Every finding on record at Optalis Health & Rehabilitation of Whitehall

Based on observation, interview, and record review, the facility failed to prevent further pressure ulcer development for 1 resident (R7) out of 2 residents reviewed for pressure ulcers resulting in 3 facility acquired pressure ulcers for R7. Findings include:Review of an Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnoses which included neuropathy, chronic obstructive pulmonary disease, and stage IV sacral pressure ulcer. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R29, with a reference date of 12/18/2025 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 R7 was cognitively intact. Further documentation revealed Active Diagnoses included I5600 Malnutrition (imbalances in a person's intake of energy and nutrients) and documented 1 unhealed pressure injury. In an observation on 3/2/26 at 9:05 AM, R7 was positioned slightly on his left side with right ankle and foot touching the bed sheet, a pillow was observed between the bed sheet and R7's shin. R7's back and buttocks were flat on the bed sheet. R7's bedspread was folded and sitting on top of his right foot.Review of R7's Progress Note Details by a visiting wound clinic Nurse Practitioner (NP) dated 1/6/26 revealed: Wound #1 - Right Gluteal Fold a chronic stage 4 (full-thickness wound with exposed muscle, tendon or bone) facility acquired pressure ulcer. Measurements were 2.1cm (centimeters) length x 0.9cm width x 0.7 cm depth with tunneled (narrow, deep channels that form beneath the top layer of skin, extending from a wound into surrounding subcutaneous tissue or muscle) area of 1.6cm. There is no change noted in the wound progression and the treatment for Wound #1 remained unchanged. Wound #2 - Right, Dorsal Second Toe a stage 4 new facility acquired pressure ulcer dated 12/23/25. Measurements were 0.9cm length x 1cm width x 0.2cm depth. There was no change in the progression of the wound and treatment remained unchanged for Wound #2.Review of R7's Progress Note Details by a visiting wound clinic NP documented a new facility acquired wound dated 1/13/26. Progress Notes revealed: Wound #3 - Right, anterior thigh was a full-thickness trauma wound on 1/13/26 and initial measurements were 1.5cm length x 0.9cm width and 0.1m depth. There was a moderate amount of purulent drainage documented. Review of R7's Order Summary Report revealed treatment for the right thigh trauma wound was ordered on 1/20/26 (a week after the wound was evaluated by the wound clinic NP) with the first documented treatment completed on 1/22/26.Review of R7's Progress Note Details by a visiting wound clinic NP dated 1/20/26 documented a new facility acquired sacral stage 3 (a deep, full-thickness pressure injury extending through the skin into subcutaneous fat) wound (wound #4) that measured 2cm length x 3.6cm width x 0.1cm depth. There was a small amount of serosanguineous (thin, watery, pink-to-light-red fluid) drainage documented at the time of the assessment. Review of R7's Order Summary Report revealed treatment for the new facility acquired sacral stage 3 wound was ordered on 1/20/26 and the first treatment was declined by R7 on 1/22/26. Upon further review of R7's January 2026 Treatment Administration Record (TAR), treatment was not completed for R7's sacrum wound until 1/24/26. Review of R7's Progress Note Details by a visiting wound clinic NP dated 2/24/26 revealed Wound #1 measured at 2.4cm length x 0.9cm width x0.3cm depth and tunneling 1.1cm. Upon further review, Wound #1 within the 8-week time frame of NP visits from 1/6/26 to 2/24/26 wound #1 had minimal healing documented and not one change in treatment. Wound #2 measured 0.3cm length x 0.7cm width and no depth. Wound #3 measured 4.2cm length x 1.0cm width x 0.1cm depth. Wound #3 had deteriorated within the same 8-week period with only 2 treatment changes documented. Wound #4 measured 3.5cm x 5.0cm x.2cm. Wound #4 had 2 treatment changes within the 8-week period and continued to deteriorate. In an observation and interview on 03/03/2026 at 1:59 PM R7 was observed slightly on his left side with back and buttocks that touched the bed sheet. R7's right foot and toes are covered with a white sock as they touched the bed sheet, and a pillow was underneath his right lower leg between the knee and ankle. R7's right foot and toes were directly placed on the top of the bed sheet and were not bridged. R7's bedspread was folded and sitting on top of his right foot. R7 did not have a heel boot placed on his right foot. R7 had spaghetti on his shirt which he reported had been what he ate for lunch. R7 states that he needed assistance to be turned and repositioned. R7 reported that staff usually repositioned him at least once during the night shift and approximately 3 times during the day shift. R7 reported that the wound clinic that does weekly visits will not be visiting any longer. R7 stated that he does not decline to be turned and repositioned and he lets staff do care. Review of a Progress Note dated 1/5/2026 revealed R7 to be completely immobile and unable to make even slight changes in body or extremity position without assistance. In an observation on 3/3/36 at 4:30 PM, R7 was in the same position he was observed in more than two hours prior.In an observation and interview on 03/04/2026 7:04 AM, R7 was positioned on his back with a pillow situated on his right side. A pillow was noted from R7's right knee to right heel with right foot and toes that touched the bed sheet. R7's bedspread was folded and sat on top of his right foot. Right foot had a white sock on it. R7 did not have a heel boot placed on his right foot. R7 stated the last time the staff turned and repositioned him was last night. R7 was unable to recall the time staff repositioned him only that it was between supper (the day before) and breakfast (today). In an observation and interview on 03/04/2026 9:22 AM, R7 was positioned on his back with a pillow situated on his right side. R7's bedspread was folded and sitting on top of his right foot. Right foot had a white sock on it. R7 did not have a heel boot placed on his right foot. A pillow was observed from R7's right knee to right heel and R7's right foot and toes were positioned on the bed sheet. R7 stated the last time the staff turned and repositioned him was last night.In an interview on 3/4/26 at 10:05 AM, Certified Nursing Assistant (CNA) L reported that R7 was her assigned resident. CNA L reported that R7 had not received care or had been repositioned since her arrival at 6:00 AM. CNA L stated that R7 should be checked and turned every 2 hours. CNA L revealed she was unsure of other interventions R7 had in place to prevent skin breakdown. CNA L reported that she was unsure when R7 was turned last because night shift and day shift do not communicate when residents are last repositioned in report.Review of a care plan Actual Pressure Injury Formation. revealed R7 had a pressure ulcer to right ischium and a wound to left second toe. interventions for R7 indicated staff were to provide surface support and pressure redistribution, position changes, and off-loading.Alternate pressure mattress.encourage R7 to float heels or wear heel boots.staff to assist in keeping any pressure from blankets off from R7's toe. monitor wound for any significant changes and alert physician of changes. Upon further review of R7's Actual Pressure Injury Formation. care plan the last intervention initiated was dated 12/24/2025. During an interview and record review on 3/4/26 at 10:43 AM, the Director of Nursing (DON) was unsure of the causation of Wound #2 stating that R7 doesn't put anything on his toes. DON reported that R7's new pressure injury to the left thigh (Wound #3) was due to a catheter stat lock (stabilization device that used adhesive to secure catheter tubing). DON stated that the intervention for Wound #3 was to rotate the catheter stat lock to different sites on R7's leg. DON stated it was an expectation that R7 be turned and repositioned every 2 hours for prevention of further pressure injuries. DON reported that staff should have been communicating related to R7's care specifically to report when R7 had last been turned and repositioned. DON stated that wound #3 and wound #4 were not addressed in R7's plan of care and should have been addressed with new pressure injuries and interventions. DON could not provide an incident report for wound #2, #3, or #4. DON stated that R7 had declined heel boot and other preventative interventions. DON could not provide documentation of R7's declinations of interventions to prevent new pressure injuries related to wound #2, wound #3, and wound #4. Record review of R7's progress notes revealed two wound check-ins on 1/29/26 and 2/25/26. When asked if wound check-ins were interdisciplinary collaboration, DON stated they were not. When asked if the interdisciplinary team had any collaboration to discuss R7's pressure wounds and what could be implemented to prevent further breakdown of his skin, DON replied no.Review of R7's Kardex Report as of 3/1/26 revealed no documentation to change position of R7's catheter stat lock. Further review of R7's medical record did not reveal documentation to the staff to rotate R7's catheter stat lock. In an observation on 3/5/26 at 9:02 AM, R7 stated he was turned and repositioned once in the night last night. R7 was on his back with head of bed up approximately 35 degrees and he was slumped over on his left side. There is no sock or boot on R7's right foot. R7's right foot and toes contacted bed sheet.In an interview on 3/5/26 at 12:57 PM, Licensed Practical Nurse (LPN) Unit Manager (UM) F stated that facility would normally complete an incident report for Wound #2, #3, and #4 but that was not part of her job duties. LPN UM F stated that R7 had a boot for his right foot and only wore the boot while in bed. LPN UM F stated that she is unsure why R7 is positioned on his back continually. LPN UM F reported that she completed wound rounds with the visiting wound clinic NP every week and the NP was not concerned about changing treatments to R7's wounds if they were deteriorating. When asked if LPN UM F voiced any concern to the visiting NP from the wound clinic regarding any possible treatment change related to deteriorating wounds, LPN UM F replied that was beyond my scope. LPN UM F stated it was her expectation to stay on top of R7's care planning to prevent any further pressure injuries. When asked how frequently staff should be in R7's room to turn and reposition him, LPN UM F stated every 2 hours.In an interview on 3/5/26 at 2:01 PM, Regional Nurse (RN) M reported that there was no incident reports completed for R7's wound #2, #3, and #4. RN M reported that there are no notifications to primary physician related to deterioration of R7's wounds. RN M stated that the expectation for care planning interventions and updating wounds in R7's care plan would be the next business day from the start of the wound.Review of facility policy/procedure Skin and Wound Guidelines revised 2/4/26 revealed .the individualized comprehensive care plan addresses the resident's problem (i.e. at risk for skin breakdown or actual wound), the goal for prevention and/or treatment, and individualized interventions to address the resident's specific risk factors and the plan for reduction of risk.

Based on observations, interviews, and record review, the facility failed to protect the resident's (R6, R7, R9, R15, R26, R34, R35, R58 and F60) right to be free from mental abuse and verbal abuse by R52 resulting in fear and physical anguish in the resident's home. Findings include:Resident #58 (R58)Review of an Face Sheet revealed R58 admitted to the facility 3/4/2025 with pertinent diagnoses which included heart failure, acute respiratory failure, anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R58, with a reference date of 12/8/2025 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 R58 was cognitively intact. Review of R52's Progress Note dated 2/7/26 at 5:05 AM indicated that R52 went into R58's room and stood over her while she laid in bed. There was no documentation of this incident in R58's electronic medical record besides the following psychology notes. Review of a psychology follow-up visit dated 2/10/26 at 4:18 PM revealed .Mood symptoms worsened over the past two weeks with increased depressive symptoms triggered by a situational stressor involving a confused male resident (R52) who repeatedly entered R58's room. This led to increased fear. Symptoms are now improving, with yesterday and today showing decreased symptoms as resident is reassured, he is not returning to the facility. R58 experienced increased depression and anxiety symptoms triggered by a confused male resident (R52) at the facility. Symptoms included fear, avoidance behaviors, and nausea. Review of a psychology follow-up visit dated 2/24/26 at 11:30 AM revealed .R58 reported increased anxiety symptoms related to another resident recently admitted to the hall. Resident states that R52 came to her doorway and stands there staring into her room. She stated she had redirected him back to his own room. R58 stated she had been keeping her door closed for this reason, however R52 had also opened her door and came into her room on multiple occasions. R58 stated her daughter was here yesterday when R52 entered her room and was also unable to redirect R52 out of the room. R58 stated her daughter put the call light on for assistance, however both were anxious while waiting for staff to respond. R58 stated she had voiced her concerns to several people in the facility but feels like no changes will be made.which scared R58. During an interview on 03/04/2026 at10:00 AM, R58 stated the man who walks around next door, (R52), will stand in my doorway and stare. R58 stated she tried to keep her door closed to prevent R52 from entering her room and he opened it just this week. R58 stated that R52 will stand in her room by the curtains (5ft to R58's bed from the curtain). R58 stated she heard a loud noise the previous night and when she looked in the hallway, R52 had pulled out a supper tray from the cart, and it was on the floor. R58 stated that R52 makes her feel anxious and very leery. R58 reported to one person about the situation with R52, when asked who that was R58 stated the administrator. R58 requested for R52 to be moved from the hall and R58 was told we are working on it. R58 stated that he (R52) still is next door to her and stated, that bothers me a lot. R58 stated I should feel safe and secure. R58 reported that her feelings haven't changed any. R58 stated I don't think he should be on our hallway. A review of R58's Electronic Medical Record on 3/4/26 at revealed no further documentation with exception of the psychologist Progress Notes on 2/10/26 and 2/24/26 of any incident that occurred or intervention that had been offered or put into effect.During an interview on 3/4/26 at 12:21 PM, R58's Family Member (FM) N stated R52 scared R58 on 2/23/26 when FM N had been visiting. FM N stated that R52 showed up multiple times in R58's doorway. R58 responded to R52 and said, Your room is down there.your room is down there!. R52 did enter R58's room again and FM N stated she rang R58's call light for assistance. During this interview, FM N stated that R58 fears R52. FM N stated that on a subsequent visit on the weekend, R52 was in R58's doorway multiple times and needed to be redirected away from R58's room. FM N stated that R58 went to the administrator with concerns regarding R52's presence in R58's room and FM N reported that the facility had planned to move R52 to a different location. FM N stated that R52s actions weighs heavily on R58 and causes high anxiety for R58 Resident #26 (R26)Review of a Face Sheet revealed R26 admitted to the facility 1/14/2019 with pertinent diagnoses which included depression, decreased range of motion, and dementia. During an interview on 3/4/2026 at 2:09 PM, Family Member (FM) O reported that R58 had been very afraid of R52 after he walked into her room at night and R58 has been anxious related to the incident ever since. FM O added that R58 feels uneasy when R52 walks in front of the door or stands in the doorway so R58 had shut the door and R52 opened it and walked in anyway. FM O stated that this week R52 had walked into R26's room and FM O stated this is a lady's room, please leave. FM O stated I do have a fear of what R52's going to do and why he's in here. Resident #60 (R60) Review of an Face Sheet revealed R60 originally admitted to the facility 6/15/2022 with pertinent diagnoses which included chronic obstructive pulmonary disease, dementia, and generalized anxiety disorder. Review of a MDS assessment for R60, with a reference date of 12/12/2025 revealed a score of 07, out of a total possible score of 15, which indicated R60 was severely cognitively impaired. Review of R52's Progress Note dated 2/7/26 at 5:05 AM indicated that R60 was crying and had stated to staff that he was scared to have R52 in the room. In an interview on 3/4/26 at 10:15 AM, R60 was asked if he had any concerns with other residents, if he was fearful of another resident. R60 stated I want to forget that. R60 stated his old roommate (R52) wanted to die. R60 stated R52 went batty. When further questioned, R60 stated R52 kept talking about dying and thoughts of suicide. R60 stated he did not feel threatened at this time. In a review of R60's Electronic Medical Record on 3/4/26 at 1:30 PM, revealed no documentation that any incident had occurred. Resident #6 (R6) Review of an Face Sheet revealed R6 originally admitted to the facility 2/15/2022 with pertinent diagnoses which included chronic heart failure, dysphagia (difficulty swallowing), obesity, and type II diabetes mellitus. Review of an MDS assessment for R6, with a reference date of 2/3/2026 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R6 was cognitively intact. In an interview on 3/2/26 at 8:10 AM, R6 stated that a strange man (R52) had been walking in and out of her room and staff had to redirect him. In an interview on 3/5/26 at 8:55 AM, R6 stated a male resident (R52) came into her room just this week. R6 was unable to recall the specific day this occurred. R6 stated that R52 gets through the door and he stood in her room. R6 reported that staff usually get R52 and redirect him out of her room. R6 reported that if R52 was at her bedside, she would be scared. Resident #7 (R7) Review of an Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnoses which included neuropathy, chronic obstructive pulmonary disease, and stage IV sacral pressure ulcer. Review of an MDS assessment for R7, with a reference date of 12/18/2025 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R7 was cognitively intact. In an interview on 3/5/26 at 9:02 AM, R7 stated that R52 was in his room yesterday (3/4/26). R7 stated when R52 had been in his room he uses his call light to alert staff to assist R52 out of his room. R7 stated that he told R52 he had been in the wrong room and to turn around and R52 complied. Resident #34 (R34) Review of an Face Sheet revealed R34 originally admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (blocked blood flow to the brain), morbid obesity, spinal stenosis, and depression. Review of an MDS assessment for R34, with a reference date of 12/15/2025 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R34 was cognitively intact. In an interview on 3/2/26 at 9:10 AM, R34 stated that a male resident (R52) had been wandering into women resident rooms and had shut doors. In an interview on 3/5/26 at 9:30 AM, R34 stated that the male resident (R52) was in his room today carrying a breakfast tray. R34 reported he said to R52 leave my room. R34 stated when he gets a stronger voice the second time he speaks to R52, he (R52) has turned around and left the room. R34 stated that the nurse came and redirected R52 this morning. R34 reported that there is a worry that R52 will harm another resident or himself. R34 reported that R52 had been noted to be standing at the foot of R34's bed staring at him. R34 stated that he would come unglued if R52 was standing over him when he was sleeping. R34 stated that the facility doesn't have enough staff to give him (R52) the care he needs. Resident #15 (R15) Review of an Face Sheet revealed R15 originally admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes mellitus, chronic obstructive pulmonary disease, and schizophrenia. Review of an assessment for R15, with a reference date of 12/15/2025 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R15 was cognitively intact. In an interview on 3/5/26 at 9:45 AM, R15 stated that there is a male resident (R52) that was in her room a couple of days ago. R15 states that R52 entered her room and he stood there and needed to be told a couple of times to leave. Resident #9 (R9) Review of an Face Sheet revealed R9 originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease, type II diabetes mellitus, and hoarding disorder. Review of an MDS assessment for R9, with a reference date of 12/19/2025 revealed a BIMS score of 14, out of a total possible score of 15, which indicated R9 was cognitively intact. In an interview on 3/5/26 at 10:00 AM, R9 stated that a male resident (R52) had come in and out of her room and hadn't listened to R9 when he was asked to exit the room. R9 stated when R52 entered her room he just stood in the room staring. R9 reported that it made her feel violated. R9 reported that R52 scared her when he entered her room on multiple occasions. R9 reported the last time R52 entered her room was two nights ago. Resident #35 (R35) Review of an Face Sheet revealed R35 originally admitted to the facility on [DATE] with pertinent diagnoses which included cerebral ischemic attack (temporary blockage of blood flow to the brain), type II diabetes mellitus, and diabetic neuropathy. Review of an MDS assessment for R35, with a reference date of 2/10/2026 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R35 was cognitively intact. In an interview on 3/2/26 at 10:00 AM, R35 reported that a resident two doors down from her room (R52) had been continuously entering resident rooms and he had recently opened the door to R58's room and a staff member had to redirect him. R35 stated that R52 belonged in a dementia unit or in a different hall. In an interview on 3/5/26 at 10:15 AM, R35 stated R52 had opened her door and the last time was 4 nights ago. R35 stated that R52 came into her room mostly on the night shift. R35 reported that when R52 opened her door at night, it did scare her. R35 stated that it does bother her and facility does not have enough staff to keep R52 out of other residents' rooms. Resident #27 (R27) Review of an Face Sheet revealed R35 originally admitted to the facility on [DATE] with pertinent diagnoses which included cerebral ischemic attack (temporary blockage of blood flow to the brain), type II diabetes mellitus, and diabetic neuropathy. Review of an assessment for R27, with a reference date of 12/29/2025 revealed BIMS score of 15, out of a total possible score of 15, which indicated R27 was cognitively intact. In an interview on 3/5/26 at 10:30 AM, R27 reported that R52 had stood in her doorway in which R27 had directed R52 that the room was a lady's room and he needed to leave. R27 stated R52 has backed out after she has repeated that phrase. R27 stated that facility needed to move R52 from this hall. Resident #52 (R52)Review of an Face Sheet revealed R52 originally admitted to the facility on [DATE] with pertinent diagnoses which included Wernicke's encephalopathy (acute neurological emergency caused by severe vitamin B1 deficiency), dementia, delusional disorders, and hallucinations. Review of an BIMS Evaluation dated 2/6/26, R52 had a score of 15, out of a total possible score of 15, which indicated R52 was cognitively intact. Review of a hospital record History and Physical dated 1/9/2026, .R52 was a [AGE] year-old male with recurrent visual hallucinations presenting to the emergency department with repeat episodes of confusion and wandering around other people's apartments. Review of R52's Behavior Note documented by Licensed Practical Nurse (LPN) P on 2/7/26 at 5:05 AM, . R52 used a wheelchair foot pedal as a potential weapon tonight, holding it up to swing it at a Certified Nursing Assistant (CNA). R52 also made multiple comments to staff and his roommate R60 regarding shooting people, guns, and it would only take one bullet. R60 cried and had stated to staff that he is scared of R52 in his room. LPN P was also informed that R52 went into R58's room and stood over her while she laid in bed. LPN P and an Agency Nurse transferred R52 to the emergency department regarding these two occurrences. Emergency department (ED) reported to LPN P that R52 attempted to elope the ED and became physical with ED security.R52 received 2 doses of intramuscular Ativan (an anti-anxiety medication) and Risperidone (an antipsychotic medication) to assist with anxiety. R52 obtained a skin tear in ED. R52 is currently awake and ready for transfer back to facility. Review of a hospital record Psychiatric Consultation Note dated 2/8/26, .R52 brought to the emergency department from his nursing home for agitation and aggressive behaviors on 2/6/26.R52's chief complaint was I was in a lockout situation . Review of R52's Progress Note dated 2/7/26 at 9:56 AM, .R52 arrived back to facility approximately 8:45AM.R52 placed into room [ROOM NUMBER] bed 2 related to history of aggressive behaviors (this room is directly beside R58's room) .R52 shows signs of delusions and confusion.R52 continues to walk down hallways without shoes and unsteady gait. Review of R52's Progress Note dated 2/7/26 at 12:50 AM, .R52 restless, running through hallways, trying to get out of the facility.R52 gait is unsteady.R52 walking into other resident's rooms. Director of Nursing (DON) notified an a one to one for R52 was initiated . Review of R52's Progress Note dated 2/7/26 at 13:54 PM, .on call Nurse Practitioner (NP) and DON notified and approved for R52 to be transferred to ED for psychiatric evaluation. R52 was transported from facility at approximately 1:50PM. Further review of Progress Notes, R52 returned to the facility on 2/11/26. Review of R52's Progress Note dated 2/12/26 at 12:38 AM, .R52 was up and wandering around hallway and wandered into another resident's room. Staff attempting to remove resident from other room and resident became physically violent. closed fist attempting to punch nurse aides in face. R52 finally came out of other residents' room and went back into his room where R52 grabbed his bedside table and attempted to [NAME] it at his CNA. Administrator notified, Unit Manager (UM) notified, on call physician assistant notified and in agreement to sending the resident to ER for evaluation. Review of R52's Progress Note dated 2/12/26 at 1:25 AM, .R52 was 1:1 with police officer after he arrived on scene. Police officer 1:1 with R52 until ambulance arrival. R52 became verbally agitated and aggressive with female Emergency Medical Technician (EMT).R52 was transported via ambulance service to the ED for evaluation. Review of R52's Progress Note dated 2/12/26 at 6:00 PM, .R52 has been up wandering the halls the entire shift today.R52 was paranoid we were giving him sleeping medication. Review of R52's Progress Note dated 2/12/26 at 9:39 PM, .R52 received his nighttime medication, and medication has had no effect on this R52.R52 continues to wander around hallway and enter other resident's rooms. R52 becomes verbally agitated when asked to leave other resident rooms . R52 given a job to help keep an eye on the hallway, R52 focused on this task for brief time, then was attempting to enter a female resident room.R52 stopped by staff and assisted back to his room. Review of R52's Progress Note dated 2/12/26 at 11:34 PM, .R52 was up wandering around and entered other resident's rooms, R52 became agitated when asked to leave the residents room. R52 redirected briefly back to his own room. R52 keeps asking where we keep the ammo. Review of R52's Progress Note dated 2/12/26 at 11:34 PM, .R52 assisted back to his room again.R52 was observed going into restroom and coming out of another resident room. Male Residents in the other room have been resting. R52 becomes agitated when staff redirect him . R52 escorted out of a female resident room again and is now back in his own room sitting on edge of his bed. Review of R52's Progress Note dated 2/15/26 at 11:06 PM, .R52 has been up wandering into several other resident's rooms. R52 is not wearing clothing but has a blanket wrapped around him. Staff that attempted to redirect have been met with resistance. R52 helped with getting dressed and R52 refused. R52 was pushing staff away and continued to wander very unsteadily down the 300 and 400 halls. Res continued to attempt to go to exit doors and in and out of other resident rooms. R52 has been muttering to himself and speaking in a non-sensical fashion. Review of R52's Progress Note dated 2/17/26 at 05:05 AM, .R52 was up wandering during the beginning of this shift. Staff attempted to redirect were met with resistance. R52 continued to attempt to go to exit doors. R52 was muttering to himself and spoke in a non-sensical fashion. Review of R52's Progress Note dated 2/24/26 at 11:52 PM, .R52 was walking down the hallway. R52 had no socks or pants on, just underwear and a T-shirt. R52 was lookinginto every room. R52 had to be guided out of other resident rooms. Review of R52's Progress Note dated 3/2/26 at 1:30 AM, .R52 noted to be walking frantically in hallway. R52 noted to have visual and auditory hallucinations, irrational beliefs, and incoherent and illogical jumbling of words. R52 cannot organize his thoughts and becomes increasingly agitated when staff attempts to assist him or offer distraction. R52 is redirected for a few seconds then proceeded to enter other residents' rooms talking about guns and not having any ammo. Review of R52's Progress Note dated 3/2/26 at 2:23 AM, .Despite R52's one time dose of Ativan, R52 continued to be anxious, constantly pacing up and down hallway trying to enter other residents' rooms. Resident became agitated when staff tried to redirect him out of other residents' rooms. Hallucinations continue.R52 kept yelling about a boat, and someone is supposed to pick him up so he can go get ammo for his gun. Review of R52's care plan At risk for changes in behavior and mood dated 2/3/2026, R52's interventions were initially documented on 2/3/26 that included administer medications per physician orders. encourage resident to attend activities of choice.offer snacks.ice cream. The last updated intervention was dated 2/3/26. Review of R52's care plan Exit seeking/elopement risk dated 2/3/26, R52's interventions are to allow to vent feelings and frustrations, alert bracelet.calmy redirect. There are no updated interventions after 2/3/26. In an interview and record review on 3/4/2026 at 9:24AM, Nursing Home Administrator (NHA) reported that the facility had transferred R52 to the hospital on 2/7/26 related to aggression toward staff and hallucinations. Upon review of the Behavior Note on 2/7/26, NHA reported she did not see the note before today. NHA stated that R52 had been wandering at night and was redirectable as the staff had R52 sort papers at the nurse's station. NHA stated she had encouraged a sleep aid so R52 could slow down. NHA reported that R58 was still scared of R52 and NHA had been counseling her. NHA reported the facility did not move R52 to a different room or hallway because it could turn into a larger concern. NHA reported that she believed she did not get all the details from the event on 2/7/26 and after reading the note stated it may be possible abuse and reportable (as an allegation of abuse to the state agency). NHA reported there were no incident reports completed from the occurrence on 2/7/26 between residents R52, R58, and R60. In an interview and record review on 3/4/2026 at 11:32AM, DON stated R52 had Wernicke's with bouts of agitation and became agitated on the evening of 2/7/26. DON stated R52 had been swinging a wheelchair pedal at a CNA and facility transferred R52 to the ED for evaluation. DON stated the facility did attempt a stop sign for R58 but R58 did not like the stop sign and it was removed. DON unable to locate further documentation related to the stop sign initiation. DON confirmed that she was unaware of the 2/7/26 behavior note until it was read in the Interdisciplinary Team Meeting (IDT) on Monday (2/9/26) morning. DON confirmed that members of the IDT were present, including the NHA. DON reported that she was unsure if the entire IDT team listened to the report completely, but team was present. DON reported there were no incident reports completed from the occurrence on 2/7/26 between R52, R58, and R60. DON stated if R52 had directly threatened with R60 with a gun it would be considered abuse and reportable. DON stated the facility is unable to meet R52's needs presently and he does present a risk. Upon review of the psychiatric notes for R58 on 2/10/26 and 2/24/26 regarding her ongoing fear of R52, DON had no response. In an interview on 3/5/26 at 1:07 PM, LPN UM F stated that R52 is newer to the facility. LPN UM F reported that the facility does not have the right or enough staff to care for R52 and he should have been a 1:1 upon return from the hospital. LPN UM F stated that we are failing R52 in this facility and I am scared for the residents on R52's hall. Review of facility policy/procedure Abuse, revised 2/2/2026, revealed .facility completing ongoing assessments and care planning for appropriate interventions, and monitoring of residents with behaviors, including but not limited to. verbally aggressive behaviors (screaming, cursing, demanding, insulting, etc.). physically aggressive behaviors (hitting, kicking, biting, spitting, throwing objects, threatening gestures, etc.). wandering into other's rooms or space, Taking/touching/rummaging through other's property. protective actions depend upon the people involved. any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient.if a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated. the facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and.reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement, when applicable) or reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials (including adult protective services and/or law enforcement, when applicable) .

Based on observation, interview and record review, the facility failed to monitor weights in a CHF resident and drug allergies in one (R89) and failed to implement and monitor ace wrap orders for one (R40) of two residents reviewed for change in condition, contributing to R89's death in the facility. Findings include:R89Review of a Face Sheet revealed R89 had pertinent diagnoses of congestive heart failure (CHF), diabetes and vascular dementia. Allergies: . Morphine (Opioid). WeightsReview of R89's weights revealed between January 2025 and July 2025 his weights averaged between 331 pounds (lbs) to 336 pounds. On August 17, 2025, R89's weight was 347 lbs. These weight values include but are not limited to:7/4/25- 333.1 lbs9/17/25- 343.9 lbs10/15/25- 357.6 lbs10/28/25- 365 lbs11/19/25- 359 lbs12/17/25- 363.5 lbs, next weight is 12/31/25.12/31/25- 350 lbs1/7/26-350.4 lbs, the last weight before expiration on 1/12/26. A 19.4 lbs average weight difference in 6 months and no daily weights since chest Xray on 1/6/26 and orders for increased Lasix 3 times a day on 1/6/26. R89 weights were done on an average of once a week, and no goal weight was established. Review of a Dietary Progress note dated 8/19/25 for R89 revealed: WEIGHT WARNING:Value: 347.4 (lbs (pounds)), +10.0% change [ 10.8%, 34.0] . Residents CBW (calculated body weight) is 347 lb and his BMI (body mass index) is 45 (obesity). Resident is triggering for sig (significant) weight gain, he has gained 10 lb this month. NP (Nurse Practitioner) assessed resident yesterday. weight gain likely related to fluid; resident is on a diuretic. oral intake is high, on average consumes 76-100% of meals, also on liquid protein BID (twice a day). will continue to monitor weight for any further fluid retention. Review of a Dietary Progress note dated 10/28/25 for R89 revealed: WEIGHT WARNING:Value: 365.0 (lbs) . Residents CBW is 365 lb and his BMI is 47, he has gained 27 lb since August, over the last month he has gained ~18 lb, weight gain is not beneficial given elevated BMI. weight gain likely related to CHF, lymphedema and diuretic use. NP notified of recent sig weight gain. Review of a Dietary Progress note dated 11/19/25 for R89 revealed: WEIGHT WARNING: Value 358.8 (lbs), +10% change . Residents CBW (is 259 lb and his BMI is 46, resident continues to gain weight, non beneficial given elevated BMI, an additional 10 lb since [DATE]. weight tends to fluctuate up and down with overall weight gain. weight gain likely related to CHF, lymphedema and diuretic use. Review of a Dietary Progress note dated 12/17/25 for R89 revealed: . recent sig (significant) weight gain, 20 lb since September, non beneficial weight gain. At risk for weight fluctuations (related to) CHF. will continue with current plan of care, monitoring weights for any sig changes . Change of ConditionReview of a Chest Xray dated 1/6/26 for R89 revealed: Impression: On comparison with prior study dated 12/3/2025; There is cardiomegaly (enlarged heart) noted. Accentuated bronchovascular (airway and blood vessels in the lungs) markings noted with prominence in the pulmonary vascularity, right sided pleural effusion, consistent with congestive heart failure. Advice 2D echocardiography for further evaluation. Review of a Nursing Progress note dated 1/7/26 for R89 revealed: Note Text: chest x-ray reviewed. Called physician. New orders received for lasix 40mg extra dose once a morning for 3 days. Potassium chloride 10meq (milliequivalent) once a day the am times 3 days. Orders placed in MAR. Medications given this AM to resident. Resident resting in bed. 02 sat 94% on 2L NC. Resident reporting difficulting (sic) breathing. Head of bed elevated to assist in breathing. Will continue to monitor. No full nursing assessment documented in the Electronic Medical Record (EMR). Review of the January 2026 Medication Administration Record (MAR) for R89 revealed the following orders and administration:-Lasix (Furosemide- a diuretic), 40 mg one time a day for vascular congestion for 3 days. Start 1/7/26 and discontinued 1/8/26. Documented as given once each day at 7 AM.-Lasix- 40 mg twice a day for CHF for 3 days. Start 1/8/26. Received one dose on 1/8 at 1PM, 1/9 at 1PM, 1/10 at 9AM and 1PM.-Lasix, 40 mg every morning and bedtime for diuretic. Start date 3/13/25, hold from 1/8/26 to 1/11/26. Received break (breakfast) dose on 1/8 and on hold after that. Review of the Lasix administration shows R89 did not receive 40 mg of Lasix three times a day as ordered between 1/9/26 through 1/12/26. No documentation to show why R89 did not receive the ordered medication and if the Practitioner was notified. Review of the January 2026 Medication Administration Record (MAR) for R89 revealed the following orders and administration:Aldactone (Spironolactone- a diuretic), 25 mg once a day for diuretic/heart failure, ordered 11/26/25 and discontinued 1/14/26. R89 did not receive this medication on 1/9, 1/11, or 1/12. No documentation indicating if the Practitioner was notified. Review of a Nursing Progress note dated 1/8/26 for R89 revealed: Note Text: resident seems sleepy this AM, refused meal although did take meds with a glass of fluid. Bilateral lower edema noted although this is not abnormal, no wheezing note O2 96% on O2 and no temp. No depth of R89's edema is documented. Review of the LATE ENTRY (unclear of date) Practitioner Progress note back dated 1/8/26 for R89 revealed: Note Text : CC: CXR (chest Xray) results . CXR results along w/ lab results from 1/6 reviewed .No reported fever, CP, SOB Labs: 1/6 CXR right pleural effusion, CHF. 12/3 CXR with infiltrates in right lung with small right pleural effusion concerning for congestive cardiac failure with possible infection, concern for pulmonary edema .A/P (Assessment and Plan): COPD (chronic obstructive pulmonary disease), Right pleural effusion, Hypercapnia (high levels of carbon dioxide in blood) .-Increase furosemide 40mg/d to BID x3 days .-Recent weight down (350lbs)-ECHO 2D (ultrasound to assess heart function) recommended based on 1/6 CXR (ordered)-Increase furosemide 40mg BID x3 days then resume 40mg/day The EMR revealed the ECHO was not done. Review of a Nursing Progress note dated 1/10/26 at 6:32 PM for R89 revealed: Note Text: Res noted to desaturate on 2L to 86%. Difficult to rouse from sleep. Shake and shout elicits eyes slightly open. [Guardian] on call said to put Res on comfort care. DON (Director of Nursing) notified. On call physician also notified. Waiting for response. No documentation indicated there was a follow up from the Practitioner. Review of a Nursing Progress note dated 1/10/26 at 10:20 PM for R89 revealed: .bed this evening and lethargic and stuporous, on 2 liters of oxygen with sats at 98%, no work of breathing noted, patient diaphoretic, not eating or drinking at this time . No documentation indicating the Practitioner was aware of R89's change in condition. Allergy Warning/Medication Interaction WarningReview of the Medication Orders for R89 revealed the following:Allergies to. Morphine, .-Morphine Sulfate (concentrate) ordered 1/11/26, give 5 mg by mouth every 4 hours as needed for moderate/severe pain. Documented as given on 1/11/26 at 3:04 PM and on 1/12/26 at 1:16 PM. No documentation or clarification indicating the Practitioner was aware of R89's allergy to Morphine. Review of a Nursing Progress note dated 1/11/26 at 11:00 AM and again at 1:13 PM for R89 revealed: Note Text: The system has identified a possible drug allergy for the following order: Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) *Controlled Drug* Give 5 mg by mouth every 4 hours as needed for pain and discomfort. Give 0.25 ml. No documentation or clarification indicating the Practitioner was aware of R89's allergy to Morphine. Review of a Nursing Progress note revealed system warnings for R89 regarding R89s allergy to Morphine and drug interactions to the Morphine dated 1/11/26 at 11:00 AM revealed: Note Text: The order you have entered Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) *Controlled Drug* Give 5 mg by mouth every 4 hours as needed for pain and discomfort. Give 0.25 ml has triggered the following drug protocol alerts/warning(s):Drug to Drug InteractionThe system has identified a possible drug interaction with the following orders:traZODone HCl Oral Tablet 50 MGSeverity: ModerateInteraction: Morphine Sulfate Oral Solution 20 MG/5ML may enhance the serotonergic effect of Sertraline HCl Oral Tablet 25 MG, Sertraline HCl Oral Tablet 50 MG, and traZODone HCl Oral Tablet 50 MG. This could result in serotonin syndrome.Amiodarone HCl Oral Tablet 200 MGSeverity: ModerateInteraction: Plasma concentrations and pharmacologic effects of morphine may be increased by P-glycoprotein / ABCB1 Inhibitors (e.g., Amiodarone HCl Oral Tablet 200 MG). Butrans (opioid pain patch) Transdermal Patch Weekly 7.5 MCG/HRSeverity: SevereInteraction: Buprenorphine, the partial mu opioid agonist and [NAME] antagonist, may diminish the analgesic effect of opioid agonists andprecipitate withdrawal symptoms in patients chronically maintained on full agonist opioids (e.g., HYDROcodone-(opioid pain medication) Acetaminophen Oral Tablet 5-325 MG and Morphine Sulfate Oral Solution 20 MG/5ML). The opiate receptor antagonist effects of buprenorphine are expected at higher doses.Butrans Transdermal Patch Weekly 7.5 MCG/HRSeverity: SevereInteraction: Buprenorphine, the partial mu opioid agonist and [NAME] antagonist, may diminish the analgesic effect of opioid agonists and precipitate withdrawal symptoms in patients chronically maintained on full agonist opioids (e.g., HYDROcodone-Acetaminophen Oral Tablet 5-325 MG and Morphine Sulfate Oral Solution 20 MG/5ML). The opiate receptor antagonist effects of buprenorphine are expected at higher doses.Sertraline HCl TabletSeverity: ModerateInteraction: Morphine Sulfate Oral Solution 20 MG/5ML may enhance the serotonergic effect of Sertraline HCl Oral Tablet 25 MG, Sertraline HCl Oral Tablet 50 MG, and traZODone HCl Oral Tablet 50 MG. This could result in serotonin syndrome.Sertraline HCl Tablet, Give 75 milligram by mouth one time a day for DepressionSeverity: ModerateInteraction: Morphine Sulfate Oral Solution 20 MG/5ML may enhance the serotonergic effect of Sertraline HCl Oral Tablet 25 MG, Sertraline HCl Oral Tablet 50 MG, and traZODone HCl Oral Tablet 50 MG. This could result in serotonin syndrome. Review of a Nursing Progress noted dated 1/11/26 at 11:40 AM for R89 revealed: Called to Res (Resident) room by CNA (Certified Nursing Assistant) stating that he is calling for help and looks bad. Res SpO2 (oxygen saturation) 79% 2L (liters). Res present short of breath. Low Fowler position (head of bed elevated 15-30 degrees). HOB (head of bed) elevated. DON notified of change of condition. On call notified with O2 (oxygen) 4L to keep sats > 88. Ativan 0.5mg po q 6 hours PRN (as needed) for anxiety. Roxanol (Morphine) 5mg (0.25ml) q (every) 4 hours PRN for pain and discomfort. Pharmacy also notified after orders signed by on call. Review of a Nursing Progress note dated 1/11/26 at 1:13 PM for R89 revealed: Note Text: The system has identified a possible drug allergy for the following order: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) *Controlled Drug* Give 5 mg by mouth every 4 hours as needed for moderate/severe pain. Review of the MAR for R89 revealed he received 5 mg of Morphine on 1/11/26 at 3:04 PM and another dose on 1/12/26 at 1:16 AM. Review of a LATE ENTRY Nursing Progress note dated 1/12/26 (unclear of the original entry date) at 11:58 PM by the Director of Nursing (DON) for R89 revealed: Note Text: Medication held today until clarification completed with physician. Last done at 0115 overnight. no c/o of nausea or vomiting at this time. Review of a Nursing Progress note dated 1/12/26 at 3:58 PM for R89 revealed: Note Text: Noted allergy to morphine, this is not a true allergy and list as an intolerance. [Hospital] documentation lists nausea and vomiting as the intolerance. Resident has had no c/o of nausea and vomiting. [Nurse Practitioner] and stated its fine to give and to Dc (discontinue) it from hisallergy list. Review of a Nursing Progress noted dated 1/12/26 at 4:06 PM for R89 revealed: Note Text: resident was found without breaths or pulse after this nurse entered room to assess effectiveness of PRN med given 40 min prior. Review of the Care Plan for R89 revealed a focus of Resident has altered cardiovascular status related to CHF, Hyperlipidemia, Hypertension, Date Initiated: 12/08/2025. Interventions included but not limited to: . Monitor daily weights as ordered Date Initiated: 12/08/2025, Monitor/document/report PRN any s/sx (signs and symptoms) of CAD (coronary artery disease): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities, Date Initiated: 12/08/2025. Administer medications per physician orders. Date Initiated: 12/08/2025. Diet to be followed as prescribed, Date Initiated: 12/09/2025. Assess for shortness of breath and cyanosis every shift, Date Initiated: 12/08/2025. Daily weights were not ordered, edema was not accurately/consistently assessed, Review of the Care Plan for R89 revealed no concise Focus, goals, or interventions related to CHF such as decreasing cardiac output, for fluid overload/excess fluid volume, positioning (e.g. semi-Fowlers position-sitting at a 30-45-degree angle to improve breathing and comfort), restricting sodium and fluid intake, and resident education. During an interview on 3/5/26 at 11:30 AM, the Director of Nursing (DON) reported the facility does not have a CHF policy or protocol to care for residents with CHF. Daily weights or other interventions would be resident specific for care. The DON did remember reporting a weight gain for R89 to the Practitioner and dietary has documentation that shows a weight gain in December. The Practitioner did order Lasix dose to increase to 3 times a day for 3 days in December and in January. The DON was not aware of an ideal goal weight for R89 and could not find documentation of nursing assessments for typical CHF assessments such as edema measurements, fluid/sodium intake, and a baseline goal weight without extra fluid retention. The DON suggested the staff were not documenting what they were doing for R89. The DON reported she would follow nursing standards of practice such as [NAME] and [NAME] for good reference. The DON conveyed she understood the concern of R89's increased weight gain, establishing a baseline weight, lack of nursing assessments for edema, and closer monitoring of weights in December and January. Labs were ordered and a positive chest X-ray was acknowledged, but no close monitoring or follow-up assessments were documented. In an interview on 3/5/26 at 1:30 PM, the Nurse practitioner (NP) Q reported she started working with R89 in December 2025 and reported the expectation of a resident assessment for congestive heart failure would include weights, respiratory status, increased orthopnea (shortness of breath when laying down), edema, and low oxygen saturations. R40Review of a Face Sheet revealed R40 had pertinent diagnoses of spinal stenosis, heart failure, and diabetes. Review of the Physician Orders dated 2/14/26 for R40 revealed: Please wrap with ACE wraps MONITORING TIGHTNESS BLE (bilateral lower extremities) two times a day for edema. Please apply in the morning and remove at night. Review of the Medication Administration Record (MAR) for R40 revealed as of 1:40 PM on 3/5/26 ACE wrap bandages were not documented as applied to R40. There is no documentation in the EMR to show any tightness in her BLE were monitored for tightness. Review of a Practitioner Progress note dated 3/3/26 for R40 revealed R40 admitted on [DATE] after a back surgery and is positive for lower extremity edema. Her weight was 256 lbs on 2/22 and is now 263 pounds. During an observation and an interview on 3/5/26 at 1:45 PM, R40 was sitting up in a wheelchair and reported her legs were to be wrapped up in bandages before she gets out of bed due to edema that pools in her legs. R40 reported she was here for short term rehab. She saw her surgeon the day before and told her the facility needs to make sure they do that first thing in the morning and to take them off when she goes to bed. She said she has lots of fluid in her legs and they need to be wrapped. R40 reported she wants to go home too just like the staff here do and doesn't want to be at the facility any longer than she needs to be. R40 reported she gained 17 pounds since she has been at the facility and is trying to prevent CHF. R40 reported she told the Social Worker about not getting her legs wrapped in the past who said he would tell the nursing staff to address it. R40 reported she already had therapy this day and her legs have not been wrapped since she got up. During an observation and an interview on 3/5/26 at 2:00 PM, Licensed Practical Nurse (LPN) A was in the hallway and reported R40's nurse was in another room admitting a new resident and would check R40's orders and provide treatment if needed. In an interview on 3/5/26 at 2:51 PM, the DON was informed of R40 not getting her legs wrapped since she has been up and out of bed. The DON reported they could look at her schedule and change the orders to wrap her legs when in bed. At this time the DON understood that it would not be ideal since R40's legs are dominant during the day and would cause more swelling if not wrapped during the day.

Based on observation, interview and record review, the facility failed to ensure sufficient staff were available to provide care and services for dependent resident's and meet resident needs including (R40 and R45) out of 87 residents who live the facility.Findings include:An early entry survey was conducted as a result of staffing concerns; because of the potential for ongoing concerns an additional early entry observation occurred on 3/5/26.On 03/05/2026 at 5:40 AM, Registered Nurse (RN) A revealed they currently had two nurse's and four aides working in the building. On 3/05/2026 at 5:42 AM, R52 was observed in his bed sleeping and wearing the same clothes he had been wearing for the past 2 days.On 3/05/2026 at 5:50 AM, Certified Nursing Aide (CNA) B revealed (Name of R52) behavior/mood had been better the last couple of days because they started him on some new medication on Monday night. I was worried about him because he usually is wandering, but he's sleeping tonight. I usually have to be on it (watching/always being observant) in order to protect my residents from him. CNA B stated, I have several residents that are scared of (Name of R52) because he goes into their rooms and looms over them in their beds and from the doorways including R58 and R60. I took (Name of R58) and wheeled her up to (Name of DON's) office because she is afraid of him. She reported her concerns and nothing changed. CNA B revealed, she usually doesn't take breaks because she needs to protect her residents and there would be no one to watch him (R52) if she took a break. CNA B stated she has taken (Name of R52) out of another female resident's room numerous times. CNA B revealed a staffing concern, One morning I had to call (use my phone) for help because (Name of R52) had a fall and I could not find anyone to help me get him up. My coworkers were working in other rooms, and I could not find anyone, so I called. No, we don't have enough help, we are often running 3rd shift with 2 aides and one nurse on each side. It runs better when we have 3 aides (one on each hall and one that helps in both hallways, but really, we need at least 2 on each hall at night because of behaviors and high acuity. We have several residents that need 2 aides to assist with the hoyers and sit-to- stands. We have a few residents that always require 2 staff because of behaviors and allegations against staff while others just need 1 to 1. So, no, we don't have enough staff.During an interview on 3/05/2026 at 6:03 AM, Certified Nursing Aide (CNA) C revealed an incident that happened involving R60 with his old roommate R52. States R60 has woken up scared because (Name of R52) was standing, hovering over him while he slept. CNA C revealed she was working the night (Name of R52) was talking about guns, shooting, and only needing one bullet. He has made numerous gun/shooting comments. He is just intimidating. CNA C revealed another recent incident she had with R52, she stated, I found him standing naked over a resident while she was sleeping. The resident did not know he was there. I got him out of her room and took him back to his room. I don't know what would have happened if I hadn't been looking for him. CNA C further stated, We do not have enough staff to take care of our residents, 2-3 aides on a side are not enough for our residents. Aides are constantly coming in early and staying late, but that does not fill the open spots or the need.During an interview on 3/05/26 at approximately 6:15AM, RN A stated, We do not have enough staff to fill the spots. RN A revealed the following about staffing on her weekends, It's awful, last weekend I only had 4 aides and 2 nurses for the building, and it wasn't enough. We have a lot of meds to pass, wounds to look at/do, help the CNA's and watch for behavior. Six people for a high acuity, high resident need building is not enough. On this hallway I have maybe 8-9 residents that get up during the night that require 2 people to get them to the bathroom. If my 2 aides are assisting a resident who is watching the hallway? It's a concern, I have a few residents that need to be redirected often throughout the night. For example, I have one resident that will start yelling and pulling things down, then he gets the other residents in surrounding rooms yelling, frightened and stirred up. When this resident starts, you need to be able to get to him quick and redirect his behavior before he wakes other residents up. There are 50 plus residents for me and 2 aides to assist even with us constantly running/moving we do not have enough staff to meet their needs. During an interview on 3/5/26 at 6:35 AM, Certified Nurse's Aide (CNA) D revealed I worked last weekend, we only had 2 nurses and four aides for the building. I clocked 70 hours last week; I picked up a 12 hour shift last weekend because they did not have enough staff. We do not have enough staff to take care of these residents; some require lots of care, many have behaviors and need re-direction it's a concern.During an interview on 3/05/26/at approximately 10:20 AM, DON stated, Yes, we do not have enough staffing. We do not have enough staff to take on new residents. However, we have been told we don't turn anyone away. On 03/05/2026 at 12:14 PM, NHA revealed there are staffing concerns and she is trying to get staff. NHA also confirmed concerns about providing timely service/labs for residents and that she is working on it. During an interview the NHA was asked to provide an Acuity list for residents that live on the 300 & 400 hallways and include those that require assistance with eating.On 3/5/26 an acuity list for the 28 residents living on the 300 Hallway was provided. Review of the list reflected 6 residents using a Sit to Stand (a piece of equipment that aids transfers) and 12 residents use a Hoyer that requires 2 staff to assist in transferring them. Out of 18 residents that require staff assistance for transferring, six of these residents require staff assistance to eat.On 3/5/26 an acuity list for 26 residents living on the 400 Hallway revealed 3 residents used a Sit to Stand, 9 use a Hoyer and 1 resident uses both the Sit to Stand or Hoyer. Out of the 13 residents, 2 of them require assistance to eat.Review of the acuity on both the 300 & 400 hallways reflect 31 out of the 54 residents living on it require extensive staff assistance, including 8 that require staff assistance to eat their meals. The level of acuity shows the increase potential of not meeting resident care needs during low weekend staffing and staffing overnight. On 3/5/26 at approximately 4:55 PM, R52 was observed walking in the hallway wearing the same gray t-shirt with white lettering and blue jeans for the third day in a row. R40Review of a Face Sheet revealed R40 had pertinent diagnoses of spinal stenosis, heart failure, and diabetes. Review of the Physician Orders dated 2/14/26 for R40 revealed: Please wrap with ACE wraps MONITORING TIGHTNESS BLE (bilateral lower extremities) two times a day for edema. Please apply in the morning and remove at night. Review of the Medication Administration Record (MAR) for R40 revealed as of 1:40 PM on 3/5/26 ACE wrap bandages were not documented as applied to R40. There is no documentation in the EMR (Electronic Medical Record) to show any tightness in her BLE were monitored for tightness. During an interview on 3/5/26 at 1:30 PM, the Nurse Practitioner (NP) Q and the Unit Manager (UM) C was questioned about residents receiving care based on concerns reported. The NP Q verified R40 has not had her bandages wrapped around her legs as ordered and talked to the floor nurse about it. The floor nurse reported she did not have time to wrap R40's legs. NP Q reported the Medical Director has shared concerns about the facility being understaffed that were expressed to the Nursing Home Administrator (NHA) and the Director of Nursing (DON). At this time UM C started to cry and reported the staff are so stressed because they know what kind of care they are capable of and want to provide good care and did they best they could and it affects them.During an observation and an interview on 3/5/26 at 1:45 PM, R40 was sitting up in a wheelchair and reported her legs were to be wrapped up in bandages before she gets out of bed due to edema that pools in her legs. R40 reported she was here for short term rehab. She saw her surgeon the day before and told her the facility needs to make sure they do that first thing in the morning and to take them off when she goes to bed. R40 reported she told the Social Worker about not getting her legs wrapped in the past who said he would tell the nursing staff to address it. R40 reported she already had therapy this day and her legs have not been wrapped since she got up. During an interview on 3/5/26 at approximately 2:10 PM, the Social Worker (SW) B reported R40 told him the nurse was not wrapping her legs up as ordered by the physician. When asked what he did with that information, SW B reported he told the Nursing Staff in the past that they needed to do it. During an observation and an interview on 3/5/26 at 2:00 PM, Licensed Practical Nurse (LPN) A was in the hallway and reported R40's nurse was in another room admitting a new resident and would check R40's orders and provide treatment if needed. During an interview on 3/5/26 at 2:51 PM, the DON (Director of Nursing) was informed of R40 not getting her legs wrapped since she has been up and out of bed. The DON reported they could look at her schedule and change the orders to wrap her legs when in bed. At this time the DON understood that it would not be ideal since R40's legs are dominant during the day and would cause more swelling if not wrapped during the day. The DON reported that the nurse in that hall is a very good nurse and acknowledged the concern of admitting new residents when the current residents care is not being provided.R45Review of a policy titled Showers last revised 1/7/25 revealed: It is the practice of the facility to assist residents with showering to maintain proper hygiene. Guidelines: Residents will be provided with showers as per request and per facility schedule based upon resident preference and safety. Review of the Electronic Medical Records (EMR) revealed R45 had pertinent diagnoses of contractures, morbid obesity, and paraplegia. During an observation and an interview on 3/2/26 (Monday) at 9:48 AM, R45 was lying in bed and not able to provide cares for herself. R45 reported she required extensive assistance from 2 staff for many activities of daily living (ADL's) due to her contractures. R45 had concerns about not having enough staff available to provide her with showers twice a week. Her last shower was 2 1/2 weeks ago and had to really push to get that shower so she could get her hair washed. R45 reported she gets a shower maybe once a month. Review of the Care Plan for R45 revealed she is to get a shower on Mondays and Fridays and is totally dependent on 2 staff for showers. During an interview on 3/4/26 at approximately 2:00 PM, R45 reported she did not get her shower on Monday 3/2/26. In an interview on 3/4/26 at approximately 2:23 PM, Certified Nursing Assistant (CNA) S and CNA T reported R45 requires 2 staff for bathing which would only leave one CNA on the floor to answer call lights. R45 likes to have her baths in the morning before breakfast and that would be hard to provide her with a shower at that time. The CNA's reported they will stay later on their shifts at times to provide her with a shower. Review of the Bathing/Shower task documentation for R45 revealed she was getting bathed but was not clear of when she was provided with a shower. In an interview on 3/4/26 at 11:51 AM, the Director of Nursing (DON) reported she addressed R45s showers a few weeks ago with R45. The DON looked into the EMR and verified that R45 was to receive showers on Mondays and Fridays and it was not clearly documented when the last time R45 received her shower. During an interview on 3/5/26 at 10:15 AM, the DON reported she talked to R45 about her showers and reported it takes 2 staff to provide the showers. R45 wants her showers before breakfast and needs to be more forceful with staff to ensure she gets them. There are usually 3 aides on the floor and if two aides provide her with a shower, that would leave one aide on the floor during mealtime. The facility did not have a shower aide at this time. Has addressed staffing with the Corporate Administrators who do not take in the acuity of a resident regarding staffing. They only look at the census. The facility does not have control over the acuity of a new admission or how many residents they admit because it is all pushed by the Corporate Administrators. The DON reported she will work on the floor as a floor nurse at times when they are short staffed. The DON reported she was not aware of the regulations of not serving as a charge nurse when the average facility census is 60 or greater. The facility census for this survey was 87. The DON reported that she is an Infection Control Nurse too. Review of a policy titled Staffing last revised on 4/18/25 revealed: The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the residents plan of care. Guidelines: Licensed nurses and nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including: o Assuring resident safetyo Attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being of the residents.o Assessment, evaluating, planning and implementing resident care plans.o Responding to resident needs.Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment. Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing.

Based on observation, interview and record review, the facility failed to prevent the Director of Nursing (DON) from working as a nurse on the floor. This deficient practice affects all 89 residents who resided at the facility.Findings include: During an observation and interview on 3/3/26 at 7:30 AM, the Director of Nursing (DON) was observed as a floor nurse attending a medication cart and passing medications. The DON reported there was a nurse that called in and was passing medications until relief was obtained. The DON reported she must work the floor sometimes.During an interview on 3/5/26 at 10:15 AM, the DON reported she has addressed staffing concerns with the Corporate Administrators who do not take in the acuity of a resident regarding staffing. They only look at the census. The facility does not have control over the acuity of a new admission or how many residents they admit because it is all pushed by the Corporate Administrators. The DON reported she will work on the floor on average once a week to cover staffing shortages. The DON reported she was not aware of the regulations of not serving as a charge nurse when the average facility census is 60 or greater. The facility census for this survey was 87. The DON reported that she is an Infection Control Nurse too. Review of a Staffing policy last revised 4/18/25 revealed: The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the resident's plan of care. Guidelines: The director of nursing services (DNS)/(DON) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.

Based on interview and record review, the facility failed to implement policies and procedures to ensure an effective Compliance and Ethics program. Findings: During an interview on 3/5/2026 at 2:31 PM, Regional Nurse (RN) M reported that the parent organization of the facility has a corporate director of compliance. RN M said staff can report suspected violations to a hotline.During the interview on 3/5/2026 at 2:31 PM, the Nursing Home Administrator (NHA) said she did not recall having training on the facility Ethics and Compliance program, but thought the online training was scheduled yearly. The NHA said she thought there were postings for the Compliance and Ethics hotline in common areas and indicated that the sorts of violations that would be reported were patient privacy/HIPAA (Health Insurance Portability and Accountability Act) violations, resident care concerns and staffing concerns. The NHA was not aware of any reported violations and had not responded to any alleged violations. When asked, the NHA was not aware who the facility Compliance liaison was and was not familiar with the procedures, but she would review the policy and find out. Review of a policy provided to the survey team Compliance and Ethics Program and Policy was dated 11/01/2019. When asked, RN M reached out to the corporate director of compliance for a more updated policy. RN M indicated that the corporate compliance director was based on the other side of the state and had not visited the facility. In an email sent on 3/5/2026 at 3:49 PM, the NHA wrote Per policy, it was confirmed that I am the Compliance Liaison. Prior to the interview on 3/5/2026 at 2:31 PM and the email follow up at 3/5/2026 at 3:49 PM, the facility NHA was not aware she was the designated facility Compliance and Ethics liaison. therefore, could not implement written policies and procedures and standards of conduct, was not involved with conducting effective training and education, was not involved in conducting internal monitoring and auditing, was not involved with enforcing standards and well-publicized disciplinary guidelines and was not involved in developing effective lines of communication with staff and ensuring participation in a compliance committee at the facility and with the Corporate Compliance officer. Review of a policy Corporate Compliance and Ethic Program Policy - Policy 227 revised 12/09/2024 reflects The facility is committed to Compliance and high Ethical standards. A Corporate Compliance and Ethic Program have been established in accordance with the Industry Segment-Specific Compliance guidelines. The program is designed to promote Quality of Care, Quality of Life, and prevent and detect criminal, civil and administrative violations. The Facility has developed a Corporate Compliance work plan in accordance with the Office of Inspector General ( OIG) and the Department of Health and Human Services ( DHHS). The Corporate Compliance Plan ( Work Plan) allows the facility to participate in the nationwide efforts to reduce health care fraud and abuse. The work plan will help the facility achieve its goals to provide the highest practicable quality of care and quality of life for its residents; to have efficient and effective operations, to provide accurate financial reporting and to legally be compliant. The facility provides a structure that makes it easy for employees to communicate questions and concerns. The Work Plan with the Code of Conduct will help the facility detect and correct errors and improper conduct. Compliance is defined as following the rules and regulations while Ethics is our adopted concept of doing the right thing because it is the right thing.Further review of the policy reflects As part of the facility's Culture of Compliance, the facility develops and distribute written standards of conduct, policies and procedures, and protocol that promote the facility's commitment to compliance with areas of potential fraud and abuse and quality of care and quality of life issues. The facility should maintain designated compliance and ethic program contact to which employees may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution. The reporting system includes a Hotline number that is posted throughout each facility, an email address and a drop box for written methods of reporting. The Compliance Officer and/or Compliance Liaison will conduct random Compliance and QAPI audits in each facility. Audit types may include but are not limited to sufficient staffing, comprehensive care plans, use of psychotropic medications, pressure ulcers, abuse, submission of accurate claims, quality of care/quality of life, therapy services kickbacks, environmental and resident safety. The facility administrator will be responsible for keeping a binder containing all documentation supporting facility QAPI efforts to ensure continued Compliance and Ethical implementation of patient care, state and federal regulations as well as policies and procedures.

Based on interview and record review, the facility failed to document in the medical record in a complete, accurate, and timely fashion for 4 residents (R7, R52, R58 and R60) out of 19 sampled residents. Findings:Resident #7 (R7)Review of an Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnoses which included neuropathy, chronic obstructive pulmonary disease, and stage IV sacral pressure ulcer. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R29, with a reference date of 12/18/2025 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 R7 was cognitively intact. Further documentation revealed Active Diagnoses included I5600 Malnutrition (imbalances in a person's intake of energy and nutrients) and documented 1 unhealed pressure injury.NOTE: Electronic copies of R7's progress notes were retained during the survey on 3/2/2026.Review of R7's Progress Note Details by a visiting wound clinic Nurse Practitioner (NP) dated 1/6/26 revealed: Wound #1 - Right Gluteal Fold a chronic stage 4 (full-thickness wound with exposed muscle, tendon or bone) facility acquired pressure ulcer. Measurements were 2.1cm (centimeters) length x 0.9cm width x 0.7 cm depth with tunneled (narrow, deep channels that form beneath the top layer of skin, extending from a wound into surrounding subcutaneous tissue or muscle) area of 1.6cm. There is no change noted in the wound progression and the treatment for Wound #1 remained unchanged. Wound #2 - Right, Dorsal Second Toe a stage 4 new facility acquired pressure ulcer dated 12/23/25. Measurements were 0.9cm length x 1cm width x 0.2cm depth. There was no change in the progression of the wound and treatment remained unchanged for Wound #2.Review of R7's Progress Note Details by a visiting wound clinic NP documented a new facility acquired wound dated 1/13/26. Progress Notes revealed: Wound #3 - Right, anterior thigh was a full-thickness trauma wound on 1/13/26 and initial measurements were 1.5cm length x 0.9cm width and 0.1m depth. There was a moderate amount of purulent drainage documented. Review of R7's Order Summary Report revealed treatment for the right thigh trauma wound was ordered on 1/20/26 (a week after the wound was evaluated by the wound clinic NP) with the first documented treatment completed on 1/22/26.Review of R7's Progress Note Details by a visiting wound clinic NP dated 1/20/26 documented a new facility acquired sacral stage 3 (a deep, full-thickness pressure injury extending through the skin into subcutaneous fat) wound (wound #4) that measured 2cm length x 3.6cm width x 0.1cm depth. There was a small amount of serosanguineous (thin, watery, pink-to-light-red fluid) drainage documented at the time of the assessment. Review of R7's Order Summary Report revealed treatment for the new facility acquired sacral stage 3 wound was ordered on 1/20/26 and the first treatment was declined by R7 on 1/22/26. Upon further review of R7's January 2026 Treatment Administration Record (TAR), treatment was not completed for R7's sacrum wound until 1/24/26. Review of R7's Progress Note Details by a visiting wound clinic NP dated 2/24/26 revealed Wound #1 measured at 2.4cm length x 0.9cm width x0.3cm depth and tunneling 1.1cm. Upon further review, Wound #1 within the 8-week time frame of NP visits from 1/6/26 to 2/24/26 wound #1 had minimal healing documented and not one change in treatment. Wound #2 measured 0.3cm length x 0.7cm width and no depth. Wound #3 measured 4.2cm length x 1.0cm width x 0.1cm depth. Wound #3 had deteriorated within the same 8-week period with only 2 treatment changes documented. Wound #4 measured 3.5cm x 5.0cm x.2cm. Wound #4 had 2 treatment changes within the 8-week period and continued to deteriorate.Review of a care plan Actual Pressure Injury Formation. revealed R7 had a pressure ulcer to right ischium and a wound to left second toe. interventions for R7 indicated staff were to provide surface support and pressure redistribution, position changes, and off-loading.Alternate pressure mattress.encourage R7 to float heels or wear heel boots.staff to assist in keeping any pressure from blankets off from R7's toe. monitor wound for any significant changes and alert physician of changes. Upon further review of R7's Actual Pressure Injury Formation. care plan the last intervention initiated was dated 12/24/2025. Review of R7's Kardex Report as of 3/1/26 revealed no documentation to change position of R7's catheter stat lock. Further review of R7's medical record did not reveal documentation to the staff to rotate R7's catheter stat lock. During an interview and record review on 3/4/26 at 10:43 AM, the Director of Nursing (DON) was unsure of the causation of Wound #2 stating that R7 doesn't put anything on his toes. DON reported that R7's new pressure injury to the left thigh (Wound #3) was due to a catheter stat lock (stabilization device that used adhesive to secure catheter tubing). DON stated that the intervention for Wound #3 was to rotate the catheter stat lock to different sites on R7's leg. DON stated it was an expectation that R7 be turned and repositioned every 2 hours for prevention of further pressure injuries. DON reported that staff should have been communicating related to R7's care specifically to report when R7 had last been turned and repositioned. DON stated that wound #3 and wound #4 were not addressed in R7's plan of care and should have been addressed with new pressure injuries and interventions. DON could not provide an incident report for wound #2, #3, or #4. DON stated that R7 had declined heel boot and other preventative interventions. DON could not provide documentation of R7's declinations of interventions to prevent new pressure injuries related to wound #2, wound #3, and wound #4. Record review of R7's progress notes revealed two wound check-ins on 1/29/26 and 2/25/26. When asked if wound check-ins were interdisciplinary collaboration, DON stated they were not. When asked if the interdisciplinary team had any collaboration to discuss R7's pressure wounds and what could be implemented to prevent further breakdown of his skin, DON replied no.On 3/4/2026 at 12:23 PM, the DON provided a previously unavailable Injury incident report, documented by the DON. The DON also provided Progress Notes that had also NOT been present in the clinical record, retrieved and retained on 3/2/2026. The progress notes were dated 12/23/2025 and 12/26/2025 indicated the IDT reviewed the new wound (this was previously denied by the DON). The discrepancy between originally retained records and the newly provided records reflected an unreasonably late entry into the clinical record, over two months late. On 3/5/2026 the Director of Nursing (DON) provided a previously unavailable incident report pertaining to R7's right thigh, dated 1/13/2026. The DON also produced Late Entry notes that were back dated 1/13/2026 and 1/14/2026 pertaining to the right thigh which alleged the IDT team had discussed the wound and the care plan had been reviewed and updated. (See above noted care plan and Kardex which do not indicate any updates had been made to the care plan since 12/24/2025.)During an investigation regarding resident-to-resident mental abuse, conducted during an annual survey from 3/2/2026-3/5/2026, involving R52, R58 and R60, it was discovered that staff failed to document late entry progress notes in a reasonable timeframe. Resident #58 (R58)Review of an Face Sheet revealed R58 admitted to the facility 3/4/2025 with pertinent diagnoses which included heart failure, acute respiratory failure, anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R58, with a reference date of 12/8/2025 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 R58 was cognitively intact.Review of R52's Progress Note dated 2/7/26 at 5:05 AM indicated that R52 went into R58's room and stood over her while she laid in bed. There was no documentation of this incident in R58's electronic medical record besides following psychology notes. Review of a psychology follow-up visit dated 2/10/26 at 4:18 PM revealed .Mood symptoms worsened over the past two weeks with increased depressive symptoms triggered by a situational stressor involving a confused male resident (R52) who repeatedly entered R58's room. This led to increased fear. Symptoms are now improving, with yesterday and today showing decreased symptoms as resident is reassured, he is not returning to the facility. R58 experienced increased depression and anxiety symptoms triggered by a confused male resident (R52) at the facility. Symptoms included fear, avoidance behaviors, and nausea.Review of a psychology follow-up visit dated 2/24/26 at 11:30 AM revealed .R58 reported increased anxiety symptoms related to another resident recently admitted to the hall. Resident states that R52 came to her doorway and stands there staring into her room. She stated she had redirected him back to his own room. R58 stated she had been keeping her door closed for this reason, however R52 had also opened her door and came into her room on multiple occasions. R58 stated her daughter was here yesterday when R52 entered her room and was also unable to redirect R52 out of the room. R58 stated her daughter put the call light on for assistance, however both were anxious while waiting for staff to respond. R58 stated she had voiced her concerns to several people in the facility but feels like no changes will be made.which scared R58.Resident #60 (R60)Review of an Face Sheet revealed R60 originally admitted to the facility 6/15/2022 with pertinent diagnoses which included chronic obstructive pulmonary disease, dementia, and generalized anxiety disorder.Review of a MDS assessment for R60, with a reference date of 12/12/2025 revealed a score of 07, out of a total possible score of 15, which indicated R60 was severely cognitively impaired.Review of R52's Progress Note dated 2/7/26 at 5:05 AM indicated that R60 was crying and had stated to staff that he was scared to have R52 in the room. In an interview on 3/4/26 at 10:15 AM, R60 was asked if he had any concerns with other residents, if he was fearful of another resident. R60 stated I want to forget that. R60 stated his old roommate (R52) wanted to die. R60 stated R52 went batty. When further questioned, R60 stated R52 kept talking about dying and thoughts of suicide. R60 stated he did not feel threatened at this time. In a review of R60's Electronic Medical Record on 3/4/26 at 1:30 PM, revealed no documentation that any incident had occurred.Resident #52 (R52)Review of an Face Sheet revealed R52 originally admitted to the facility on [DATE] with pertinent diagnoses which included Wernicke's encephalopathy (acute neurological emergency caused by severe vitamin B1 deficiency), dementia, delusional disorders, and hallucinations. Review of a Brief Interview for Mental Status (BIMS) evaluation dated 2/6/26, R52 had a score of 15, out of a total possible score of 15, which indicated R52 was cognitively intact.Review of a hospital record History and Physical dated 1/9/2026, .R52 was a [AGE] year-old male with recurrent visual hallucinations presenting to the emergency department with repeat episodes of confusion and wandering around other people's apartments. Review of R52's Behavior Note documented by Licensed Practical Nurse (LPN) P on 2/7/26 at 5:05 AM, . R52 used a wheelchair foot pedal as a potential weapon tonight, holding it up to swing it at a Certified Nursing Assistant (CNA). R52 also made multiple comments to staff and his roommate R60 regarding shooting people, guns, and it would only take one bullet. R60 cried and had stated to staff that he is scared of R52 in his room. LPN P was also informed that R52 went into R58's room and stood over her while she laid in bed. LPN P and an Agency Nurse transferred R52 to the emergency department regarding these two occurrences. Emergency department (ED) reported to LPN P that R52 attempted to elope the ED and became physical with ED security.R52 received 2 doses of intramuscular Ativan (an anti-anxiety medication) and Risperidone (an antipsychotic medication) to assist with anxiety. R52 obtained a skin tear in ED. R52 is currently awake and ready for transfer back to facility. Review of R52's Progress Note dated 2/7/26 at 9:56 AM, .R52 arrived back to facility approximately 8:45AM.R52 placed into room [ROOM NUMBER] bed 2 related to history of aggressive behaviors (this room is directly beside R58's room) .R52 shows signs of delusions and confusion.R52 continues to walk down hallways without shoes and unsteady gait.Review of a hospital record Psychiatric Consultation Note dated 2/8/26, .R52 brought to the emergency department from his nursing home for agitation and aggressive behaviors on 2/6/26.R52's chief complaint was I was in a lockout situation .Review of progress notes from 2/7/26-3/2/2026 reflected R52 demonstrated ongoing, threatening, aggressive behaviors and frequently wandered into other resident rooms. On 2/7/2026, R52 was transferred to the Emergency Department (ED) and was hospitalized until 2/11/2026. On 2/12/2026 R52 was again sent back to the hospital after becoming physically violent while staff attempted to remove R52 from another resident room and R52 began attempting to punch staff and fling a table toward staff, requiring police supervision until an ambulance arrived.In an interview and record review on 3/4/2026 at 9:24AM, Nursing Home Administrator (NHA) reported that the facility had transferred R52 to the hospital on 2/7/26 related to aggression toward staff and hallucinations. Upon review of the Behavior Note on 2/7/26, NHA reported she did not see the note before today. NHA stated that R52 had been wandering at night and was redirectable as the staff had R52 sort papers at the nurse's station. NHA stated she had encouraged a sleep aid so R52 could slow down. NHA reported that R58 was still scared of R52 and NHA had been counseling her. NHA reported the facility did not move R52 to a different room or hallway because it could turn into a larger concern. NHA reported that she believed she did not get all the details from the event on 2/7/26 and after reading the note stated it may be possible abuse and reportable (as an allegation of abuse to the state agency). NHA reported there were no incident reports completed from the occurrence on 2/7/26 between residents R52, R58, and R60. In an interview and record review on 3/4/2026 at 11:32AM, DON stated R52 had Wernicke's with bouts of agitation and became agitated on the evening of 2/7/26. DON stated R52 had been swinging a wheelchair pedal at a CNA and facility transferred R52 to the ED for evaluation. DON stated the facility did attempt a stop sign for R58 but R58 did not like the stop sign and it was removed. DON unable to locate further documentation related to the stop sign initiation. DON confirmed that she was unaware of the 2/7/26 behavior note until it was read in the Interdisciplinary Team Meeting (IDT) on Monday (2/9/26) morning. DON confirmed that members of the IDT were present, including the NHA. DON reported that she was unsure if the entire IDT team listened to the report completely, but team was present. DON reported there were no incident reports completed from the occurrence on 2/7/26 between R52, R58, and R60. DON stated if R52 had directly threatened with R60 with a gun it would be considered abuse and reportable. DON stated the facility is unable to meet R52's needs presently and he does present a risk. Upon review of the psychiatric notes for R58 on 2/10/26 and 2/24/26 regarding her ongoing fear of R52, DON had no response.Further review of the Electronic Medical Record (EMR) for R52 and R58 on 3/5/2026 (a day after NHA and DON were made aware of the feelings of mental abuse by R58 and R60), the DON created progress notes withing R52 and R58's EMR that appeared as if they were present in the EMR at the time of the occurrences. Close review of the EMR reflects the notes added were in fact late entries, but this is not reflected in the text of each note, easily understood by the reader. The DON also created incident reports for R58 and R60 that were dated 2/7/2026 which the DON denied having during an interview and record review on 3/4/2026.Review of a Nursing Progress Note, discovered in R58's EMR, effective date 2/7/2026 at 1:24 PM, CREATED on 3/4/2026 at 3:32 PM reflected Male resident (R52) wondered (sic) into resident's room during the over nigh (sic) hours and it scared (R58). No verbal aggression or physical aggression occurred. But resident reported being scared of resident entering her room on this evening. Resident was re-directed out of resident's room. Review of a Nursing Progress Note, discovered in R52's EMR, effective date 2/9/2026 at 3:15 PM, CREATED on 3/4/2026 at 3:16 PM reflected Resident (R52) had episodes of aggression and was sent to ER over the weekend. Facility physician aware, Son notified. Resident returned and was placed in a private room aware with no roommate for safety of other residents. Resident also has his night dose of Risperdal increased with consent from son to assist with agitation and behaviors. Care plan reviewed and updated as needed. Will continue to follow care plan.Review of a Nursing Progress Note, discovered in R58's EMR, effective date 2/11/2026 at 2:12 PM, CREATED on 3/4/2026 at 2:15 PM, the DON documented Resident has been utilizing a stop sign at her door to help deter wandering residents from entering. Resident (R58) is not preferring this on her door, says it is keeping other visitors from seeing her. Stop sign was taken off her door per her preference.Review of a Nursing Progress Note, discovered in R52's EMR, effective date 2/11/2026 at 2:12 PM, CREATED on 3/4/2026 at 2:15 PM, the DON documented an identical progress note found in R58's clinical record with the same effective and CREATED on date, Resident has been utilizing a stop sign at her door to help deter wandering residents from entering. Resident (R58) is not preferring this on her door, says it is keeping other visitors from seeing her. Stop sign was taken off her door per her preference.Review of a Social Work note, discovered in R58's EMR, effective date 2/16/2026 at 11:07, CREATED on 3/4/2026 at 10:36 AM, Social Worker (SW) E documented SS met with resident (R58) for a wellness visit r/t (related to) the incident with the gentleman. Resident appeared calm and was smiling throughout the visit. Resident did endorse anxiety over the situation but states she does not feel threatened or fearful. Resident is A&O X 4 and her own decision maker. Affect observed as appropriate. No signs of acute emotional distress noted. Resident able to verbalize feeling safe in the facility. Resident does not appear fearful at this time.Review of a policy Documentation in the Medical Record reviewed 2/3/2026 reflected The purpose of this policy is to provide guidelines for documentation in the medical record.Principles of documentation include , but are not limited to: Documentation should be factual, objective and resident centered. False information will not be documented. Record descriptive and objective information based on knowledge of the assessment, observation, or service provided. Subjective information will be recorded only as relevant, such as the resident's verbalizations. Documentation should be accurate, relevant, and complete. Documentation should be timely and in chronological order . Documentation should be completed at the time of service or by the end of the shift in which the evaluation, observation, or care service occurred.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Timely entries are essential in a patient's ongoing care, as delays in documentation can lead to unsafe patient care.It is necessary to document all the nursing care you provide for each patient, including assessment data, nursing problems or diagnoses, interventions, and evaluation of patient responses, in the health record. Your data enable providers and outside reviewers of the medical record to track a patient's clinical course.It is also crucial that your documentation accurately reflects the status of the patient and responses to interventions, especially upon admission, transfer, or discharge. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of facility. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living of residents. Findings Include:On 03/03/2026 at 9:13AM, observed on wall near the nurses' station on 200 hall, a wall mounted mini-split unit had grey and green crusted material on the unit. This crusted material was observed both on interior of the mini-split and the face of the unit. On 03/03/2026 at 3:00PM during tour of facility with Maintenance Director (MD) R, MD R confirmed observation of crusted material on the mini-split and stated the mini -splits in the facility are not in use during the winter and were scheduled to be professionally cleaned before starting them up for the year. On 03/03/2026 at 2:44PM, observed in the shower room on the 400 hall, tile coving at the wall and floor juncture was broken and chipped, exposing the wall to moisture and humidity from the shower and general cleaning of the room. There were sections of the wall (average length of six inches) with tiles missing on the wall across from the shower table washing area and areas adjacent to the shower area. During this observation, MD R stated that the tile coving in the shower room was scheduled for removal and replacement within the next month. MD R indicated equipment used in the room to facilitate bathing of residents is causing the damage to the tile when the equipment runs into the tile. On 03/03/2026 at 2:50PM, observed in 300 hall shower room, portions of tile coving adjacent to the shower area, have tiles that are broken and chipped. MD R confirmed the tile condition at time of observation. On 03/03/2026 at 2:58PM, observed in 200 hall shower room, portions of the coving tile are missing, chipped or broken in several areas of the room. MD R confirmed the condition of the tile. On 03/03/2026 at 3:03PM, observed in 100 hall shower room, portions of the coving tile are missing, chipped or broken, affecting several areas in the room. MD R indicated that all the shower rooms' tile coving will be replaced with a rubber coving but did not have a timeline as to when it would be started or completed with exception of the shower room in 400 hall that will be replaced within the next month.

Based on observation, interview, and record review the facility failed to implement and update individualized care plans for 3 residents (R6, R7, and R52) of 12 residents reviewed. Findings include:Resident #6 (R6)Review of an Face Sheet revealed R6 originally admitted to the facility 2/15/2022 with pertinent diagnoses which included chronic congestive heart failure, type II diabetes mellitus, anxiety, and morbid obesity. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R6, with a reference date of 2/3/2026 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 R6 was cognitively intact.In an observation on 3/2/26 at 8:34 AM, R6 stated her skin is always itchy. R6 had multiple small scabs that traveled up R6's left upper arm. R6 reported facility did think it was scabies at one time, and the rash had not healed. Review of a current Skin Care Plan intervention for R6, initiated on 5/29/2025, revealed R6 had concerns she had scabies and was on precautions until a dermatologist appointment. Further review revealed a treatment to apply petroleum jelly to arms, torso, and back twice per day initiated 4/21/2025. Review of a current Order Summary Report dated 3/2/2026 revealed hydrocortisone cream (assists with itching) to buttocks every shift to prevent scratching. Further review of R6's current orders did not reveal a treatment for R6's rash to her left upper arm. In an interview on 3/4/26 at 11:32 AM, the Director of Nursing (DON) stated that R6 did visit the dermatologist, and she would locate the document from that visit. DON reported that the care plan should be updated to reflect the status of R6. Review of R6's Patient Handout provided by the DON, dated 6/2/2025, Plans.rash likely secondary to xerosis (abnormally dry skin) .no burrows suggestive of scabies.recommend using Vaseline as a moisturizer.Resident #7 (R7)Review of an Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnoses which included neuropathy, chronic obstructive pulmonary disease, and stage IV sacral pressure ulcer. Review of R7's Progress Note Details by a visiting wound clinic Nurse Practitioner (NP) documented a new facility acquired wound dated 1/13/26. Progress Notes revealed: Wound #3 - Right, anterior thigh was a full-thickness trauma wound on 1/13/26 and initial measurements were 1.5cm length x 0.9cm width and 0.1m depth. There was a moderate amount of purulent drainage documented. Review of R7's Progress Note Details by a visiting wound clinic NP dated 1/20/26 documented a new facility acquired sacral stage 3 (a deep, full-thickness pressure injury extending through the skin into subcutaneous fat) wound (wound #4) that measured 2cm length x 3.6cm width x 0.1cm depth. There was a small amount of serosanguineous (thin, watery, pink-to-light-red fluid) drainage documented at the time of the assessment. Review of a care plan Actual Pressure Injury Formation revealed R7 had a pressure ulcer to right ischium and a wound to left second toe. interventions for R7 included for staff to provide surface support and pressure redistribution, position changes, and off-loading.Alternate pressure mattress.encourage R7 to float heels or wear heel boots.staff to assist in keeping any pressure from blankets off from R7's toe. monitor wound for any significant changes and alert physician of changes. Upon further review of R7's Actual Pressure Injury Formation. care plan the last intervention initiated was dated 12/24/2025. During an interview and record review on 3/4/26 at 10:43 AM, the Director of Nursing (DON) DON stated that the trauma wound to R7's thigh and Stage 3 wound to R7's sacrum had not been addressed in R7's plan of care and should have been addressed with the new pressure injuries and interventions. Resident #52 (R52)Review of an Face Sheet revealed R52 originally admitted to the facility on [DATE] with pertinent diagnoses which included Wernicke's encephalopathy (acute neurological emergency caused by severe vitamin B1 deficiency), dementia, delusional disorders, and hallucinations. Review of a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) Evaluation dated 2/6/26, R52 had a score of 15, out of a total possible score of 15, which indicated R52 was cognitively intact.Review of R52's Progress Note dated 2/15/26 at 11:06 PM, .R52 has been up wandering into several other resident's rooms. R52 is not wearing clothing but has a blanket wrapped around him. Staff that attempted to redirect have been met with resistance. R52 helped with getting dressed and R52 refused. R52 was pushing staff away and continued to wander very unsteadily down the 300 and 400 halls. Res continued to attempt to go to exit doors and in and out of other resident rooms. R52 has been muttering to himself and speaking in a non-sensical fashion.Review of R52's Progress Note dated 2/7/26 at 9:56 AM, .R52 arrived back to facility approximately 8:45AM.R52 placed into room [ROOM NUMBER] bed 2 related to history of aggressive.R52 shows signs of delusions and confusion.R52 continues to walk down hallways without shoes and unsteady gait.Review of R52's Progress Note dated 2/7/26 at 12:50 AM, .R52 restless, running through hallways, trying to get out of the facility.R52 gait is unsteady.R52 walking into other resident's rooms. Director of Nursing (DON) notified an a one to one for R52 was initiated .Review of R52's Progress Note dated 2/17/26 at 05:05 AM, .R52 was up wandering during the beginning of this shift. Staff attempted to redirect were met with resistance. R52 continued to attempt to go to exit doors. R52 was muttering to himself and spoke in a non-sensical fashion.Review of R52's care plan At risk for changes in behavior and mood dated 2/3/2026, R52's interventions were initially documented on 2/3/26 that included administer medications per physician orders. encourage resident to attend activities of choice.offer snacks.ice cream. The last updated intervention was dated 2/3/26. Review of R52's care plan Exit seeking/elopement risk dated 2/3/26, R52's interventions are to allow to vent feelings and frustrations, alert bracelet.calmy redirect. There are no updated interventions after 2/3/26. In an interview on 03/05/2026 at 1:06 PM, License Practical Nurse (LPN) Unit Manager (UM) F stated that the team discusses issues as they come. LPN UM F reported that there has been no time for her to update plans of care for residents related to working the floor so much. LPN UM F stated that she attempts to attend care conferences and update plans of care for residents, but she is stretched thin. In an interview on 3/5/26 at 2:01 PM, Regional Nurse (RN) M reported the expectation for care planning interventions and updating wounds and changes in a resident's plan of care would be the next business day. Review of facility/policy Care Plan - Comprehensive and Revision, reviewed 2/2/2026 revealed .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.the interdisciplinary team reviews and updates the care plan.when there has been a significant change in the resident's condition.when the desired outcome is not met.when the resident has been readmitted to the facility from a hospital stay.

Based on observation, interview and record review, the facility failed to provide showers for 1 (R45) of 1 resident reviewed for showers.Findings include:Review of the Electronic Medical Records (EMR) revealed R45 had pertinent diagnoses of contractures, morbid obesity, and paraplegia. During an observation and an interview on 3/2/26 (Monday) at 9:48 AM, R45 was lying in bed and not able to provide cares for herself. R45 reported she required extensive assistance of 2 staff for many activities of daily living (ADL's) due to her contractures. R45 had concerns of not enough staff available to provide her showers twice a week. Her last shower was 2 1/2 weeks ago and had to really push to get that shower so she could get her hair washed. R45 reported she gets a shower maybe once a month. Review of the Care Plan for R45 revealed she is to get a shower on Mondays and Fridays and is totally dependent on 2 staff for showers. During an interview on 3/4/26 at approximately 2:00 PM, R45 reported she did not get her shower on Monday 3/2/26. In an interview on 3/4/26 at approximately 2:23 PM Certified Nursing Assistant (CNA) S and CNA T reported R45 requires 2 staff for bathing which would only leave one CNA on the floor to answer call lights. R45 likes to have her baths in the morning before breakfast and that would be hard to provide her with a shower at that time. The CNA's reported they will stay later on their shifts at times to provide her with a shower. Review of the Bathing/Shower task documentation for R45 revealed she was getting bathed but was not clear of when she was provided with a shower. In an interview on 3/4/26 at 11:51 AM, the Director of Nursing (DON) reported she addressed R45s showers a few weeks ago with R45. The DON looked into the EMR and verified that R45 was to receive showers on Mondays and Fridays and it was not clearly documented when the last time R45 received her shower.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls and injuries for 1 Resident (R52) contributing to increase and likelihood of further injuries and potential for harm.Findings include:Resident #52 (R52)Review of a Face Sheet revealed R52 originally admitted to the facility on [DATE] with pertinent diagnoses which included Wernicke's encephalopathy (acute neurological emergency caused by severe vitamin B1 deficiency), dementia, delusional disorders, and hallucinations. Review of a Psychiatry Note dated 4/13/26 reflected, BIMS (Brief Interview of Mental Status, a mental status assessment) score declined significantly from 15 on 2/16/2026 to 3 on 4/14/2026 which indicated resident is severely cognitively impaired.Observation of the locked 100 Hallway on 4/13/26 at approximately 5:43AM, revealed that the hallway was absent of staff, it was quiet and the lights were low with one bright light noted at the far end of the hallway.Observation on 4/13/26 at 5:45 AM, revealed R52 had his own room, he was asleep in a low positioned bed. Further observation revealed a wheelchair was being stored in the hallway, and his walker was not observed.During an interview on 4/13/26 at 5:51 AM, Agency Certified Nurse's Aide (A-CNA) D stated, Today was my first night on this unit, and the second night being in this building. Last night I had 10 residents on the 300 and 400 hallways. A-CNA D was observed sitting in the 100 hallways' dining/seating area on the couch in front of a TV, on her phone. The hallway and the call lights were not visible from her location. A-CNA D stated she was the only one working this hallway, The nurse and other aide were outside the locked unit doors.During an interview on 4/13/26 at 8:16 AM, the NHA revealed they had increased supervision, they hired an additional unit manager, brought 3rd shift nurse to 1st to help with wounds, hired some hospitality aides, and are still hiring staff. The NHA further revealed that R52 is now on the locked unit and revealed they have cameras on the unit where they can watch him. (During the survey it was revealed that their system with the cameras are live feed and can be watched on the computer monitors so other staff can assist if needed) It was brought to NHA's attention that the 3rd shift staff were observed working on the units and were not watching monitors to see if the aide on the locked unit needed assistance.During an observation on 4/13/26 at 8:30 AM, R52 was observed in his room eating breakfast wearing a gray T-shirt, black jeans, and shoes on his feet. Resident has a bandage dated 4/13 on his right arm. R52 was also observed to have two skin tears/injuries on his left arm. One above the crease of his elbow the other just below the crease. Both skin tears are about the size of a quarter around, dark red in color and have black- and purple-colored bruises in the area surrounding the tears.During an observation on 4/14/26 at 8:27 AM, R52 was in his room eating breakfast and was unaware of where he was (Nursing Home). Resident believed he was working at one of his friend's businesses. Resident's wheelchair, gait belt and walker were not located in his room at this time.Review of the current Care Plan Report (on 4/13/26) reflected, page 4, Focus of R52 At risk for falls secondary to Wernicke's encephalopathy initiated 2/03/2026, with a Goal of Minimize risk for falls initiated on 2/03/2026 with a target date of 6/27/2026. The following Interventions were initiated on 2/03/2026: Bed at transfer height with assistive device (walker, wheelchair with brakes locked) at bedside. 2.) Bed in low position when resident is resting. Further interventions included, Resident to wear gait belt during ambulation as tolerated. Date initiated 3/12/2026. Keep walker near resident and encourage use of walker, push bedside table away when not in use. Date initiated 4/03/2026.Review of the current Care Plan Report (on 4/13/26) reflected, page 4, Focus of R52 At risk for alteration in skin integrity related to Wernicke's encephalopathy at risk for bruising due to poor safety awareness, history of falls, and bumps to his body on walls and other items in the facility. Date Initiated: 02/03/2026. The following Intervention was initiated on 2/10/2026: Provide preventative skin care routinely and prn.During an interview on 4/14/26 at 8:34 AM, Certified Nurse's Aide (CNA) O revealed, We really need at least 2 people at all times on the unit (locked unit) to help watch the residents. [Name of R52] is a huge fall risk. Even more since he had a fall a week or so ago. When he does not have his walker sometimes, he will get up and push his wheelchair, or he will just get up and leave it and take off walking. He has been more unsteady, seems to want to sprint often rather than walk. He's quick.On 4/14/26 at 8:43 AM, while CNA O picked up R52's breakfast tray, R52 stated he did not know where his walker or wheelchair were. CNA O stated he was using the wheelchair outside his door. The wheelchair outside of his door was noted to have a different resident's name on the back, and the previous resident who had used the wheelchair had passed away. CNA O found a front wheeled walker and attempted to have him use it. R52 reported he was 6'3 (appeared to be factual). The walker provided by CNA O was not adjusted to his height. R52 had a very forward posture when he pushed it. While using the walker R52 would not keep his right hand on the walker and at times stumbled with his right leg. At one point, R52 left his walker and walked away unassisted. CNA O ended up holding R52's left arm to get him to walk into the dining room. R52 needed physical assistance to turn to sit in the chair at the table. CNA O did not offer/provide a gait belt prior to walking with him. Further observation of the wheelchair (located outside of R52's room) appeared to be on the small/ short side compared to resident's tall frame/stature.On 4/15/26 at 9:05 AM, R52 was observed exiting the unit's dining/sitting area and ambulating in the hallway without a gait belt or walker (both interventions listed on his care plan) while Hospitality Aide (HA) P followed him. HA P did not notify other staff working on the unit that she needed any assistance with R52. (The Nurse was passing meds and CNA working on the unit was assisting other residents.)During an interview with the Director of Nursing (DON) on 4/15/26 at 11:55 AM, the DON was made aware of the observation of R52 walking with HA P without a gait belt and/or walker. The DON confirmed that R52 required physical assistance with the use of a gait belt when walking and Hospitality Aides cannot do care or walk residents with gait belts. Review of a Nursing Progress Note Effective Date 4/13/26 at 10:10 (AM) reflected, Noted resident in bed, supine position prior to breakfast. His eyes were closed. Respirations even and unlabored. Noted to his right elbow a skin tear with total flap loss. When asked, resident lifted up his arm to look at it and stated, I bumped it. He was unable to report where or on what. Area cleansed, a dressing was applied. Treatment orders updated. Observations left elbow, noted that a prior skin tear to this area was closed, blue discoloration continues. He denied pain. Will update treatment plan to include glen sleeves for protection of his arms. Call placed to (Name of R52's son) unable to leave message will retry. Resident placed on the provider list for further update. Review of a Nursing Progress Note Effective Date 4/13/2026 at 14:27, revealed, This nurse was notified by staff members at noon that they noted a small abrasion like area to the left cheek. This nurse and facility wound nurse assessed. Resident did state it is tender to touch. Superficial abrasion noted with petechiae eye present to left cheek. Physician notified. A message has been left with the son to call the facility back. No reported incident of causation. Staff statements say it was not noted to be present this AM upon their observations. Resident does not have safety awareness and history of falls. Has a history of bumping into items including walls in the facility. Resident is ambulatory and has been witnessed putting himself on the floor and getting himself off the floor without assistance from staff members. Due to cognition of the resident and injury on unknown origin state reportable was made to the state of Michigan and the local Police Department. Five-day investigation to continue.Review of Physician Team Progress Note Effective Date 4/14/2026 at 11:49, .Pt (patient) seen today for f/u (follow-up). Nursing reporting that pt has a laceration to his left cheek from unknown source, has right sided weakness, and back pain. PE (Physical Exam): NAD, non-labored breathing on RA, small area of petechiae on left cheek w/some xerosis, no facial drop, no slurred speech, facial nerve intake (can puff out cheeks), bilateral UE (Upper Extremity) ROM (Range of Motion) is normal, grips/strength equal, bilateral LE (Lower Extremity) is equal .Review of IDT Progress Note Effective Date 4/14/2026 at 12:16, reflected, Resident met to review new skin tear that was observed on right elbow yesterday. Wound nurse assessed, treatment in place, physician and son notified. [NAME] sleeves Initiated for protection of arms. Resident has known risk for bumping into items due to poor safety awareness, no spatial awareness, and impulsivity and requires directing and queuing by staff. Care plan review and updated.

Based on interview and record review, the facility failed to honor the resident's right to set their own schedule for 1 resident (R24) out of 2 residents reviewed for dignified care. Findings:Review of a Face Sheet reflected R24 admitted to the facility on [DATE] with diagnoses that included congestive heart failure, adjustment disorder with anxiety and insomnia. During an interview on 3/2/2026 at 11:50 AM, R24 reported the facility is short staffed and a second shift Certified Nurse Aide (CNA) wanted her to go to bed for the night at 7:00 PM for staff convenience. R24 said she would like to stay up until after taking their evening medications and when she refused to be put to bed at 7:00 PM a CNA told the resident that they would have to wait for third shift to arrive because they couldn't accommodate the resident's preference for staying up a few more hours. R24 said that a few days over the weekend she didn't get her evening medications until 1:30 AM. An audit of a February 2026 Medication Administration Record including administration time confirmed that on 2/28/2026 R24's evening medication was not administered until 1:26 AM. During an interview on 3/4/2026 at 2:20 PM, Agency Registered Nurse (RN) D reported that she did administer R24's evening medications at almost 1:30 AM on 2/28/26. RN D said she arrived at the facility at approximately 12:40 AM to relieve Unit Manager (UM) C who was already covering a staffing shortage. RN D said that R24 was not in bed when she brought her evening medications.

Based on observations, interviews, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings include:Resident #58 (R58)Review of an Face Sheet revealed R58 admitted to the facility 3/4/2025 with pertinent diagnoses which included heart failure, acute respiratory failure, anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R58, with a reference date of 12/8/2025 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 R58 was cognitively intact.Review of R52's Progress Note dated 2/7/26 at 5:05 AM indicated that R52 went into R58's room and stood over her while she laid in bed.Review of a psychology follow-up visit dated 2/10/26 at 4:18 PM revealed .Mood symptoms worsened over the past two weeks with increased depressive symptoms triggered by a situational stressor involving a confused male resident (R52) who repeatedly entered R58's room. This led to increased fear. Symptoms are now improving, with yesterday and today showing decreased symptoms as resident is reassured, he is not returning to the facility. R58 experienced increased depression and anxiety symptoms triggered by a confused male resident (R52) at the facility. Symptoms included fear, avoidance behaviors, and nausea.Review of a psychology follow-up visit dated 2/24/26 at 11:30 AM revealed .R58 reported increased anxiety symptoms related to another resident recently admitted to the hall. Resident states that R52 came to her doorway and stands there staring into her room. She stated she had redirected him back to his own room. R58 stated she had been keeping her door closed for this reason, however R52 had also opened her door and came into her room on multiple occasions. R58 stated her daughter was here yesterday when R52 entered her room and was also unable to redirect R52 out of the room. R58 stated her daughter put the call light on for assistance, however both were anxious while waiting for staff to respond. R58 stated she had voiced her concerns to several people in the facility but feels like no changes will be made.which scared R58.In an interview on 03/04/2026 at10:00 AM R58 stated the man who walks around next door, (R52) he will stand in my doorway and stare. R58 stated she tried to keep her door closed to prevent R52 from entering her room and he opened it just this week. R58 stated that R52 will stand in her room by the curtains (5ft to R58's bed from the curtain). R58 stated she heard a loud noise the previous night and when she looked in the hallway, R52 had pulled out a supper tray from the cart, and it was on the floor. R58 stated that R52 makes her feel anxious and very leery. R58 reported to one person about the situation with R52, when asked who that was R58 stated the administrator. R58 requested for R52 to be moved from the hall and R58 was told we are working on it. R58 stated that he (R52) still is next door to her and stated, that bothers me a lot. R58 stated I should feel safe and secure. R58 reported that her feelings haven't changed any. R58 stated I don't think he should be on our hallway. In an interview on 3/4/26 at 12:21 PM, R58 Family Member (FM) N stated R52 scared R58 on 2/23/26 when FM N had been visiting. FM N stated that R52 showed up multiple times in R58's doorway. R58 responded to R52 and said, Your room is down there.your room is down there!. R52 did enter R58's room again and FM N stated she rang R58's call light for assistance. FM N stated that R58 fears R52. FM N stated that on a subsequent visit on the weekend, R52 was in R58's doorway multiple times and needed to be redirected away from R58's room. FM N stated that R58 went to the administrator with concerns regarding R52 presence in R58's room and FM N reported that the facility had planned to move R52 to a different location. FM N stated that R52 weighs heavily and causes high anxiety for R58. In a review of R58's Electronic Medical Record on 3/4/26 at 12:30 PM, revealed no further documentation with exception of the psychologist Progress Notes on 2/10/26 and 2/24/26 of any incident that occurred or intervention that had been offered or put into effect.Resident #26 (R26)Review of an Face Sheet revealed R26 admitted to the facility 1/14/2019 with pertinent diagnoses which included depression, decreased range of motion, and dementia. In an interview on 3/4/2026 at 2:09 PM, Family Member (FM) O reported that R52 resided next door to R26 and R58 (roommates). FM O stated that R58 had been very afraid of R52 after he walked into her room at night. FM O stated that R58 was anxious related to R52 during the night that he would walk into her room. FM O reported that she felt uneasy when R52 would walk in front of the door and stand at the doorway of R26 and R58's room. FM O reported that R58 had shut the door and R52 had opened it and walked in. FM O reported that this week R52 had walked into R26 room and FM O stated this is a lady's room, please leave. FM O stated I do have a fear of what R52's going to do and why he's in here. Resident #60 (R60)Review of an Face Sheet revealed R60 originally admitted to the facility 6/15/2022 with pertinent diagnoses which included chronic obstructive pulmonary disease, dementia, and generalized anxiety disorder. Review of a MDS assessment for R60, with a reference date of 12/12/2025 revealed a score of 07, out of a total possible score of 15, which indicated R60 was severely cognitively impaired.Review of R52's Progress Note dated 2/7/26 at 5:05 AM indicated that R60 was crying and had stated to the facility staff that he was scared to have R52 in the room. In an interview on 3/4/26 at 10:15 AM, R60 was asked if he had any concerns with other residents, if he was fearful of another resident. R60 stated I want to forget that. R60 stated his old roommate (R52) wanted to die. R60 stated R52 went batty. When further questioned, R60 stated R52 kept talking about dying and thoughts of suicide. R60 stated he did not feel threatened at this time. In a review of R60's Electronic Medical Record on 3/4/26 at 1:30 PM, revealed no documentation that any incident had occurred.Resident #52 (R52)Review of an Face Sheet revealed R52 originally admitted to the facility on [DATE] with pertinent diagnoses which included Wernicke's encephalopathy (acute neurological emergency caused by severe vitamin B1 deficiency), dementia, delusional disorders, and hallucinations. Review of an BIMS Evaluation dated 2/6/26, R52 had a score of 15, out of a total possible score of 15, which indicated R52 was cognitively intact.Review of a hospital record History and Physical dated 1/9/2026, .R52 was a [AGE] year-old male with recurrent visual hallucinations presenting to the emergency department with repeat episodes of confusion and wandering around other people's apartments.Review of R52's Behavior Note documented by Licensed Practical Nurse (LPN) P on 2/7/26 at 5:05 AM, . R52 used a wheelchair foot pedal as a potential weapon tonight, holding it up to swing it at a Certified Nursing Assistant (CNA). R52 also made multiple comments to staff and his roommate R60 regarding shooting people, guns, and it would only take one bullet. R60 cried and had stated to staff that he is scared of R52 in his room. LPN P was also informed that R52 went into R58's room and stood over her while she laid in bed. LPN P and an Agency Nurse transferred R52 to the emergency department regarding these two occurrences. Emergency department (ED) reported to LPN P that R52 attempted to elope the ED and became physical with ED security.R52 received 2 doses of intramuscular Ativan (an anti-anxiety medication) and Risperidone (an antipsychotic medication) to assist with anxiety. R52 obtained a skin tear in ED. R52 is currently awake and ready for transfer back to facility.Review of a hospital record Psychiatric Consultation Note dated 2/8/26, .R52 brought to the emergency department from his nursing home for agitation and aggressive behaviors on 2/6/26.R52's chief complaint was I was in a lockout situation .Review of R52's Progress Note dated 2/7/26 at 9:56 AM, .R52 arrived back to facility approximately 8:45AM.R52 placed into room [ROOM NUMBER] bed 2 related to history of aggressive behaviors (this room is directly beside R58's room) .R52 shows signs of delusions and confusion.R52 continues to walk down hallways without shoes and unsteady gait.Review of R52's Progress Note dated 2/7/26 at 12:50 AM, .R52 restless, running through hallways, trying to get out of the facility.R52 gait is unsteady.R52 walking into other resident's rooms. Director of Nursing (DON) notified an a one to one for R52 was initiated .Review of R52's Progress Note dated 2/7/26 at 13:54 PM, .on call Nurse Practitioner (NP) and DON notified and approved for R52 to be transferred to ED for psychiatric evaluation. R52 was transported from facility at approximately 1:50PM. Further review of Progress Notes, R52 returned to the facility on 2/11/26. Review of R52's Progress Note dated 2/12/26 at 12:38 AM, .R52 was up and wandering around hallway and wandered into another resident's room. Staff attempting to remove resident from other room and resident became physically violent. closed fist attempting to punch nurse aides in face. R52 finally came out of other residents' room and went back into his room where R52 grabbed his bedside table and attempted to [NAME] it at his CNA. Administrator notified, Unit Manager (UM) notified, on call physician assistant notified and in agreement to sending the resident to ER for evaluation.Review of R52's Progress Note dated 2/12/26 at 1:25 AM, .R52 was 1:1 with police officer after he arrived on scene. Police officer 1:1 with R52 until ambulance arrival. R52 became verbally agitated and aggressive with female Emergency Medical Technician (EMT).R52 was transported via ambulance service to the ED for evaluation.Review of R52's Progress Note dated 2/12/26 at 9:39 PM, .R52 received his nighttime medication, and medication has had no effect on this R52.R52 continues to wander around hallway and enter other resident's rooms. R52 becomes verbally agitated when asked to leave other resident rooms . R52 given a job to help keep an eye on the hallway, R52 focused on this task for brief time, then was attempting to enter a female resident room.R52 stopped by staff and assisted back to his room.Review of R52's Progress Note dated 2/12/26 at 11:34 PM, .R52 was up wandering around and entered other resident's rooms, R52 became agitated when asked to leave the residents room. R52 redirected briefly back to his own room. R52 keeps asking where we keep the ammo.Review of R52's Progress Note dated 2/12/26 at 11:34 PM, .R52 assisted back to his room again.R52 was observed going into restroom and coming out of another resident room. Male Residents in the other room have been resting. R52 becomes agitated when staff redirect him . R52 escorted out of a female resident room again and is now back in his own room sitting on edge of his bed.Review of R52's Progress Note dated 2/15/26 at 11:06 PM, .R52 has been up wandering into several other resident's rooms. R52 is not wearing clothing but has a blanket wrapped around him. Staff that attempted to redirect have been met with resistance. R52 helped with getting dressed and R52 refused. R52 was pushing staff away and continued to wander very unsteadily down the 300 and 400 halls. Res continued to attempt to go to exit doors and in and out of other resident rooms. R52 has been muttering to himself and speaking in a non-sensical fashion.Review of R52's Progress Note dated 2/24/26 at 11:52 PM, .R52 was walking down the hallway. R52 had no socks or pants on, just underwear and a T-shirt. R52 was looking into every room. R52 had to be guided out of other resident rooms.Review of R52's Progress Note dated 3/2/26 at 1:30 AM, .R52 noted to be walking frantically in hallway. R52 noted to have visual and auditory hallucinations, irrational beliefs, and incoherent and illogical jumbling of words. R52 cannot organize his thoughts and becomes increasingly agitated when staff attempts to assist him or offer distraction. R52 is redirected for a few seconds then proceeded to enter other residents' rooms talking about guns and not having any ammo.Review of R52's Progress Note dated 3/2/26 at 2:23 AM, .Despite R52's one time dose of Ativan, R52 continued to be anxious, constantly pacing up and down hallway trying to enter other residents' rooms. Resident became agitated when staff tried to redirect him out of other residents' rooms. Hallucinations continue.R52 kept yelling about a boat, and someone is supposed to pick him up so he can go get ammo for his gun.In an interview and record review on 3/4/2026 at 9:24AM, Nursing Home Administrator (NHA) reported that the facility had transferred R52 to the hospital on 2/7/26 related to aggression toward staff and hallucinations. Upon review of the Behavior Note on 2/7/26, NHA reported she did not see the note before today. NHA stated that R52 had been wandering at night and was redirectable as the staff had R52 sort papers at the nurse's station. NHA stated she had encouraged a sleep aid so R52 could slow down. NHA reported that R58 was still scared of R52 and NHA had been counseling her. NHA reported the facility did not move R52 to a different room or hallway because it could turn into a larger concern. NHA reported that she believed she did not get all the details from the event on 2/7/26 and after reading the note stated it may be possible abuse and reportable (as an allegation of abuse to the state agency). NHA reported there were no incident reports completed from the occurrence on 2/7/26 between residents R52, R58, and R60. Review of facility policy/procedure Abuse, revised 2/2/2026, revealed .facility completing ongoing assessments and care planning for appropriate interventions, and monitoring of residents with behaviors, including but not limited to. verbally aggressive behaviors (screaming, cursing, demanding, insulting, etc.). physically aggressive behaviors (hitting, kicking, biting, spitting, throwing objects, threatening gestures, etc.). wandering into other's rooms or space, Taking/touching/rummaging through other's property. protective actions depend upon the people involved. any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient.if a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated. the facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and.reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement, when applicable) or reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials (including adult protective services and/or law enforcement, when applicable) .

Based on interview and record review, the facility failed to evaluate 1 resident (R6) out of 4 residents reviewed every 14 days before as needed benzodiazepine (psychotropic) medication was renewed. Findings include:Review of an Face Sheet revealed R6 originally admitted to the facility 2/15/2022 with pertinent diagnoses which included chronic congestive heart failure, type II diabetes mellitus, anxiety, and morbid obesity. Review of R6's Physician Orders dated 12/16/25, revealed an order for . Clonazepam (used to treat panic disorder, anxiety, and various seizure disorders by calming the brain and nerves) tablet 0.5 milligrams (MG) take one by mouth every 12 hours as needed for anxiety for 90 days. Review of R6's Electronic Medication Record (MAR) documented Clonazepam was administered 8 times from 12/16/25 to 12/31/25. Further review of the R6's MAR revealed Clonazepam was administered 15 times in January, 12 times in February and 4 times in March of 2026. In an interview and record review on 3/4/2026 at 11:27 AM, the Director of Nursing (DON) reported she was aware that R6's medication required a physician to evaluate the medication use every 14 days before it was continued and had spoken to R6's provider regarding this evaluation. DON was unable to reveal an evaluation every 14 days for R6's use of Clonazepam and stated she would continue to review R6's electronic medical record for further evaluations. Review of an Progress Note provided by the DON with an effective date of 2/3/26 and a created date of 3/4/2026 (indicating the progress note had been created a month late) revealed documentation by Nurse Practitioner (NP) Q that R6 may use Clonazepam 0.5mg every 12 as needed because benefits are greater than risks at this time. Further documentation revealed a Progress Note dated 3/3/26 by a physician that stated Clonazepam 0.5mg every 12 hours as needed to be continued because benefits are greater than risks at this time. No further evaluation related to R6 and the continued use of the as needed Clonazepam were revealed or provided. Review of facility policy/procedure Psychotropic Medication Use, reviewed 2/3/2026, revealed .if the resident is prescribed a PRN psychotropic medication, the medication should only be used when the medication is necessary to treat a documented diagnosed condition, and it should only be used for a limited period of time.prior to ordering a new PRN psychotropic medication, staff should first attempt and document non-pharmacological interventions and whether or not they were successful.all PRN psychotropics (excluding antipsychotics) should be limited to 14 days. If the prescribing practitioner believes that the PRN order should be extended past 14 days, they should document their rationale in the resident's medical record and indicate the specific duration of the PRN order. o This process should be completed every time the physician believes it is necessary to extend the PRN order.all PRN antipsychotics are limited to 14 days with no exceptions. If the prescribing practitioner believes the resident would still benefit from continued antipsychotics, they must: evaluate the resident and assess their current condition and progress to determine if the PRN antipsychotic is still warranted.document why the PRN antipsychotic is still needed on a PRN basis, explain the benefit of the medication to the resident and if the resident's indications of distress improved as a result of the PRN antipsychotic.all residents prescribed PRN psychotropic medications will be tracked and reviewed by facility staff routinely.

Based on interview and record review the facility failed to ensure medication was administered according to professional standards for 5 residents (R3, R24, R38, R93, R94) out of 19 residents reviewed. Findings:R24Review of a Face Sheet reflected R24 admitted to the facility on [DATE] with diagnoses that included congestive heart failure, adjustment disorder with anxiety and insomnia. During an interview on 3/2/2026 at 11:50 AM, R24 reported that due to staffing problems at the facility she did not get her evening medications until 1:30 AM over the previous weekend. An audit of a February 2026 Medication Administration Record including administration time confirmed that on 2/28/2026 R24's evening medication, scheduled to be given at 7:00 PM on 2/27/2026, was not administered until 1:26 AM on 2/28/2026. During an interview on 3/4/2026 at 2:20 PM, Agency Registered Nurse (RN) D reported that she did administer R24's evening medications at almost 1:30 AM on 2/28/26. RN D said she arrived at the facility at approximately 12:40 AM to relieve Unit Manager (UM) C who was already covering a staffing shortage. RN D said that four or five residents had not been given their evening medications that night. RN D reported that she did not notify the physician of the late administration or obtain orders confirming the late administration would be appropriate because she assumed UM C had done so already. R38Review of a Face Sheet reflects R38 admitted to the facility with diagnoses that included sepsis, acute respiratory failure with hypoxia, high blood pressure and heart failure. An audit of a February 2026 MAR, including administration time reflected on 2/28/2026 R38's evening medication, scheduled to be given at 7:00 PM on 2/27/2026, was not administered until 12:32 AM on 2/28/2026. R93Review of a Face Sheet reflected R93 admitted to the facility with diagnoses that included burns involving 10-19% of body surface with 0% to 9% third degree burns, severe protein malnutrition, obstructive sleep apnea and insomnia. An audit of a February 2026 MAR, including administration times, reflected that R93 did not receive his evening medication, scheduled to be given at 7:00 PM on 2/27/2026, were not administered until 1:16 AM on 2/28/2026. R94Review of a Face Sheet reflected R94 admitted to the facility with diagnoses that included Type 2 Diabetes, high blood pressure, depression and anxiety. An audit of February 2026 MAR, including administration times, reflected R94 did not get a medication scheduled for 8:00 PM on 2/27/2026 until 12:24 AM on 2/28/2026 and did not receive Insulin Glargine (long-acting insulin) scheduled to be given at 7:00 PM on 2/27/2026 until 12:24 AM on 1/28/2026. During an interview on 3/5/2026 at 1:05 PM, UM C reported that she had to work very late on 2/27/2028 and into 2/28/2026 because she had to cover for a staffing shortage. UM C said the expectation is that medications not administered at the right time would require an order approving the late administration. UM C said she did not obtain orders authorizing the late medication administration. During an interview on 3/5/2026 at 1:10 PM, the MARs for R24, R38, R93, & R94 were reviewed with Nurse Practitioner (NP) Q. After each medication was considered, NP Q reported she would approve the late administration, however, she would have expected a request for approval to administer the medications late due to the potential for significant errors. Review of a policy Medication Administration dated 8/7/2023 reflected Medications are administered in accordance with the following rights of medication administration: . Right time and frequency . Administer medication in accordance with frequency prescribed by physician and standards of practice. Review of an Face Sheet revealed R3 originally admitted to the facility on [DATE] with pertinent diagnoses which included bipolar disorder, type II diabetes mellitus, and depression. Review of R3's Physician's Orders revealed an active order for Lispro Insulin (a prescription medication used to treat diabetes), Inject 10 units subcutaneously (underneath the skin) with meals, hold if BS (blood sugar) is (less than) <120, with a start date of 7/29/2025. Review of R3's Medication Administration Record (MAR) on 3/4/2026, revealed nursing staff were not holding the Lispro Insulin for a BS less than 120 and administering the 10 units on the following day and times: 12/17/25 at 8:00AM, Blood sugar was 112. 1/4/26 at 8:00AM, Blood sugar was 107. 1/29/26 at 8:00AM, Blood sugar 95. 2/6/26 at 5:00PM, blood sugar 68. 2/13/26 at 8:00AM, Blood sugar 113. 2/20/26 at 5:00PM, Blood Sugar 108. In an interview on 3/4/26 at 11:34 AM, the Director of Nursing (DON) reported that she was unaware of the Lispro Insulin not being held for blood sugars less than 120 for R3 on those dates and times. DON stated she would review R3's medical record and reveal if there was documentation that could be provided that the Lispro insulin was held or documented about. In an interview on 3/5/26 at 2:01 PM, Regional Nurse (RN) M reported that facility was unable to reveal any other documentation regarding R3's Lispro insulin not being held when his blood sugar was less than 120. Review of facility policy/procedure Medication-Insulin Administration, revealed .review and follow blood glucose parameters in the physician order for when to hold insulin administration and/or when to call the medical practitioner.

This citation pertains to intake # 2695940 and 2690356Based on interview and record review, the facility failed to ensure that weights were obtained, and medications were administered in accordance with physician orders for 5 out of 7 residents (Resident #4, #8, #9, #10, and #11), reviewed for the provision of nursing services.Findings:Resident #4 (R4) Review of an admission Record revealed R4 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: adrenocortical insufficiency (adrenal glands don't produce enough cortisol and aldosterone.)Review of R4's Order Summary dated 12/2/25 revealed a steroid taper dose:predniSONE Oral Tablet 10 MG (Prednisone) Give 2 tablet by mouth two times a day for inflammation for 2 Days thenpredniSONE Oral Tablet 10 MG (Prednisone)Give 1 tablet by mouth two times a day for inflammation for 3 Days thenpredniSONE Oral Tablet 10 MG (Prednisone) Give 1 mg by mouth one time a day for inflammation for 3 Days.Review of R4's December Medication Administration Record revealed:On 12/5/25 the morning dose was not administered.On 12/6/25 the morning dose was not administered. Review of R4's Electronic Medical Record revealed no documentation for the rationale or a provider order for withholding the prednisone.During an interview on 12/26/2025 at 1:03 PM, the Director of Nursing (DON) confirmed there were 2 doses of prednisone not administered to R4 on 12/5/25 in the morning and on 12/6/25 in the morning. DON reported that the licensed nurse received a medication error write up and immediate 1:1 education on medication administration.Resident #8 (R8) Review of an admission Record revealed R8 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R8's Order Summary dated 12/10/25 revealed, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for Hypertension HOLD for SBP <110 (systolic blood pressure [top number] less than 110) and/or HR <60 (heart rate less than 60).Review of R8's Blood Pressure Summary and Pulse Summary revealed the last assessment of R8's pulse and blood pressure was completed on 12/14/25. The previous assessments were completed on 6/30/25.Review of R8's December Medication Administration Record revealed the metoprolol was administered 12/11/25-12/15/25, 12/17/25-12/21/25,and 12/23/25-12/25/25.Review of R8's Electronic Medical Record revealed no documentation for the rationale for administering the medication without first obtaining a heart rate or blood pressure.Resident #9 (R9) Review of an admission Record revealed R9 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure and hypertension.Review of R9's Order Summary dated 8/19/25 revealed, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 2 tablet by mouth every morning and at bedtime for HTN (hypertension) hold for SBP less than 100 or pulse less than 60.Review of R9's Blood Pressure Summary and Pulse Summary revealed the only blood pressure and heart rate assessments were completed on 12/2/25, 12/8/25, and 12/9/25.Review of R9's December Medication Administration Record revealed every dose of metoprolol was administered from 12/1/25 through 12/26/25.Review of R9's Electronic Medical Record revealed no documentation for the rationale for administering the medication without first obtaining a heart rate or blood pressure.Resident #10 (R10 ) Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R10's Order Summary dated 10/27/25 revealed: Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth at bedtime for heart failure Hold for HR < 60 (heart rate less than 60). Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth at bedtime for beta blocker (12.5 mg) Hold for HR < (less than) 60 or SBP < 90.Review of R10's Pulse Summary revealed the only assessments were completed on 12/8/25 and 12/24/25.Review of R10's December Medication Administration Record (MAR) revealed every dose of digoxin was administered from 12/1/25 through 12/22/25 and 12/24/25-12/25/25.Review of R10's Blood Pressure Summary revealed a blood pressure assessment was not completed on 12/2/25, 12/9/25, 12/10/25, 12/14/25, 12/15/25, 12/21/25, 12/23/25, or 12/25/25.Further review of the Blood Pressure Summary revealed:R10's blood pressure of 120/80 was documented in the MAR for 12/8/25, 12/9/25, and 12/10/25. R10's blood pressure of 138/64 was documented in the MAR for 12/13/25 and 12/14/25. R10's blood pressure of 135/67 was documented in the MAR for 12/20 and 12/21. R10's blood pressure of 124/74 was documented in the MAR for 12/22/25 and 12/23/25. Review of R10's Electronic Medical Record revealed no documentation for the rationale for administering the medication without first obtaining a heart rate or blood pressure.Resident #11 (R11) Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R11's Order Summary dated 11/26/25 revealed, Daily weights, report to provider if > (greater than) 3# (pound) gain in 1 day or 5# in 1 week every day shift for CHF (congestive heart failure).Review of R11's Weight Summary revealed a weight was not obtained on 12/8/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, or 12/25/25.From 12/9/25-12/10/25 R11 had a 3 pound 2 ounce weight increase. There was no documentation that the provider was notified.From 12/19/25-12/21/25 R11 had a 9 pound weight increase. There was no documentation that the provider was notified.During an interview on 12/26/2025 at 3:01 PM, the DON confirmed that R8, R9, and R10's ordered parameters were not followed and that R11's weights were not constituently documented or acted upon. The DON reported that the expectation was for licensed nurses to follow the provider orders and act upon them accordingly. The DON reported that all licensed nurses would receive medication administration re-education. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication.Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences. Kindle Edition.

Based on observations, interviews and record review the facility failed to resolve grievances in a timely manner for 2 residents (R1 and R5) of 3 residents reviewed for grievances.Finding includedReview of the facility policy for Concern (Grievances) Process. Dated 5/31/24 revealed Concerns, grievances, recommendations stemming from resident or family group council concerning issues of resident care in the facility will be documented. Actions on such issues will be responded to at or before the next resident or family meeting. Concerns/Grievances may be voiced in the following ways: -verbal complaint to 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 staff member receiving the concern form will review the specifics of the grievance on the concern form. - take immediate actions needed to prevent potential violation of the resident's rights. - Forward concern to the Grievance Officer as soon as practicable.R1Review of R1's admission assessment dated [DATE] revealed she was a [AGE] year-old female with a last admission date of 3/22/25 and had diagnoses that included: Urinary Tract Infection onset 8/8/25, diabetes mellitus type 2, rheumatoid arthritis, lack of coordination, contractures, paraplegia (spinal cord injury affecting the lower body muscles and nerves) and retention of urine. She was her own responsible party.Review of R1's care plan dated 1/3/25 revealed, Resident has limited/impaired physical mobility r/t (related to) limited mobility d/t (due to) weakness r/t paraplegic (spinal cord damage affecting lower body). Interventions included: Bed mobility: Participates by: total assist with 2 staff. Eating: 1:1 feed at meals. Toileting - bed pan 2 assist.Review of R1's care plan dated 8/19/25 revealed, Resident requires Enhanced Barrier Precautions related to indwelling Urinary Catheter, resident prefers catheter to be place on to her bed during cares. Interventions included: encourage residents to put leg portion of the bed downward during cares, to encourage urine to flow to gravity, dated 9/9/25 (during survey). Use a gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray.During an observation and interview on 9/9/25 at 8:42 AM R1 was in bed and had a urinary catheter with the Foley bag attached to the right side of her bed below her bladder level. R1 reported she had to go to the hospital again yesterday for a urinary tract infection (UTI. R1 stated she was started on antibiotics yesterday and they changed her catheter. R1 complained of staff not always using gloves, gowns and masks (personal protective equipment (PPE)) when they provided care. She expressed concern that the lack of staff using PPE was contributing to her UTI. She expressed concerns of staff not using an alcohol swab to clean the tubing after they emptied the catheter bag. R1 was very upset that staff refused to help her with her catheter for over 2 hours recently when the balloon was stuck in her urethra (event 8/29/25). One of the staff members who refused to help her was the Registered Nurse Unit Manager (RNUM) J. She reported on-going care and treatment concerns with RNUM J which were not resolved. R1 said she reported these things to the Director of Nursing (DON) but nothing was being done. She said the DON wrote her concern on a sticky note about when the catheter balloon was stuck in her urethra, but she never got back to her. R1 said the DON did not provide her with a copy of any concerns she reported. R1 said she cannot write due to lack of hand coordination so staff would need to write her concerns. R1 was unable to move her fingers, and they were contracted in a fisted position.During an interview with two Certified Nursing Assistance (CNA's) the morning of 9/9/25 the CNA's wanted to remain anonymous but reported R1 has had ongoing concerns related to some staff not cleaning her catheter correctly, lack of PPE use and Registered Nurse Unit Manager (RNUM J) not addressing her medical concerns. The anonymous CNA's reported RNUM J also refused to follow with medical concerns they had brought to him related to R1's catheter care. They reported he was notified of R1's catheter leaking 9/9/25 right after morning care and his response was, It is not leaking. They said he refused to assist with care at that time. Both CNA's said management was aware of these concerns. They reported the concern to another nurse that did help R1. They denied completing any grievance forms related to R1's care concerns.During an interview with the Director of Nursing (DON) on 9/9/25 at 10:15 AM a request was made for all of R1's concern forms for the last two months.During an interview with the DON on 9/10/25 at 10:00 AM the DON confirmed that R1 had reported a concern about staff not helping her with catheter replacement a little over a week ago. The DON confirmed that she took that concern and she would get the concern form. No other concern forms were located related to ongoing care concerns between RNUM J and R1, or staff lack of using appropriate infection control during care.Review of R1's Concern Form dated 8/29/25 revealed, had pain and issue with Catheter. Nurse would not assess or look at it. Had to wait for 3rd shift nurse to come in and look at and she did fix the issue. Actions taken revealed, see back of paper. The resolution was discussed evaluation that was completed and was signed on 9/10/25 (during the survey and 12 days after the concern was shared with the DON). However, the signature was not legible, so it was unknown who signed the form. The back of the form revealed, a handwritten note that read, [Name of Registered Nurse Unit Manager (RNUM) J] instructed [name of Licensed Practical Nurse (LPN) K] to call physician and let them know to get an order to change Catheter and I was working 400 hallway and in the middle of med (medication) pass felt I didn't have time to do that. When completed Med pass [name of LPN L] was here and had done it all ready. [Name of LPN K] says assessed Catheter and abdomen, but resident stated she wanted it discontinued. Attempted physician with no answer to get orders/interventions on how to unable to read word for resident. [Name of LPN K] did not deflate balloon says she thought she needed orders to do that. PRN (as needed) change of Catheter and irrigation orders were on the computer. Educated [name of LPN K] on clinical nursing ability with Catheters, assessing balloon for cc (measurement cubic centimeter) amount, assess location of balloon and correct positioning. Educated [name of LPN K] to call DON if ever questioning clinical capabilities or need direction on how to continue for a Resident. Education completed on Catheter Policy.Review of a One-on-One In-Service Record with RNUM J dated 9/9/25 (during the survey) revealed, We cannot refuse to assess residents, when they need help. If issues arise, we complete what we are doing at that time and assess resident in a timely manner.No concern forms were located to address R1's ongoing concerns of staff lack of PPE (personal protective equipment) during care, infection control concerns or ongoing care issues related to RNUM J.R5Review of R5's admission record dated 9/10/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Cerebral infarction (stroke), disease of spinal cord, and left hip pain. He was his own responsible party.During an interview with R5 on 9/10/25 at 8:47 AM he was very upset with the lack of communication from management. He said he has complained multiple times about not being informed of outside medical appointments in advance. He said sometimes he only gets two days' notice. He has been trying to get an orthopedic appointment and when he went to his neurosurgeon on 8/8/25 they made a referral to the orthopedic surgeon for him, and he still has not been able to confirm if that appointment was made. R5 said he did not know anything about concern forms and even if he did, he was not able to write well so staff would need to complete the form. R5 denied staff ever offered to complete a concern form. The facility Social Worker (SW) N came in R5's room at this time. He repeated this concern to SW N at that time. SW N did not offer to complete a concern form, she said she would take the concern to the scheduler. During an interview with Appointment Scheduler (AS) M on 9/10/25 at 10:15 AM, AS M confirmed R5 was to have an appointment with an orthopedic surgeon. She was alerted by the summary follow-up from R5's medical appointment on 9/8/25. AS M had not been able to get confirmation of R1's orthopedic appointment, but she had made attempts. AS M said she was to inform residents of appointments on the Friday the week before any appointments. AS M was not aware R5 wanted to know about the appointment as soon as it was scheduled.During an interview with the Nursing Home Administrator (NHA) on 9/10/25 at 10:15 AM the NHA said she was not aware of R5's concerns about advanced notice of appointments until today when she received information from Social Worker N. The NHA said she started at the facility in July and was working to educate staff to use concern forms and she had instructed SW N to complete a concern form for R5 today. The NHA said she would check with Activity Director (AD) L to see if she was aware of R5's concern about appointments. The NHA reported AD L was R5's care partner. She said all residents have care partners and they are to complete concern forms when residents have concerns. The NHA said she would work with staff to implement an appointment schedule for R5 so he would be aware of any outside appointments as soon as possible.During an interview with AD L on 9/10/25 at 1:00 PM she confirmed that she was R5's care partner. She said they recently started a tracking sheet to complete when she meets with the residents she was assigned to. She documented meeting with R5 two times in the last two weeks and each time she met with him she asked him five questions. They were questions about care and call light response. She said none of the answers rose to the level of a concern form. She also said none of the questions were related to outside appointments.

Based on observation, interviews and record review the facility failed to safely transfer with an electronic lift 2 of 2 residents (R5 and R6) reviewed for lift transfers. Findings include:During an interview with R5 on 9/10/25 at 12:05 PM, R5 reported that he did not like the new electronic lift to get out of bed. R5 was not sure why he could not still use the other facility lift. R5 said the lift did not fit him right and when they got him out of bed on 9/8/25 he hit his head on the bar. Review of R5's Kardex (care guide) dated 9/10/25 revealed, Toileting - use toileting sling and hoyer, 2 assist. Transfer: [brand name of electronic lift] with 2 staff assistance for transfers. UP 2 TIMES A DAY IN WC (wheelchair) AS TOLERATED, CERVICAL PRECAUTIONS-NO BENDING, PUSHING/PULLING, NO OVERHEAD LIFTING, NO BENDING NECK DOWN.Review of R5's progress note dated 9/5/25 at 14:34 (2:34 PM) revealed, Quarterly Therapy screen completed: R5 has had a decline in function, but at this time is not getting up in wheelchair daily due to left hip pain. Provider aware of decline in ability to complete PT (physical therapy) with discharge 8/14/25. Awaiting follow up tests as x-ray of hip did not show a change that could be causing the pain. Discussed this week with management of patients not getting up in wheelchair. Will follow up with patient once follow up tests have been completed.Licensed Practical Nurse (LPN) O documented a progress note for R5 on 9/6/25 at 9:39 AM that revealed R5 had an evaluation for a significant change.During an interview with LPN O on 9/10/25 at 2:24 PM LPN O confirmed that she did the significant change evaluation for R5 on 9/6/25 and he had declined in function. When reviewing R5's Kardex she was able to see there were still instructions to get R5 up daily with an [brand name of electronic lift device], despite the therapy note indicating he was no longer getting up in the wheelchair. The Kardex did not indicate which brand of lift or size slings R5 should use. LPN O did not know who did the assessments for slings and was not aware what size sling R5 was able to safely use.On 9/10/25 at 12:10 PM Certified Nurse Aide (CNA) G confirmed the facility used two different brands of electronic lifts. CNA G was told there are only two residents allowed to use the old lift and many residents including R5 do not like the new lift. CNA G was aware R5 hit his head when he was transferred out of bed on 9/8/25. CNA G said they have had several residents complain about the new lift and they do not like that the bar is close to their head. She pointed out that the old lift has a different design and a bar doesn't get up in their face. CNA G said management was aware that residents do not like this lift and management informed them this was the replacement. CNA G was not aware if anyone reported that R5 hit his head on the transfer lift bar on 9/8/25. CNA G denied any training on lifts since the facility purchased this lift. CNA G stated she was getting ready to get R6 out of bed and asked Registered Nurse (RN) H to assist with transferring R6 out of bed.On 9/10/25 at 12:15 PM CNA G transferred R6 out of bed with the new lift with the assistance of RN H. When they lifted R6 up off the bed his bed was in the highest position and his buttock did not clear the mattress prior to starting to move him toward his chair. RN H and CNA G did not check to ensure the loops were all in place prior to starting to move him. When they lifted him and started to move him the legs of the lift were not in the open position. R6 could not speak or communicate with the staff. Both staff were questioned about checking the loops once the resident was off the surface, asked if the resident should have cleared the surface prior to moving him and asked if the leg on the lift should be in the fully open position. RN H and CNA G did not know they were to check loop placement, ensure the resident clears the surface being transferred from and the legs need to be in the fully open position.On 9/10/25 the Nursing Home Administrator (NHA) was informed of R5 concerns with the new lift and report of R5 hitting his head on the bar during a transfer out of bed on 9/8/25. The NHA was also informed of the safety concerns observed when staff transferred R6 out of bed today. The instruction manuals for both lifts were requested, all training and information related to residents' concerns related to the lifts. Upon exit no training was provided for the use of the new lift. No information that the facility was aware of R5 hitting his head on the lift on 9/8/25.Review of the electronic lift instruction manual page 34 revealed, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are on longer under the bed, return the legs of the lift to the maximum open position and immediately lock the shifter handle. Page 37 revealed, WARNING! - When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to ensure the sling is properly connected to the hooks of the hanger bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem; otherwise, injury or damage may occur. -Adjustments for safety and comfort should be made before moving patient. The patient's arms should be inside of the straps. - [company name] slings are made specially for use with [company name] patient lifts. DO NOT use slings and patient lifts from different manufacturers. 3. When the patient is clear off the bed surface, swing his/her feet off the bed.

This citation pertains to intake 2590962.Based on observations, interviews and record review the facility failed to provide proper infection control for 1 Resident (R1) of 3 residents sampled for infection control. Findings include:R1Review of R1's admission assessment dated [DATE] revealed she was a [AGE] year-old female with a last admission date of 3/22/25 and had diagnoses that included: Urinary Tract Infection onset 8/8/25, diabetes mellitus type 2, rheumatoid arthritis, lack of coordination, contractures, paraplegia (spinal cord injury affecting the lower body muscles and nerves) and retention of urine. She was her own responsible party. Review of R1's care plan dated 1/3/25 revealed, Resident has limited/impaired physical mobility r/t (related to) limited mobility d/t (due to) weakness r/t paraplegic (spinal cord damage). Interventions included: Bed mobility: Participates by: total assist with 2 staff. Eating: 1:1 feed at meals. Toileting - bed pan 2 assist.Review of R1's care plan dated 8/19/25 revealed, Resident requires Enhanced Barrier Precautions related to indwelling Urinary Catheter, resident prefers catheter to be place on to her bed during cares. Interventions included: encourage resident to put leg portion of the bed downward during cares, to encourage urine to flow to gravity, dated 9/9/25 (during survey). Use a gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray.During an observation and interview on 9/9/25 at 8:42 AM, R1 was in bed and had a urinary catheter with the Foley bag attached to the right side of her bed below her bladder level. R1 reported she had to go to the hospital again yesterday for a urinary tract infection (UTI). She said she started on antibiotics yesterday and they changed her catheter. R1 complained of staff not always using gloves, gowns and masks (personal protective equipment (PPE)) when they provided care. She expressed concern that the lack of staff using PPE was contributing to her UTI. R1 said she was in the hospital for several days in August in 2025 on intravenous (IV) antibiotics due to severe UTI.Review of R1's Hospital Infectious Disease noted dated 8/8/25 revealed, R1 is a [AGE] year-old woman with PMHx (past medical history) of rUTI (recurrent Urinary Tract Infection) in the past, previously seen by ID (Infectious Disease) multiple times and by urology for ureteral stenting (no longer has stent). She also has a history of multiple antibiotic allergies including Keflex, ceftriaxone and Bactrim. She was seen in the ER on 8/5 with complaint of flank pain/cva tenderness (costovertebral angle) (area on the back above the kidney) and nausea. She was seen initially in the ER (Emergency Room) 8/5 and diagnosed with pyelonephritis based on symptoms.She received 1 dose of ertapenem (an antibiotic) and then was initially discharged with ciprofloxacin (another antibiotic) given her history of multiple antibiotic allergies. She returns today with ongoing symptoms, and urine culture now confirms E coli which is resistant to ciprofloxacin.Given the clinical course with her worsening on ciprofloxacin, with isolation of a quinolone resistant organism I think reasonable to treat for 7 days.R1 was observed getting care on 8/9/25 at 9:14 AM by Certified Nurse Aides (CNA) E and F. They remove the Foley catheter bag from the privacy bag on the bed. The bag had an external plastic measuring device attached to it. The measuring device held 300 cc (cubic centimeters) of urine. CNA E placed the catheter bag on the bed (above the level of her bladder) and the urine from the measuring device went up the catheter tube into R1's bladder. When discussing the type of Foley bag being used the CNA's said, they were not familiar with the external measuring device and denied any training on precautions of placement with this type of device. When they turned R1 on her side the soaker pad had a large wet area (same color as the urine in R1's bag) approximately 5 inches by 10 inches. CNA E and F said R1 does not normally have leakage from her catheter. Review of R1's hospital Discharge summary dated [DATE] revealed two pages of instructions for Indwelling Urinary Catheter Care to Prevent Infection under the section, Be careful with your drainage bag revealed, Always keep the drainage bag below the level of your bladder. This will help keep urine from flowing back into your bladder. Step 3 after emptying the catheter bag revealed, 3. Use and alcohol wipe to clean the tip of the tubing attached to the bedside bag. Review of R1's hospital Discharge summary dated [DATE] revealed, Foley catheter was replaced today 9/8/25. Patient did receive dose of antibiotics, Fosfomycin, in ED (emergency department) today. Urine culture is sent and pending. Review of the facility Catheter Draining Bag Emptying policy dated 8/24/23 revealed no information on keeping the Foley bag below the level of the bladder to prevent back flow of urine or cleaning the emptying device tip with alcohol after emptying the bag. Review of R1's concern form dated 9/10/25 revealed, Resident care concerns regarding not being checked and changed last evening by 3rd shift CNA. Action taken Report sent to [name of online program that facilities use to report incidents to the State Survey Agency]. Investigation in process. Attached with a statement from CNA C revealed, This am (morning) got report from [name of CNA I]. In the report [name of CNA I] stated that she had been in throughout the night and checked her a few times, she didn't need care, emptied the catheter bag at 0430, and said she's good. When [name of CNA C] entered with R1's room for AM care, R1 stated, she had not been repositioned or anything all night long. R1 stated, she came in here didn't use alcohol swabs, didn't put paper towel down, emptied into cylinder, emptied cylinder and put back in close.

Based on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of seven Residents on the 100 hall (R202, R207, R210, R212, R215, R216 and R207) and five residents on the 200 hall (R204, R206, R208, R211, and R214). Findings Include: Review of the staff schedules provided by the facility for 8/12/25 through 8/14/25 reflected that one Certified Nurse aide (CNA) was scheduled for the 100 hall and one CNA was scheduled for the 200 hall for each day, afternoon, and night shifts.A review of documentation provided by the facility reflected fourteen residents resided on the 100 hall and eight residents on the 200 hall.R202 - 100 HallR202 was admitted to the facility 7/10/2025 with diagnoses that include Muscular Dystrophy and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) reflected R202 scored 15 out 15 which indicated the Resident was cognitively intact.Review of the care plan for R202 reflected Activities for Daily Living (ADL) focus of resident refuses to get out of bed for meals times to allow (sic) and prefers to eat in his room. Review of the interventions for this focus reflected R202 will be encouraged to go to the Dining Room for meals initiated 8/1/2025. The care plan further reflected that R202 required full mechanical lift with two staff members for transfers, is at risk for constipation, is at risk for falls, and the bed is to be in a low position when the Resident is in it.On 8/12/2025 at 12:16 PM an observation and interview were conducted with R202 in his room. R202 was observed to be in bed which was in a high position. A bedside commode was observed in the room. R202 reported staffing at the facility was inadequate as it was not unusual to wait as long as an hour for a response to a call light. R202 indicated a clock on the wall across from his bed and reported he had timed call light responses. R202 reported while he does prefer to eat in his room he still likes to get out of bed and use his power wheelchair. R202 reported that if he asks for help to get out of bed, he often will have to wait several hours before two staff are available to transfer him. R202 reported that sometimes a staff member will return to his room later and tell him they are not going to be able to get him up. R202 reported that the last time this happened was two or three days prior to this interview and that he only gets out of bed two or three times a week. R202 reported he has constipation but when he does have a BM he must have it in bed. R202 reported the facility had a special Hoyer sling with a hole in it that allowed him to have a BM out of bed. R202 reported inconsistent availability of this special sling and a lack of available two personnel required for the operation of the mechanical lift when he must void. R202 reported at one point that the facility took away the special sling, so he had a family member bring in a bedside commode from home. However, R202 reported the facility does not have the available staff to transfer him when he needs to have a BM. The Electronic Medical Record (EMR) Progress Notes for R202 were reviewed. No documentation was identified that reflected that R202 had refused to get out of bed. Physician documentation on 7/22/2025 at 1:55 PM reflected the Resident had complained to the physician that He (R202) has concerns about staff: timely care, communication between shifts etc. Documentation on 7/23/2025 at 11:37 AM reflected that R202 was verbalizing frustration that he is not getting out of bed due to using the bed pan ineffectively. The documentation reflected supervision would be notified to formulate a solution. On 7/29/2025 at 3:35 PM physician documentation reflected that R202 continued to (complain) about cares. Physician documentation dated 7/31/2025 reflected that R202 reports he has a hard time having a (bowel movement) (because) the Hoyer pad doesn't have a hole in it anymore . having his brother bring in his commode from home. On 8/4/2025 physician documentation reflected a continued concern that the proper Hoyer sling was not available and that this was discussed with administrationAs of survey exit, no additional documentation was providedR207 -100 HallReview of the medical record reflected R207 admitted to the facility 8/30/2024 with pertinent diagnoses that included amputation of the right leg below the knee, and retention of urine. The MDS dated [DATE] reflected a BIMS score of 15 which indicated R207 was cognitively intact.During an interview conducted on 8/13/25 at 2:30 PM, R207 reported the facility is short staffed. R207 reported he regularly used a urinal in bed and often gets his bedding wet. R207 indicated he will initiate a call light and will have to wait, and wait, and wait. R207 reported he sees staff walking fast past his door and indicated staff know my light is on. R207 reported around 6:00 AM, if the night shift was still on duty, he was able to get his bedding changed but if the day shift was on often, it would be 2:00 PM before his bedding was changed. R207 was asked if he had complained of this but conveyed that everyone knows it, everyone talks about it referring to his perception of lack of adequate staff numbers, and it's common knowledge.R210 - 100 HallReview of the medical record reflected R210 admitted to the facility 5/8/2021 with pertinent diagnoses that included schizophrenia and Parkinson's disease. The care plan for R210 reflected two staff are required for bed mobility, has acute chronic pain due to immobility, and has communication and cognitive deficits.During an observation and interview conducted 8/13/2025 at 2:55 PM a Family Member (FM) L was observed at the Resident's side. FM L reported visiting the facility and Resident often. FM L reported that a response to a call light took about an hour and was likely due to low staff numbers. FM L indicated there may be fewer staff on the weekend but reported this because of having to look for someone to allow exit from the facility. FM L reported some nurses aids try to skip the showers, but I speak up . It definitely helps if you have someone advocating for you. R212 - 100 HallReview of the medical record reflected R212 originally admitted to the facility 9/14/2021 with a pertinent diagnosis of Crohn's disease (an inflammatory bowel disease). Review of the Kardex (a summary of a resident's care needs) reflected R212 required a mechanical lift for transfers and extensive assistance of two staff for toileting.On 8/13/2025 at 2:49 PM an interview was conducted with R212 in her room. R212 reported two staff were not often available to help her into the bathroom. R212 stated I can't hold it that long. R212 was asked how often this had happened. R212 stated Oh gosh, I'd rather not say.R215 -100 HallReview of the admission Record reflected R215 admitted to the facility 8/7/2025 with pertinent diagnoses that included a history of stroke, muscle wasting and atrophy, and unsteadiness on feet. The documentation reflected that R215 was her own responsible party.On 8/14/2025 at 11:05 AM the call light for R215 was observed to be on. R215 was observed with an arm in a sling sitting in a wheelchair next to her bed. R215 reported she had turned on her call light and had been sitting next to her bed for thirty minutes waiting for assistance to get into bed. R215 reported she felt it was not safe for her to attempt self-transfer and had no choice but to wait until staff arrived.R216 - 100 HallReview of the admission Record reflected R216 originally admitted to the facility 2/25/2020 with pertinent diagnoses that included irritable bowel syndrome (IBS). The admission Record reflected R216 was her own responsible party.On 8/12/2025 at 11:57 AM an interview was conducted with R216 in her room. R216 reported staff are wonderful but that staff numbers had been reduced over the past two months. R216 reported two CNA's share the 100 and 200 halls when it used to be three CNA's. R216 reported it was not unusual to wait an hour or more for a response to her call light and she had sat in (stool) for an hour waiting for assistance. R216 reported staff apologize when they come and she has not complained to administration because she felt it would reflect poorly on the staff working who are . doing all they can do.R217- 100 HallReview of the admission Record reflected R217 admitted to the facility 12/1/2021 with pertinent diagnoses that include congestive heart failure, chronic obstructive pulmonary disease (COPD) and dependance on oxygen. R217 was his own responsible party.On 8/14/2025 at 11:08 AM an interview was conducted with R217 in his room. R217 reported he had been at the facility for about four years and was wheelchair bound. R217 reported he was the Resident Council President and call light response complaints come up all the time and there isn't a meeting that it (call light response) doesn't come up at Council meetings. R217 reported that the one nurse and two aides staffed the 100 and 200 halls were inadequate staff numbers for the type of residents living on these two halls. R217 reported the residents living on these halls required extra help. R217 reported that with so few staff to assist this delayed call light response for the other the residents. R217 relayed a recent experience when he felt he needed breathing treatment and initiated his call light. R217 reported that after over an hour without a response he self-propelled in his wheelchair down the hall to find staff. R217 conveyed frustration at what he perceived as an ongoing issue the facility is aware of but not addressing.200 HallR204 - 200 HallR204 admitted to the facility 3/28/2025 with pertinent diagnoses that included a history of stroke and an overactive bladder.On 8/13/2025 an interview was conducted with R204 in her room. R204 reported long call light response times and that staff are never around when you need them. R204 reported she is too weak to hold (her urine) and that she will take herself to the bathroom. R204 reported the facility did not have enough help any time of the day. R204 was asked about the signs on her wall for her to use the call light but reported they still don't come when she uses the call light.R206 - 200 HallReview of the medical record reflected R206 admitted to the facility 7/2/2025 with pertinent diagnoses that included history of stroke and hemiplegia (weakness or paralysis of one side). Review of the MDS BIMS reflected R206 had a score of 12 which indicated mild cognitive impairment. Review of the care plan for R206 reflected the Resident required two staff to assist with a sit-to-stand mechanical lift.On 8/13/2025 at 1:41 PM an interview was conducted with R206 in her room. R206 reported call light response was not too quick and due to the facility being short-handed. R206 reported she must wait to go to the bathroom as she requires the assistance of two staff. R206 indicated that two staff are not always available. R206 reported when she must wait too long to go to the bathroom that sometimes I make it and sometimes I don't (unable to hold her urine).On 8/13/2025 at 1:24 PM an interview was conducted with CNA C who reported that the 100 and 200 halls were staffed with one CNA each. CNA C reported that there were a lot of two person transfers and some (residents) just take a while, CNA C reported that R206 regularly took forty minutes for one CNA in the morning and that means only one CNA for the rest (of the 100 and 200 halls). CNA C reported the nurses will help but they have meds and treatments to do.R208 - 200 HallReview of the medical record reflected R208 admitted to the facility 3/22/2021 with a pertinent diagnosis of multiple sclerosis. The MDS dated [DATE] reflected a BIMs score of 15 out of 15 which indicated the Resident was cognitively intact. Review of the care plan for R208 reflected the Resident is dependent on two staff members for toilet use and a mechanical lift for transfers.During an interview conducted on 8/13/2025 at 1:46 PM, R208 reported call light wait times of twenty minutes but more often a lot longer than that. R208 indicated that the long wait is only a problem when she must go to the bathroom. R208 reported that if two staff are not available to transfer her we wait. R208 reported that it often takes her a long time to void and that it is hard to empty out if she had to hold her urine a long time before two staff were available to help. R208 stated I hate it when forced to use a bed pan and that she has a brief but I don't want to use it.R211 - 200 HallReview of the medical record reflected R211 originally admitted to the facility 8/4/2025 with pertinent diagnoses that included lack of coordination and unsteadiness on feet. Review of the MDS dated [DATE] reflected a BIMS score of 15 out of 15 which indicated R211 was cognitively intact. On 8/13/2025 at 1:56 PM, R211 reported long call light response times when he had wanted to return to his bed from his wheelchair. R211 reported a half hour wait was not unusual when he required two staff for transfers. R211 reported it had been better since he now only requires one staff member for transfer, but the wait is still longer than he would like.R214 - 200 HallReview of the admission Record reflected R214 admitted to the facility 7/27/2025 with diagnoses that included cognitive communication deficit and Parkinson's disease.On 8/13/2025 an interview was conducted in the room of R214 where Spouse D was visiting. Spouse D reported while visiting R214, who is in bed two the resident in bed one, now discharged , was tangled in his shirt. Spouse D reported she initiated the call light to summon staff for assistance for the resident in bed one. Spouse D reported after a while the resident had the shirt wrapped around his neck and would have to been lifted to free him and that she couldn't do it because of a bad back. Spouse D reported she went to the nurses station but she initially could not find any staff. Spouse D reported she eventually found staff and informed them the resident in bed one needed assistance. Spouse D reported help never came down and I had to lift (the resident) to untangle him. Spouse D reported she was worried for R214 who may attempt to self-transfer to the bathroom if he had to wait too long for assistance. On 8/13/2025 at 2:14 PM an interview was conducted with Licensed Practical Nurse (LPN) E. LPN E reported that there was one nurse for both the 100 and 200 halls and one CNA for each hall. LPN E reported she felt the staff were not able to meet the needs of the residents. LPN E reported she had nursing duties to perform, too, but she would jump in where I can. LPN E reported she had heard many complaints from residents about the long wait times, apologizes to the residents, and tells them We're doing the best we can. LPN E reported she had passed this complaint up the chain but had been told there are budget restrictions based on the census.During an interview conducted 8/14/2025 at 12:30 PM, LPN H was asked if the 100 and 200 halls had enough staff to meet the needs of the residents. LPN H reported we're told we meet the state guidelines but no. we're doing the best we can. LPN H reported there have been lots of complaints of call light times and waiting and things of that nature. LPN H reported that, while she was working the floor today, her primary duties do not have her on the floor, but her hours are counted as if she were working the floor.On 8/13/2025 at 12:38 PM an interview was conducted with CNA J. CNA J was asked if the facility was providing enough staff to meet the resident's needs? CNA J stated, You know the answer to that . We're only allowed to have so many staff members on (working). CNA J reported she had many residents that require two staff to transfer and to provide care for stating it's hard. CNA J reported we have some really good people (working at the facility) and indicated she was afraid of retribution if she reported more information. CNA J reported that the nurses will help but they struggle and have their own work to do.On 8/14/2025 at 12:10 PM an interview was conducted with the Director of Nursing (DON) in her office. The DON reported that two nurses are routinely scheduled for the 100 and 200 halls from 7:00 AM until 11:30 AM then it drops to one nurse. The DON reported one CNA is scheduled for each 100 hall and the intersecting 200 hall. The DON reported that she is not aware of any recent resident concern of untimely call light response. The DON was asked about a recent concern form from the Resident Council dated 7/23/2025. The document was retrieved and the DON clarified that the Concern Form from Resident Council indicated a low-staffing concern and not call light response. Under the document section headed ‘Resolution of Concern' reflected handwritten and signed by the DON Facility is meeting State Minimum Requirements for Staffing and indicated the facility is actively hiring staff. The document further indicated that the DON would provide support if the minimum staffing is not met. The DON reported she did not further investigate this concern and is just getting used to answering concerns from a group. The DON indicated she will instruct the Activities Director, who is a facilitator during Resident Council meetings, to gather more information when documenting a concern.On 8/14/2025 at 2:37 PM an interview was conducted with LPN Unit Manager (UM) A who is the manager for the 100 and 200 halls. UM A reported that extended call light response does feel like a concern. UM A stated, I have been vocal about more hands-on deck . I do think we need this.

Based on observation, interview, and record review the facility failed to accurately document weekly skin assessments, monitor wounds, and promote the healing of pressure ulcers for one resident, Resident #537 (R537) reviewed for skin integrity and pressure ulcers. This deficient practice resulted in R537's skin impairments, two Stage II, one unstageable and one Stage III pressure ulcer to go unassessed, measured, and monitored and potential for nonhealing and infection to occur. Findings include: The facility provided a copy of the policy for Skin Monitoring and Management - Pressure Ulcer dated 7/11/2018 for review. The policy reflected, A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing .A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each wound .This assessment/evaluation should include but not limited to: Measuring the wound, Staging the wound, Describing the nature of the wound (e.g., pressure, stasis, surgical wound), Describing the location of the wound, Describing the characteristics of the wound, Describing the progress with healing, and any barriers to healing which may exist, Identifying any possible complications or signs/symptoms consistent with the possibility of infection .Weekly skin check conducted by a facility licensed nurse: All residents will have a head to toe skin check performed at least weekly by a facility nurse .Any skin issues identified as a result of the weekly skin check should be documented and responded to as outlined above . R537 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R537 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R537 was cognitively intact. Record review of the admission assessment with an initiated dated of 1/18/23 at 3:32 PM (note locked on 1/23/23 at 8:20 AM) was reviewed. The notes of the skin section reflected, Bruising upper posterior back, abdomen, and buttocks right side. Scattered small scabs and bruising upper and lower extremities. The assessment reflected the following four wounds with measurements: -Stage II pressure ulcer 0.5 x 0.5 x 0.1, to the perineal -Stage II pressure ulcer 0.5 x 0.5 x 0.1, to the perineal -Unstageable vascular ulcer 0.5 x 0.5 x 0.1 to the right lower leg -Stage III pressure ulcer 4.0 x 3.0 x 0.3 to the right heel Record review of a Nurse Practitioner's admission assessment dated [DATE] at 12:30 PM reflected a note for a new patient (R537) who admitted on [DATE]. The entire note was reviewed including all problems and assessment/plan portions. The noted did not reflect that R537 admitted with 4 ulcers. There was no assessment nor plan to care for the ulcers identified in the nursing admission assessment. Record review of the pressure ulcer care plan with an initiated date of 1/23/23 (5 days after noted on the admission assessment) listed the following interventions also dated 1/23/23: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Obtain and monitor lab/diagnostic work as ordered. Report results to the MD and follow up as indicated. Record review of the actual impairment to skin integrity care plan with an initiated date of 1/23/23 (5 days after noted on the admission assessment) listed the intervention to elevate heels off bed surface while at rest in bed. Record review of the skin assessment dated [DATE] reflected the box No new alterations in skin integrity was checked and did not reflect any of the existing skin issues observed on the admission assessment. According to the policy a head-to-toe skin assessment will be completed weekly and document findings. During an interview and record review on 2/2/23 at 11:00 AM, the Director of Nursing (DON) reviewed the 1/26/23 skin assessment with the surveyor. When asked how the facility documents the head-to-toe assessment findings weekly, the DON stated you'd have to go back and look at the admission assessment. When asked how it is possible to discern what the skin looked like at the point of the 1/26/23 skin assessment without documenting it, the DON stated, I see what you're saying, you're not able to tell. During an observation and interview on 1/31/22 at approximately 10:00 AM, R537 was resting in his bed with a dressing on his right foot. R537 stated he developed a sore to his right heel before he was admitted to the facility. The right heel was resting directly on the mattress surface (according to the care plan heels should be elevated) and the dressing reflected, 1/29/23 @ 1400 (the initials of Nurse G) written on it. When asked how often the dressing is changed, R537 stated that they do daily. When asked if this Surveyor could observe the dressing change today, R537 stated, Sure. During an interview on 1/31/23 at approximately 10:00 AM, Nurse G stated that R537 had been refusing to allow staff to change his dressing to his heel. Nurse G stated she'd let this Surveyor know when she's ready to do the dressing change. During an observation on 2/1/23 at approximately 8:30 AM, R537 was observed resting in his bed with his heel directly on the surface of the bed (according to the care plan the heels should be elevated). The dressing was observed and reflected the same as observed on 1/31/23, 1/29/23 @ 1400 (the initials of Nurse G) written on it. During an observation on 2/2/23 at approximately 9:15 AM, R537 was observed resting in his bed. The dressing was observed and reflected the same as first observed on 1/31/23, 1/29/23 @ 1400 (the initials of Nurse G) written on it. When asked if this Surveyor could observe the dressing change today, R537 stated, Yes. According to the Treatment Administration Record for January 2023 and February 2023 reflected three treatment orders: -Calmoseptine External ointment 0.44-20.6% (Menthol-Zinc Oxide) Apply to coccyx, perineal area, topically every shift for wound care. Ordered 1/18/23 to current. -Cleanse right calf wound apply Alginate and small boarder gauze dressing. Every day shift for wound care. Ordered 1/18/23 to current. -Cleanse right heel, apply calcium alginate and abd (abdominal) pad and wrap with kerlix and coban from the toes to the knee. Every day shift for wound care. Ordered 1/18/23 to current. The dressing change sign outs for the right heel and right calf from 1/19/23-2/2/23 were reviewed and noted that the TAR was left blank on 1/19/23 and 2/1/23 and the treatment was refused on 1/20, 1/22, 1/28, 1/30, and 1/31/23. According to the progress notes dated 1/18/23-2/2/23 reviewed at 10:00 AM, there were no entries made regarding dressing change refusals, education, behaviors, or notifications to physicians. There were no indications of weekly wound measurements for the 4 wounds noted since admission (14 days ago) that had daily wound treatments according to the TAR. During an interview on 2/2/23 at approximately 9:20 AM, Licensed Practical Nurse (LPN) M stated that the midnight nurse reported to her that R537 refused the dressing change at 5:30 AM. According to the TAR the dressing change was scheduled for 7:00 AM not 5:30 AM. This Surveyor advised LPN M that R537 stated he would allow this Surveyor to observe the dressing change today. During an interview and record review on 2/2/23 at approximately 9:30 AM, the DON reviewed the TAR's and progress notes together from 1/18/23-2/2/23 with the Surveyor. The DON stated she was not aware that R537 was frequently refusing his dressing changes and had no idea why. The DON stated that she would not want a dressing changed at 5:30 AM either. When asked what the facility expectation was if a resident refuses a treatment or multiple treatments was, the DON stated that she would expect the nurse to document that refusal in the progress notes along with the reason why the treatment was refused such as a behavioral issue or pain, notify the physician and the DON. The DON stated the expectation would be to obtain an order, educate the resident and update the care plan. There were no refusal notes found to review. When asked where the facility documents the weekly wound measurements within the record, the DON stated in the progress notes but there were none located to review. The DON stated that she had only measured the wounds (all four) upon admission but not since because there was no unit manager, at this time who would do the wound measurements. The DON stated that R537 along with three other residents need to be referred to the wound clinic, but the orders/referrals haven't been made yet. This Surveyor advised the DON that R537 had just given permission for this Surveyor to observe the dressing change and therefore a request was made for measurements to be taken at that time. During an observation on 2/2/23 at approximately 10:30 AM, the DON and LPN F were observed as R537 dressing that reflected 1/29/23 @ 1400 (with the initials of Nurse M) was cut off his foot by LPN F. LPN F was asked to read aloud what was written on the dressing to confirm the accuracy and it had been 4 days since the dressing was last changed. The DON measured the heel wound which was 2.0 x 3.0 x 0.3. The LPN F cleaned and redressed the foot placing the date of 2/3/23, the time and her initials on the dressing when completed. Multiple scabbed areas were noted on the leg and toes as well. An email request was made on 2/2/23 at 1:46 PM for all skin assessments, wound measurements, and physician notes for R537 since his admission (1/18/23). The Nursing Home Administrator (NHA) responded back on 2/2/23 at 3:05 PM with nine pages of documents for review. The NHA provided the skin documentation from the admission assessment that reflected only 2 ulcers instead of four. The new document reflected, an unstageable vascular ulcer 0.5 x 0.5 x 0.1 to the right lower leg and a Stage III pressure ulcer 4.0 x 3.0 x 0.3 to the right heel. The new document conflicted with the previously reviewed document. The Admission Assessment no longer contained the Stage II pressure ulcer 0.5 x 0.5 x 0.1, to the perineal and the second Stage II pressure ulcer 0.5 x 0.5 x 0.1, to the perineal despite there being treated as evidenced on the TAR. The NHA provided a copy of a progress note with a created date of 2/2/23 at 2:11 PM that reflected, Late entry for 1/30/23 at 2:08 PM. The late entry note reflected a measurement of the Stage III right heel pressure ulcer 2.5 x 3.25 and no depth. The note did not contain a treatment change, notification to the physician nor education regarding treatment refusals. There was no evidence of weekly monitoring of the two, Stage II ulcers on the perineal and the unstageable vascular ulcer on the right calf provided for review before the exit of this survey. During an interview on 2/2/23 at approximately 3:30 PM, the DON stated that she forgot that she did measure the Stage III right heel ulcer on 1/30/23. The DON stated that she found the measurements on her desk and put the measurements in as a late entry. This statement and the late entry for the wound measurement conflicted with the repeated observations of seeing R537's dressing to the right heel dated 1/29/23. The dressing would need to be removed to measure the wound on 1/30/23. The TAR reflects that R537 refused his dressing changes on 1/30/23 as well. When asked if she had measured the other three wounds, the DON stated, No. There was no evidence of weekly monitoring of the two Stage II ulcers on the perineal and the unstageable vascular ulcer on the right calf provided for review before the exit of this survey.

This citation pertains to Intake #'s: MI 017, MI 361, MI 305, MI 673, MI 908, and MI 805 Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet resident needs in 5 residents (Resident #112, #102, #110, #115, and #119) reviewed for sufficient staffing, resulting in R112 sustaining a femur fracture from improper transferring, unmet care needs and the potential for impaired physical, mental, and psychosocial well-being for all residents residing in the facility. Resident #112 (R112) Review of an Admission Record revealed R112 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R112, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R112 was cognitively intact. Review of the Functional Status revealed that R112 required extensive 2 person assist for bed mobility and personal hygiene and total dependence of 2 persons for transferring. Review of R112's Care Plan revealed, .Transfers with full mechanical (Hoyer) lift and 2 staff assist. Please adjust hips to facilitate positioning once hoyered to wc (wheelchair) .Revision on [DATE] . Review of R112's Incident Report dated [DATE] at 3:48 PM revealed, While being transferred to bed from electric chair, CNA (Certified Nursing Assistant) bumped his hip into the lift. I spun around while up in the air, and bumped the lift . During an interview on [DATE] at 10:46 AM, Registered Nurse (RN) A reported that she was the nurse responsible for R112's care following the hoyer transfer incident on [DATE]. RN A reported that R112 had significant bruising to his left hip and increased pain with movement. RN A reported that she was informed that the incident occurred because of a hoyer transfer with one person when the transfer required 2 staff assistance. RN A reported that staffing at the facility was not sufficient to meet the needs of the residents. RN A reported that because of the insufficient staffing, staff and residents were put in unsafe situations. During an interview on [DATE] at 4:08 PM, Certified Nursing Assistant (CNA) J reported that she was R112's CNA on [DATE] (the date of the incident). CNA J reported that the facility was very very short that day. CNA J reported that there were 2 CNA's and 1 nurse on the 300 Unit and 2 CNA's and 1 nurse on the 400 Unit at that time. CNA J reported that her hall partner (2nd CNA) was on lunch and the 400 Unit nurse was not available and R112 was very uncomfortable and needed to get back to bed in that moment, not in 15 minutes. My hands were tied. CNA J reported that she knew she was not supposed to transfer R112 in his hoyer without a 2nd person to assist, but this man needed help. CNA J reported that R112 was transferred via hoyer with only 1 person because the facility was short staffed at that time and R112 needed immediate assistance. During an interview on [DATE] at 1:32 PM, R112 reported that in the afternoon on [DATE] he had requested assistance with returning to bed from his motorized wheelchair. R112 reported that he required a hoyer transfer from his wheelchair to his bed. R112 reported that he was transferred via a hoyer lift with only 1 staff member due to short staffing at that time. During the transfer, R112 reported that his leg was caught in his motorized wheelchair, but the CNA continued to attempt to transfer him/move the hoyer lift to his bed. R112 reported that he suffered a left femur fracture which required surgical repair because of the improper hoyer transfer. R112 reported that the facility did not have sufficient staff to meet the needs of the residents. Review of R112's Hospital Records dated [DATE] revealed, (R112) is a 87 y.o. male who presented to (Hospital Emergency Department) via EMS on [DATE] for abnormal labs and left hip pain. Patient and chart review are the source of the information. Past medical history listed below. Patient reportedly was brought to ED (emergency department) for further evaluation of low hemoglobin from his place of residence, (facility). During ED evaluation, labs significant for hemoglobin (red blood cells) of 5.7 (critical low level. Reference range 12.5 - 17.0) .Left femur XR (xray) imaging demonstrated a left subtrochanteric femur fracture (fracture of the femur/thigh bone close to the hip). Patient was given 2 units of pRBC (units of blood) .in ED to correct abnormalities. Patient admitted to (name omitted). Orthopedic service consulted for management of left hip fracture .Patient reports injury likely occurred last week when being moved by (facility) staff with Hoyer lift . He had an x-ray for suspected left femur fracture at least 6 days ago. Fracture may actually be about 10 days old. Seem to have occur while moving him with a Hoyer lift. Presented to the ER with a severe [CONDITION(S)] (low blood levels) and subtrochanteric femur fracture. He is anemic secondary to bleeding within the fracture (loss of blood/low blood level because of the injury/femur fracture). Physical exam does show a rent (tear/hole) in the IT (iliotibial) fascia (long piece of connective tissue connecting several muscles in the lateral thigh) with a lateral bulge not likely hematoma (bruise) but muscle bulge from the new hernia caused by puncture wound from the fracture itself. Requires intramedullary fixation (surgical repair of the fracture) and working on plan to proceed with that today . Patient presented with a hemoglobin was 5.7 on admission. He was given 4 units total during admission. Hemoglobin is 8.2 the day of discharge. Presenting [CONDITION(S)] likely due to underlying hematoma from hip fracture .Addendum .Presented to the ER with a severe [CONDITION(S)] and subtrochanteric femur fracture. He is anemic secondary to bleeding within the fracture. Physical exam does show a rent in the IT fascia with a lateral bulge not likely hematoma but muscle bulge from the new hernia caused by puncture wound from the fracture itself. Review of the DIRECT CARE STAFF DAILY SCHEDULE for [DATE] at the time of the incident revealed: DAY SHIFT 6AM-2PM: 1 nurse and 3 CNA's for the 300 Unit and 1 nurse and 2 CNA's for the 400 Unit. (1 CNA call off on the 300 Unit and 1 CNA call off for the 400 Unit. A CNA was pulled from the 200 Unit to work on the 300 Unit). EVENING SHIFT 2PM-10PM: 1 nurse and 2 CNA's for the 300 Unit (with 1 additional CNA on orientation) and 1 nurse and 2 CNA's for the 400 Unit. A 3rd CNA (agency staff) scheduled to arrive at 4PM-10PM). During an interview on [DATE] at 11:57 AM, Staffing Scheduler (SS) M reported that for the ,d+[DATE] Units on 1st shift and 2nd shift, a total of 6 CNA's and 2 nurses were scheduled for each shift. The ,d+[DATE] Units on 3rd shift were scheduled with a total of 4 CNAs and 1 nurse. SS M reported that the Rehab Unit (,d+[DATE] Unit) was staffed based on numbers but typically required 2 nurse and 3 CNAs for 1st and 2nd shift and 1 nurse and 2 CNAs for 3rd shift. SS M reported that when there are covid positive residents in the building, 1 CNA is designated to those residents which would bring the numbers on the floor down even more (less available CNAs to work). SSM reported that the ,d+[DATE] Unit had a Unit Manager, and the ,d+[DATE] Unit currently did not have a Unit Manager. SS M reported that when there are residents that have frequent falls or need increased monitoring, increased staffing for the unit is attempted. SS M reported that for each meal, floor CNAs assist in the dining room. Staff on orientation do not count as a staff member scheduled on a unit until the orientation is complete. During an interview on [DATE] at 5:21 PM, Nursing Home Administrator (NHA) reported that the ideal staffing for the facility is a total of 6 CNAs and 2 nurses for 1st shift, 6 CNAs and 2 nurses for 2nd shift, and 1 nurse and 4 CNAs for 3rd shift on the ,d+[DATE] Unit and 3 CNAs and 2 nurses for 1st shift, 3 CNAs and 2 nurses for 2nd shift, and 1 nurse and 2 CNAs for 3rd shift on the ,d+[DATE] Units. NHA reported that staffing is adjusted based on resident behaviors and acuity. NHA reported that staffing is assessed daily in morning meeting because census and acuity changes frequently on the ,d+[DATE] Units. Review of the Resident Census and Conditions received on [DATE] revealed the following: *Bathing: 50 residents required ,d+[DATE] person assist and 46 residents were dependent. *Dressing: 90 residents required ,d+[DATE] person assist and 3 residents were dependent. *Transferring: 68 residents required ,d+[DATE] person assist and 24 residents were dependent. *Toileting: 87 residents required ,d+[DATE] person assist and 7 residents were dependent. *Eating: 36 residents required ,d+[DATE] person assist and 4 residents were dependent. Received a list of residents that required hoyer transfer, 2 person assist for transferring, bed mobility, hygiene and dressing, and 1:1 feeding assistance/supervision on [DATE] at 11:29 AM: 2 assist for transferring: *5 residents used a hoyer lift and 2 residents required 2 staff assist for transferring on the 100 Unit (total of 7 residents required 2 staff assist). *3 residents used a hoyer lift and 4 residents required 2 staff assist for transferring on the 200 unit (total of 7 residents required 2 staff assist). *11 residents hoyer lift and 1 resident required 2 staff assist for transferring on the 300 unit (total of 12 residents required 2 staff assist). *5 residents hoyer lift and 5 residents required 2 staff assist for transferring on the 400 unit (total of 10 residents required 2 staff assist). 2 assist with bed mobility: *4 residents required 2 staff assist for bed mobility on the 100 Unit *2 residents required 2 staff assist for bed mobility on the 200 Unit *6 residents required 2 staff assist for bed mobility on the 300 Unit *1 resident required 2 staff assist for bed mobility on the 400 Unit 1:1 Feeding assistance/Supervision *0 residents on the 100 Unit *2 residents on the 200 Unit *4 residents on the 300 Unit *3 residents on the 300 Unit 2 assist with hygiene/dressing *2 residents on the 100 Unit *1 residents on the 200 Unit *6 residents on the 300 Unit (1 resident requiring 2 person shower assistance only) *1 resident requiring 2 person shower assistance on the 400 Unit Resident #102 (R102) Review of an Admission Record revealed R102 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R102's Progress Note dated [DATE] revealed, Alert and oriented x3 (person, place, and time). BIMS 15 (indicating R102 was cognitively intact) . Review of R102's Progress Note dated [DATE] revealed, Alert with some confusion. Makes needs and wants known. Limited assist with adls (activities of daily living) with set up. Up with 1 assist walker and gaitbelt . During an interview on [DATE] at 4:13 PM, FM T reported that following R102's hospitalization on [DATE] a decision was made to not send R102 back to the facility due to concerns with the care provided and the lack of staff available to meet the needs of the residents. FM T reported that R102 was left on a bed pan for an extended period of time during a visit, causing R102 discomfort, at the beginning of R102's stay. FM T reported that R102 would report to family that she did not receive prompt assistance and would yell for help. FM T reported that when she would visit R102, FM T would assist R102 to the bathroom as there was insufficient staff to meet the needs of the residents and provide toileting assistance. Resident #110 (R110) Review of an Admission Record revealed R110 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R110, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R110 was cognitively impaired. Review of the Functional Status revealed that R110 required 1 person physical assist with eating. During an observation on [DATE] at 8:40 AM R110 was in his bed lying flat on his back. His breakfast tray was untouched and on his tray table (unknown when tray was originally passed out to R110). On [DATE] at 8:57 AM a staff member entered R110's room to assist him with eating. Review of the DIRECT CARE STAFF DAILY SCHEDULE for [DATE] revealed: DAY SHIFT (6a-2p): 2 nurses and 3 CNAs scheduled for the ,d+[DATE] Units. Resident #115 (R115) Review of an Admission Record revealed R115 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 R115, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R115 was cognitively intact. During an interview on [DATE] at 11:41 AM, R115 reported that there were not enough staff available to assist the residents in the facility. R115 reported that staff do not assist her when she is in need and tell her that there are other call lights on that must be answered prior to assisting R115. R115 reported that evening shifts are especially short staffed, and she recently had to stay in her room and miss out on an activity because staff did not have time to get her an oxygen tank (had to remain in her room connected to her oxygen concentrator which cannot be transported around the facility and must be plugged into an outlet). R115 reported that staff are short tempered and burned out. R115 reported that her wound care has been delayed due to the nurses being short staffed. R115 reported that her needs are not met resulting in feelings of frustration and discouragement. Resident #119 (R119) Review of an Admission Record revealed R119 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R119, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R119 was cognitively intact. During an interview on [DATE] at 12:17 PM, R119 reported that there are 36 residents on the ,d+[DATE] Unit with 1 aide (CNA). R119 reported that there are not enough staff to assist the residents and meet their basic needs. R119 stated that he requires assistance with care and it took 45 minutes to get in here and help me use the bathroom. R119 stated, 18 people (residents) per person (CNA) is impossible (to meet the needs of the residents). R119 reported that there are also insufficient licensed nurses to meet the needs of the residents. R119 reported that over the weekend ([DATE]-[DATE]) there was only 1 licensed nurse to provide care for the ,d+[DATE] Unit for the evening shift. R119 reported that his scheduled medications are often late because they (nurses) can't get to everyone. R119 reported that over the weekend his 8PM medications were not administered until approximately 11PM. R119 reported that late medications and delayed care is because of the lack of scheduled staff. R119 stated that staff won't let us eat in the dining room unless there's a nurse aide in there. They try to make us eat in our rooms if there aren't enough staff. R119 reported that the dining room has been closed for dinner because there were not enough staff to assist the residents in the dining room. R119 reported that he and other residents in the facility have made their staffing concerns known through concern forms and resident council and there has been no changes. R119 reported that administrative staff state they want to hear resident concerns but do not follow up with the concerns that are voiced. R119 was visibly agitated during the interview and expressed feelings of frustration with the care he received because of the lack of staff. Review of the DIRECT CARE STAFF DAILY SCHEDULE for [DATE] revealed: EVENING SHIFT (2PM-10PM): 1 nurse scheduled for the ,d+[DATE] Unit with an Open 6p-11p licensed nurse shift (no documentation that the shift was covered). Review of the DIRECT CARE STAFF DAILY SCHEDULE for [DATE] revealed: EVENING SHIFT (2PM-10PM): 1 nurse scheduled for the ,d+[DATE] Hall with an Open 3p-11p licensed nurse shift (no documentation that the shift was covered). 1 CNA was dedicated to the COVID rooms from 2pm-6pm and 3 CNAs were scheduled for ,d+[DATE] Unit (the CNA to be designated to the COVID rooms from 6pm to the end of the shift was not identified on the staffing schedule). During an interview on [DATE] at 12:54 PM, Family Member (FM) S reported that on [DATE] there were insufficient staff to meet the needs of the residents on the ,d+[DATE] Units. FM S reported that there was only 1 CNA staffed for the 400 Unit, 1 CNA staffed for the 300 Unit, and 1 CNA to split both the ,d+[DATE] Unit. FM S reported that she arrived at the facility to visit her family member at approximately 6:20 PM on [DATE] and her family member was in her nightgown in bed and had not been fed her dinner. FM S reported that her family member was to be up in a chair for meals due to her risk of aspiration. FM S reported that she had concerns that residents were not being repositioned and changed as needed because of the lack of staff available. FM S reported that the units were not being staffed based on the resident acuity and because of that the residents' basic needs were not being met. Review of the DIRECT CARE STAFF DAILY SCHEDULE for [DATE] revealed: EVENING SHIFT (2PM-10PM): 1 nurse and 1 CNA for the 300 Unit and 1 nurse and 1 CNA scheduled for the 400 Unit with 1 CNA scheduled to split the 300 and 400 Unit. (1 CNA to work 2pm-6pm and 1 CNA to work 6PM-10PM for the split assignment). During an interview on [DATE] at 6:31 AM, RN B reported that 3rd shift is staffed with 2 licensed nurses for the building. 1 nurse for the ,d+[DATE] Unit and 1 nurse for the ,d+[DATE] Unit. RN B reported she was responsible for approximately 60 residents for the ,d+[DATE] Unit. RN B reported that the ,d+[DATE] Unit had many residents that required 2 staff assist for cares (transferring, toileting, bed mobility). LPN E reported that it was difficult to get all dependent/2 assist residents repositioned and care provided with the number of staff scheduled. LPN E reported that when there was an emergency such as a code (resident requiring CPR), there would be no licensed nurses available for the other residents residing in the facility as both nurses would be providing care for the resident in distress. During an interview on [DATE] at 10:46 AM, RN A reported that resident needs were not being met because of the facility staffing shortage. RN A reported that it was difficult to take the time to feed residents because of lack of staff. RN A reported that often there were only 3 CNA's and 2 nurses to care for the residents on the ,d+[DATE] Unit and reported that 2nd shift is the worst. During meals, 1 CNA is sent to assist with meals in the dining room leaving the unit with even fewer staff to assist residents on the ,d+[DATE] Unit. RN A reported that 90% of the falls I deal with are because of (the lack of) staff. RN A reported that because of the lack of staff available, showers were not being done. RN A reported that at times, residents will go ,d+[DATE] weeks without a shower (with only bed baths provided). During an interview on [DATE] at 4:08 PM, CNA J reported that residents often must wait for assistance because of the lack of staff. CNA J reported that it can take 30 minutes to get a second staff member to assist with transferring. CNA J reported that it was difficult to turn and reposition and feed residents because of the lack of staff. CNA J reported that it was difficult to shower the residents when they were running 2 and 2 you don't have time (2 CNAs for the 300 Unit and 2 CNA's for the 400 Unit). CNA J reported that residents that require a transfer with a hoyer lift will wait approximately 30 minutes or more because a hoyer transfer requires 2 staff. CNA J stated, overall they (residents) don't all get proper care. How can they? CNA J reported that she had been a CNA for [AGE] years and has never experienced working as short as she works at the facility. During an interview on [DATE] at 10:57 AM, Licensed Practical Nurse (LPN) Q reported that more staff were required to meet the needs of the residents. LPN Q reported that staffing was based on a number ratio and based somewhat on acuity. LPN Q reported that because the ,d+[DATE] Unit was typically rehab residents, the acuity could change day to day based on the census and the needs of the new admits. LPN Q reported that there were many high needs and impulsive residents residing on the ,d+[DATE] Units at that time. LPN Q reported that the ,d+[DATE] Units were typically staffed with 1 nurse for each unit and 1 CNA for each unit with 1 CNA doing split during 1st and 2nd shift. The CNA scheduled for split would assist in the dining room for each meal which left the units even shorter during mealtimes. LPN Q reported additional staff were needed to meet the needs of the residents. During an interview on [DATE] at 5:02 PM, CNA G reported that there were not enough CNA's to meet the needs of the residents. CNA G reported that on 2nd shift, there was usually 1 CNA for the 300 Unit and 1 CNA for the 400 Unit with 1 CNA scheduled to split the ,d+[DATE] Unit. CNA G reported that there were not enough staff to meet the needs of the residents based on the resident acuity of those units. During an interview on [DATE] at 5:05 PM, LPN 'R reported that there was not enough staff to meet the needs of the residents based on the acuity of the residents on the ,d+[DATE] Units. LPN R reported that she was responsible for 32 residents (medication administration, treatments, ADL assistance when needed). LPN R reported that typically there was 1 nurse and 2 CNA's scheduled for 300 Unit but at times they would work with less (CNA's). LPN R reported that based on the acuity of the residents, 1 nurse and 3 CNA's on 2nd shift was required to meet the resident needs. Review of the Resident Council Minutes revealed: *[DATE] New Business .6. Resident want to be assured they get biweekly showers *[DATE] for February .New Business .2. Resident want biweekly showers *[DATE] Old Business .2. Biweekly showers (does not show resolved) .New Business .1. Call light response on 3rd shift . *[DATE] . New Business .6. Concerns regarding showers and beds on 300 (unit) . *[DATE] New Business .2. Call light response times 300 hall . *[DATE] (for June) New Business .2.cleanliness of rooms mopping and beds being made . *[DATE] New Business .1. Beds not being made ,d+[DATE] .3. Call light response on 3rd shift . *[DATE] New Business .1. 300 hall beds not made + 100. 2. Call light response 3rd shift improving but not as quick as hoped . *[DATE] old Business .call light response 3rd shift (not resolved). *[DATE] New Business .1. Call light response 300 hall 2nd shift . Indicating insufficient staff to meet the needs of the residents was voiced in Resident Council meetings. Requested the facility policy for Staffing (how are the number of cna's/nurses determined) on [DATE] at 3:35 PM with no documents received prior to survey exit.

Based on observation, interview and record review, the facility failed to develop and implement person centered interventions and approaches to address behaviors exhibited by residents with dementia for 3 (Resident #1, Resident #3, and Resident #4), resulting in continued unsupervised wandering, repeated unwitnessed falls and injuries and the potential for all 13 residents who wander at risk for further unwitnessed incidents and accidents, harm, and abuse. Findings include: Resident #1 Review of a Face Sheet revealed Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) indicating he was cognitively intact and only behaviors for rejecting care. He required extensive assistance of 2 staff for transfers and care and had limited range of motion on one side of his upper and lower extremity and required a walker or wheelchair. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Section V, the Care Area Assessment (CAA) revealed the resident was not triggered for Cognitive Loss/Dementia, psychosocial wellbeing, or behavioral symptoms. Resident #3 Review of a Face Sheet revealed Resident #3 is an [AGE] year old female admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS for Resident #3 revealed she had a BIMS indicating she is severely cognitively impaired and no behaviors or wandering. She requires extensive assistance of 1 person for transfers and extensive assistance of 2 people for toileting, dressing, and bed mobility. She is not on a toileting schedule and is frequently incontinent. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #4 Review of the MDS dated [DATE] revealed Resident #4 is a [AGE] year old female originally admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 Review of the MDS dated [DATE] revealed Resident #5 is a [AGE] year old female admitted to the facility on [DATE]. A BIMS indicated she is cognitively intact. The complainant reported to the State Agency. On 6/17/21 My spouse keep telling me about this man named (Resident #1) on the 100 hall that is always in his room late at night. She's scared the life out of him. He wakes up and he's standing over him. He's going to give him a heart attack sooner later. How is this acceptable? The complainant reported to the State Agency that There is a resident here (Resident #1) and he has been naked in my room [ROOM NUMBER] times this week. He goes in everyone's room especially at night. He always ask for sex and holds his privates while he talk to you. He asked me to touch it the other night. There is not enough employees here to watch him 24/7. I'm afraid he is going to rape someone. The complainant reported to the State Agency Staffing is so short and resident was able to get outside. Staff is forced to work on two halls and can't get to do alarms in time because they are on a different hall. The complainant reported to the State Agency We have a resident (Resident #1) in 100 hall. He tries to get on the bed with other residents all day long. He constantly ask people to have sex with him. He rubs other residents the hands and legs and management will do nothing. I see the nurses all the time calling and letting (NHA) know and she doesn't ever have a solution. My little female ladies are afraid of him. He come in their room at night. Most of them are confused. I know night shift do their job to the best of ability but something need to change. If family knew these residents was getting waken up by a naked man they would be livid. The complainant reported to the State Agency The nurse gets so frustrated with the cnas (Certified Nursing Assistants) when resident gets outside or go in other residents room and scare them. But we are so short and management will not give (Resident #1) a one to one. (Resident #1) is going get farther next time he elope or he is going to touch a resident sexually before management give us enough staff to watch him properly. Review of a list provided by the facility revealed 13 residents who wander. Upon request of the Incident and Accident Reports for 3 residents, the facility provided reports with incomplete investigations. The post fall assessments, Interdisciplinary Team (IDT) notes with interventions were missing. There were no statements from staff who worked, witnesses, or names of people who may have been in the building or caring for the residents. The facility later provided additional information but still lacked statements and names of staff who worked at the time of the incidents or other residents during the times of the incidents and not all events had an IDT follow up, intervention or updated care plan. Resident #1 Review of the Electronic Health Records for Resident #1 revealed inconsistent medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The facility provided 13 unwitnessed Incident and Accident Reports for Resident #1 dated between April 2021 to June 2021 that included falls and injuries. The Incident and Accident Reports did not include all the incidents and accidents involving Resident #1 as reflected in the Nursing Progress Notes from date of admission to the date of his discharge. Review of a document titled Wandering Risk Scale dated 4/15/21 Admission revealed Resident #1 was a High Risk To Wander. Review of a Fall Risk assessment dated [DATE] for Resident #1 revealed he was a High Risk for Falling. Review of the Care Plan for Resident #1 revealed a focus initiated on 4/18/21 and last revised on 4/23/21 revealed: Resident at risk for falls r/t (related to) confusion, deconditioning, incontinence, unaware of safety needs. Review of a Care Plan for Resident #1 revealed an Activities of Daily Living (ADL) Care Plan initiated on 5/19/21 revealed: Focus: Resident has an ADL self-care deficit r/t (related to) Activity Intolerance, Aggressive Behavior, Alzheimer's Confusion, Dementia, fatigue, Impaired balance, Limited Mobility. On 6/2/21 a Care Plan initiated for a focus of: Resident is resistant to leaving door shut and staying in room for infection control r/t Dementia.' On 5/13/21 a care plan focus of: The resident has impaired cognitive function/dementia or impaired thought processes r/t difficulty making decisions, mild cognitive impairment, impaired decision making. Review of the Care Plan for Resident #1 revealed on 6/3/21 a focus for: Resident is an elopement risk and/or exhibits wandering behavior r/t (related to) disoriented to place, history of attempts to leave facility unattended, impaired safety awareness, significantly intrudes on the privacy or activities of others, wandering and/or exit seeking behavior. Review of Incident and Accident Reports for Resident #1 revealed on 4/16/21 at 1:30 a.m. revealed: Call light turned on by roommate. Resident noted crawling in room on hands and knees. Patient unable to give description. Resident assessed. Knee tear noted on left shin 0.9 x 0.5x 0.1. Abrasion on left knee 1.2 x 1.3x0.1. Wounds cleaned, dressing placed. Resident assisted off floor, 3 staff and Hoyer lift. Reorientation attempted. Room rearranged, bed pushed against wall. Bed locked and low. Review of Incident and Accident Reports dated 4/17/21, Resident #1 had unwitnessed falls at 5:45 p.m. and then at 6:12 p.m. and again at 6:58 p.m. Interventions on the care plan dated 4/18/21. At 5:45 p.m. the resident stated he was trying to help the people at the window. Intervention was mattress replaced with scoop mattress. At 6:12 p.m. Resident #1 observed on the floor next to his bed and stated, I rolled out of bed. Intervention was a passed call light. At 6:58 p.m. the resident observed on the floor next to his bed and stated, I rolled out of bed. Intervention was a medication review. Review of the Nursing Progress note for Resident #1 dated 4/18/21 at 2:12 a.m. revealed: Resident continues on neuros. Neuro status unchanged. VSS (vital signs stable). Alert and oriented X1. Confused and disoriented. Resident noted with feet out the bed multiple times. Mattress at bed side for safety. Review of a Nursing Progress Note dated 4/18/21 at 10:49 a.m. for Resident #1 revealed: Resident was observed on the floor next to his bed. Resident was unable to say what happened just I rolled out of bed. No incident report provided for this incident. Review of an Incident Accident Report dated 4/18/21 at 9:15 p.m. for Resident #1 revealed: Resident observed on the floor next to roommates bed on his back. Resident state the police is in the window I called them, I wanted to let them in. Immediate action taken: . Resident assisted up two staff and a lift. Paddle light in reach, scoop mattress in place. Bedside mattress as well. Review of a Nursing Progress note dated 4/18/21 at 9:15 p.m. for Resident #1 revealed: Resident observed on the floor next to roommates bed on his back. Resident State the police is in the window I called the, I wanted to let them in. Resident asked why he called the police and he states to help me up. Resident reassured staff will help him up. Resident does not have a phone and did not call the police. Resident is confused and disoriented at this time. Resident assisted up two staff and a lift. Review of a Nursing Progress note dated 4/18/21 at 10:34 p.m. for Resident #1 revealed: Resident observed on the floor next to roommates bed on his back. Resident state the police is in the window I called them, I wanted to let them in. Resident asked why he called the police and he states to help me up. Resident is confused and disoriented at this time. Oriented only to self. No injuries noted. Review of a Nursing Progress note dated 4/19/21 at 4:36 a.m. for Resident #1 revealed: Resident observed on bedside mat approximately 6 times this shift. Each time resident asked what had happened resident unable to describe events. No injuries noted. Resident state he wanted to lay down each time resident was assisted back to bed with 2-3 staff and hoyer lift. Resident is now dressed and up for the day in chair. Review of a Physician note dated 4/19/21 for Resident #1 revealed: He cannot answer many of my questions due to his mental status. He denies any pain. He is eating well and sleeping well. He does not know the day of the week. He does not know the day, he does not know the year, he does not know the season. He cannot tell me who the president is. He could not repeat 3 words. The patient has a BIMS score of 3 indicating severe cognitive impairment. He is not competent to make medical or legal decisions regarding his care. Review of an Incident and Accident Report dated 4/28/21 at 5:21 p.m. for Resident #1 revealed: Resident observed on floor by staff in room, supine position. Attempting to ambulate without assistance. Appropriate gripper socks on bilateral feet. Unable to answer. Immediate Action Taken: . Abrasion to left elbow, left knee and bruise to left buttock. Resident assisted from floor to bed. Resident observed in bed with eyes closed shortly after assistance. Completed Neuro assessments incomplete post fall. IDT intervention: offer to lay down in the afternoon. Review of an Incident Accident Report dated 5/1/21 at 12:30 a.m. for Resident #1 revealed: Resident observed on the floor in other resident's room. Immediate Action Taken: Resident entered through the bathroom. Resident assessed, no apparent new injuries, . Resident unable to tell staff what he was attempting to do. IDT intervention is to ensure bathroom light is off when patient lays down for night. Care plans reviewed and updated to reflect appropriate interventions to assist in maintain resident's optimal functional status and safety. Review of an Incident and Accident Report dated 5/8/21 at 7:48 a.m. for Resident #1 revealed: (2 CNAs) brought to my attention a cut on resident's left foot at the second webspacing. Resident stated he bumped his foot on the bed when he was transferring back to bed. Notes: Resident did not know what happened, was unsure of injury, expressed pain with application of dressing. No skin assessments provided. No IDT disciplinary notes provided and injury was not reported to the state. Review of a Nursing Progress note dated 5/8/21 at 8:05 a.m. for Resident #1 revealed: . Resident is resting calmly and not reporting any pain at this time, will continue to monitor and treat as needed. Laceration was covered w xeroform gauze and wrapped w kerlix. Review of a Nursing Progress note dated 5/8/21 at 10:05 p.m. for Resident #1 revealed: Laceration to left foot second toe bleeding is controlled with gauze and kerlix, bruising around that toe, painful to touch, resident is unable to move second toe. Patient will be getting sent to (Hospital) per on call. Review of a Nursing Progress note dated 5/9/21 at 2:10 a.m. for Resident #1 revealed: Resident returned via ambulance. Resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He returned with sutures to the second toe left foot. Sutures is to be removed 10-14 days. Resident has no c/o pain and is currently resting in bed. Review of a Nursing Progress note dated 5/9/21 at 9:20 a.m. for Resident #1 revealed: Resident had a wandering episode and mistook a resident for his wife. Resident was alert and oriented times 4. Resident entered female residents' room and tapped her. Resident was then redirected back to his room. Skin assessment completed with no concerns. No incident report provided for this incident. Review of an Incident and Accident Report dated 5/10/21 at 3:08 a.m. for Resident #1 revealed: Resident has been behavioral most of shift, resting in chair then having sudden outbursts of comments about the police, his wife ect. Resident also taking self down 100 hall in wc (wheelchair) as well as attempting to go down 200 hall. Resident then transferred self to floor. I asked resident why he was trying to sit on floor, resident then proceeded to act as though he was unconscious and would not answer., then attempted to lay on the floor. I instructed the aid to get help as I attempted to arouse the resident with a shake and calling his name. I then grabbed his arm and attempted to reposition him and he called out. As I attempted to sit him upright from his leaned over position he again tried to go limp and force himself to the floor. Once again resident called out when his posture was corrected. The hoyer was used to place the resident into a broda chair where he then slept without incident. Immediate Action Taken: Neuros started, Resident monitored and kept in nurses station . No IDT information provided or long term intervention implemented. Review of an Incident and Accident Report dated 5/16/21 at 10:28 p.m. for Resident #1 revealed: Resident was observed on the floor on his stomach army crawling up the hallway on his blanket. Resident unable to answer what he was doing. Immediate action taken was no blanket while up in a chair. Review of the Nursing Progress note dated 5/16/21 at 10:13 p.m. for Resident #1 revealed: Resident was observed on the floor in the hallway with his chair tipped over. Resident was army crawling down the hallway on his blanket. Different details than the Incident and Accident report. Review of a Nursing Progress note dated 5/16/21 at 11:40 p.m. for Resident #1 revealed: Resident was observed on the floor in the hallway with his chair tipped over. Resident was army crawling down the hallway on his blanket. ROM assessed, pain assessed, skin assessed. Review of the IDT report referencing the 5/16/21 incident at 11:00 p.m. for Resident #1 revealed: Resident was observed on floor in hallway army crawling down hallway on blanket. Resident had previously been observed approximately 15 minutes prior. At the time of staffs observation, resident did not ask for assistance when last observed. Staff did not observe resident's call light on. Resident has poor safety awareness and often forgets to ask for assistance. New/long term intervention: no blanket while up in chair. Care plans reviewed and updated to reflect appropriate interventions to assist in maintain resident's optimal functional status and safety. Was this fall preventable? No. Review of an Incident and Accident Report dated 5/18/21 at 11:12 a.m. for Resident #1 revealed: Res observed on the floor, laying on his left side. I was going to get my wife. IDT new/long term intervention: offer to call wife after lunch. Review of a Nursing Progress note dated 5/19/21 at 3:32 a.m. for Resident #1 revealed: Resident alert with confusion at baseline. Self transfers. Review of an Incident and Accident Report dated 5/19/21 at 4:47 p.m. for Resident #1 revealed: Observed on the floor on knees beside bed. Chair behind resident. States Its not my fault, this time. States Chair pushed off the wall and I slide right out of it. Review of a Nursing Progress note dated 5/19/21 at 5:55 p.m. for Resident #1 revealed: Observed on the floor on knees beside bed. Chair behind resident. States Chair pushed off the wall and I slide right out of it. Assessed in the supine position, rom within normal limits, Feet without gripper socks or shoes. Skin intact. Does not indicate where the resident was. Review of IDT notes for a fall dated 5/19/21 at 5:55 p.m. for Resident #1 revealed: Root Causes and Contributing Factors as determined by IDT: IDT met to review resident's occurrence from 5/19/21. Resident was observed on floor in hallway army crawling down hallway on blanket. ROM was assessed Resident previously been observed approximately 15 minutes prior. At the time of staff's observation, resident did not ask for assistance when last observed. Staff did not observe resident's call light on.Resident has poor safety awareness and often forgets to ask for assistance. New/long term intervention: replace Geri chair with standard wheelchair with anti rollbacks in place. Care plans reviewed and updated to reflect appropriate interventions to assist in maintain resident's optimal functional status and safety. Was this fall preventable? No. Care plan reflects this was implemented on 5/21/21. Review of a Nursing Progress note dated 5/20/21 at 6:31 a.m. for Resident #1 revealed: Self transferring into female resident's room with no clothes on. Resident redirected. Grabs staff hand and ask staff to have sex with him. Resident informed about appropriate behavior towards staff, resident does not respond. Resident resting in chair in room. No Incident Report provided for this. No IDT intervention noted and no care plan intervention noted. Review of a Nursing Progress note dated 5/24/21 at 2:35 a.m. for Resident #1 revealed: Resident self transferring into female resident room, attempting to get in bed with her naked. Resident is combative with staff. Waving closed fist at staff and pushing through staff to get in another resident's room. Resident yelling and swearing, accusing staff of hiding his wife from him. Resident redirected with no success. On-call notified. Resident sent to (hospital) for evaluation. No Incident Report provided for this or IDT follow up. Review of a Nursing Progress Note dated 5/26/21 at 12:57 p.m. for Resident #1 revealed: remains in isolation for covid, asymptomatic. Behaviors continue, wandering, exit seeking, looking for spouse, redirects this shift. Review of a Nursing Progress note dated 5/28/21 at 2:57 p.m. for Resident #1 revealed: Confused early this shift. Seeking female in next room, stating that is my wife, redirected many times. No incident report or IDT follow up provided. No care plan intervention noted. Review of a Nursing Progress note dated 5/30/21 at 4:40 a.m. for Resident #1 revealed: Resident awake all night, self transferring and attempting to go in female resident's room. Resident requires constant redirecting. Resident makes sexually inappropriate comments to staff. Teaching provided, resident continues. No incident report or IDT follow up provided. No care plan updated. Review of several progress notes for Resident #1 in June 2021 revealed he wandered, self transferred through hall with no clothes on, confused, anxious, attempting to go into other residents rooms. He displays sexually inappropriate verbal and physical gestures documented toward female staff. Review of a Nursing Progress note dated 6/5/21 at 3:09 p.m. for Resident #1 revealed: Resident observed laying on the floor in his rm. He is alert to self and ? situation. According to him, He was getting out of bed but didn't know why. No Incident and Accident Report provided. IDT note revealed: Resident was observed on floor in middle of room floor.previously been observed approximately 70 minutes prior when staff toileted residents.staff did not observe resident's call light on. Was this fall preventable? No. New long term intervention: paddle call light to side while in bed. Review of a Social Serviced Progress note dated 6/8/21 at 10:03 a.m. for Resident #1 revealed: Contact was made with resident as he was agitated and difficult to redirect. SS attempted to redirect resident. Resident is making suicidal statements stating I would end it all, if I just had a 9 millimeter'; resident does not have the means to complete. SS will follow up with resident as needed. Review of a Social Services Progress note dated 6/8/21 at 10:18 a.m. for Resident #1 revealed: Contacted resident's wife to notify of resident's transfer out to the hospital. No Nursing Progress note indicated the resident transferred to and from the hospital. Review of a Nursing Progress note dated 6/8/21 at 11:17 a.m. for Resident #1 revealed: Resident appears fatigued. States this a.m. That if I am is here for life, I might as well end it with a 5 mm bullet . when resident asked, 15 minutes later, if he feels if he want to hurt himself, Does not recall nor answer the same at this time. Resident has no plan or means to execute statement. Review of a Progress Note dated 6/12/21 at 8:23 p.m. for Resident #1 revealed: Resident exit seeking setting off door alarms. In an out of other resident's room. Confused and disoriented. Agitated when staff attempts to redirect. Resident observed by staff going out of 100 hall door. Staff assisted resident back in. DON and administrator notified. No incident report or IDT notes provided. Review of a Progress note dated 6/12/21 at 11:06 p.m. for Resident #1 revealed: Resident observed in a male resident room standing over bed. Resident redirected and assisted out of room. No incident report or IDT interventions noted. Review of a Progress Note dated 6/13/21 at 8:08 p.m. for Resident #1 revealed: Resident continues to exit seek. Resident set off 200 emergency exit alarm. Resident observed by staff outside on the side walk. Staff assisted resident back in, resident resistive with staff. No incident report provided for this incident. Review of a Nursing Progress note dated 6/14/21 at 5:50 a.m. for Resident #1 revealed: Resident up all night self transferring in and out of other resident's room. Resident goes into neighbors room through joining bathroom. Resident yelling throughout the hall . No Incident report or IDT interventions provided. Review of a Nursing Progress note dated 6/14/21 at 6:40 a.m. for Resident #1 revealed: Resident self transferring, observed by staff off the unit. Resident assisted back to unit. Now attempting to leave out of patio door. Staff attempting to redirect. No incident report or IDT interventions provided. Review of an Incident and Accident report dated 6/14/21 at 6:00 p.m. for Resident #1 revealed: At 5:55 PM, resident had an attended fall in the administrator's office. Resident stated he was going to get up and walk out, and proceeded to get up from his wheelchair and fall to the floor, resident was pivoted and fell on his buttocks, administrator assisted to the floor, resident did hit his head on the paper boxes, but stated he was not in any pain. Nurse and CNA immediately notified. CNA assisted resident back into chair. Review of a Nursing Progress note dated 6/15/21 at 1:34 a.m. for Resident #1 revealed: Resident sleeping at beginning of shift (1900). When resident woke up, resident self transferred, ambulated into another residents room, and raised his voice, yelling at the other resident. Staff were attempting to redirect at this point, unsuccessful. Redirection attempted until successful. Resident self ambulated through hall, into multiple residents rooms, yelling nonsense . This nurse called (NHA) received permission for 1:1 supervision through shift. No incident report or IDT intervention noted. In an interview on 6/24/21 at 9:41 a.m. Resident #5 reported she remembered Resident #1 who was perverted, very inappropriate and aggressive. She reported Resident #1 resided at the end of her hall on the left and was pretty independent. Resident #5 reported he would say things to her like You know I could have had my way with you last night. She reported Resident #1 would come into her room several times with his genitals showing. She named a male resident who had several incidents with him. Resident #5 reported the social worker would come in and ask if she felt threatened and she said no but that he should because if he came into her room again she would defend herself. Resident #5 reported she would just start yelling at him and he would leave. When queried about any other residents wandering in her room, Resident #5 reported Resident #4 likes to wander around into other peoples rooms and likes to pilfer things but she is harmless. In an interview on 6/24/21 at 10:12 a.m., Resident #8 reported she felt safe here but the alarms to the doors that go outside went off a couple times last night and woke her up. In an interview on 6/24/21 at 10:18 a.m., Licensed Practical Nurse (LPN) C reported she did not recall during report that any residents got out of the building, but it may have been the resident in room [ROOM NUMBER]. LPN C reported if a resident did get out, then it should have been reported on an incident report, then to the DON (Director of Nursing) and NHA (Nursing Home Administrator). In an interview on 6/24/21 at 10:22 a.m., the DON reported there were no Facility Reported Incidents (FRI's) reported to the State Agency for Resident #1. In an interview on 6/24/21 at 10:52 a.m., Resident #9 reported Resident #1 was all talk and naked sometimes. He had foul language and sexually inappropriate with the girls. In an interview on 6/24/21 at 1:24 p.m., CNA D reported Resident #1 was naked sometimes in the hall but is unaware of him going into other residents' rooms without clothes on. In an interview on 6/24/21 at 3:35 p.m., Registered Nurse (RN) I reported Resident #1 got out of the building when he was at the facility 2 nights in a row about 1-2 weeks ago. The first night he got out the 100 hall exit in his wheelchair. He was very quick, and the facility was very short staffed with one CNA on each hall. He would be good one night and not good the next. There are many residents who require the assistance of 2 staff for care and both CNA's were in another room assisting another resident at the time Resident #1 got out of the building. RN I reported she was on the 200 hall passing medications and heard the alarm going off and saw the 100 hall exit door shut and ran down there to Resident #1 outside. The next night RN I reported she was in the bathroom when the exit door alarm went off again and she ran down the 100 hall and did not see anything then ran to the 200 hall where she looked out the window and saw Resident #1 made it all the way down the sidewalk where the EMS (Emergency Medical Service) Van comes. The other CNA's were in a room assisting other residents. He was a constant wanderer, sexually inappropriate and tried to climb in bed with 2 residents (one male and the other a female) who have since been discharged from the facility. One night Resident #1 tried to climb in bed with a female resident and RN I reported she notified Unit Manager and the physician. The resident went to the emergency room that night. Resident #1 was on the COVID unit which was at the back of the 100 hall. RN I reported she was the only nurse on the 100 and 200 halls at night and was told to not go on the COVID unit unless necessary because there was not a nurse assigned specifically to the COVID unit. Resident #1 was in room [ROOM NUMBER] and had an adjoining bathroom to room [ROOM NUMBER]. Resident #1 would go through the bathroom and enter room [ROOM NUMBER] and tried to climb in bed with the male resident thinking it was his wife. RN I reported Resident #1 would go into other residents' rooms and sometimes would have no clothes on. Did not recall any residents complaining of being scared. When queried about staffing, RN I reported staffing for second shift is worse for staffing. Resident #1 was a 1:1 supervision during the day shift but it was hard for him to be a 1:1 supervision at night. In an interview on 6/25/21 at 10:03 a.m., CNA J reported Resident #1 was combative, mean, exit seeking and sexually inappropriate and asking for sex mostly with staff. He would expose himself to walkers and call staff into his room and do sexually inappropriate things. CNA J reported she is unaware of the resident exposing himself to other residents and he usually had clothes on. Sometimes he would walk down the hallway but then fall. It would take two staff members to redirect him back to his room. A resident who resided in room [ROOM NUMBER] would complain that Resident #1 was inappropriate. Resident #1 was inappropriate with one guy and was in this guys room. CNA J reported he wanted to have sex with his wife and staff had to redirect him. Other residents were scared because he would randomly wander into resident rooms. Resident #1 became a 1:1 the last 2 days before he left. When queried about staffing, CNA J reported there has been some call offs and the last couple nights she worked by herself. The second and third shift are very short staffed. Resident #3 During an observation on 6/24/21 at 8:52 a.m., Resident #3 was in her doorway in her wheelchair with wet pants on and was non sensical/confused when asked how she was doing. During an observation on 6/24/21 at 10:27 a.m., Resident #3 was in the Activities room with new pants on. She was smiling and non-verbal. During an observation on 6/25/21 at 9:08 a.m., Resident #3 was in her room in a wheelchair with the bedside table in front of her and a call bell on top of the table. When talking to the resident, she was nonverbal and smiled then spoke soft with nonsensical words. Review of a Timeline of Events provided by the facility revealed from 4/2/21 to 6/19/21 Resident #3 has had a total of 17 falls. On 4/24/21 she had fall and diagnosed with an acute right [CONDITION(S)] on 4/24/21 and sent to the hospital. On 5/28/21 and diagnosed on [DATE] with a fractured clavicle (collar bone). All falls were unwitnessed except for one fall witnessed by her roommate on 5/17/21. No statements obtained from the roommate or staff as to where they were and who saw the resident last. Review of the Progress Notes for Resident #3 revealed there were more incidents/accidents not included in the Incident and Accident Reports provided. Review of a Nursing Progress note dated 4/16/21 at 8:14 p.m. Resident was walking to the bathroom with CENA this am and she w [TRUNCATED]

This citation pertains to intake #MI000- 2 Based on interview and record review, the facility failed to prevent a facility acquired pressure wound and provide timely and comprehensive care for that pressure wound, for 1 resident (Resident #101), resulting in a stage 4 wound that required surgical intervention. Findings: Resident #101 (R101) Review of a Face Sheet revealed R101 was an [AGE] year old male, originally admitted to the facility on [DATE] for short term subacute rehabilitation following extensive surgery of the cervical spine, with pertinent [DIAGNOSES REDACTED]. R101 required total assistance form 2 staff persons to turn and be repositioned in bed. Review of a Nursing Admission Screen, dated 8/4/20, indicated that R101 did not have any skin concerns at the time of admission to the facility. Review of a Physician Admission Screen, dated 8/5/20, indicated that R101 did not have any skin concerns at the time of this assessment. Review of a Care Plan for R101, initiated on 8/5/20, specified the following: FOCUS-limited physical mobility and INTERVENTION- resident requires extensive to total assist by 2 staff to turn and reposition in bed frequently and as necessary. Review of a CNA (certified nurse aid) Kardex for R101 revealed no instructions for staff to monitor for skin concerns/breakdown related to the residents very limited mobility. Review of a Care Plan for R101 showed that no interventions were put in place to address the resident's high probability for and prevention of skin breakdown related to significant limitations in mobility. Review of a Skin progress note, dated 8/17/20, revealed alteration in skin noted to left heel, order for transparent dressing in place to bilateral heels for protection, heels to be floated while in bed and feet to be separated with pillow while in bed, wound team to make necessary adjustments if needed during assessment in wound rounds. The next progress note located in the electronic medical record (EMR) that addressed the condition of R101's skin/heels was dated 8/25/20. Review of a Care Plan for R101 revealed that no interventions were put into place following the 8/17/20 Skin progress note. Review of a CNA Kardex revealed no instructions for staff to float heels while in bed and to keep R101's feet separated with a pillow while in bed. Review of a physician progress notes [REDACTED]. Review of a Skin/Wound Evaluation progress note, dated 8/25/20, reflected the following assessment: wound evaluation completed, resident wound type is pressure, location is left heel, wound measurements are Area-11.0 cm2 (square centimeters), Length-3.3 cm, Width-4.1 cm, Depth-not applicable, Amount of exudate (drainage) is moderate, type of exudate is Sanguineous/bloody, and odor noted after cleansing was done. Instructions for how dressing changes were to be conducted were included in the progress note. Review of a Care Plan for R101 revealed that no interventions were put into place following the 8/25/20 Skin/Wound Evaluation progress note. Review of a CNA Kardex reflected no instructions for direct care staff to monitor, assess, or prevent further deterioration of R101's left heel wound. Review of a physician progress notes [REDACTED]. The note indicated that R101 was not doing well in therapy and per R101's reporting to the practitioner, was not able to walk or stand. Review of a General Progress Note, dated 8/27/20, reflected that R101's left heel wound was assessed for healing, wound had deteriorated and was unstageable, and the wound bed was covered in slough. New orders for dressing changes and wound care were listed in the progress note. Review of a Care Plan for R101 revealed that no interventions regarding assessment, monitoring and treatment of [REDACTED]. Review of a CNA Kardex revealed no instructions for direct care staff to monitor, assess, or prevent further deterioration of R101's left heel wound. Review of a General Progress Note, dated 8/28/20 at 2:30 A.M., revealed no mention that a dressing change was completed, nor any information related to the condition of the wound. Review of R101's EMR for 8/29/20 failed to show that any progress notes were completed on this day. Review of a Skilled Nursing progress note, dated 8/30/20, indicated that R101 had difficulty keeping the left heel wound dressings on as well as the protective boots. No new interventions were initiated for this concern. Review of R101's EMR for 9/1/20 failed to show that any progress notes were completed on this day. Review of a General Progress Note, dated 9/2/20, found no mention of the condition of the left heel wound. Review of a General Progress Note, dated 9/3/20, indicated that R101 had difficulty keeping the left heel dressing on as well as keeping the protective boots on. No new interventions were initiated for this concern. The note indicated this was due to R101 rubbing both heels together. The progress note did not mention the condition of the wound. Review of a General Progress Notes dated 9/4/20, 9/5/20, and 9/6/20 time stamped 12:32 A.M., reflected no information about the condition of R101's left heel wound. Review of a physician progress notes [REDACTED]. Review of a General Progress Note dated 9/6/20 and time stamped 3:26 P.M., specified left heel, protruding bone observed. Review of a Care Plan for R101 revealed that no interventions regarding assessment, monitoring and treatment of [REDACTED]. Review of a CNA Kardex revealed no instructions for direct care staff to monitor, assess, or prevent further deterioration of R101's left heel wound. Review of a Radiology Report for R101, dated 9/6/20, showed no fracture or [DIAGNOSES REDACTED] of the left foot and listed the reason for exam as pain, redness, and swelling-rule out [DIAGNOSES REDACTED]. Review of an Order Summary Report for R101 showed an order on 9/6/20 for an arterial doppler to the left leg related to poor pedal pulses. The arterial doppler was not completed. Review of a Wound Care Note dated 9/9/20 revealed that the wound care specialist was consulted because R101 developed a wound on the left heel and it was not getting better. They have been applying border gauze, sock and foam boot. Wound care notations indicated that the measurements for the wound were 4.7 x 5.7 x 0.4, 75% slough-25% pink tissue with bone exposed in the center. There was a moderate amount of maceration around the wound and a moderate amount of serosangenous drainage seeping out of the border gauze onto the sock. Assessment- pressure ulcer of left heel stage 4. The wound care specialist had requested an arterial doppler. Review of a Care Plan for R101 revealed that no interventions regarding assessment, monitoring and treatment of [REDACTED]. Review of a CNA Kardex revealed no instructions for direct care staff to monitor, assess, or prevent further deterioration of R101's left heel wound following the 9/9/20 Wound Care Note. Review of an Order Summary Report for R101 showed an order on 9/11/20 for an arterial doppler to the left leg related to poor pedal pulses. The arterial doppler was not completed. Review of the EMR for R101 reflected no progress notes on 9/11/20 that documented the condition of the left heel wound. Review of an Order Summary Report for R101 showed a STAT order for an arterial doppler on 9/15/20 and was completed. Review of a Wound Care Note, dated 9/16/20, revealed that the wound care specialist requested that the facility make a referral to a vascular surgeon related to R101's left heel wound and arterial doppler findings. Review of a Wound Care Note, dated 9/23/20, indicated that nursing staff were unsure if the referral to a vascular surgeon had been made, as requested by the wound care specialist on 9/16/20. Review of a General Progress Note, dated 9/24/20, revealed that a referral to a vascular surgeon was made for R101 and was scheduled for 11/5/20. Review of R101's EMR reflected that there were no progress notes documented on both 9/27/20 and 9/28/20. Review of a Wound Care Note, dated 9/30/20, showed that the wound care specialist requested that the facility contact the vascular surgeon's office and see if the appointment for R101 on 11/5/20 could be moved up sooner since it is still five weeks away and the wound care specialist was concerned with the bone being exposed. Review of R101's Care Plans revealed that a care plan for the left heel wound was initiated on 9/30/20. Review of R101's EMR indicated that there were no progress notes documented on 10/1/20 and 10/3/20. Review of a Nursing Skilled Charting note, dated 10/5/20, reflected the section of the charting identified as SKIN INTEGRITY noted the following: no new changes to skin integrity noted. Review of an Emergency Department note, dated 10/6/20, noted: wound pressure injury, left foot, assessment, drainage amount: large, drainage description: serosangenous; foul, State of Healing: tunneling, wound description: full thickness, pressure injury stage: Stage 4. Review of an emergency room x-ray report of R101's left foot, dated 10/6/20, showed soft tissue deformity with air projecting adjacent to the calcaneal cortex which raises concern for [DIAGNOSES REDACTED]. Review of an emergency room Social Work Consult, dated 10/6/20, specified . Patient has been at ( a nursing home) .family not pleased with care. (Patient) has a left heel ulcer that has developed since at the facility,to the point they are now discussing surgery/amputation, and family was not aware of this until yesterday. Also feel patient's not well groomed or cared for there. Review of a Hospital Note, dated 10/12/20, revealed that R101 had been admitted to the hospital, was taken to surgery on 10/9/20 for a left heel debridement with wound vac placement, tissue cultures from surgery were [MEDICAL CONDITION] ([MEDICAL CONDITION]-resisitant staphylococcus aureus), a PICC (peripherally inserted central catheter) line was placed and IV (intravenous) Vancomyacin was being administered. During an interview on 10/28/20 at 11:40 A.M., Registered Nurse (RN) U indicated that weekly skin assessments were done on all residents, that the wound specialist or team would evaluate if any new concerns came up, and the physician and family were notified of any changes and kept up to date. RN U also reported that nurses can update care plans as needed to make sure they are meeting the needs of the residents.

Based on observation, interview and record review, the facility failed to follow a treat per physician's order and accurately assess a pressure ulcer for one resident (Resident #65) and failed to prevent a pressure ulcer for one resident (Resident #21) out of 5 residents reviewed for pressure ulcers, resulting in the potential for worsening of a pressure area (Resident #65) and the actual development of a pressure area (Resident #21). Findings include: Resident #21 According to a facility face sheet dated 9/15/19, Resident #21 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Review of a care plan for Resident #21 reflected, At risk for alteration in skin integrity related to history of non-healing pressure ulcers and diabetic [MEDICAL CONDITION]. Resident is still non-compliant with cares at times. Resident has declined and requires moderate/max staff assist with adls (activities of daily living), toileting and positioning. A progress note for Resident #21 reflected, 7/18/2019 at 21:31(9:31 PM) Default PN Type for eMAR (electronic medical record) Note Text: Cleanse open area to coccyx with NS. Cover with Blue super absorbent dressing Daily and PRN every evening shift for Open area No open skin, or red skin, or evidence of previous wound. Resolved. Another progress note for Resident #21 reflected, 8/25/2019 14:15 General Progress Note Text: Resident noted to have open area to sacrum. Area presents as a Stage II pressure ulcer. 1 cm long x .3 cm wide. Surrounding tissue is pink/blanchable. (Name of nurse practioner) notified of area. New order for [MEDICATION NAME] dressing. Call placed to (name of guardian). Message left to call this facility back for update. Resident #21 had a history of [REDACTED]. A 9/8/19 at 4:45 PM skin assessment for Resident #21 reflected, Right buttock excoriation. 0.3 x 0.2 x 0.1 cm. Skin assessment completed. Continue with current tx (treatment) for excoriation to right upper buttock. No new or suspicious alterations noted. Review of a 9/15/19 at 4:45 PM skin assessment for Resident #21 reflected, No new skin alterations noted this shift. On 9/16/19 at 3:05 PM during an observation with Unit Manager (UM) G of Resident #21, it was observed that the Resident #21 was in bed and had an air mattress that was on standby. When asked, UM G tried to reset the air mattress, and nothing happened. UM G pushed the power button and the mattress was activated. Resident #21 was rolled on her right side and a less than dime size area was observed with a yellow slough on it to right by the sacral dimple. When UM G was asked what type of wound this was she stated she would like someone else to come and observe the area. UM G stated the excoriated area was to the right of this area that she saw on Friday. On 9/16/19 at 3:18 PM during an observation of Resident #21's right sacral dimple area with the Director of Nursing (DON) and UM G, the DON stated this was a pressure area. The DON stated she wasn't sure if there was slough on the wound. The DON stated they would measure the wound now and have the Physician Assistant assess it tomorrow. On 9/17/19 at 9:01 AM during an interview with the DON, the facility audited all the APM mattress and nursing education was done that staff was to check the alternating pressure mattresses with each resident interaction. The mattress should be on or alternating and not on stand by. Review of a facility policy titled, Skin Monitoring and Management - Pressure Ulcer dated adopted 7/11/18 reflected, It is the policy of this facility that: a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing. Purpose: the purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services to: promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible; and prevent the development of additional, avoidable pressure ulcers. Resident #65 According to a facility face sheet dated 9/15/19, Resident #65 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. On 9/15/19 at 10:52 AM, Resident #65 was observed to be in bed and stated he goes to the wound clinic on 9/30/19 at 12:15 PM. Resident #65 was observed to have an air mattress control to the foot of his bed. Resident #65 stated has had wounds for a long time. Resident #65 stated he had a wound on his left rear. During an observation of wound care on 9/15/19 at 3:30 PM, Resident #65 was observed lying in bed slightly to his right, a pillow behind his back. A alternating pressure mattress control was observed on the foot of his bed. Certified Nurse's Aide (CNA) D left the room. CNA D came back into the room, grabbed gloves from the wall dispenser but was not observed to have washed his hands upon reentering the room. Resident #65's dressing removed by Licensed Practical Nurse (LPN) E. This was observed to be painful for Resident #65. The sacral/coccyx area was observed to be with what LPN [NAME] stated was Stage 2 (pressure ulcer) irregular wound (denuded area, difficult to draw), and a left ischium with deeply dressing packed approximately 1.5 inch around hole pressure area. An old area resembling the anus at the end of the coccyx was observed and was healed. Surrounding skin was red for both the sacral wound and the left ischium wound. LPN [NAME] cleansed her hands with gel after glove removal. LPN [NAME] donned gloves and wounds were cleansed with spray saline. LPN [NAME] applied H Chloride to ABD (large dressing) pad. Saline was applied to a 4 x 4 gauze dressing and packed into left ischium wound gently. LPN [NAME] then covered the ischial wound with H Chloride soaked ABD pad. LPN [NAME] stated the coccyx wound was cleansed with saline and put antifungal cream. LPN [NAME] was observed to have applied plastic tape to the dressing after CNA D had brought some back into the room. LPN [NAME] had dropped the [MEDICATION NAME] tape she had brought into the room and had asked CNA D to get some tape. CNA D again re applied his gloves, no hand hygiene was observed. No date was noted to new applied ABD dressing. LPN [NAME] then took off gloves and used hand gel. LPN [NAME] applied new gloves. LPN [NAME] used saline on a 4 x 4 gauze to cleanse coccyx wound. LPN [NAME] stated she messed this up and sent CNA D after a 4 x 4 (gauze). CNA D removed his gloves and left the room. CNA D came back in the with 4 x 4's gauze and reapplied his gloves, no hand hygiene observed. LPN [NAME] opened 4 x 4's gauze, covered wound on coccyx with 4 x 4 and held in place with plastic tape. Resident #65 rolled to his back and an adult brief was applied. LPN [NAME] was asked what type of tape she used. LPN [NAME] stated the tape she had brought dropped on the floor. LPN [NAME] stated she was not supposed to use the plastic tape. Resident #65 complained of discomfort through the procedure. Edges are rolling in on pressure area on ischium. According to the (MONTH) Treatment Record order for Resident #65 reflected, Dakins Solution 0.125 % Apply to Left Ishium topically every evening shift for Wound care Left ishium cleanse wound with Dakins Solution, pack wound with dakins moist gauze cover with abd (ABD dressing) and secure with fix tape 3PM (no date noted but documentation began on 9/3/19). During an interview on 9/15/19 at 3:58 PM during an interview with the Director of Nursing (DON) about the dressing change, the DON was asked if plastic tape and [MEDICATION NAME] tape can be used interchangeably. The DON stated the order say's fix. The DON revealed on wound was on his coccyx was a yeasty area. The DON was asked if H Chloride or Dakins was to be placed on the ABD dressing and be placed over ischium wound. The DON stated it was not. The DON revealed that if a CNA left the room and comes back in her expectations would be hand hygiene when returning to the room. [MEDICATION NAME] Dressing Retention Tape is a medical tape that can be used to securely hold wound dressings, catheters, ostomy appliances, [MEDICAL CONDITION] in place. This dressing tape is made from soft, non-woven, water-resistant fabric. It keeps the wound moist, and also promotes airflow to reduce maceration (skin maceration is a term used to describe the oversaturation of the skin due to a prolonged exposure to moisture) The material is [MEDICATION NAME], so it won't constrain joints and features a low-allergy adhesive . Permeable to moisture and air, reduces maceration (plastic tape holds in moisture) Soft, non-woven medical tape ideal for wound dressings [MEDICATION NAME] and easy to use around joints and awkward body areas A versatile medical tape to hold dressings, catheters, [MEDICAL CONDITION] securely in place. (https://www.exmed.net/p-2263-bsn-medical-[MEDICATION NAME]-dressing-retention-tape.aspx) Pour (Dakins) on or apply to affected area. For wound management, use as an irrigant, cleanser, or the wetting agent for a wet-to-moist dressing. Apply once daily for lightly to moderately exudative wounds. Apply twice daily for heavily exudative or highly contaminated wounds. Protect surrounding intact skin with a moisture barrier ointment or skin sealant as needed. (https://dakins.net/faq/) On 9/16/19 at 9:18 AM during an interview with the DON, she stated the pressure area dressing was redone last night. The DON stated the coccyx area does not look like pressure but moisture. The Physician's Assistant (PA) was called and a new treatment cream (drying) was started. LPN [NAME] had revealed that the coccyx/sacrum area was a stage 2 pressure area. According to a Nursing Assessment Screening/History tool, a Stage 2 pressure area was a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. According to a progress note dated 10/24/19 at 4:51 PM for Resident #65 reflected, Skin Resident (#65) was readmitted to the facility on [DATE] from (type of facility). He (Resident #65) was admitted .1.5 cm x (by) 0.7 cm x 0.2 cm unstageable as wound bed is 50 % (percent) eschar (dead material) to the left gluteal fold, 2.4 cm x 1 cm unstageable as wound bed is covered in slough, area surrounding coccyx wound is excoriated and measures 8.5 cm x 7 cm. The corresponding Nursing Assessment Screening/History dated 10/23/18 at 10:12 PM reflected, Sacrum, pressure, 1/2 length, 1/4 width, n/a (not applicable) depth, stage unstageable (in centimeters) Right gluteal fold, pressure, 1/4 length, 1/4 width, n/a depth, unstageable (in centimeters). Unstageable: full thickness tissue loss 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. Review of Resident #65 timeline and documentation review and interview with the DON on 9/17/19 at approximately 10:15 AM regarding Resident #65's pressure ulcer revealed: After Resident #65's hospitalization a skin progress note dated 10/24/18 at 4:51 PM the DON stated she was not able to decipher the wound note. She stated it appeared Resident #65 returned from the hospital with more wounds. The DON stated measurements from the admission assessment did not correspond to the wound note and the ischium pressure ulcer was listed as right and sacrum (which is the wound that he returned with and is now healed) but the ischium wound was on Resident #65's left. Accurate wound assessment is a critical component of effective wound management. A skilled nurse who can accurately assess a wound, plays a vital role in determining the appropriate management of a wound to promote healing and avoid secondary complications .Begin the assessment by documenting the anatomic location of the wound, using landmarks to define the position . (https://www.rn.com/nursing-news/secrets-of-accurate-wound-assessment/) According to a facility policy titled, Dressings, non-Sterile dated adopted 7/11/18 reflected, It is the policy of this facility to perform treatments and dressing changes per physician orders. PR[NAME]EDURE: Supplies: Bedside table Dressings and medication Prescribed cleaning solution Gloves Plastic bags Towels 1. Verify physician's order. 2. Gather supplies. 3. Explain procedure to resident. 4. Provide privacy. 5. Assist resident to required position and expose area to be dressed. Allow for as much comfort as possible and avoid unnecessary exposure. 6. Prepare a clean, dry work area at bedside, with all necessary supplies. 7. Wash hands, apply gloves. 8. Remove dressing and discard in plastic bag. 9. Remove gloves, wash hands, re-apply clean gloves 10. Clean wound as ordered. Cleanse wound from center to outer boarders (sic) using a circular motion (area of most contamination to area of least). Ensure you do not touch other skin surfaces, furniture, bedding etc., and return to wound bed as this will contaminate the wound bed. 11. Dispose of cleaning supplies in bag. 12. Remove gloves, wash hands, re-apply clean gloves/ 13. Assess wound. 14. Apply dressing as ordered. 15. Discard all waste material into plastic bag and tie off. 16. Remove gloves. 17. Assist resident to allowed position of comfort, ensure call light within reach. 18. Wash hands. 19. Return supplies and medication to appropriate areas. Discard plastic bag. 20. Document all appropriate information in medical record. Review of a facility policy titled, Skin Monitoring and Management - Pressure Ulcer dated adopted 7/11/18 reflected, .Procedure: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: [NAME] Complete an admission assessment/evaluation and skin risk assessment to identify risk and to identify any alterations in skin integrity noted at that time .E. Assessment of wounds on admission, readmission and discharge: A licensed nurse (which may be the Wound Nurse) must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, must be documented in the Admission Assessment. A licensed nurse (which may be the Wound Nurse) must assess/evaluate each wound that exists on the resident. this assessment/evaluation should include but not be limited to: measuring the wound, staging the wound, describing the natures of the wound (e.g. pressure, stasis, surgical wound), describing the location of the wound, describing characteristics of the wound .Monitoring: [NAME] daily via medication administration and treatment administration records .B. Weekly via weekly skin committee. Prepare and maintain Skin committee review notes and recommendations in the resident's clinical record. document and implement recommended additions or change to care plan in resident clinical record.

Based on observation, interview and record review, the facility failed to monitor an existing wound until healed and prevent the development of this area into a stage 3 pressure ulcer for one resident (Resident #3), out of 3 residents reviewed for pressure ulcers, resulting in a stage 3 pressure ulcer and pain. Findings include: According to a facility face sheet dated 9/11/18 at 5:37 PM, Resident #3 was a [AGE] year old male admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. During an interview with Resident #3, in his room while in his wheelchair on 09/10/18 at 10:56 AM, he confirmed he had a bed sore (pressure ulcer). He was unsure of where he got this but stated the nurses changed the dressing daily. He confirmed he had a roho cushion (pressure relieving cushion) on his wheelchair and he demonstrated how he redistributed his weight by shifting his weight in his wheelchair. Resident #3 stated he had an air mattress on his bed. He stated in the afternoons he tried to rest in bed to help heal the pressure ulcer. Resident #3 also stated that the area was painful. On 09/11/18 at 02:37 PM, Resident #3 was observed in bed on his back, with his right leg stump up on a pillow. On 09/11/18 at 02:31 PM, review of the electronic medical record and skin risk for break down score or Braden Score revealed: 8/31/2018 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Complete Other LOW RISK 15.0 8/24/2018 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Complete Admission LOW RISK 17. 9/7/2018 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Complete Admission LOW RISK 16.0 On 09/12/18 at 07:48 AM, Resident #3 was observed up in wheelchair in his room. Review of a timeline submitted by Unit Manage (UM) K on 9/12/18 for Resident #3's left buttock pressure ulcer reflected: 1/5/18 Left buttock noted with sheering after slide board transfer 1.7 cm (centimeters) by 1 cm. Depth is superficial granulation (healing) tissue . 1/10/18 L (Left) buttock sheering measures 1.5 cm by 1 cm. Depth is superficial, granulation tissue . 1/24/18 L buttock sheering measures 1 cm by 0.5 cm, depth is superficial, granulation tissue . 1/31/18 L buttock sheering 1 cm by 0.5 cm, depth is superficial, granulation tissue . 2/7/18 L buttock sheering 0.5 cm by 0.5 cm, depth is superficial, granulation tissue . 2/14/18 L buttock sheering 0.5 cm by 0.5 cm, depth is superficial, granulation tissue . 4/25/18 Left buttock unstagable 1.7 cm by 1.8 cm, depth is superficial slough covered . The sheering wound on the left buttock wound had now become a pressure ulcer. 5/1/18 hospitalization for LBKA (left [MEDICAL CONDITION]) 5/9/18 L buttock unstg (unstagable) slough covered R (right) medial buttock DTI (deep tissue injury) on admit now stage II (2) measure 0.9 cm by 0.7 cm. Resident #3 returned from the hospital with a worsening left buttock pressure ulcer and a new deep tissue injury. 5/16/18 L buttock 1.2 cm by 1 cm granulation tissue. R medial buttock 0.4 cm by 0.2 cm, depth is superficial, granulation tissue. 5/24/18 L buttock now presents as stage III (3) measures 1 cm by 0.2 cm, granulation tissue 5/25/18 hospitalization 5/28/18 Return to facility 5/31/18 L buttock 1 cm by 1 cm granulation tissue . 6/6/18 L buttock 1 cm by 0.8 cm, granulation tissue . The measurements and assessments continue until 9/5/18 with another hospitalization on [DATE] with the left buttock ulcer again slightly worsened. 9/5/18 L buttock 1.2 cm by 1 cm, depth is superficial . A pressure ulcer classified as Unstagable/Unclassified: Full thickness skin or tissue loss - depth unknown:. Full thickness tissue loss in which 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. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage 3 or 4. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) On 09/12/18 at 10:04 AM, during a review of progress notes in the electronic medical record for Resident #3 dated 8/8/2018 at 9:58 PM reflected, Skin Late Entry: Note Text: This is a 60 y/o (year old) long term care resident that was readmitted to facility on 05/28/2018 after hospitalization for pneumonia. Other dx (diagnosis) and history include; DMII (type 2 diabetes) with [MEDICAL CONDITION] (nerve pain) .[DIAGNOSES REDACTED] (low potassium level), generalized muscle weakness, hypertension, [MEDICAL CONDITION]. He had a LBKA (left [MEDICAL CONDITION]) in 11/17 and RBKA (right [MEDICAL CONDITION]) 5/1/18. Resident readmitted with a Stage III (3) pressure ulcer to his left buttock that now measures 0.9 cm (centimeters) x (by) 0.5 cm, superficial in depth. Wnd (wound) bed is granulation tissue with light slough (dead tissue) covered with scant amt (amount) of serous (clear fluid) drainage noted. Will continue with tx (treatment) orders to cleanse with ns (normal saline), apply iodosorb with [MEDICATION NAME] to wnd (wound) bed and cover with [MEDICATION NAME] (dressing), change daily and PRN (as needed). His Braden score puts him at moderate risk for skin breakdown related to slightly limited sensory perception, occasionally moist, chair fast, very limited mobility, excellent nutrition and a friction and shear problem. Wound is without signs or symptoms of infection. Current care planned interventions to promote healing and prevent further skin alterations include; administer treatment/diet/supplements as ordered, follow up with specialty and physician as needed, daily skin audit by licensed nurse, air mattress, equagel cushion to w/c (wheelchair), float bilateral stumps as resident will allow, and encourage to re-position with rounds and as needed. Wound healing is expected to be slow and further alterations in skin can be anticipated. A pressure ulcer Category/Stage 3: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of the head) and malleolus (ankle) do not have (fat or adipose) subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ On 09/12/18 at 01:21 PM, during a dressing change observation for Resident #3, Unit Manager (UM) K was observed to move items off of the over bed table. She proceeded to wash her hands in the bathroom, apply gloves and wash off the over bed table. A towel was placed as a barrier on the bedside table by UM K. Dressing supplies were removed from a plastic bag and placed on this barrier on the over bed table. A [MEDICATION NAME] dressing with the date 9/11/18 in marker was observed on Resident #3's left buttock in the lower ishium area (bone area where you sit) which was removed and a superficial wound less than dime size covered in slough was observed. UM K stated she is considering this wound to be unstagable. The tissue surrounding the wound was discolored. UM K proceed to cleanse and dress the wound. Resident #3 indicated pain in the area during the dressing change. On 09/12/18 at 01:58 PM, during an interview with the Director of Nursing (DON) and UM K, they revealed the Wound Team quit following Resident #3's left buttock wound area with wound rounds. The DON stated treatments were in place, this being a foam dressing on the left buttock wound. UM K stated the Wound Team followed pressure ulcers yet she indicated the initial left buttock wound for Resident #3 was not a pressure ulcer. No measurements were being done after the Wound Team quit following the wound on 2/14/18. On 4/25/18 an unstagable 1.7 cm by 1.8 cm with superficial depth wound was discovered. The DON stated the area may have developed because there had been a change of care givers, a change of room/hall for Resident #3. The left buttock wound had increased in size when it was discovered on 4/25/18 and was now considered a pressure ulcer UM K and the DON confirmed. The DON confirmed that assessments of the wound should have been done until the initial wound had healed and she confirmed there was no documentation to support that this had been done nor could she confirm that preventative measures had been done consistently to prevent the worsening of the left buttock pressure ulcer for Resident #3. Certified Nurses Aide skin assessment sheets or any other documentation about skin checks for Resident #3 and a policy regarding pressure ulcer care and prevention were requested from the DON at this time. Review of facility sheets submitted by the facility as requested titled, Skin Worksheet for Resident #3 reflected (assessments completed by Certified Nurses Aides (CNA's) and reviewed by nurses): 3/29/18 Normal was checked 4/12/18 Normal was checked 4/19/18 Normal was checked yet Abnormal areas on the body figure were circled indicating abnormal skin on the right leg front of the shin and two circles on the right buttock and left buttock with the written notation current txs (treatments) on. Re did patches (dressings). 4/22/18 Abnormal was checked. The body figure was circled at the top of the gluteal cleft, coccyx (above the buttock meeting). No other documentation from 2/14/18 to 3/29/18 regarding assessment of Resident #3's skin or wound was submitted by survey exit on 9/12/18 at 4:00 PM. On 4/19 and 4/22/18, abnormalities had been noted by the CNA staff on the skin worksheet but wasn't assessed and documented by nursing until 4/25/18 as a left buttock unstagable (pressure ulcer) 1.7 cm by 1.8 cm, with a depth that was superficial and slough covered. Review of a facility policy titled, Policy/Procedure - Infection Prevention and Control: Resident Care, Wound Care Prevention dated adopted 7/11/18 reflected, At least weekly documentation of the wound's description and progress toward healing shall be done. Review of a facility policy titled, Policy/Procedure - Infection Prevention and Control: Resident Care, Wound Care/Treatment Guidelines dated adopted 7/11/18 reflected, A weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description .The are plan should reflect the current status of the wound and appropriate goals.

This citation pertains to MI 939 Based on interview and record review, the facility failed to perform dressings and topical treatments for one resident (Resident # 1), out of 2 residents reviewed for treatments, from a total sample of 13 residents, resulting in missed treatments and ongoing skin infection and infection requiring intravenous antibiotics. Findings include: According to an Administration Record dated 9/1/16 to 9/30/16, Resident #1 was a [AGE] year old male readmitted into the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. During an interview on 4/13/17 at 4:00 p.m. with Director of Nursing (DON) B, DON B stated there's a lot of holes in the treatment records. for Resident #1. An interview was done with Unit Manager (UM) S on 4/14/17 at 12:00 p.m UM S was asked to do a timeline for wound care since 9/2016. UM S stated there were 3 to 4 days she could not support a dressing change as being completed. UM S stated she did do a skin teaching on October 6, 2016 because, things weren't as they should be. After education in October, UM S stated dressing changes were being done. Before it was a problem. UM S stated. UM S was asked what her expectation was as to documentation after a dressing change, if the treatment is completed, should the nurse initial the treatment record? UM S agreed that initialing a treatment record indicating the treatment was completed was an expectation of the nurse completing the treatment. During an interview on 4/13/17 at 4:00 p.m. with Director of Nursing (DON) B, DON B stated there's a lot of holes in the treatment records. for Resident #1. Review of facility documents for Resident #1, titled Administration Record dated 9/1 to 9/30/16 revealed: 1) Cleanse LLE (left lower extremity or leg) apply [MEDICATION NAME] AG (a type of dressing material), to open wounds and anterior and posterior to between toes. Cover with hydrofoam, an ABD pad (absorbent dressing), wrap with kling (gauze dressing to hold in place) and tubi grip (elastic tubular dressing to hold dressing into place). This is to be done once a day. This dressing was not initialed as been done on 9/14, 9/15, 9/20/16. 2) Cleanse RLE (Right lower extremity or leg) apply [MEDICATION NAME] AG (a type of dressing material), to open wounds and anterior and posterior to between toes. Cover with hydrofoam, an ABD pad (absorbent dressing), wrap with kling (gauze dressing to hold in place) and tubi grip (elastic cloth like tubular dressing to hold dressing into place). This is to be done once a day. This dressing was not initialed as been done on 9/14, 9/15, 9/20/16. 3) Zinc oxide (a barrier cream) to buttocks every shift until healed. No start date was noted. This medication was not initialed as given on 9/7, 9/16/ 9/19/16 on the 11:00 p.m. to 7:00 a.m. shift. This medication was not initialed as given on 9/5 through 9/9, was marked as ref on 9/9, 9/10/16 but no notation was made on the back of the administration record, was circled as not given on 9/11 but no noted was made on the back of the administration record, not initialed as given from 9/12 to 9/16/16 for the 7:00 a.m. to 3:00 p.m. shift. And was not initialed as being given on the 3:00 p.m. to 11:00 p.m. shift on 9/5 and 9/6, was circled and an r below it but not noted as a refused treatment on the back of the administration record, it was not marked as being given on 9/10 and 9/14/16. 4) [MEDICATION NAME] 100,000 Units/GM (gram) cream apply one application to groin topically once daily Diagnosis: [REDACTED]. This medication was circled as refused on 9/1, 9/9/16 through 9/19/16 and there are no notations of the back of the administration record as to why this was refused. Review of facility documents for Resident #1, titled Administration Record dated 10/1/16 to 10/31/16 reflected: 1) [MEDICATION NAME] (an antibiotic) 0.1 % cream apply topically to left leg twice daily. There were no initials indicating the treatments were complete on 7:00 a.m. to 3:00 p.m. shift on 10/4, 10/9, 10/17 10/19, 10/22 and 10/26 through 10/31/16. There were no initials indicating the treatment was complete for the 3:00 p.m. to 11:00 p.m. shift for 10/4, 10/8, 10/9, 10/11 through 10/13, 10/15, 10/16 ,10/18, 10/22, 10/26 and 10/27/16. There were no notations regarding missed treatments on the back of this administration record. 2) [MEDICATION NAME] cream (a moisture cream) apply topically to bilateral lower extremity dry areas twice daily. No initials indicating the treatment was complete for the 7:00 a.m. to 3:00 p.m. shift was noted on 10/5, 10/8, 10/17, 10/19, 10/22 and 10/26 through 10/31/16. There was no initials indicating the treatment had been done for the 3:00 p.m. to 11:00 p.m. shift for 10/2, through 10/5, 10/8 and 10/9, 10/11 through 10/13, 10/15, 1/16, 10/22 10/26 and 10/27/16. There were no notations regarding missed treatments on the back of this administration record. 3) [MEDICATION NAME] 100,000 units/gm cream, apply topically to groin daily until resolved. No initials indicating this treatments was completed on 10/9, 10/17 through 10/19. There were no notations regarding missed treatments on the back of the administration record. 4) Cleanse bilateral lower extremity wounds with diluted chlorahexadine, apply [MEDICATION NAME] AG, wrap between toes, left heel and leg wounds with drawtex over 4 x 4 (gauze), kerlix and coban (to cover and keep in place) every day and twice a day if wet. No start date was noted. The notations that a dressing change was done began 10/10/16. Initials indicating the treatment was complete was no noted on 10/17, 10/19, 10/22, 10/26 and 27, and 10/29 through 10/31/16. There were not notations on the back of the Administration records regarding these dates. 5) May be up for meals only then bed rest with legs elevated above heart. Initials that this has been followed for 7:00 a.m. to 3:00 p.m. are missing for shift on 10/6, 10/7 10/9, 10/17, 10/19, 10/22, and 10/26 through 10/31/16. Initials that this has been followed for 3:00 p.m. to 11:00 p.m. shift are missing for 10/8, 10/11 through 10/13, 10/15, 10/16, 10/26 and 10/27. Initials that this has been followed for 11:00 p.m. to 7 a.m. are missing for 10/1, 10/2, 10/6 through 10/28/17. There are no notations on the back of the administration record when this order was not noted as being followed. Review of facility documents for Resident #1, titled Administration Record dated 11/1 to 11/30/16 revealed: 1) Cleanse bilateral lower extremity wounds with diluted chlorahexadine, apply [MEDICATION NAME] AG, wrap between toes, left heel and leg wounds with drawtex over 4 x 4 (gauze), kerlix and coban (to cover and keep in place) every day and twice a day if wet. No start date was noted. No initials indicating the treatment was completed noted on 11/4, 11/7, 11/16, 11/28 and 11/29/16. 11/23/16 date was noted to be circled indicating the treatment was not done but no notation was noted on the back of the administration record as to why all these treatments had not been completed. 2) [MEDICATION NAME] 100,00 units/gm cream topically to groin twice a day and re eval in 14 days on 11/11/16. there were no initials as the treatment had been completed on 11/5, 11/6, 11/9 to 11/11/16. There were no notations on the back of the administration record as to why the treatments had not been completed. 3) [MEDICATION NAME] (an antibiotic) 0.1 % cream apply topically to left leg twice daily. There were no initials indicating the treatments were complete on 7:00 a.m. to 3:00 p.m. shift on 11/2 through 11/10, 11/14, 11/15 and 11/21/16. There were no initials indicating the treatments were complete on 7:00 a.m. to 3:00 p.m. shift on 11/5, 11/6, 11/9 through 11/12, 11/15, 11/19 and 11/20/16. There were no notations on the back of the administration record as to why these administrations were not complete for either shift. This treatment was discontinued on 11/24/16. 4) May be up for meals only then bed rest with legs elevated above heart. Initials that this has been followed for 7:00 a.m. to 3:00 p.m. are missing for shift on 11/4 through 11/10, 11/16, 11/23 and 11/29/16. There were no initials that this treatment was followed for the 3:00 p.m. to 11:00 p.m. shift on 11/5, 11/6, 11/9 through 11/12, 11/15, 11/19 and 11/20, 11/28 and 11/29/16. There are no initials or the box is initialed and circled as not completed or refused treatment on the 11:00 p.m. to 7:00 a.m. shift from 11/1 through 11/18/16. There are no notations on the back of the treatment record why the order had not been followed. The Unit Manager (UM) S stated that Staff Development had been done from early October 2016 to early November 2016 regarding skin management to licensed nurses and Certified Nurses Aides (CNA) staff. This development had been completed and teaching materials were in regards to assessment and prevention of pressure ulcers. Follow up documentation dated 3/20/17, no time noted for Resident #1 from the Wound Clinic reflected, Assessment: Bilateral leg venous stasis ulcers, left leg with infection Stasis ulcer, open wound of foot, left heel, [MEDICAL CONDITION], bilateral lower legs. This report also reflected, Patient resident in (name of long term care facility). Spends most of the day up in wheelchair. Patient (Pt.) getting dressing changes daily. Denies pain/itching. No new issues. 11/22/16 Pt. states that is better. They (facility) continue to do daily dressing changes. No pain/itching. 12/3/17 Pt. states it is getting much better. They are doing dressing changes correctly . 1/10/17 Pt. is on [MEDICATION NAME] and [MEDICATION NAME] (two antibiotics) started on 1/5 for left great toe wound. no pain/itching. He had pain and redness and he states that he was concerned and they (facility) did the culture. He says it is better. 2/14/17 Pt states they (facility) have not been washing it (wounds) as much and it got infected. they cultured the wound last week and grew Pseudomonas and citrobacter (2 bacteria). He stared on [MEDICATION NAME] (an intravenous antibiotic) for 6 weeks and has a PICC (peripherally inserted central catheter. An IV that is inserted in the arm and the tip is threaded into the top of the heart and infusions can be given through this). They also started him [MEDICATION NAME](an antibiotic) but the culture that they sent states that it (the bacterial infection) is resistant (the antibiotic won't kill the bacteria cultured) to it. No new pain/itching. 2/28/17 Pt said he is doing better. He is still on [MEDICATION NAME] through the PICC line. Done with Cipro. No new issues/pain. They do not have [MEDICATION NAME] AG so (name of facility) is asking what to use instead. No pain/itching. In a telephone interview with Resident #1 on 4/13/17 at 2:14 p.m., Resident #1 was asked about his wound care. He stated the facility staff were not washing his feet and not performing dressing changes to his legs every day. A facility policy titled, Dressing change: Non Sterile (Clean) dated revised 4/2016 reflected, Suggested documentation: Condition of wound site and surrounding area, completion of dressing change and tolerance to procedure, unusual observations and or complaints and subsequent interventions including communications with physician. The record is a means by which health care team members communicate (resident) needs, and progress, individual therapies .The record should be the most current and accurate source of information about a (resident)'s health care status. (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby). After administering a medication (or completing a treatment), the nurse records it immediately on the appropriate record form. Recording immediately after administration prevents errors. (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). If there is a missed dose (missed treatment) for any reason the nurse is require(d) to circle (her initials on) the prescribed administration time on the medication administration record and explain the reason for the missed dose on the back side of the MAR. (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete.

This citation pertains to MI 208 and MI 750 Based on interview and record review, the facility failed to prevent a significant medication error for 1 (Resident #3) of 3 reviewed for medication errors, from a total sample of 4, resulting in an acute episode of [DIAGNOSES REDACTED] (low blood sugar) and transfer to the emergency department after Resident #3 received another resident's insulin. Findings include: Review of the facility's Medication and Treatment Administration Guidelines updated 12/2014, revealed .Medications are administered in accordance with the following rights of medication administration - right patient - right medication - right dose - right route - right time (including duration of therapy) - right documentation - right of patient to refuse - right clinical indication Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3 did not have a [DIAGNOSES REDACTED].#3 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The MDS revealed Resident #3 did not receive insulin injections. Review of the Skilled Nursing Note dated 9/10/16 at 7:30 pm, revealed When I arrived on floor nurse informed me that patient was unresponsive and sweaty. bs (blood sugar) of reading of 41. We then gave her oral instant glucogen rechecked her bs at 3:15 and it was 82 rechecked at 3:30 with bs of 117. Rechecked at 4:30 and it was back down to 68 given glucogen im (intramuscular) and rechecked at 5 up to 112. On call dr (doctor) was notified and want IV d5 (intravenous sugar solution) started but family stated they wanted her sent to er. 911 called and emt arrived at 5:50 pm bs at that time for them read 102 . Review of the Incident Report-Patient Involved dated 9/10/16, revealed that on 9/10/16 at 12:00 pm, Resident #3 received 18 units of Humalog (short acting insulin). The Incident Report revealed Resident #3's family was notified at 3:30 pm and the physician was notified at 4:30 pm. The Incident Report revealed Resident #3 was transferred to the hospital at 6:00 pm. Review of the Acute Care Transfer form dated 9/10/16, revealed Resident was mistakenly given insulin at lunch time, family wishes to send to ER (emergency room ) for evaluation. Review of the ED (Emergency Department) Physician Note dated 9/10/16, revealed a patient at the nursing home apparently was given some subcutaneous insulin accidentally . The note revealed Resident #3 was transferred back to the facility on [DATE]. In a telephone interview on 12/15/16 at 11:36 am, Licensed Practical Nurse (LPN) C reported on 9/10/16 she received in report from Registered Nurse/Unit Manager (RN/UM) D that Resident #3 was acting weird and clammy. LPN C reported that RN/UM D checked Resident #3's blood sugar and it was low. At that time, LPN C mentioned to RN/UM D that she was surprised that RN/UM D checked Resident #3's blood sugar level since Resident #3 was not diabetic. LPN C reported that is the point where the medication error was identified. LPN C reported Resident #3 was administered glucogen gel (used to treat low blood sugar). LPN C reported Resident #3's blood sugar level bottomed out again and she had to give intramuscular glucogon. LPN C reported Resident #3 was transferred to the emergency department. In a telephone interview on 12/15/16 at 3:43 pm, RN/UM D reported on 9/10/16, she was working on the side of the building where she did not know the residents well. RN/UM D reported she was preparing insulin for another resident when Resident #3's daughter approached her and began asking questions about Resident #3. RN/UM D reported she then walked into Resident #3's room and gave Resident #3 insulin. RN/UM D stated I was distracted. RN/UM D reported she was not aware of the medication error at that time. RN/UM D reported Resident #3 then ate lunch and went to bingo, at which time an aide brought Resident #3 back to the unit and reported Resident #3 was lethargic. RN/UM D reported Resident #3 was also diaphoretic (sweating heavily) at that time. RN/UM D reported LPN C was coming in for her shift and was more familiar with Resident #3 so RN/UM D asked LPN C to go to Resident #3's room with her. After RN/UM D checked Resident #3's blood sugar and left the room, LPN C told RN/UM D good job for checking Resident #3's blood sugar because she was not diabetic. RN/UM D reported that was when she realized a medication error (insulin) occurred. RN/UM D reported the resident who was ordered to receive the insulin at 12:00 on 9/10/16 did not receive her insulin. RN/UM D was unable to recall the resident's name. Review of the One-On-One Inservice Record dated 9/11/16, revealed Ensure 1. Right med (medication), 2. Right dose, 3. Right time, 4. Right route, 5. Right patient. If interrupted or distracted during a med pass, ensure that you have the correct patient by validating with the MAR (Medication Administration Record) prior to administering medication. Review of the Medication Management Skills Evaluation (Licensed Nurse), revealed RN/UM D was evaluated for the 6 rights of medication administration-patient, medication, dose, time, route, documentation on 4/7/16. ( )

This citation pertains to intake # MI 625, #MI 634, MI 364, MI 607. This citation has two deficient practice statements, A and B. A. Based on observation, interview and record review the facility failed to prevent avoidable falls in 4 of 7 residents (Residents #2, 4, 5 and 6) reviewed for falls, in a total sample of 8 residents resulting in Resident #2 falling and sustained a hip fracture, Resident #4 rolling out of bed and sustained lacerations to her head and elbow, Resident #5 sustained an injury on unknown origin (fractured leg) and had multiple falls and Resident #6 sustained a T6 compression fracture from a fall. All three residents #2, 4, and 6 were harmed from a preventable fall. Findings include: Resident #2 Review of Resident #2's face sheet revealed Resident #2 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #2's Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 required extensive assistance of 2 people for transfers. Review of Resident #2's care plan for Activities of Daily Living dated revision on 5/06/15 revealed Resident #2 used a sit to stand lift with a yellow sling for transfers. Review of the Care giver Kardex for Resident #2, no date, revealed, Resident #2 used a sit to stand lift with a yellow sling for transfers. Review of Resident #2's progress note dated 9/16/15 at 2:29 AM documented, Resident was being transferred by CNA (Certified Nurses Aide) to use the bathroom at 1:10 AM., when she began to sliding down, CNA assisted resident to the floor. Resident complained of right hip and leg pain. Xray ordered per on call physician. Vital sign WNL (with in normal limits). PRN (as needed) Narco (narcotic pain medication) administered as ordered for pain of 10, effective results, signed by Licensed Practical Nurse H. Review of an Investigation Report for Resident #2 dated 9/16/15 revealed Resident #2 slid off her bed when a Certified Nurses Aide positioned Resident #2 on the side of her bed. Resident #2's x-ray revealed she had a possible right hip fracture and Resident #2 was sent to the emergency room for treatment. Review of a Statement for Resident #2 dated 9/16/15 revealed CNA G was interviewed by Director of Nursing (DON) B on 9/16/15. CNA G said she was putting the sit to stand sling on Resident #2 prior to calling for help and suddenly Resident #2 went forward while on the edge of the bed and slid off the bed. Resident #2 landed on her right hip on top of the sit to stand sling. During and interview with CNA G on 10/7/15 at 10:30 PM this Surveyor observed CNA G demonstrate how CNA G independently sat Resident # 2 on the edge of her bed on 9/16/15. CNA G said she was attempting to put the sling around Resident #2's back while Resident #2 was sitting on the edge of the bed. CNA G said Resident #2 liked her bed up high and it was not clear if Resident #2's feet where able to reach the floor when she was sitting on the edge of the bed. CNA G said Resident #2 suddenly flung forward and CNA G grabbed Resident #2 by her hospital gown but was not able to stop Resident #2 from sliding to the floor and landing on her right hip. CNA G said Resident #2 was screaming about her right hip. CNA G said LPN H came in to assess Resident #2 and LPN H said they could put Resident #2 back to bed. CNA G said she and another CNA used the full body lift and put Resident #2 back to bed. CNA G said she did not have a second person in the room to assist when she sat Resident #2 on the edge of the bed and the facility gave her a written counseling and education on lift transfers because she did not have anyone assist her with resident #2's transfer. During an interview with LPN H on 10-7-15, LPN H said she was working on 9/16/15 and around 1:00 AM, CNAG told her Resident #2 slid out of bed. LPN H said Resident #2 said her pain was 1000 all over. LPN H told the CNAs to get vital signs. LPN H said she assessed Resident #2 in a semi sitting position on the floor and then instructed the CNAs to put Resident #2 back in bed. LPN H said another resident fell at about the same time. LPN H said when she went back to give Resident #2 pain medication Resident #2 was sleeping, but woke her up to give her a pain pill. LPN H said she worked until 6:00 AM and Resident #2 slept the rest of the shift. LPN H was requested to locate the physical assessment she did on 9/16/15 for Resident #2 and H was not able to locate any physical assessment documentation. LPN H was asked if she knew why Resident #2 was sent to the hospital at 8:25 AM on 9/16/15. LPN H said the on coming (day shift) nurse said, Resident #2 later woke up in pain and Resident #2's leg was not straight. Documentation of this was not located in the progress notes. Review of a typed time line for Resident #2 provided by the DON B on 10/8/15 documented, Resident slid off edge of bed on 9/16/15 at 1 AM. CNA G, was present at the time of her fall. CNA G reported the fall to LPN H immediately. LPN H went to resident's room to assess the resident for injury. After assessing resident, she was returned to bed using name of full body lift and was medicated for pain. On call physician was notified of fall and order for, stat Xray of right femur and 2 view of right hip obtained at 1:30 AM. Spoke with name of mobile Xray staff and per their records, a stat Xray for Resident #2 ws called at 1:30 AM but that it was taken at 6:50 AM. Resident had fallen asleep after being placed in bed. Did complain of some discomfort with repositioning, but would quickly fall back asleep. Resident remained in bed after the fall. No leg displacement was noted by staff. The Xray tech who took the Xray alerted the staff to probable fracture and she was transferred to the hospital for evaluation at 7:53 AM. Staff education was started immediately. It was reviewed that all use of all mechanical lifts require 2 assists and that if the resident is using a sit to stand lift, the 2nd person should be in the room prior to sitting the resident up on the edge of the bed to provide trunk support if needed . (# ) Resident #4 Review of Resident #4's face sheet (undated) revealed Resident #4 was a [AGE] year old female admitted to the facility on [DATE] had had the following Diagnoses: [REDACTED]. Review of Resident #4's Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 required extensive assistance of 2 people for bed mobility. Review of an incident report for Resident #4 dated 9/14/15 at 3:00 PM documented, Resident was on her side while CNA was providing peri care. Resident rolled off the opposite side of her bed, landing face down. Stabilized resident, cleaned and put pressure to laceration to right temple and right elbow skin tears, neuro assessment. Patient was taken to a hospital on [DATE] at 3:30 PM. Review of a progress note for Resident #4 dated 9/15/15 at 00:07 (12:07 AM) documented, Resident had been toileted on the bed pan. CNA had rolled PT (patient) on her side to provide peri care, and PT (patient) rolled off the opposite side of he bed landing face down. Laceration to right temple had 3 sutures upon returning from the hospital. Resident also had a laceration to her right outer elbow, which was glued in the ER (emergency room ) and a Tegaderm (dressing) covering it once her return for ER. CT performed (of the head) in ER with negative results. Xray of right arm from shoulder to wrist performed, negative for fracture. Residents pain controlled with Narco as ordered. Resident alert and oriented . Review of Resident #4's care giver Kardex, date printed 9/23/15, revealed Resident #4 was a 2 person assist for bed mobility. Review of Resident #4's care plan for falls dated revision 9/23/15 revealed Resident #4 was a 2 person assist for bed mobility. Review of an Employee Warning Notice for CNA M dated 9/15/15 documented under counseling received by the employee, Provided CNA M with bed positioning policy and reviewed with her that when positioning a resident in bed, they are to be rolled toward her. Never roll a resident away form you unless you have another staff member on that side of the resident to assist and prevent falls. During a telephone interview with CNA M on 10/8/15 at 10:30 AM. CNA M said she rolled Resident #4 in bed to clean her up after Resident #4 had a bowel movement on the bed pan. CNA M said she rolled Resident #4 away from her so she would not get soiled when she cleaned Resident #4. When CNA M bent down to put the bed pan on the floor, Resident #4 rolled off the bed. CNA M said she received discipline and education because she rolled Resident #4 away from her in bed. (# ) Resident #6 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #6 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #6 had severe cognitive impairment and required staff assistance for all activities of daily living. During an interview and record review of incident reports and falls care plan on 10/8/15 at approximately 2:50 PM, the DON B stated that Resident #6 sustained a fall on 9/6/15 when she attempted to self-transfer from one chair to another. When asked what intervention was put into place to prevent reoccurrence, the DON B stated, Increase monitoring and supervision. When asked if that intervention was placed on the falls care plan, the DON reviewed the care plan and stated, It doesn't look like it. The DON B stated that Resident #6 had another fall on 9/25/15 at approximately 8:00 PM when Resident #6 attempted to self-transfer from the bed, fell and sustained a compression fracture to the spine (T6). The root cause was identified as attempting to self-transfer. The DON B stated that CNA O did not follow the care plan to ensure that Resident #6 had grip socks on during hours of sleep when she assisted Resident #6 to bed that evening and subsequently received an Employee Warning Notice. Resident #5 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #5 had moderate cognitive impairment and required staff assistance for all activities of daily living. During an interview and record review of incident reports and falls care plan on 10/8/15 at approximately 3:30 PM, the DON B stated that Resident #5 was an assist of 2 staff members with a mechanical lift for all transfers and due to the healing left hip fracture, was also non weight bearing. The DON B counted a total of 7 falls during an approximate 12 week period (6/21/15 - 9/18/15). The DON B stated that Resident #5 sustained a fall on 6/21/15 and 7/1/15, then on 7/16/15 upon return from a routine orthopedic appointment (to check the healing of the left hip fracture), an Xray confirmed a new left femur (upper leg) fracture. On 8/17/15 at 5:20 AM Resident #5 was observed asleep on the floor. The DON B stated, We assumed that he rolled out of bed. When asked what intervention was put into place to prevent re-occurrence, the DON B reviewed the incident report and the care plan then stated, I don't know, it's not on here. On 8/30/15 at 5:15 AM, Resident #5 was observed sliding out of bed and landed on his bottom. The DON B stated that the root cause was identified as attempting to get up without staff assistance so the facility implemented a scoop mattress which was placed on the care plan on 9/2/15 (approximately 2 weeks after the initial fall from bed on 8/17/15). (# ) B) Based on observation, interview and record review the facility failed to ensure safe transfer with wheelchairs and mechanical lifts in 2 of 3 residents (Residents #8 and 7) reviewed for safe transfers in a total sample of 8 residents resulting in the potential for injury when Resident #8 was pushed in a wheelchair without foot rests and Resident #7 was prepared for a mechanical lift transfer by one staff member (care plan indicates assist of 2) and that staff member was not medically cleared for duty (due to lifting restrictions). Findings include: Resident #8 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #8 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #8 was cognitively intact and required staff assistance for all activities of daily living. During an observation on 10/7/15 at approximately 4:50 PM, CNA J was observed pushing Resident #8 in a wheelchair (walking directly behind Resident #8) from room #212 to room #205 while Resident #8's shoes skimmed the floor as he was pushed in the wheelchair. After a few moments CNA J then pushed Resident #8 from room 205 to room 213 and again Resident #8's shoes skimmed the floor as he was pushed in the wheelchair. Resident #8's wheelchair did not have foot rest peddles on the wheelchair to allow for safe transport. In an interview on 10/8/15 at approximately 1:10 PM, the DON B stated that the staff were trained not to push residents in wheelchairs without foot rests. (# ) Resident #7 Review of Resident #7's face sheet dated 10/8/15, revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. On 10/7/15 at 11:11 AM CNA C was observed in Resident #7's room. Resident #7 was in a wheel chair and CNA D was bringing the sit to stand lift (mechanical lift) into the room. CNA C asked Resident #7 to lean forward in her wheel chair and CNA C put the sit to stand sling on Resident #7. When CNA E entered the room CNA C said she was light duty and could not help then left the room. CNA D and CNA E used the sit to stand lift to take Resident #7 to the bathroom. During an interview with CNA C on 10/7/15 at 1:20 PM she was asked what her work restrictions were. CNA C said she was not to lift more than 10 to 20 pounds. CNA C said she was not provided a list of job duties she was able to do. This Surveyor asked CNA C if she could have stopped Resident #7 from falling if she had slid forward in her wheel chair when applying the lift sling. CNA C said, No since that would be over her lift restrictions; she added that she would have to check what her job duty limits were. During an interview with Human Resource Director (HR) F on 10/7/15, (HR) F was asked the type of work restrictions for CNA C. (HR) F reviewed the work file and said CNA C was not to lift more than 10 to 20 pounds. (HR) F was asked if CNA C was provided a list of specific job duties she could preform. (HR) F said there was no list CNA C could do but was expected to do things like pass water. (HR) F was asked if CNA C should be assisting Residents with slings for transfer lifts and F said, No and that CNA C should not be helping at all with any Resident transfers. (# )

This citation pertains to intake number MI 020. Based on observation, interview and record review the facility failed to ensure that residents are free of significant medication errors in 2 (Residents #101 & #102) of 5 sampled residents reviewed for medication errors, from a total sample of 5 residents, resulting in Residents #101 & #102 being sent to the hospital for evaluation and treatment due to facility nurses administering medications to the wrong patient. Findings include: The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. To identify a client correctly, the nurse checks the medication administration form against the client's identification bracelet. When asking the client's name, the nurse should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her name. (Fundamentals of Nursing, 6th edition, 2005, pgs. 841-842.) Review of the facility policy "Medication Management Guidelines: "Six Right's" Plus One (1) of Medication Administration" dated 8/11/06 revealed under the "Right Patient" included that facility staffs are to: "Confirm the identity of each individual patient, Be sure every patient has an identification band, Maintain a current photo of each patient in the Medication Administration Record [REDACTED]." A medication pass observation was conducted on 7/10/14 from 9:45 - 10:40 a.m. During the medication pass it was noted by this surveyor that some residents did not have an identification bands present. It was also noted that the nurses observed during the medication pass observation did not look at or for resident identification bands to ensure the correct resident was receiving the correct medications. Resident #101 Review of a facility "Progress Notes" dated 6/26/14 indicated Resident #101 was an [AGE] year old woman originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to an "Incident Report" dated 6/25/14 at 8:00 p.m., Resident #101 ingested the wrong medication causing blood pressure to drop after a nurse was called away and put medications down resulting in incorrect resident ingesting them. Review of a facility "Investigation Report" dated 6/30/14, indicated Resident #101 had inadvertently taken another patient's medication ...(Resident #101) had ingested [MEDICATION NAME] 8 mg (a medication used to treat high blood pressure), [MEDICATION NAME] 0.2 mg (A centrally acting alpha-agonist hypotensive agents. It works by decreasing your heart rate and relaxing the blood vessels so that blood can flow more easily through the body), and [MEDICATION NAME] sulfate (iron). Review of the "Skilled Nursing Progress Notes" dated 6/25/14 at 6:36 p.m. indicated "(Resident #101) BP (blood pressure) recorded as 79/60 at 3:34 p.m. (Resident #101) asymptomatic. Recheck done due to possible machine/cuff malfunction the first time. Recheck reported to nurse at 4:20 p.m. as 112/73 and recorded in the MAR." Review of a "Skilled Nursing Progress Notes" dated 6/25/14 at 8:10 p.m. indicated "Nurse notified by nurse aide that resident self-administered medication belonging to (another resident) ..." Review of a "Skilled Nursing Progress Notes" dated 6/25/14 at 8:50 p.m., indicated RN "J" was given orders by a Physician Assistant at 8:20 p.m. to send Resident #101 to the hospital for monitoring. Resident #101 was alert and oriented and in no distress, however BP was reading low at 76/48, pulse 76. Review of an "Emergency Department Physician Note" dated 6/25/14 revealed Resident #101 was admitted to the hospital for treatment of [REDACTED]. The course of treatment in the Emergency Department reflected "(Resident #101) has a history of [MEDICAL CONDITION], so at this point she was responsive and I kept giving her 250 cc boluses as her blood pressure would go down, but despite this her blood pressure continued to go down. I (the ED physician) am not willing to continue down this course of fluid resuscitation when this is clearly an alfa mediated response (response of Resident #101's body due to medications given in error) and given her history of [MEDICAL CONDITION], I could make things worse. I did discuss the case with toxicology at Poison Control. Their initial response was to fluid resuscitate, but due to the aforementioned reasons, I felt she was adequately fluid resuscitated and I have looked for other interventions. At this time, the recommendation is for [MEDICATION NAME] (a vasopressor used to treat unstable patients with [MEDICAL CONDITION] in critical care) with the feeling that [MEDICATION NAME] could cause increased oxygen to remain on the heart, so at this time [MEDICATION NAME] was started and the patient's (#101) blood pressure was titrated. At this point, we did discuss the case with Specialists in Hospitalist Medicine for further evaluation and treatment." Review of a hospital "History and Physical" dated 6/25/14, indicated the plan for Resident #101 was to "admit her to critical care for treatment with [MEDICATION NAME] to counteract the alpha blockade of [MEDICATION NAME] and central alpha agonism with peripheral vasodilation by [MEDICATION NAME] and maintain until these medications wear off, which the [MEDICATION NAME] half-life is 22 hours and [MEDICATION NAME] half-life is 6-12 hours, so may require out to 3 half-lives of the medications or up to 66 hours. Hydrate the patient for her blood pressure as well as her pre-renal azotemia (a type of kidney failure). Observe for any medical issues that may arise." During an interview on 7/10/14 at 2:45 p.m., Registered Nurse (RN) "J" confirmed that she was the nurse responsible for the medication error involving Resident #101 on 6/25/14 at 8:00 p.m. RN "J" explained that she had prepared medications intended for a different resident when she was asked to complete a treatment on Resident #101 who was in the bathroom. RN "J" she said she stopped her medication pass to the other resident in order to tend to Resident #101. RN "J" stated she realized she still had the medicine prepared for a different resident in her hand as she made her way into the bathroom to care for Resident #101 and set the medications down on Resident #101's bedside table in haste. RN "J" reported that after she completed the treatment for [REDACTED]. RN "J" went to check on the resident who was calling out, leaving the medications intended for a different resident on the bedside table in Resident #101's room. RN "J" put her treatment supplies away and was then told by a nursing assistant that Resident #101 had just taken the medication intended for another resident. Resident #102 Resident #102 was a [AGE] year old woman originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE], indicated Resident #102 had memory problems and required extensive assistance for bed mobility, transfers, dressing and toilet use, was occasionally incontinent of bladder and frequently incontinent of bowel. . Review of "Progress Notes" dated 6/2/14 at 7:30 p.m., documented by Licensed Practical Nurse (LPN) "M" indicated Resident #102 was in her room eating a snack and identified herself as (Resident #102's roommate) and LPN "M" gave Resident #102 pills intended for her roommate. LPN "M" notified the physician and wrote "will monitor". A "Progress Note" dated 6/3/14 at 3:00 a.m. documented by LPN "M" indicated "This writer called to (Resident #102's room). (Resident #102) was on floor in a puddle of urine. (Resident #102) did not have socks or slippers on. (Resident #102) stated she fell when asked. Full range of motion normal for resident. (Resident #102) did some (sic) jerking movements hitting head on wall. Transferred to bed with lift, head stabilized by writer." Review of an "Ambulance/Emergency Medical Services Transport Sheet" dated 6/3/14 indicated Resident #102 was being brought to the emergency room for "evaluation of an altered level of consciousness (LOC) s/p (status [REDACTED]. Normally takes self to bathroom, found this morning lying on the floor in the bathroom in front of the toilet, and bathroom floor was wet. She is not at her usual baseline of alert and oriented to self and place. Patient states she fell . Initially when found was unable to state her name, but can now. Does not follow commands. No grips to commands. Having episodes of jerking--further described as large muscle twitching by nursing, "Like an exaggerated startle reflex" and is awake during episodes. Patient was being monitored closely tonight due to receiving wrong meds at 7:00 p.m. last evening. Meds given were [MEDICATION NAME] 50 mcg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 30 mg, and [MEDICATION NAME] XR 14 mg. Message left with family of transport to ER (emergency room ). According to a hospital "ED (Emergency Department) Physician note dated 6/03/2014, "(Resident #102) was given the wrong medications at the nursing home tonight, was given [MEDICATION NAME] (an anticonvulsant), [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (a [MEDICAL CONDITION] hormone) and [MEDICATION NAME] (used to treat symptoms of [MEDICAL CONDITION]). She then did get up to go to the bathroom and did fall striking her head, then she was found against the wall in the restroom. The patient denies any pain. Originally only alert to first name. However is able to answer every question appropriately, and does remember all of the events...she just stated that she felt weak and that is why she fell down." allergies [REDACTED].#102 was given in error). The "Treatment and Plan" documented in the physician's note indicated "At this time, with the medications she received, I do feel that she is likely going to be a little bit lethargic for the next few hours..." During a telephone interview on 7/11/14 at 6:00 p.m., Licensed Practical Nurse (LPN) "M" stated she was an agency nurse, contracted to work at the facility through an outside agency to work open shifts at the facility. LPN "M" stated she had been a nurse for [AGE] years. On 6/2/14, the night the medications were administered to Resident #102 in error, LPN "M" was working a 'double shift' (2 eight hour shifts in a row). LPN "M" said it had been a 'crazy' night and she had never worked on the unit Resident #102 lived on before. LPN "M" said that she normally checks the photographs of the residents on the Medication Administration Record [REDACTED]. On 6/2/14 at approximately 8:00 p.m., LPN "M" said she looked at the resident photographs and noticed both residents in Resident #102's room looked similar and when she asked Resident #102 what her name was, Resident #102 identified herself as her roommate. LPN "M" said that after medication pass was over, somehow she was able to realize she had given Resident #102 medication intended for her roommate. LPN "M" was asked if she knew Resident #102 had a documented allergy to [MEDICATION NAME] and LPN "M" said she did not. LPN "M" said that she did call the physician and reported the medication error and was told to "closely monitor" Resident #102. During an observation on 7/10/14 at 2:30 p.m. in Resident #102's room, Resident #102 was asked what her name was and she responded appropriately. Resident #102 was asked if she remembered falling on 6/3/14 and she replied "Yes." Resident #102 was asked if she knew she had been given the wrong medications in error and she said she had never heard anything about it. During an interview on 7/9/14 at 3:00 PM with the Director of Nursing (DON) "B", the medication error report and investigation into the incident on 6/2/14-6/3/14 was requested. The DON returned with a report about the fall that occurred on 6/3/14 at 3:00 a.m. only, stating she was not aware of the medication error.

THIS CITATION PERTAINS TO INTAKE MI 312. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT ACCIDENTS FOR 1 (#102) OF 5 SAMPLED RESIDENTS, OF A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN RESIDENT #102 SUSTAINING A CRUSHING INJURY AND LACERATION, WHICH REQUIRED SUTURES, TO HER RIGHT GREAT TOE, AND PAIN. FINDINGS INCLUDE: ACCORDING TO THE FACILITY ROSTER MATRIX, RESIDENT #102 WAS NOT LIVING AT THE FACILITY AT THE TIME OF THE INVESTIGATION (3/8/12). REVIEW OF RESIDENT #102'S MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE WHO HAD BEEN 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 TRANSFERS, AND MAXIMUM ASSIST OF ONE PERSON FOR AMBULATION, DRESSING AND PERSONAL HYGIENE. FACILITY INCIDENT REPORT FOR RESIDENT #102 DATED 8/3/11 INDICATED RESIDENT #102's TOE WAS CRUSHED UNDER STAND-IN FRAME IN THE PHYSICAL THERAPY ROOM, AND THAT RESIDENT #102 WAS TAKEN TO THE HOSPITAL BY AMBULANCE. UNDER SECTION TITLED "DESCRIBE CAUSE OF INCIDENT" IT IS WRITTEN THAT RESIDENT #102 WAS BROUGHT TO PHYSICAL THERAPY ROOM AND WAS POSITIONED IN HER WHEELCHAIR BY THE STAND-IN FRAME/TABLE. THE STAND-IN TABLE WAS BROUGHT UP TO RESIDENT #102 IN PREPARATION FOR STANDING AND WHEN THE TABLE'S LOCKING MECHANISM WAS ENGAGED IT WAS LOWERED ONTO HER TOE (RIGHT GREAT TOE). IT WAS ALSO DOCUMENTED THAT RESIDENT #102 DID NOT FEEL THE PRESSURE ON HER TOE AND SHOWED NO SIGNS OR SYMPTOMS OF PAIN AND AFTER STANDING FOR APPROXIMATELY 20 MINUTES, RESIDENT #102 WAS LOWERED BY THE TABLE INTO HER WHEELCHAIR AND IT WAS DISCOVERED THAT HER TOE HAD BEEN CRUSHED. FACILITY NURSE'S NOTES FOR RESIDENT #102 DATED 8/3/11 INDICATED RESIDENT #102 RETURNED FROM HOSPITAL emergency room AND COMPLAINED OF TOE PAIN. IN AN INTERVIEW ON 3/8/12 AT 10:15 AM, IN THE THERAPY ROOM, PHYSICAL THERAPY ASSISTANT #11 (PTA #11) STATED SHE WAS PRESENT DURING THE INCIDENT WHEN RESIDENT #102 HAD HER TOE INJURED. PTA#11 DEMONSTRATED, USING THE SAME STAND-IN FRAME/TABLE, WHAT SHE OBSERVED HAPPEN TO RESIDENT #102 ON 8/3/11. PTA #11 STATED SHE OBSERVED RESIDENT #102 IN HER WHEELCHAIR IN FRONT OF STANDING TABLE, AND PT #7 RAISED RESIDENT #102 UP TO A STANDING POSITION. PTA #11 STATED SHE WAS UNSURE OF HOW LONG RESIDENT #102 STOOD, BUT WHEN PT #7 LOWERED RESIDENT #102 INTO HER WHEELCHAIR AND TRIED TO BACK HER AWAY FROM THE TABLE, HE (PT#7) STATED THAT HE COULDN'T MOVE HER. PTA #11 STATED SHE CAME CLOSER TO THE TABLE AND OBSERVED PART OF RESIDENT #102'S RIGHT SOCK UNDER THE METAL PART OF THE STANDING TABLE. PTA #11 STATED SHE THOUGHT IT WAS JUST RESIDENT #102'S SOCK, SO SHE (PTA#11) TRIED TO PULL IT OUT, BUT IT WOULDN'T COME OUT, SO PTA #11 STATED SHE TOLD PT#7 THEY HAD TO LIFT THE TABLE. PTA #11 STATED PT#7 LIFTED THE TABLE WITH THE LEVER AND SHE (PTA #11) PULLED RESIDENT #102'S FOOT OUT, THEN PT #7 PULLED RESIDENT #102'S WHEELCHAIR BACK AWAY FROM THE TABLE. PTA #11 STATED SHE THEN SAW BLOOD ON RESIDENT #102'S RIGHT GREAT TOE AREA, AND PT #7 WENT TO GET A NURSE. DURING AN OBSERVATION ON 3/8/12 AT 10:15 AM, THE SURVEYOR OBSERVED A SIGN ON THE FRONT, LOWER PORTION OF THE STANDING TABLE, NEAR THE FLOOR THAT READ " WARNING: UNIT MUST BE FULLY LOWERED BEFORE USE". REVIEW OF THE MANUFACTURER'S GUIDELINES FOR THE STAND-IN TABLE, MODEL 2E, PROVIDED TO THE SURVEYOR BY THE FACILITY ADMINISTRATOR, REVEALED A DOCUMENTED WARNING: NEVER ROLL A PATIENT INTO LIFTING POSITION BEFORE FULLY LOWERING UNIT TO THE FLOOR. IN AN INTERVIEW ON 3/8/12 AT 1:30 PM, PT #7 STATED ON 8/3/11 HE BROUGHT RESIDENT #102 TO THE THERAPY ROOM, WITHOUT SHOES ON, LOCKED HER WHEELCHAIR, MOVED THE STANDING TABLE TO HER, LOCKED IT DOWN, PLACED THE BELT AROUND HER, AND STOOD HER UP, USING THE TABLE. PT #7 STATED RESIDENT #102 STOOD FOR APPROXIMATELY 15 MINUTES, SAT BACK DOWN, USING THE TABLE, AND WHEN HE ATTEMPTED TO WHEEL HER (RESIDENT #102) AWAY FROM THE TABLE, RESIDENT #102 STATED, "MY FOOT IS CAUGHT." PT #7 STATED HE LOOKED AT HER FOOT AND THOUGHT, "OH NO". PT #7 STATED THE END OF RESIDENT #102'S RIGHT BIG TOE WAS CAUGHT UNDER THE FRAME OF THE STANDING TABLE. PT #7 STATED HE RAISED THE STANDING TABLE FRAME WITH THE LOCKING MECHANISM BAR ON THE SIDE, PULLED RESIDENT #102 BACK, REMOVED HER SOCK, AND HER (RESIDENT #102) TOE WAS BLEEDING. PT #7 STATED RESIDENT #102'S TOENAIL ON HER RIGHT GREAT TOE WAS CRACKED AND HER RIGHT GREAT TOE WAS CRUSHED. PT #7 STATED HE HAD PUT RESIDENT #102'S FEET ON THE FLOOR, AND WHEN HE PUSHED THE STANDING TABLE FRAME UP TO HER, RESIDENT #102'S TOE SLID UNDER THE FRAME BECAUSE SHE HAD SOCKS ON. PT #7 STATED IF RESIDENT #102 WOULD HAVE HAD SHOES ON IT WOULD NOT HAVE HAPPENED BECAUSE SHOES WOULDN'T FIT UNDER THERE. THE SURVEYOR ASKED PT #7 WHY RESIDENT #7 DID NOT HAVE SHOES ON AND PT #7 STATED THE ONLY REASON WAS BECAUSE HE DIDN'T PUT THEM ON HER. PT #7 STATED WHEN RESIDENT #102 SAW HER TOE SHE BECAME UPSET AND KEPT ASKING WHAT HAPPENED. PT #7 STATED IT WASN'T PAINFUL FOR RESIDENT #102. THE SURVEYOR ASKED PT #7 IF RESIDENT #102 TOLD HIM IT WASN'T PAINFUL AND PT #7 STATED NO. THE SURVEYOR ASKED PT #7 HOW HE KNEW IT WASN'T PAINFUL FOR RESIDENT #102 AND PT #7 STATED "SHE DIDN'T SAY IT WAS" AND THAT RESIDENT #102 WAS JUST SCARED OF THE BLOOD. PT #7 STATED RESIDENT #102 WENT TO THE HOSPITAL FOR TREATMENT. HOSPITAL EMERGENCY PHYSICIAN NOTES FOR RESIDENT #102 DATED 8/3/11 INDICATED RESIDENT #102 HAD A CRUSH INJURY TO THE RIGHT GREAT TOE WITH AVULSION OF THE GREAT TOE NAIL(NAIL PLATE IS TORN FROM THE NAIL BED), WHILE BEING LIFTED AT THE NURSING HOME, AND HAD A PAIN LEVEL OF 7 OUT OF 10. A PROCEDURE NOTE DOCUMENTED IN THE PHYSICIAN NOTES DOCUMENTED THAT RESIDENT #102 REQUIRED A DEBRIDEMENT (REMOVAL OF DAMAGED TISSUE) OF HER RIGHT GREAT TOE, HER TOE NAIL WAS PLACED BACK UNDERNEATH THE NAIL FOLD, AND SUTURED IN PLACE. PROVISIONAL [DIAGNOSES REDACTED]. 1. ACUTE CRUSH INJURY RIGHT GREAT TOE WITH AVULSION OF NAIL. 2. REDUCTION OF AVULSED TOENAIL WITH DEBRIDEMENT OF DEVITALIZED TISSUE. 3. A CRUSH INJURY AND TUFT FRACTURE, RIGHT FIRST GREAT TOE. 4. DIGITAL NERVE BLOCK. IN AN INTERVIEW ON 3/8/12 AT 11:00 AM, RESIDENT #102'S HUSBAND STATED THE FACILITY DID NOTIFY HIM WHEN HIS WIFE'S TOE HAD BEEN INJURED, AND HE WAS WITH HER IN THE emergency room . RESIDENT #102'S HUSBAND STATED HIS WIFE WAS COMPLAINING OF A LOT OF PAIN IN HER TOE AT THE emergency room , AND THAT THE DOCTOR HAD TO PUT STITCHES IN HER TOE. RESIDENT #102'S HUSBAND STATED HIS WIFE'S TOE WAS CRUSHED, THE INJURY WAS UNCALLED FOR, AND THAT THE FACILITY STAFF WERE NOT WATCHING HER LIMBS OR IT WOULD NOT HAVE HAPPENED. RESIDENT #102'S HUSBAND STATED HIS WIFE REPORTED TO HIM THAT THE THERAPIST HAD TO MANUALLY LIFT THE MACHINE OFF FROM HER TOE. IN AN INTERVIEW ON 3/8/12 AT 4:15 PM, FACILITY ADMINISTRATOR #1 STATED SHE DID NOT BELIEVE THE INJURY TO RESIDENT #102 ON 8/3/11 WAS HARM BECAUSE THERE WAS NO FRACTURE AND BECAUSE WHEN THERE IS ONLY ONE OCCURRENCE IT IS NOT HARM. #