragile skin, immobility, incontinence, peg tube use. Date Initiated 12/20/18 The care plan stated, Follow facility protocols for treatment of [REDACTED]. Review of Resident #59's ADL's care plan dated 1/2/19, stated SKIN INSPECTION: The resident requires SKIN inspection with care. Observed for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the facility Skin Monitoring and Management-Pressure Ulcer policy/procedure dated 7/11/18, stated, 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 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 wound, Staging the wound, Describing the nature of the wound (e.g., pressure, stasis, surgical wound), Describing the location of wound, Describing the characteristics of the wound, Describing the progress with healing and any barriers to healing which may exist, Identifying any possible complications. Once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the physician's orders [REDACTED].>Review of Resident#59's Skin Observation Tool (used to show/reference areas of the human body) effective date 3/20/19 at 04:49, reflected that the resident had, Sacrum Pressure 1.5 cm length 2.8 cm width and 0.1 depth and was not staged. Review of Resident #59's progress note on 3/20/19 at 4:46 by Registered Nurse (RN)X stated, open area noted to coccyx 1.5 x 2.5 x 0.1. Area cleansed with normal saline, skin prep applied to bordering area and comfort border drs. applied. Incontinent of bowel. Peri-care provided. Review of Resident #59 done on 3/21/19 by Nurse Practitioner (NP) Y revealed the following The patient was alert, resting in bed on a regular mattress, and in no acute distress . The old dressing was removed. the sacrum wound measures 1.3 x 2.1 x 0.2. it was approximately 50% slough, 50% granulation tissue. no maceration or [DIAGNOSES REDACTED] around. No odor. There was scant serous drainage on the old dressing. Assessment/Plan: Unstageable pressure ulcer to sacrum. We will cleanse with saline and apply Santyl and [MEDICATION NAME] Blue Moistened with saline with the foam dressing over daily. Resident needs alternating air mattress Review of Resident #59's 3/22/19 at 12:42 PM Physician orders [REDACTED]. Every day and night shift for wound healing. Review of Resident #59's electron Medication Administration Record [REDACTED]. Every day and night shift for wound healing. -D/C (Discontinue) Date-04/19/2019 1321 During an interview on 5/2/19 at 2:55 PM, Nursing Unit Manager (NUM) N revealed that they had no written orders to treats the residents wound prior to 3/22/19 either in the electronic record or in the resident's hard chart. NUM N confirmed had no orders for 3/20 or 3/21/19. NUM N revealed that it was not documented in the medical record that the family was notified of the wound. NUM N stated Resident #59's spouse comes in daily; I know I ran it by him, just don't know when. NUM N stated that residents pressure ulcer was unavoidable, but provided no documentation for avoidability prior to end of survey. Review of facility provide timeline that on 5/3/19 reflected, that on 3/26/19, an Alternating Pressure Mattress (APM) and was also noted in residents care plan. Review of Resident#59's Skin Observation Tool, effective date 3/27/19 at 04:49, reflected that the resident had, Coccyx Pressure and Left heel Pressure. (Neither of the wounds were measured or staged) Review of Resident #59 done on 3/28/19 by Nurse Practitioner (NP) Y revealed the following, The nurse requested that I see the patient and reassess the area that she has on her sacrum (Name of Nurse Unit Manager (NUM) N) Registered Nurse (RN), states that there are no new issues. She is on an alternating air mattress. She had a [MEDICATION NAME] island on the sacrum without any Blue. The wound measures 1.2 x 1.9 x 0.2. It is approximately 75% slough, 25% granulation tissue without any maceration or [DIAGNOSES REDACTED] around. No rash. Unstageable pressure ulcer of the sacrum. We will continue cleansing with saline and apply, Santyl [MEDICATION NAME] Blue moistened with saline with foam dressing over During the 5/2/19 at 2:55 PM, interview with NUM N stated, that nurses do skin assessments weekly, and Resident #59 has weekly skin assessments done. NUM N stated I have no response to why they (nursing staff) missed the first week of Aprils' Skin Assessment, nothing is documented. NUM N stated for wounds she expected measurements, odor, drainage, how patient tolerated treatment, what wound looked like, treatment place and put it on Point Click Care and Gentell Fastcare (programs they use for charting and monitoring residents). NUM N revealed the they did not have documentation that could be reviewed. During an interview on 5/2/19 at 4:00 PM, NUM N stated that they did not have a, Skin Observation Tool, Nurse Practitioner note or doctor visit note for Resident #59 from 3/28 until 4/9/19, but a progress note was in the residents record on 4/5 that alerted risk management of a the residents left heel pressure ulcer. Review of Resident #59's General Progress Note Effective Date: 4/5/19 at 07:08:00 revealed, Created Date: 4/24/19 at 08:01:02 observed area of dark purple heel when providing care. APM was set to firm setting, floated heel on pillow. Notified Durable Power Of Attorney (DPOA) (Name of DPOA), and Primary Care Provider (name of doctor). No new orders obtained at this time. Review of Resident #59's Progress Note from Physician Assistant Certified (PAC) Z on 4/9/19, reflected Pressure injury of deep tissue of left heel. Pressure relief heel protectors ordered bilaterally, culture any drainage that does occur, continue foam dressing daily and as needed, will have wound service see her this week. Case was reviewed with the spouse. Review of physician order [REDACTED]. During an interview with on 5/2/19 at 4:00 PM, NUM N revealed that she had no answer for why the first treatment was not ordered for Resident #59's left heel until 4/9/19. NUM N stated she assumed a nurse would have contacted the doctor or put in an order. NUM N reflected that she was not aware of the 3/27/19 Skin Observation Tool documentation of a pressure ulcer on left heel, only the 4/5 documentation. NUM N confirmed that Yes the resident went untreated for [REDACTED]. Review of Resident#59's Skin Observation Tool, effective date 4/10/19 at 12:14, reflected that the resident had, Coccyx Pressure and Left heel Pressure. (Neither of the wounds were measured or staged) Review of Resident #59 done on 4/11/19 by Nurse Practitioner (NP) Y revealed the following, The [MEDICATION NAME] island was removed and the sacral wound is 1.2 x 1.4 x 0.2. It is approximately 50% slough, 50% granulation tissue. There is no maceration or [DIAGNOSES REDACTED] around. There is no bone palpated. The left heel has dry black eschar that is firm that measures 3.8 x 3.2. (15 days after the wound was discovered on 3/27, a measurement was provided in medical record). It is firm and not peeling up yet. There is no redness or drainage around. No [MEDICAL CONDITION] of the feet or ankles. The left DPP is +1 and regular. 1. Unstageable pressure ulcer to the sacrum. Apparently, the order was never changed, so they are going to start doing what I had requested of cleansing with saline and apply Santyl of [MEDICATION NAME] Blue moistened saline with a foam dressing over daily 2. Unstageable pressure ulcer to left heel. Use Skin Prep and keep pressure off the area. They did order the Prevalon boot Review of Resident #59's Progress Note from Physician Assistant Certified (PAC) Z on 4/17/19, reflected Pressure injury of deep tissue of left heel. Pressure relief heel protectors in place. No signs of secondary infection, continue to follow-up with wound service. Review of Resident#59's Skin Observation Tool, effective date 4/17/19 at 12:14, reflected that the resident had, Coccyx Pressure 3 x 2 x 0.1 Stage II and Left Heel Bruising 7 x 5 x 0.1 Unstageable. Review of Resident #59 done on 4/18/19 by Nurse Practitioner (NP) Y revealed the following, There was a [MEDICATION NAME] island on the sacrum. The wound measures 1.3 x 1.0 x 0.1. It is approximately 75% slough, 25% granulation tissue. There is no maceration or [DIAGNOSES REDACTED] around. The left heel, a Tefla island was removed. There is dry black eschar that is firm, and it measures 3.0 x 3.0. It is not peeling up yet. There is no redness or drainage around: No [MEDICAL CONDITION] in the foot or ankle. 1. Unstageable pressure ulcer to the sacrum. I talked with (Name of Registered Nurse Unit Manager R) and (Name of NUM N), RN's as she had a Tefla island on for the last two weeks and when I have come to see her and make sure that the order is correct with Santyl, [MEDICATION NAME] Blue moistened with saline with the foam dressing over daily. 2. Unstageable pressure ulcer to left heel. I also requested that the assess to make sure that the correct treatment is in place as there was a Tefla island on today and I just want Skin Prep to keep it dry and wait for it to peel up on its own an then the Prevalon boot to keep pressure off the area Review of Resident#59's Skin Observation Tool, effective date 4/24/19 at 12:14, reflected that the resident had, Coccyx Pressure Stage II and Left heel Pressure Unstageable. (The wounds were not measured) Review of Resident #59 done on 4/25/19 by Nurse Practitioner (NP) Y revealed the following assessment /plan1. Unstageable pressure ulcer of the sacrum. Continue cleansing with saline and apply Santyl, [MEDICATION NAME] Blue, moistened with saline and with a foam dressing over daily. 2. Unstageable pressure to the left heel. She did not have the right treatment on today as there was another dressing on and now that it is open and draining. I had to remove a portion of the eschar so it could drain instead of keeping the bacteria inside. Now that it is open, we will clean with saline and apply Santyl on Xeroform with 4 x 4 and Kerlix over daily p.r.n. (as needed) Use the Prevalon boot to keep pressure off the area. There are no signs of infection. The sacrum measured 0.8 x 1.1 x 0.2. It was approximately 50% slough, 50% granulation tissue. There was no maceration or [DIAGNOSES REDACTED] around. No odor. The left heel measured 3.4 x 4.0 x 0.2. After debridement, it was approximately 50% eschar, 50% slough, 50% granulation tissue. Resident #59 was observed in her room on 5/01/19 at 8:15 AM laying in her bed. Resident #59 was observed to be sleeping while the tube feed was running at the time. APM mattress and boots on residents foot were in place. Review of Resident #59's comprehensive care plan revealed a care plan for Potential for impairment to skin integrity of the r/t fragile skin, immobility incontinence, peg tub use dated 12/20/18. Goal- The resident will maintain or develop clean and intact skin by the review date 12/20/18 initiated with a target date of 7/4/19. Interventions reflected, Alternating Pressure Mattress (APM) Initiated 3/26/19 by NUM N (6 days after discovery of coccyx pressure ulcer) Frequent repositioning Initiated 4/23/19 by Director of Nursing (DON); Wound dressing as ordered Initiated 3/26/19 by NUM N (6 days after discovery of coccyx pressure ulcer) During an Interview on 5/2/19 at 2:55 PM, Nurse Unit manager (NUM) N revealed that interventions to a care plan are usually discussed by the team then added within a day or two of incident/problem developing. Stated MDS person usually does it. During an interview on 05/03/19 at 07:41 AM, Minimum Data Set Coordinator Registered Nurse (MDSCRN) W was asked to explain why a care plan had been developed on 4/30/19 for both of Resident #59's PU's (coccyx and left heel). MDSCRN stated, it was discovered during an audit that day and I was asked to create care plans for PU's. I was given a list of who had PU, I went to the rooms, saw what interventions they had, put them on the care plan accordingly, and double checked the orders to make sure they were in. We do care plans, interventions and audits daily and fixing/adjustments daily. MDSCRN W stated, an intervention should be put in place immediately, when things such as PU are found. No, interventions should not be put in place days or weeks later. MDSCRN W revealed that her expectation is to only review care plans to make sure they are there, and up to date, quarterly, sig change, and annual but will jump in when I need help. The nurses and should be making sure that care plans put in. During an interview on 05/03/19 at 4:00 PM , NUM N revealed that they developed new focused Pressure Ulcer Care Plans on 4/30/19. During the interview the NUM N stated that care plan interventions for pressure ulcers should have been implemented within a day or two of development. During an observation on 05/02/19 at 02:30 PM, Resident # 59's dressing change to Resident #59's coccyx (tailbone area) and left heel was observed. The dressing change was performed by Licensed Practical Nurse (LPN) E with certified nursing assistant (CNA) V assisting to hold Resident #59 in position. Resident #59's coccyx wound was open and irregularly shaped and measured 2.3 cm (centimeters) x (by) 2 cm (as measured by LPN E) at the top portion and 0.6 cm x 0.5 cm along the bottom portion of the wound. The wound appeared to have been 2 separate wounds that connected together at some point (as verbalized by LPN E). The wound bed(s) had 2 red center areas (like binary stars circling each other) with the surrounding tissue being reddened/pink. The total area of the coccyx wound appeared to be the size of a quarter. Resident #59's left heel wound encompassed total area of meatus of heel (the area over the heel bone). Resident #59's heel wound was open and the wound bed contained blackened tissue with red tissue surrounding the wound bed and a ring of blackened tissue surrounding this area. Resident #59's left heel wound measured 5 cm x 4.5 cm (total area) while the debrided area (area of red tissue surrounding the wound bed) measured 3.5 cm x 3.5 cm.

This Citation Pertains to Intake #MI 749 Based on interview and record review the facility failed to maintain and monitor adequate hydration for 1 Resident (Resident #8) of 3 residents who received tube feedings that were reviewed for hydration resulting hospitalization with acute kidney injury and metabolic alkalosis and the potential for all dependant residents receiving tube feedings to be at risk for dehydration. Findings include: Resident #8 was a [AGE] year old female admitted to the facility 7/25/17 with [DIAGNOSES REDACTED]. Review of the medical record reflected Resident #8 was to take nothing by mouth but had a jejunum tube (J- tube) to receive nutrition and fluids. Resident #8 also had a gastric drainage tube. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #8 was severely cognitively impaired. The MDS also reflected that Resident #8 was unable to walk and required staff assistance with transfers, dressing, and personal hygiene. The Electronic Medical Record (EMR) Progress Note dated 8/3/17 at 6:20 PM by Physician's Assistant (PA) X was reviewed. The entry indicated Resident #8 was re-evaluated for a cough. The Progress Note indicated the family of Resident #8 were present and had conveyed that the Resident, just doesn't look well. The assessment conducted by PA X reflected Resident #8 was, well nourished but displayed generalized weakness. The entry indicated laboratory studies were ordered at the request of the family. Review of the laboratory results for Resident #8 reflected a blood specimen was obtained at 11:15 PM on 8/3/17 and the results were reported to the facility on [DATE] . The report indicated a variety of abnormal results. The EMR Progress Note dated 8/4/17 at 2:44 AM reflected the Lab results reflected high levels and were reported to PA X. The entry indicated PA X ordered Resident #8 be transported to a hospital for an emergency evaluation. Review of the hospital Final Report for Resident #8 dated 8/9/17, reflected emergency room (ER) initial laboratory results of 8/4/17, at 4:15 AM, that, revealed acute kidney injury and metabolic alkalosis with significant [MEDICAL CONDITION] with a lab result of 156 (normal sodium range 135 -145) and a Blood Urea Nitrogen (BUN) of 117 (normal range 6 - 20). The hospital report acknowledged the Resident had a Jejunal feeding tube and a Gastric venting tube. The report reflected it was suspected the Acute kidney injury cause was suspected due to gastrointestinal losses from venting of gastric tube and inadequate enteral free water intake (dehydration). The hospital document reflected Resident #8 was treated with IV saline (hydration) and antibiotics. The report indicated an initial ER plan of a hospital admission stay of (greater than) 2 midnights and that Resident #8 was at high risk for [MEDICAL CONDITION] (blood clots). Resident #8 was discharged from the hospital 8/10/17; 6 days after arriving at the ER. The accepted Osmolarity calculation of 2(sodium) + (BUN / 2.8) + (Glucose / 18) reflected a result of 359 using the ER initial laboratory results. The calculation parameters are: a result > 296 equaled dehydration with a normal range of 282 to 296. A result of 359 indicated severe dehydration. On 11/16/17 at 12:55 PM an interview was conducted with Registered Dietician (RD) U. RD U reported she had used a set calculation to determine the nutritional needs and fluid requirements of residents admitted with feeding tubes. RD U reported outside of the set calculation she would consider other factors such as, if a resident was on diuretics (water pills), the condition of the resident's skin, and past medical history. RD U reported she was aware Resident #8 had a gastric tube and indicated this would have required to be monitored closely. During an interview on 11/17/17 at 1:35 PM, Director of Nursing B reported the facility did not monitor the gastric output of Resident #8. Review of the medical record did not reveal output from the gastric tube had been monitored. However, an entry in the EMR Progress Note dated 8/1/17, at 1:56 AM, reflected, [DEVICE]. 1600 milliliters (ml) (dark) green output today. Review of the Progress Note by RD U dated 7/26/17 at 1:56 PM reflected Resident #8 was receiving through the J tube 1000 ml of nutritional formula and 700 ml of water totaling 1700 ml a day. Review of the medical record reflected Resident #8 was incontinent of urine and wore an adult brief. Therefore, no no quantitative record of urine output was found in the medical record. On 11/16/17 at 12:05 PM, an interview was conducted with DON B. DON B reported during her admission Resident #8 displayed gross, large movements (involuntary) and would disconnect the tube feeding. DON B reported the bedding on the Resident's bed linens had to be changed often due to the spillage. On 11/16/17, at 1:53 PM, a telephone interview was conducted with Registered Nurse (RN)Y. RN Y reported she was aware of the spastic, involuntary movements of Resident #8. RN Y reported Resident #8 had dislodged (disconnected) her feeding tube an average of 2 times per 12 hour shift. RN Y reported it was not surprising the hospital would find her dehydrated. RN Y did not indicate if any measures were taken to compensate for the nutritional formula and water that was lost and not administered to Resident #8. On 11/16/17, at 2:31 PM Licensed Practical Nurse (LPN) Z was interviewed. LPN Z reported it was common for Resident #8 to dislodge her feeding tube. LPN Z did not indicate if any measures were taken to compensate for the nutritional formula and water that was lost and not administered to Resident #8. The EMR Progress Note by RD U dated 7/26/17 at 1:56 PM reflected, Resident has a problem with fast moves and knocking over her feedtube stand so she needs to be fed fast and mostly while she is asleep. The entry did not indicate if consideration was given to the gastric drainage or direction to monitor the feed tube connectivity while running.

This citation refers to MI 042 and MI 447. Based on interview and record review, the facility failed to properly assess and monitor a resident's declining condition and immediately notify the health care practitioner of a worsening change in condition for 1 of 3 sampled residents (Resident #1), from a total sample of 3 residents, resulting in immediate jeopardy when Resident #1 (who had been identified to have a history of GI (gastrointestinal) hemorrhaging, [MEDICAL CONDITION], and [MEDICAL CONDITION] ulcers) was observed to have unresolved nausea, vomiting, and abdominal pain from 6:15 p.m. on [DATE] until 8:30 a.m. on [DATE] when Resident #1 was transported to the hospital emergency room via ambulance and subsequently died . This deficient practice placed 5 additional residents identified as at risk for bleeding at risk for serious harm, injury, and/or death. Findings include: According to the facility admission record, dated [DATE], Resident #1 was a [AGE] year old resident who was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple [DIAGNOSES REDACTED]. In addition, Resident #1's admission record indicated Resident #1 was his own responsible party (could make decisions about his care). According to Resident #1's Minimum Data Set (MDS) (a tool used to evaluate a resident's cognitive, emotional, and physical needs) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) (a tool use to determine a resident's cognitive status) score of 13 which indicated Resident #1 was cognitively intact. According to the facility's Incident Summary, undated, Resident #1 vomited at 6:15 p.m. ([DATE], but date not specified). (Name of Resident #1) complained of side abdominal pain. It was noted that he was crying out and restless. Vital signs were BP (blood pressure) ,[DATE] (low), Pulse- 66, Resp. (respirations) 20, Temp was 98.7 (*Fahrenheit), and O2 (oxygen) saturations (level) on room air was 97%. At approximately 9:30 p.m., Resident #1 asked to go to the hospital. He vomited once or twice. It was orange in color. Looked like food. Licensed Practical Nurse (LPN) F notified Nurse Practitioner (NP) C and received orders to administer a one-time dose of [MEDICATION NAME] (a narcotic pain medication) and another dose of [MEDICATION NAME] (an anti-nausea medication). Per NP (Nurse Practitioner C) statement she believed he (Resident #1) was still upset about the conversation they had earlier about his cataract surgery. At approximately 1:00 a.m. (on [DATE]), Resident #1 became restless, complaining of pain, and vomited (orange color with food-like chunks). Between 2:00 a.m. and 3:00 a.m., Resident #1 vomited. The color of the vomit was a clear/ mucus/ dark brown color. (Name of Resident #1) had been given his medicine in chocolate pudding. He (Resident #1) had an open package of Oreo cookies at his bedside. LPN F showed the vomit to Registered Nurse (RN) G and they did not think there was blood in the vomit. Between 3:00 a.m. and 5:00 a.m., Resident #1 vomited 3 more times with the same consistency as approximately between 2:00 to 3:00 a.m. Vital signs were BP- ,[DATE], pulse- 64, Resp. - 16, Temp-97.6, O2 saturation 97% on room air. At 5:30 a.m. Resident #1 had 3 dark brown emesis. LPN F called NP C to notify of more emesis. At approximately 6:30 a.m., Resident #1 began vomiting and LPN E' administered [MEDICATION NAME]. At approximately 8:00 a.m., NP C was called and instructed LPN E to send Resident #1 to the hospital. At 8:46 a.m., EMS (emergency medical service) arrived and transported Resident #1 to the hospital emergency room (ER). According to Resident #1's acute care transfer form, dated [DATE], Resident #1 was sent to the hospital emergency room due to vomiting black emesis during the night and conts (continues) to vomit black emesis this a.m. (morning). Resident #1's transfer form indicated LPN E called report (contacted the emergency room ) to the ER nurse at 8:15 a.m. During an interview on [DATE] at 3:55 p.m., RN G stated, It was around midnight. The nurse (LPN F) came up to me and asked me if I could look at some vomit- emesis. (Name of LPN F) said she wanted me to give her a second opinion. I went to the gentleman's (Resident #1) room and she had a kidney basin (emesis basin) with dark brown emesis. I didn't see any blood. I poured it in the toilet slowly looking for blood. I didn't see any. The emesis was brown, mucousy. There was no coffee ground color or anything that would indicate there was blood. I asked the nurse, (name of LPN F), if she'd called the nurse practitioner or not. She said the nurse practitioner (NP C) had been notified earlier in the evening. She (LPN F) said there was no real change in the emesis (since earlier). I told her to monitor him (Resident #1) close and update the nurse practitioner at 5:00 in the morning when we usually do. I didn't hear anything else. According to RN G's written and signed statement, dated [DATE], when RN G poured Resident #1's emesis in the toilet on [DATE], they (RN G and LPN F) were looking for any red color. They could not find any red color. This all occurred somewhere between midnight and 1:00 (a.m.). During an interview on [DATE] at 5:00 a.m., LPN F stated, At 6:15 p.m., he (Resident #1) vomited. It was orangish color. It looked like food. He was also complaining of right side abdominal pain. I gave him Gas-X (a medication for indigestion) and Tylenol. That didn't work. I told the aides, I don't remember their names, not to give him (Resident #1) anything to eat or drink. I called the nurse practitioner (NP C) about 8:30 p.m. I told her I had checked his bowel sounds, vitals, and he was vomiting. She told me to give him (Resident #1) [MEDICATION NAME]. She told me he was probably upset from an argument with his family earlier. I gave him the [MEDICATION NAME] at 9:30-ish (p.m.). He had 2 more vomiting episodes shortly after that. They were orangish. I called (name of NP C) back around 10:30-ish. I told her he (Resident #1) was still vomiting and had pain. I told her it looked like food. It didn't look unusual at that time. A couple of hours later he had no vomiting, but he still had pain. He was yelling his right side hurt and he wanted to go to the hospital. He had been yelling that (he wanted to go to the hospital) from the first time I called her (NP C) at about 8:30-ish to midnight. Around 2:30-ish, he was getting restless and I gave him another [MEDICATION NAME]. At about 3:30 (a.m.) he had 3 more emesis that were starting to get darker in color each time. By the 3rd time it was dark brown in color. I had (name of RN G) look at the emesis at approximately 3:30 a.m. It was probably the second or third emesis at that time because I was concerned it (the emesis) might be stool or a bleed. I thought it might be stool or a bleed because it got darker and darker. He looked at it and it wasn't coffee ground (color). He said it looked more like pudding and not stool or blood. I had given him [MEDICATION NAME] with pudding at approximately 2:30 a.m. At 5:30 a.m., I called (name of NP C) back and told her he (Resident #1) had dark brown emesis and she ordered an abdominal x-ray. I believe she ordered it (abdominal x-ray) for abdominal pain and emesis. In the morning (6:00 a.m.) I told (name of LPN E) that he (Resident #1) had been vomiting during the night and it had gotten darker and darker. I told her it was small amounts each time. During an interview on [DATE] at 5:35 a.m., certified nursing assistant (CNA) H stated, I remember he (Resident #1) was vomiting and complaining of pain. I told the nurse on duty (LPN F) he was throwing up (vomiting) and in pain. He was shouting out in pain. He could verbalize what he wanted. When this Surveyor asked CNA H if Resident #1 had requested to go to the hospital at anytime during the shift, CNA H stated, Nuh uh (no). He was just shouting he was in pain. According to CNA H's written and signed statement, dated [DATE], CNA H stated, I worked 3rd shift (10:00 p.m. on [DATE] to 6:00 a.m. on [DATE]). CNA H further stated, I heard him (Resident #1) calling out wanting to go to the hospital. During an interview on [DATE] at 9:30 a.m., LPN E stated, He (Resident #1) seemed fine at first in the morning. When (name of LPN F) gave me report she made it seem like it was the flu or something he ate. (Name of LPN F) said it was dark, but she thought it was because he had been eating chocolate stuff during the night. She told me it had been light and had been getting darker. She (LPN F) had told me he (Resident #1) had not thrown up in a while, so she thought it (the vomiting) was over with. LPN E further stated, I gave him [MEDICATION NAME] because he had vomited during the night. He vomited shortly after I gave him the [MEDICATION NAME]. Then he looked pale and haggard. He looked really sick. I saw the vomit and you could see it was old blood. It was dark, old blood looking, vomit. I knew what it was when I saw it. I immediately called (name of NP C). I told (name of NP C) he's (Resident #1) definitely vomiting old blood and she said to get him out of here (transfer Resident #1 to the hospital). During an interview on [DATE] at 11:15 a.m., Certified Nursing Assistant (CNA) L stated, When I walked by the room (Resident #1's) he (Resident #1) was pale grey and had black stuff on his chin and gown. This was at 2:00 a.m. (on [DATE]). I knew his nurse was (name of LPN F). I asked her what's going on with (name of Resident #1)? I had told her he was pale, grey, and there was black stuff around his mouth and gown. I told her I thought it (the black stuff) was a GI (gastrointestinal- stomach) bleed. She (LPN F) told me he was throwing up and had been since 10:00 p.m. She (LPN F) said, I've talked to the doctor and there's no need to send him (Resident #1) out (to the hospital). (Name of LPN F) told me that at 10:00 p.m. she had called (name of NP C) and said it (the vomiting) was the Oreo cookies or the pudding he (Resident #1) had. I then went in the room and asked him (Resident #1) if he's ok. He was just moaning and groaning in pain. He had his hand on his stomach. He (Resident #1) said, No. I'm sick and I want to go to the hospital. I went back and told the nurse (LPN F). This Surveyor asked CNA L if she noticed if Resident #1 had any food or liquids at the bedside when she saw him at 2:00 a.m. on [DATE]. CNA L stated, His (Resident #1's) Oreo cookies weren't even open. During an interview on [DATE] at 2:00 p.m., CNA I stated, He (Resident #1) put on his light (call light) and said he had to puke (vomit). This was about 6:30-ish (p.m.). The puke was light pink-ish. I thought it was from the juice he had been drinking (at dinner). The girls (certified nursing assistants) in the dining room said he was drinking that kind (color) of juice. He kept saying his side hurt. He had his hand on his right side. I told his nurse (LPN F) that (pain and vomiting). From 6:30 p.m. to 10:00 p.m. when I left he (Resident #1) kept putting on his light saying, It hurts. It hurts. He was yelling and screaming he was in pain as loud as he could. He would yell Help. Call an ambulance. He kept asking me if the ambulance was coming. He said he wanted to go to the hospital because of the pain and the medicine wasn't working. I think he puke once or twice before I left This Surveyor asked CNA I if Resident #1 had any food or drink at the bedside during this time. CNA I stated, He might have had juice or something at the bedside. He didn't have any food at the bedside. I don't remember him eating anything. According to NP C's written and signed statement, dated [DATE], NP C stated LPN F contacted NP C between 6:00 p.m. and 7:00 p.m. on [DATE] because Resident #1 c/o (complained of) (R) (right) side pain and he (Resident #1) was anxious. Gave order for [MEDICATION NAME] (a medication for anxiety). I had-had a prior conversation w/ (with) he and his sister r/t (related to) eye surgery- probably of no one taking his case and he would not regain his eye sight. He was very upset with this news. As he has in the past [MEDICATION NAME] in the past (had) been very effective to relieve anxiety. Between 8P-10P (8:00 p.m. to 10:00 p.m.) phone call- (Resident #1) still had pain on (R) side and was nauseated. Was told he had eaten pudding and Oreo's. Ordered [MEDICATION NAME] (medication for nausea) and extra dose of [MEDICATION NAME] (a narcotic pain medication) to be given. No interaction from staff between 10 PM (10:00 p.m.) and 5:30 AM. Next morning (5:30 a.m. on [DATE]) received phone call- 3 more emesis in night c/o right side abd (abdominal) pain. (LPN F) informed me that anxiety ([MEDICATION NAME]?) had decreased anxiety & (and) [MEDICATION NAME] helped pain. Ordered x-ray of abd (abdomen)- displaying bowel obstruction symptoms. 8:30 A (a.m.)- Received call from (name of LPN E}- vomited black liquid and ordered to be sent out to ER for further evaluation and treatment. All calls throughout night VS (vital signs) stable. According to CNA J's typed and signed statement, dated [DATE], CNA J indicated she worked on [DATE] to [DATE] from 10:00 p.m. to 6:00 a.m. CNA J stated, (Name of Resident #1) beats on the garbage can when he needs help or wants something. I answered his (call) light and asked him (Resident #1) what he needed and he stated his stomach was hurting and he wanted to go to the hospital. I told him I would go tell the nurse . When I came out of his room I went straight down to the nurses station 2 and told the nurse . I know I talked with a nurse and told her (name of Resident #1) was down there (in his room) hollering and beating on his trash can and stating he wanted to go to the hospital. She (the nurse) stated he's ok. He can't go out. What did you do? I left it alone. I didn't feel there was anything else I could do. CNA J further stated that Resident #1 had complained about his stomach pain all night. According to CNA K's written and signed statement, dated [DATE], CNA K indicated she worked on [DATE] from 2:00 p.m. to 10:00 p.m. CNA K stated Resident #1 complained of pain in stomach and asked to see the nurse. CNA K stated Resident #1 said, It's an ulcer or fibroid. CNA K stated Resident #1 was moaning stating stomach hurt. CNA K further stated, He did say he wanted to go to the hospital. According to LPN M's typed and signed statement, dated [DATE], Resident #1 had been crying out during the shift (6:00 p.m. on [DATE] to 6:00 a.m. on [DATE]). LPN M stated she did not know what Resident #1 was saying she just heard him crying out. LPN M stated LPN F had called NP C several times during the shift and had received orders for [MEDICATION NAME] and [MEDICATION NAME]. LPN M stated during the shift Resident #1 continued to vomit some brown emesis. I (LPN M) told her (LPN F) nurses aren't supposed to diagnose, But I told her I thought he (Resident #1) might have a GI bleed and told her I would call (name of NP C) again. I don't know if she did or not. I was too busy doing my stuff. According to unit manager (UM) N's typed and signed statement, dated [DATE], UM N spoke with Resident #1's sister (SIS O) and she stated, My brother had an ulcer that rubbed through to an artery and he bled to death. UM N asked SIS O if Resident #1 had problems with ulcers in the past. SIS O stated, Yes. According to the EMS (emergency medical service) narrative documentation, dated [DATE], Staff (facility) called for EMS to respond PR (priority) 2 (non-emergent- no lights or sirens). Upon arriving to the facility and gaining entry into the building, no staff was with the patient (Resident #1) when EMS arrived or came to his room shortly after to give report or assist. After a significant delay, it was found that the pt (patient) had been vomiting black emesis since yesterday at 1800 (6:00 p.m.). Nurse called for EMS at 8:30 a.m. today. Pt (Resident #1) last vomited about a half hour prior to EMS being called . Pt (Resident #1) laying in his bed. Alert to himself and event, pale, extremities cool, core (torso) cooling somewhat warm, moist .Pt was groaning in pain . When asked, he (Resident #1) stated that it was his stomach (that was painful). Upon palpation, it (stomach) was found to be rigid (firm) and very tender to palpation . Pt (Resident #1) stated it was hard to breathe . EMS was getting ready to transport as pt was being attempted to be adjusted, Pt started having black coffee ground emesis run out of his mouth. There was no sound as he vomited. The pt (Resident #1) wasn't trying to lean to the side, cough, or spit out. Pt (Resident #1) had a forward gaze and was gurgling and making sounds. Unable to lean forward or to the side with being so stiff. Suction was quickly done. Mouth and back throat were cleared. Pt (Resident #1) was not responding, but was breathing. LS (lung sounds) rales and rhonchi (abnormal rattling sounds in lungs) throughout. Pt had aspirated (gotten fluid in lungs) by then. Present with agonal (gasping) respirations. Ventilation was started with BVM (bag valve mask- a type of face mask used for delivering oxygen) and O2 (oxygen) . carotid pulse (artery in neck) was not found right away. It was weak at that time. Ventilations were continued . He started breathing on his own after sometime of assisting. Pt (Resident #1) then came around trying to pull the BVM from his face. This persisted as he was trying to talk He was saying that his stomach hurt . Pt (Resident #1) was alert and responsive upon arrival in the ED (emergency department). He was starting to groan with pain like he had done previously at the nursing home . Pt was transported PR 1 (priority 1- emergent with lights and sirens) to the (name of hospital) ED in declining condition. The EMS documentation indicated that EMS had been alerted at 8:30 a.m., arrived at the facility at 8:43 a.m., left the facility at 9:07 a.m., and arrived at the emergency room at 9:13 a.m. According to the emergency room physician note, dated [DATE], It was noted that the patient (Resident #1) was having coffee ground emesis throughout the night. This continued into the morning and it was noted that his abdomen was distended . In route patient (Resident #1) had another episode of coffee-ground emesis . He likely aspirated (got fluids into the lungs) at this point in time. He did become apneic (quit breathing) and was ventilated temporarily with a bag valve mask . After exiting the room (after performing a physical assessment), I (the emergency room physician) immediately called blood bank and asked for 2 units of emergency release of O- (type O negative) blood to be available for transfusion immediately. Before the patient's (Resident #1) airway was able to be secured, he vomited a massive amount of black emesis and aspirated this . The patient's airway was suctioned but because of the patient's flexed rigid neck, his airway was very difficult to intubate (put a breathing tube into the lungs) and suction successfully. I was called into the room the patient (Resident #1) was pulseless and apneic (no heart beat and no breathing) and for this reason chest compressions were begun with ACLS (advanced cardiac life support) protocol . compressions were continued for duration of 20 minutes with ACLS protocol. Unfortunately, the patient's (Resident #1) rhythm strip showed asystole (a flat line heart rate= no heart rate) . time of death was called at 9:47 PM (AM?) . Impression (conclusion): Massive upper GI bleed, Aspiration pneumonia, Cardiopulmonary arrest. According to Resident #1's death certificate, dated [DATE], Resident #1 was pronounced dead at 0947 (9:47 a.m.) on [DATE]. Resident #1's causes of death included hypotensive shock (a life- threatening condition that results when you lose more than 20 percent of your body's blood or fluid), GI bleed, and chronic [MEDICAL CONDITION]. According to the facility's abuse and neglect policy and procedure, dated [DATE], Neglect is the failure of the facility, its employees or service providers, to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On [DATE], the facility was notified of an Immediate Jeopardy that began on [DATE] when Resident #1 was observed to have unresolved nausea, vomiting, and abdominal pain (from 6:15 p.m. on [DATE] until 8:30 a.m. on [DATE] when Resident #1 was transported to the hospital emergency room via ambulance). Resident #1 expired shortly after arriving at the hospital from massive upper GI bleed, aspiration pneumonia, and cardiopulmonary arrest. On [DATE], this surveyor confirmed the facility Immediacy was removed on [DATE] when the facility had the following in place: 1. On [DATE] at 9:00 a.m., staff education was begun regarding the process of identification and assessment of residents who have risk of GI bleed, immediate notification to the health care practitioner of a worsening condition, and documentation of occurrence. Education is on-going. 2. On [DATE] at 11:00 a.m., the facility identified 5 of 66 facility residents that have a risk for GI bleeding that place them at risk for serious harm, injury, and/or death. 3. On [DATE] at 11:00 a.m., the facility reviewed and updated the care plans for all 5 residents that have a risk for GI bleeding that place them at risk for serious harm, injury, and/or death. 4. On [DATE] by 11:00 a.m., the facility had ensured all 5 residents that have a risk for GI bleeding that place them at risk for serious harm, injury, and/or death were assessed and no signs or symptoms of GI bleeding were found. 5. On [DATE], the facility put an audit program in place to audit newly admitted residents and current residents for signs or symptoms of GI bleed. Audits are on-going. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified and the facility was out of compliance at tag F224 for concerns related to a delay in treatment that subsequently led to death.

This refers to MI 844. Based on observation, interview, and record review, the facility failed to prevent a pressure ulcer from developing and implement interventions to prevent a pressure ulcer from worsening once it developed for 1 of 1 residents (Resident #3) reviewed for pressure ulcers, from a total sample of 7 residents, resulting in Resident #3 developing two avoidable pressure ulcers and increased pain. Findings include: According to the admission record, dated 11/2/16, Resident #3 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to Resident #3's Minimum Data Set (MDS) (a tool used to assess a resident and help determine the amount, or level, of care they need) assessment, dated 10/14/16, Resident #3 had a Brief Interview for Mental Status (BIMS) (a tool used to determine a resident's cognitive ability) score of 13 which indicated Resident #3 was cognitively intact. In addition, Resident #3's MDS indicated Resident #3 needed extensive assistance (resident involved in activity and staff providing weight-bearing support) of 2 staff members for bed mobility (turning and repositioning in bed) and transferring from one surface to another (e.g. from the bed to a wheelchair). Resident #3's MDS also indicated Resident #3 was at risk of developing a pressure ulcer, but did not have a pressure ulcer. According to Resident #3's Braden Scale (a scale used to determine the risk of developing a pressure ulcer, dated 10/11/16, Resident #3 scored a 10 which indicated Resident #3 was at a high risk of developing a pressure ulcer. According to Resident #3's risk for skin alteration care plan, dated 7/7/16, Resident #3 had a pressure reducing mattress, but did not have other interventions in place to reduce pressure to bony prominences (areas) and prevent pressure ulcers from developing (e.g. turning and repositioning from side to side and heels elevated off the bed). According to a nursing progress note, dated 10/11/16, Resident #3 is a two person assist for transferring and bed mobility. She has to be encouraged to get out of bed and rarely will allow staff to get her up. She is able to make her needs known . She has [MEDICAL CONDITION] in her feet with her right one being worse and frequently complains about that pain more so than other pain . She has dark areas on her heels . According to a physician progress notes [REDACTED].#3 complained of pain in her feet and the physician increased her [MEDICATION NAME] (a medication for nerve pain) from once daily to twice daily. According to Resident #3's skin worksheet, dated 10/12/16, Resident #3 had an abnormal finding of peeling skin on heels. According to Resident #3's skin worksheet, dated 10/15/16, Resident #3 had an abnormal finding of 1.5 inch blister? to coccyx and left heel (covered in dead skin with black in middle. Resident #3's right heel did not have any skin alterations noted on the skin worksheet. According to a nursing progress note, dated 10/16/16 at 00:26 (12:26 a.m.), Resident (Resident #3) is alert and oriented. Able to make needs known. Complains of buttock and heel pain. According to a nursing progress note, dated 10/16/16 at 19:19 (7:19 p.m.), Patient (Resident #3) has skin alteration on coccyx. Started out with fluid filled area approx. (approximately) 4.5 cm (centimeters) x (by) 2.5 (cm). According to a physician progress notes [REDACTED].#3 is in increased pain (to) her back & (and) right foot. (sic) According to a skin progress note, dated 10/20/16, Resident #3's wound areas assessed by treatment team. Coccyx wound measures 4 (cm) x 2 (cm) x 0.1 (cm) (4 cm long, 2 cm wide, and 0.1 cm deep) . R (right) heel wound measures 1.6 (cm) x 1.2 (cm) x 0.1 (cm) . According to Nurse Practitioner (NP) F's progress note, dated 10/20/16, I assessed the coccyx and there is skin that is peeling back and the wound measures 4 (cm) x 2 (cm) x 0.1 (cm) . The right heel had thick, dry black eschar (dead skin) that I excised (cut out) nonviable (dead) tissue . the open wound underneath is 1 (cm) x 1 (cm) x 0.1 (cm) . Assessment/Plan: 1. Unstageable pressure ulcer to the coccyx . 2. Stage II (two) pressure ulcer to the right heel. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .A Stage II pressure ulcer is defined as partial thickness loss of dermis (top layer of skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (skin shedding off). May also present as an intact or open/ruptured serum-filled blister .An unstageable pressure ulcer is full thickness tissue loss (through all layers of the skin) in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed . Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. A pressure ulcer develops from Stage I (one) to Stage IV (four). (www.npuap.org, 2007) According to a skin progress note, dated 10/31/16, Resident #3's coccyx wound measures 3.5 (cm) x 2.8 (cm) x 0.1 (cm) (an increase of 0.8 cm width) . R (right) heel wound measures 1 (cm) x 1 (cm) x 0.1 (cm) . During an interview on 11/1/16 at 10:45 a.m., Resident #3's granddaughter (GDAU D) stated, They (the facility staff) don't turn her (Resident #3) in bed or get her up. They just let her lie in bed all day. They say she hurts. That's why they don't get her up. Of course she hurts. She has a bed sore on her bottom and raw feet. GDAU D stated she visits Resident #3 frequently and that she had not noticed if Resident #3 had ever been out of bed. On 11/1/16 at 4:30 p.m., this Surveyor requested copies of Resident #3's coccyx and right heel pressure ulcer documentation, including care plans, from Nursing Home Administrator (NHA) A. According to Resident #3's coccyx and right heel pressure ulcer care plans (instructions to staff on what interventions need to be in place to prevent further deterioration), received on 11/2/16 at 9:00 a.m. and dated 11/2/16, interventions to prevent further skin breakdown and to promote healing were initiated on 10/13/16 (2 to 3 days before the pressure ulcers were discovered).However, the care plans were created on 11/2/16. Therefore, a plan of care was not actually in place to prevent further skin breakdown and to promote healing until 11/2/16 (17 days after the coccyx and right heel ulcers were discovered). During an interview on 11/2/16 at 9:00 a.m., this Surveyor asked Director of Care Delivery (DCD) H why Resident #3's coccyx and right heel pressure ulcer care plans were created on 11/2/16, but she documented they were initiated on 10/13/16. DCD H stated, I did them today because I noticed they weren't done. She's (Resident #3) not my resident, but we all do the wound rounds so anyone can write the care plans. DCD H could not verbalize to this Surveyor why she documented the care plans were initiated on 10/13/16 for wounds not discovered until 10/15/16 or 10/16/16. When this Surveyor asked DCD H if she had intentionally back-dated Resident #3's coccyx and right heel pressure ulcer care plans, or been asked to back-date them, to make it look like there were interventions in place prior to 11/2/16, DCD H stared at this Surveyor with stunned silence and stated, I did them today because I noticed they weren't done. During an interview on 11/2/16 at 9:10 a.m., Director of Nursing (DON) B stated, I know she (Resident #3) developed them (coccyx and right heel pressure ulcers) here. They were noticed on 10/15/16 on the first shift (day shift) shower sheet (skin worksheet) by the nurse. On 10/16/16, she (Resident #3) was assessed by (name of DCD I). On 10/20/16, the wound team saw her wounds and assessed them. This Surveyor showed DON B Resident #3's coccyx and right heel pressure ulcer care plans. DON B stated, I agree. It looks like she (DCD H) back-dated the care plans for October 13 th. I don't know why she (DCD H) would have done that. I see she created them today. On 11/2/16 at 9:45 a.m., after obtaining verbal permission from Resident #3, this Surveyor observed Resident #3's coccyx and right heel pressure ulcers with Licensed Practical Nurse (LPN) G. Resident #3's coccyx pressure ulcer was approximately quarter-sized with yellow tissue in the middle of a reddened wound bed with pink tissue surrounding the wound. Resident #3's right heel pressure ulcer was approximately pencil eraser-sized with a reddened wound bed. After the observation, this Surveyor asked Resident #3 about the pressure ulcer pain. Resident #3 stated, It hurts on and off. The pain is horrible. According to Resident #3's October 2016 Medication Administration Record [REDACTED]. However from 10/15/16 (the day the facility documented on Resident #3's skin worksheet a blister on the coccyx) to 10/31/16, Resident #3 rated her pain as a 4 or more (range from 4 to 7) on 6 of the 17 days. ( )

This citation refers to MI 105 Based on observation, interview, and record review, the facility failed to ensure the safety of and implement facility policy to prevent a fall in 1 of 1 sampled residents (Resident #103) reviewed for falls, from a total sample of 5 residents, resulting bilateral femur fractures for Resident #106. Findings include: According to the Admission Record, dated 7/25/14, Resident #103 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) (a tool used to assess a resident and help determine the amount/ level of care they need), dated 6/22/14, Resident #103 had a Brief Interview for Mental Status (BIMS) (a tool used to determine a resident's cognitive function) of "15" which indicated Resident #103 was cognitively intact. The MDS indicated Resident #103 needed extensive assistance (staff providing weight bearing support) of 2 staff members for toileting and bed mobility. According to the facility Incident report, dated 7/8/14, Resident #103's legs "slid off the edge of the bed and then resident (Resident #103) slid to the floor onto her bilateral (both) knees when Certified Nursing Assistant (CNA "D") was providing incontinence care. Resident #103 was sent to the ER (emergency room ) and x-ray findings indicated Resident #103 had sustained bilateral femur (leg bone) fractures and had bilateral leg braces when she came back to the facility (this was collaborated with the ER notes, dated 7/9/14, and the x-ray results from the hospital, dated 7/9/14). According to CNA "D"'s typed statement, dated 7/8/14 and signed by CNA "D" on 7/9/14, CNA "D" had assisted Resident #103 onto the bed pan after providing incontinence care. When CNA "D" rolled Resident #103 off the bed pan, Resident #103 stated she was uncomfortable. CNA "D" then rolled Resident #103 a second time and Resident #103's legs "swung off the side of the bed." CNA "D" stated, "I scooted her (Resident #103) over in the bed towards me so that I could roll her on her side to put her on the bed pan. That was successful and then I cleaned her up and positioned the bedpan. I told her to roll back and I asked her (Resident #103) how how did it feel and she said that it was uncomfortable. So I said okay let's roll back so I can fix it. When I rolled her over onto her side her legs swung off the side of the bed and she started to slide down as I was reaching over the bed to guide her down so she would go down easy." The question was asked of CNA "D", in her statement, "Did you reposition her (Resident #103) the 2nd (second) time when getting ready to roll her?" CNA "D" responded, "No, I didn't scoot her over the 2nd time. I sure if I would have she (Resident #103) would have been fine." (sic) On 7/24/14 at 11:30 a.m., Administrator (ADM) "A" was interviewed regarding Resident #103's fall on 7/8/14. ADM "A" stated, "My understanding is the aide (CNA "D") rolled her (Resident #103) away from her. Her (Resident #103's) legs went over the side of the bed (opposite CNA "D") and she (Resident #103) slid off the bed." ADM "A" stated the facility terminated (fired) CNA "D" for "rolling the resident away from her." On 7/25/14 at 1:30 p.m., Resident #103 was observed in her room lying in her bed with bilateral leg braces on. Resident #103 was interviewed regarding her fall on 7/8/14. Resident #103 stated that CNA "D" was changing her when she fell off the side of the bed. Resident #103 stated she had told CNA "D" that "they use 2 people, 1 on each side, when they change me." Resident #103 stated that when she told CNA "D" this, CNA "D" responded, "there's no one around to help me". Resident #103 stated CNA "D" then rolled her onto her right side facing away from CNA "D" and started providing care. Resident #103 stated she told CNA "D" 'I'm sliding' and started to slide out of the bed. Resident #103 stated CNA "D" reached across the bed to grab her, but her knees hit the floor before CNA "D" could stop her from falling. On 7/25/14 at 4:40 p.m., CNA "D" was contacted regarding Resident #103's fall on 7/8/14. CNA "D" asked this surveyor if I could get her-her job back. When this surveyor told CNA "D" that her termination was between her and the facility, she stated she would not talk about the incident, and hung up. According to CNA "D"'s Employee Warning Notice, dated 7/15/14, CNA "D" was terminated for "rolling a patient away from you, patient's legs slid off bed, and patient slid to floor resulting in serious injury." (sic) According to the facility's bed positioning policy, dated 10/11, when turning a resident back to their side you "reach across the patient and place one hand behind the shoulder and the other hand behind the hip and gently roll the patient toward you."

This citation pertains to MI 801. Based on observation, interview and record review the facility failed to provide an assistive device to prevent accidents (gait/transfer belt) in 1 of 3 residents (Resident #101) from a total sample of 3 residents reviewed for falls, resulting in Resident #101 falling and sustaining a fractured (broken) leg. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was cognitively intact and required an extensive assist of 2 person's for transfer. Review of the Facility Nursing Procedure Manual dated 12/2009 revealed under "nursing procedures" section "G" the purpose of a gait belt was "to safely and effectively transfer or ambulate a patient." Review of the Facility Nursing Procedures Manual dated 1/2011 revealed under "nursing procedures" section "T...Transfer bed-chair/wheelchair...one person-stand pivot" was to "#5. apply gait belt to patient" then "#8. Rock patient up to standing position...". In an interview on 12/13/13 at 2:20 p.m., Director of Nursing (DON) #2 stated the Facility Nursing Procedures Manual was used by staff "to know how to do a procedure" like a transfer. Review of the Patient Information Worksheet dated 8/16/13 revealed Resident #101 was "1 person assist..." for "transfers." Review of the Care Plan Activities of Daily Living Self care deficit dated 7/26/13 revealed Resident #101 was a "1 person assist..." with "transfers." Review of the Physical Therapy Notes dated 8/15/13 revealed "Tinetti (test) (Tinetti test is an assessment for older adults that measures gait and balance abilities) completed with score of 17 out of 28 with high fall risk" by Physical Therapist (PT) #3. In an interview on 12/11/13 at 3:40 p.m., PT #3 stated a "Tinetti" test "is for balance and walking." PT #3 stated Resident #101 "was still a high fall risk" based on the Tinetti test score. PT #3 stated Resident #101 "would not have been independent, she (Resident #101) would have had somebody (staff) with her. PT #3 stated, "anytime it says 1 person assist, they (staff) are to use a gait (transfer) belt." In an observation and interview on 12/11/13 at 1:05 p.m., Resident #101 was noted to be in her wheelchair with a halo (a brace attached to the chest and secured to the patients head via pins into the skull to restrict head and neck movement after a fracture) attached to her head. Resident #101 stated on 8/18/13 "at night" she needed to use the bathroom. Resident #101 stated Certified Nurse Aide (CNA) #5 came into her room and put her wheelchair next to the bed. Resident #101 stated CNA #5 "just walked up behind the wheelchair and said 'ok get up.'" Resident #101 stated, "I stood up, tried to pivot around, I reached (for the wheelchair) and went down (fell to the ground)." Resident #101 stated she struck a hard object and stated, "I think it was the register (heater)" in her room. Resident #101 stated Licensed Practical Nurse (LPN) #6 "came in" to her room." Resident #101 stated 3 staff members "picked me up" and put her back into bed. Resident #101 stated when she laid down in bed "it was hurting then...I was in such agonizing pain, there's nothing that compared to that." Resident #101 stated she had surgery to repair her right hip. In an interview on 12/13/13 at 10:00 a.m., CNA #5 stated, on 8/18/13, Resident #101 "needed to go to the bathroom." CNA #5 stated Resident #101 was "a 1 person assist" then stated "she's (Resident #101) a stand by assist." CNA #5 was asked by the surveyor if she placed a gait/transfer belt on Resident #101. CNA #5 stated, "no, I did not...I did not feel it was necessary to help her." CNA #5 stated she brought Resident #101's wheelchair next to her bed. CNA #5 stated Resident #101 stood up and did a "pivot turn toward the wheelchair." CNA #5 stated Resident #101 "said 'whao'" and Resident #101 fell toward the wall. CNA #5 stated Resident #101 "bumped the heater (register)" when she fell to the floor. CNA #5 stated Resident #101's "right hip" hit the heater. In an interview on 12/13/13 at 2:16 p.m., LPN #6 stated, on 8/18/13, CNA #5 "came down and told me she (Resident #101) was on the floor." LPN #6 went to Resident #101's room. LPN #6 stated Resident #101 "said she fell ." LPN #6 stated Resident #101 told her CNA #5 "was behind the wheelchair". LPN #6 stated Resident #101 told her she "lost her balance" and "hit hard" against the heater. LPN #6 was asked by the surveyor if Resident #101 was independent with ambulation. LPN #6 stated, "no she (Resident #101) was a stand by assist because of the halo" and then stated Resident #101 "was a 1 person assist." Review of the One-on-One In-service Record dated 8/26/13 revealed CNA #5 received "in-service" for "following patient plan of care" and "use of gait belt per policy." The One-on-One In-service Record revealed under "3) Gait belt is to be part of your uniform therefore if you transfer a patient to bathroom you need to remove the gait belt so that you have it with you to use for other patients while you wait for that patient to complete their toileting." Review of the Hospital Diagnostic Radiology Report dated 8/18/13 at 12:59 p.m., revealed Resident #101 had an "angulated, displaced and comminuted intertrochanteric right hip fracture." ( )

THIS CITATION PERTAINS TO INTAKE MI 524. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE TO PREVENT ACCIDENTS IN 1 (#101) OF 3 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 3 RESIDENTS, RESULTING IN RESIDENT #101 HAVING HER KNEE TWISTED IN A NEAR FALL DURING A TRANSFER, CAUSING PAIN, SWELLING AND SUBLUXATION (MILD DISLOCATION) OF HER RIGHT PATELLA (KNEE CAP). FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO WAS ORIGINALLY admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT SHE WAS COGNITIVELY INTACT, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR BED MOBILITY, TRANSFERS, AND TOILET USE, AND EXTENSIVE ASSISTANCE OF ONE PERSON FOR DRESSING AND PERSONAL HYGIENE. RESIDENT #101 WAS SENT TO THE HOSPITAL FOR treatment of [REDACTED]. REVIEW OF THE NURSING ADMISSION assessment dated [DATE] INDICATED RESIDENT #101 REQUIRED ASSISTANCE OF TWO PERSONS FOR TRANSFERS. RESIDENT #101'S MINIMUM DATA SET (MDS) WITH AN ASSESSMENT REFERENCE DATE OF 12/29/11 INDICATED THAT SHE WAS COGNITIVELY INTACT, AND REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR BED MOBILITY, TRANSFERS, AND TOILET USE. ORTHOPAEDIC SURGEON physician progress notes [REDACTED]. THE PROGRESS NOTE STATED RESIDENT #101 WOULD BE IN A BRACE FOR AT LEAST THREE MONTHS FOR PROTECTION OF THE QUADRICEPS MECHANISM AND SURGERY WOULD BE SET UP. PHYSICAL THERAPY NOTES FOR RESIDENT #101 DATED 1/6/12 INDICATED RESIDENT #101 WENT TO THE SURGEON ON 1/3/12 AND HAD RUPTURED PATELLAR TENDON (THOSE AFFECTED CANNOT STAND, AS THEIR KNEE BUCKLES AND GIVES AWAY WHEN THEY ATTEMPT TO) WITH NEW ORDERS FOR NO AMBULATION AND SEATED EXERCISES FOR GOOD LEG. REVIEW OF RESIDENT #101'S FALLS CARE PLAN DATED 12/4/12 REVEALED RESIDENT #101 HAD BEEN IDENTIFIED TO BE AT RISK FOR FALLS DUE TO AN UNSTEADY GAIT AND PAIN. INTERVENTIONS LISTED ON THE FALLS CARE PLAN INCLUDED ENCOURAGE TO TRANSFER AND CHANGE POSITIONS SLOWLY, PROVIDE ASSIST TO TRANSFER AND AMBULATE AS NEEDED. NO RESIDENT SPECIFIC INTERVENTIONS WERE NOTED. REVIEW OF RESIDENT #101'S ADL (ACTIVITIES OF DAILY LIVING) CARE PLAN DATED 12/4/12 REVEALED RESIDENT #101 HAD BEEN IDENTIFIED TO HAVE A SELF CARE DEFICIT AS EVIDENCED BY VERBALIZATION AND WEAKNESS RELATED TO PHYSICAL LIMITATIONS AND RECENT RIGHT KNEE REPLACEMENT SURGERY. INTERVENTIONS LISTED ON THE ADL CARE PLAN INCLUDED ASSIST TO BATHE/SHOWER AS NEEDED, ASSIST WITH DAILY HYGIENE, GROOMING, DRESSING, ORAL CARE AND EATING AS NEEDED. NO RESIDENT SPECIFIC INTERVENTIONS WERE NOTED. REVIEW OF THE FACILITY INCIDENT REPORT DATED 1/12/12 INDICATED RESIDENT #101 STATED WHILE CNA (CERTIFIED NURSE AIDE) WAS TRANSFERRING HER TO THE WHEELCHAIR SHE (CNA) ALMOST DROPPED HER AND RESIDENT #101 STATED HER KNEE WENT INWARD AND ALMOST TOUCHED THE FLOOR. THE INCIDENT REPORT ALSO INDICATED ICE WAS APPLIED PER RESIDENT REQUEST AND AN XRAY WAS ORDERED. RADIOLOGY REPORT FOR RESIDENT #101 DATED 1/13/12 INDICATED A REASON FOR THE XRAY OF PAIN AND TRAUMA WITH IMPRESSIONS LISTED AS 1. RIGHT KNEE ARTHROPLASTY WITH QUESTION OF MILD SUPERIOR SUBLUXATION OF THE PATELLA. 2. JOINT EFFUSION (FLUID IN THE JOINT) AND SOFT TISSUE SWELLING WITH NO DEFINITE FRACTURE DEMONSTRATED. NURSE'S NOTE FOR RESIDENT #101 DATED 1/13/12 INDICATED "LATE ENTRY FOR 1/12/12 6A-6P" REVEALED AT 3:00 PM RESIDENT REQUESTED TO GET OUT OF BED AND INTO A WHEELCHAIR AT 4:00 PM TO GET HER HAIR DONE BY STYLIST WHO CAME IN TO THE FACILITY TO SEE HER. THE LATE ENTRY NURSE'S NOTES INDICATED AT 5:00 PM RESIDENT #101 REPORTED TO NURSING STAFF THAT A CNA WAS TRANSFERRING HER (RESIDENT #101) INTO HER CHAIR, ALMOST DROPPED HER, HER KNEE BENT FORWARD AND ALMOST HIT THE GROUND. THE NURSE'S NOTES INDICATED THAT RESIDENT #101 STATED SHE HEARD A POP AND NOW HER KNEE HURT. THE NURSE'S NOTES ALSO INDICATED THAT RESIDENT #101 WAS TEARFUL AND STATED INCREASED ANXIETY ABOUT HER KNEE BEING EVEN MORE MESSED UP, AND REQUESTED ICE. IN AN INTERVIEW ON 4/18/12 AT 2:10 PM, CNA #12 STATED ON 1/12/12 SHE WAS "SUBSTITUTING" AND RESIDENT #101 "WASN'T MY ASSIGNED RESIDENT". CNA #12 STATED EARLY IN HER SECOND SHIFT A NURSE ASKED HER (CNA #12) TO TRANSFER RESIDENT #101 FROM HER BED INTO HER WHEELCHAIR, SO SHE REFERRED TO THE PIW (PATIENT INFORMATION WORK SHEET). CNA #12 STATED SHE ASKED RESIDENT #101 IF SHE WAS OKAY WITH A ONE PERSON TRANSFER AND RESIDENT #101 SAID YES, SO CNA #12 EXPLAINED "PUSHING OFF WITH HER HANDS" AND TIED A GAIT BELT AROUND HER, COUNTED 1,2 3, AND LIFTED. CNA #12 STATED AS SHE LIFTED FROM THE BED TO THE WHEELCHAIR RESIDENT #101'S LEGS WENT WEAK, SO SHE SAT RESIDENT #101 IN HER WHEELCHAIR. CNA #12 STATED RESIDENT #101 DIDN'T SAY ANYTHING TO HER ABOUT THE TRANSFER. THE SURVEYOR ASKED CNA #12 HOW SHE WOULD HAVE FOUND OUT WHAT TYPE OF TRANSFER TO USE FOR RESIDENT #101 AND CNA #12 STATED SHE LOOKED AT THE PIW. THE SURVEYOR ASKED CNA #12 WHAT THE PIW STATED AS TO WHAT TYPE OF TRANSFER RESIDENT #101 WAS, AND CNA #12 STATED IT WAS LONG TIME AGO AND SHE DIDN'T REMEMBER WHAT THE PIW SAID ABOUT RESIDENT #101. CNA #12 STATED ABOUT HALF THE SHIFT LATER, THE EVENING SUPERVISOR CAME TO HER (CNA #12) AND SAID RESIDENT #101 SAID THERE WAS A PROBLEM. WHEN ASKED BY THE SURVEYOR WHAT THE PROBLEM WAS, CNA #12 STATED SHE COULDN'T REMEMBER WHAT RESIDENT #101 SAID THE PROBLEM WAS, IT WAS A LONG TIME AGO. THE SURVEYOR OBSERVED CNA #12, WHO WAS PETITE IN SIZE, WITH LIGHT RED COLORED HAIR. IN AN INTERVIEW ON 4/19/12 AT 12:25 PM, RESIDENT #101 STATED SHE REMEMBERED THAT GIRL WHO ALMOST DROPPED HER TO THE FLOOR. RESIDENT #101 STATED THE GIRL CAME IN HER ROOM TO HELP HER GET UP TO GET HER HAIR DONE AND SHE (RESIDENT #101) TOLD HER (CNA) SHE WASN'T BIG ENOUGH TO HELP HER ALONE BECAUSE SHE WAS SO LITTLE. RESIDENT #101 STATED THE GIRL WAS LITTLE WITH RED HAIR, SHE DIDN'T LISTEN, AND SHE PUT A BELT AROUND HER WAIST AND LIFTED HER UP OFF THE BED. RESIDENT #101 STATED HER (RESIDENT #101) KNEE BENT INWARD AND THE GIRL ALMOST DROPPED HER TO THE FLOOR AND HER KNEE ALMOST TOUCHED THE FLOOR. RESIDENT #101 STATED THIS WAS BEFORE HER SECOND SURGERY. RESIDENT #101 STATED SHE TOLD THE GIRL, "OUCH YOU REALLY HURT ME." RESIDENT #101 STATED IT HURT A LOT, AND THE GUY WHO CAME TO DO HER HAIR SAW THE ENTIRE THING. RESIDENT #101 STATED THE GIRL FINISHED GETTING HER IN HER CHAIR, AND WHEN SHE GOT BACK FROM GETTING HER HAIR DONE, HER KNEE STILL HURT, SO SHE TOLD HER NURSE. IN AN INTERVIEW ON 4/18/12 AT 11:35 AM, THE SURVEYOR ASKED THE FACILITY DIRECTOR OF NURSING (DON #2) WHERE THE DOCUMENTED TRANSFER STATUS OF RESIDENT #101 COULD BE LOCATED. DON #2 STATED ON THE "PIW" (PATIENT INFORMATION WORKSHEET). THE SURVEYOR REQUESTED A COPY OF THE PIW FOR RESIDENT #101 FOR 12/4/11 AND 1/12/12. DON #2 STATED SHE DID NOT HAVE THEM BECAUSE NEW PIW'S ARE PRINTED EVERYDAY, AND PIW'S ARE UPDATED REGULARLY. THE SURVEYOR AGAIN ASKED DON #2 IF THE PIW FOR RESIDENT #101 FOR 12/4/11 AND 1/12/12 WERE STILL AVAILABLE AND DON #2 STATED SHE NO LONGER HAD THEM. IN AN INTERVIEW ON 4/19/12 AT 2:20 PM, THE SURVEYOR HAD THE FACILITY ADMINISTRATOR (ADMINISTRATOR #1) REVIEW A TYPED STATEMENT PROVIDED TO THE STATE AGENCY, SIGNED BY HIM, WHICH INDICATED TWO STAFF MEMBERS PERFORMED A TWO ASSIST TRANSFER FROM THE WHEELCHAIR TO THE BED OF RESIDENT #101, AND THIS TRANSFER WAS CONSISTENT WITH RESIDENT #101'S PLAN OF CARE AT THE TIME. THE ADMINISTRATOR WAS GIVEN THE PLAN OF CARE FOR RESIDENT #101 TO REVIEW AND THE ADMINISTRATOR WAS UNABLE TO LOCATE A TRANSFER STATUS ON THE PLAN OF CARE FOR RESIDENT #101. ADMINISTRATOR #1 STATED HE DID NOT LOOK AT THE PLAN OF CARE WHEN HE WROTE THAT STATEMENT BUT HE KNEW THE TRANSFER THAT THE STAFF DID WAS CONSISTENT WITH RESIDENT #101'S TRANSFER STATUS BASED ON WHAT HE WAS TOLD FROM THE NURSING DEPARTMENT. IN AN INTERVIEW ON 4/18/12 AT 1:30 PM, CNA #15 STATED THE PIW IS THE ONLY PLACE WHERE SHE CAN FIND INFORMATION ON HOW TO TRANSFER A RESIDENT AND THE INFORMATION ON THE PIW IS NOT ALWAYS CORRECT BECAUSE IS DOESN'T GET UPDATED BY NURSING. CNA #15 STATED FOR EXAMPLE SOMETIMES THE PIW IS BLANK, AND CNA #15 PULLED A PIW OUT OF HER POCKET. THE SURVEYOR OBSERVED NON-SAMPLED RESIDENT #A ON THE PIW WITH THE TRANSFER AND MOBILITY, MEAL ASSIST, TOILETING NEEDS, USE OF INCONTINENT PRODUCTS, AND PRESCRIBED DIET AND LIQUID CONSISTENCY SECTIONS WERE ALL BLANK. NON SAMPLED RESIDENT #A WAS LISTED AS A CURRENT RESIDENT IN THE FACILITY ON THE ROSTER/SAMPLE MATRIX PROVIDED TO THE SURVEYOR BY THE DIRECTOR OF NURSING ON 4/18/12 AND CNA #15 STATED NON-SAMPLED RESIDENT #A WAS A RESIDENT SHE WAS ASSIGNED TO PROVIDE CARE FOR THAT DAY. CNA #15 STATED RESIDENT #101 HAD ALWAYS BEEN A 2 PERSON TRANSFER SINCE SHE HAD BEEN IN THE FACILITY. CNA #15 STATED AFTER HER INJURY WHEN HER TENDON WAS TORN, SHE WAS A TWO PERSON ASSIST WITH TRANSFERS BECAUSE ONE PERSON HAD TO HOLD HER LEG WHILE THE OTHER PERSON TRANSFERRED HER. IN AN INTERVIEW ON 4/18/12 AT 1:45 PM, RN #14 STATED HE WAS RESIDENT #101'S REGULAR NURSE ON FIRST SHIFT AND KNEW THE RESIDENT WELL. RN #14 STATED RESIDENT #101 WAS A 2 PERSON TRANSFER AND HAD BEEN A TWO PERSON TRANSFER SINCE HER ADMISSION TO THE FACILITY DUE TO HER KNEE INJURY. IN AN INTERVIEW ON 4/18/12 AT 2:25 PM, CNA #11 STATED SHE HAD PROVIDED CARE ONCE IN A WHILE FOR RESIDENT #101. CNA #11 STATED WHILE PROVIDING CARE TO RESIDENT #101 WITH CNA #4, RESIDENT #101 REPORTED TO THEM THAT THE LITTLE RED HEADED GIRL HAD DROPPED HER THE DAY BEFORE. CNA #11 STATED RESIDENT #101 SAID SHE DIDN'T WANT THAT GIRL TO TAKE CARE OF HER ANYMORE. CNA #11 STATED RESIDENT #101 WAS A TWO PERSON TRANSFER AT THAT TIME AND WAS STILL A TWO PERSON TRANSFER NOW. IN AN INTERVIEW ON 4/19/12 AT 11:15 AM, PHYSICAL THERAPIST #10 (PT #10) STATED WHEN RESIDENT #101 FIRST ARRIVED AT THE FACILITY HER RANGE OF MOTION IN THE RIGHT KNEE WAS GOOD, BUT SHE EXPERIENCED SUDDEN DECLINE IN HER ABILITY TO EXTEND HER RIGHT KNEE AROUND 12/23/12. PT #10 STATED ON 12/23/12 SHE BELIEVED THE TENDON WAS RUPTURED AND WAS VERY CONCERNED BECAUSE RESIDENT #101 WAS UNABLE TO STAND OR EXTEND HER KNEE. PT #10 STATED WHEN RESIDENT #101 ATTEMPTED TO STAND SHE WOULD FALL BACKWARD DUE TO THE INJURY TO HER KNEE, AND WAS A TWO PERSON ASSIST. IN AN INTERVIEW ON 4/19/12 AT 1:00 PM, CNA #8 STATED SHE PROVIDED CARE REGULARLY FOR RESIDENT #101 AND SHE HAD ALWAYS BEEN A TWO PERSON TRANSFER BECAUSE HER KNEE WAS BAD. IN AN INTERVIEW ON 4/19/12 AT 2:10 PM, CNA #4 STATED WHILE SHE PROVIDED CARE FOR RESIDENT #101 SHE REPORTED TO HER THAT A SHORT WHITE GIRL WITH RED HAIR HAD DROPPED HER. CNA #4 STATED RESIDENT #101 WAS UPSET AND REQUESTED NOT TO HAVE THAT GIRL TAKE CARE OF HER ANYMORE BECAUSE SHE HAD TRANSFERRED HER (RESIDENT #101) BY HERSELF. CNA #4 STATED RESIDENT #101 REQUIRED TWO PEOPLE TO ASSIST HER WITH A TRANSFER NOW AND ALWAYS HAD, BECAUSE OF THE INJURY TO HER KNEE. IN AN INTERVIEW ON 4/25/12 AT 4:20 PM, STYLIST #16 STATED HE WAS IN THE ROOM WITH RESIDENT #101 ON 1/12/12 WAITING TO TAKE HER TO THE FACILITY BEAUTY SHOP TO DO HER HAIR WHEN A GIRL CAME IN TO HELP RESIDENT #101 MOVE FROM HER BED TO HER WHEELCHAIR. STYLIST #16 STATED THE GIRL WHO CAME IN HAD RED HAIR AND WAS TINY AND SEEMED OVER CONFIDENT. STYLIST #16 STATED RESIDENT #101 COMMENTED TO THE GIRL THAT SHE WASN'T COMFORTABLE WITH THE GIRL TRANSFERRING HER BY HERSELF, BUT THE GIRL DID IT ANYWAY AND SEEMED TO LOSE CONTROL DURING THE TRANSFER. STYLIST #16 STATED THE GIRL PUT A BELT AROUND RESIDENT #101 AND LIFTED THE RESIDENT, BUT INSTEAD OF RESIDENT #101 TURNING TOWARD HER WHEELCHAIR, HER BODY TURNED AWAY FROM THE WHEELCHAIR AND HER KNEE BUCKLED. STYLIST #16 STATED RESIDENT #101 WENT DOWN, BUT NOT QUITE TO THE FLOOR, AND THE GIRL CAUGHT RESIDENT #101, AND LIFTED HER TO HER WHEELCHAIR. STYLIST #16 STATED HE REACHED FOR RESIDENT #101 BUT COULD NOT QUITE GET TO HER. STYLIST #16 STATED RESIDENT #101 DID EXPRESS THAT SHE WAS VERY UNCOMFORTABLE AND TOLD THAT GIRL SHE WAS UPSET WITH HER. STYLIST #16 STATED THE TRANSFER WAS UNCOMFORTABLE FROM START TO FINISH AND RESIDENT #101 STATED TO HIM THAT SHE KNEW THAT GIRL DIDN'T KNOW WHAT SHE WAS DOING. #