Every finding on record at Optalis Health & Rehabilitation of Wyoming

This citation is related to intake # 3045819 Based on interview and record review, the facility failed to complete physician ordered care and treatments for one of three residents (R101) reviewed for wound care. Findings:Resident #101 (R101) Review of a Face Sheet revealed R101 was a [AGE] year-old male, admitted to the facility on [DATE], with a pertinent diagnoses of sepsis. Review of a nursing admission Evaluation date 06/08/26 reflected R101 was admitted with the following skin concerns: open areas on the right and left buttock and open areas to the front and back side of the right thigh. During an interview on 06/23/26 at 7:50 AM, R101 indicated that staff have not completed wound care and dressing changes per physician orders. Review of a Electronic Treatment Administration Record (E-tar) for R101, dated June 2026, reflected a wound care order for the right leg twice daily was not documented as completed on 06/11/26 second shift, 06/13/26 second shift, 06/15/26 second shift, and 06/21/26 first shift. Review of an Etar for R101, dated June 2026, reflected a wound care order twice daily for the right buttock was not documented as completed on 06/11/26 second shift, 06/13/26 second shift, 06/15/26 second shift, and 06/16/26 second shift. During an interview on 06/23/26 at 8:50 AM, the Director of Nursing indicated that she was aware that there were missed ordered wound care and treatments for R101 and the issue had been addressed with nursing staff.

This citation pertains to intake # 3034407 Based on interview and record review, the facility failed to administer antibiotics and monitor labs per physician orders for one of three residents (Resident #102) reviewed for antibiotic stewardship. Findings:Resident #102 (R102) Review of Face Sheet revealed R102 was a [AGE] year-old Spanish speaking male, originally admitted to the facility on [DATE], with pertinent diagnoses of a small bowel obstruction that was surgically repaired and a colostomy was placed, and an abdominal abscess that developed after surgery and required IV (intravenous) antibiotics. Other pertinent diagnoses include a history of a brain bleed that required a craniotomy and resulted in aphasia (difficulty speaking) and weakness to one side of his body. Review of a hospital Transfer Summary For R102, revealed the following orders: meropenem (an antibiotic) 1 gram IVPB (Intravenous piggy back) every 8 hours for 42 doses. Final duration to be determined at outpatient infectious disease follow-up appointment. (05/21/26) Review of a Infectious Disease physician progress note for R102, dated 05/21/26, reflected the following orders: (a) continue Meropenem 1 gram IV every 8 hours, (b) CT (cat scan) ordered, final antibiotic duration will depend on results, (c) continue weekly labs CBC (complete blood count) with differential, CMP (Comprehensive Metabolic Profile), and CRP (C-reactive protein) while on IV antibiotics and fax results to our office (last labs reviewed were from the hospital on [DATE]), and (d) Infectious Disease clinic follow up in 2 weeks (06/03/26). Review of the Electronic Health Record (EHR) for R102 revealed no lab results. During an interview on 06/23/26 at 3:08 PM, the Director of Nursing (DON) indicted that lab work had not been completed for R102 until she received a telephone call from the Infectious Disease (ID) office on 06/03/26. ID called to make the facility aware that weekly labs were not being completed as ordered. The DON then produced lab results for R102 from 06/05/25 and weekly thereafter. The DON could not explain why the weekly labs had not been completed as ordered. Review of an Electronic Medication Administration Record (E-mar) for R102 dated May 2026 revealed the order for Meropenem 1 gram IV every 8 hours was stopped on 05/25/25. During an interview on 06/23/26 at 3:15 PM, the DON stated she did not know why the IV antibiotic for R102 was discontinued on 05/25/26, and after receiving the telephone call from the Infectious Disease office on 06/03/26, the IV antibiotic Meropenem was re-started. R102 had missed 27 ordered doses of antibiotics.

This citation is related to intake # 3034407 Based on interview and record review, the facility failed to provide standard professional care to one of one resident's (Resident #102) reviewed for Intravenous (IV) access and fluids. Findings:Resident #102 (R102) Review of Face Sheet revealed R102 was a [AGE] year-old Spanish speaking male, originally admitted to the facility on [DATE], with pertinent diagnoses of a small bowel obstruction that was surgically repaired and a colostomy was placed, and an abdominal abscess that developed after surgery and required IV (intravenous) antibiotics. Other pertinent diagnoses include a history of a brain bleed that required a craniotomy and resulted in aphasia (difficulty speaking) and weakness to one side of his body. Review of a hospital Transfer Summary revealed that on 05/13/26 R102 had a PICC (peripherally inserted central catheter) inserted prior to discharge from the hospital. The PICC was placed for IV (intravenous) antibiotic use once R102 arrived at the skilled nursing facility on 05/14/26. Detailed information regarding the PICC was documented on the hospital transfer summary. Review of a nursing admission Evaluation for R102, dated 05/15/26, reflected that (a) an IV was present and (b) the location was midline left upper arm. Not documented on the nursing admission evaluation were the following: (1) venous access type, (a PICC), (2) size and length of the access, (3) circumference of the arm (or other insertion location if applicable) at the access site, and (4) an observation and description of the IV access site. During a telephone interview on 06/21/26 at 1:45 PM, a Registered Nurse from a local infectious disease clinic, (RN) A, reported the following concerns that were observed in the clinic on 05/21/26 regarding R102's PICC: (a) the dressing was peeling off at the corners, (b) the PICC was not clamped off, (c) there was no legible date on the dressing, and (d) the stat lock was not in use. Review of a facility physician order reflected: (a) change needless connector during a routine flush every 7 days for infection prevention. The due date for this order was 05/20/26, and (b) change midline dressing every 7 days for safety monitoring. The due date for this order was also 05/20/26. Review of an Electronic Medication and Treatment Record (Emar and Etar) for R102, dated May 2026, revealed (a) that the needless connector was not changed on 05/20/26. It was changed when the PICC was replaced on 05/22/26 due to pain in the left arm and possible SVT (superficial venous thrombosis-a blood clot), and (b) the dressing change was not completed on 05/20/26. It was changed when the PICC was replaced on 05/22/26. The needless connector for R102's PICC would next be replaced on 05/29/26 (7 days after previous change). No documentation in the Electronic Health Record (EHR) could be located to show the connector was changed on 05/29/26. The dressing change for R102's PICC would next be completed on 05/29/26 (7 days after previous change). No documentation in the EHR could be located to show the dressing was changed on 05/29/26. Review of an the E-mar and E-tar for R102, dated May and June 2026 revealed that when the IV antibiotics were stopped on 05/25/26, there were no maintenance flushes of the PICC completed every 12 hours. Unused catheters that do not at least receive twice daily maintenance flushes are at high risk for infection. During an interview on 06/23/26 at 3:08 PM, the Director of Nursing stated that on 03/20/26 all nurse had been re-educated on PICC and IV therapy, including required orders, documentation, dressing care, and proper use of connectors.

This citation pertains to intake # 3034407 Based on observation, interview, and record review, the facility failed to monitor and assess one of three resident's (Resident #102) reviewed for ostomy care. Findings:Resident #102 (R102) Review of Face Sheet revealed R102 was a [AGE] year-old Spanish speaking male, originally admitted to the facility on [DATE], with pertinent diagnoses of a small bowel obstruction that was surgically repaired and a colostomy was placed, and an abdominal abscess that developed after surgery and required IV (intravenous) antibiotics. Other pertinent diagnoses include a history of a brain bleed that required a craniotomy and resulted in aphasia (difficulty speaking) and weakness to one side of his body. During a telephone interview on 06/22/26 at 10:29 AM, Registered Nurse (RN) A, from a local Infectious Disease clinic, stated that on 05/21/26, R102 had an appointment in their office and R102 arrived with a colostomy that was leaking stool onto his lap and clothes. During an observation on 06/23/26 at 10:12 AM, R102's call light was on and R102 pointed to his colostomy bag that was full of stool. During an interview on 06/23/26 at 10:20AM, Family Member 'K indicated that frequently when he visits, he has to tell staff that R102's colostomy is full or it is leaking. Review of a physician Progress Note dated 06/03/26, revealed R102 reported to the infectious disease physician that he (R102) had concerns about the wound care and the ostomy bag leaking over the surgical site. Review of Electronic Treatment Administration Record's (E-tar's) for R102, dated May and June 2026, revealed no colostomy orders, (i.e how frequently to check the bag, when to burp the bag, when to change to the appliance/wafer, monitoring of the stoma for skin changes or breakdown, monitoring stool amount, color and consistency for changes). Review of a Care Plan for R102 reflected that the only staff intervention/task regarding the colostomy was .change ostomy appliance as needed. Wears ileostomy product. Review of the facility policy/procedure Ostomy Care revealed .the purpose of this policy is to provide guidelines for the colostomy and ileostomy care, to maintain cleanliness and good skin condition, and to monitor the amount of fecal drainage .Ostomy care includes: the release of flatulence that has accumulated in the ostomy bag or pouch as needed, evaluating the ostomy site and visible surrounding skin for any signs of skin breakdown, evaluating the amount, consistency, and color of stool for any changes, and emptying the ostomy bag of feces.

This citation pertains to Intake 2975792Based on interview and record review, the facility failed to provide thorough, effective quality care to treat and prevent recurrence of a pressure sore for one facility Resident (R108) of five residents reviewed for quality of care. Findings:Review of the Electronic Medical Record (EMR) reflected R108 admitted to the facility 3/23/2024 with pertinent diagnoses that included: Chronic Respiratory failure, Dementia, and Severe Protein Calorie Malnutrition. Review of the Minimum Data Set (MDS- a tool used to assess a resident's status) reflected that R108 was moderately cognitively impaired and had a legal guardian in place for medical decisions.In an interview on 4/8/2026 at 8:41 AM, Registered Nurse (RN) C reported that nurses conducted a full body skin assessment on each resident at least once a week.Review of the EMR did not reflect that any skin assessments had been completed on R108 from 2/25/2026 to 3/10/2026.Review of the EMR for R108 reflected a Progress Note entry dated 3/10/2026 at 1:38 PM that a Stage 2 pressure sore had been identified on the coccyx of R108. The entry reflected this wound had measured 0.45 by 0.66 centimeters (cm) and a depth of 0.1 cm. The entry did not reflect the legal guardian of R108 had been notified of the new wound.Review of the EMR reflected on 3/12/2026 at 11:12 AM a Medical Provider evaluated R108 and the new wound which had increased in size to 0.83 by 0.9 cm. The documentation did not reflect that the wound was avoidable and recommendations were made for an alternating pressure mattress ( APM) and Offload (position the resident to prevent pressure being applied to the affected area).Review of the Care Plan for R108 revealed that a plan of care for a Stage 2 pressure ulcer was not formulated until 3/19/2026; nine days after the wound was identified. The Care Plan reflected Interventions to include Administer treatment per physician orders, Monitor, Document, Report evidence of infection but no actionable interventions to offload or documentation of a repositioning regimen. The Care Plan reflected the APM was refused by the Resident in 2024 and that a Reattempt would occur but no documentation of when this would be done and no documentation that this had occurred as of 3/19/2026.The EMR revealed a Progress Note dated 3/19/2026 at 1:13 PM. The entry reflected Stage 2 Pressure ulcer/Injury- partial thickness skin loss with exposed dermis. Wound acquired in-house. It is unknown how long the wound has been present. The entry reflected Additional Care: Turning/ repositioning program . Pressure reducing device for bed . Pressure reducing device for chair.On 4/8/2026 at 11:49 AM, an interview was conducted with the Director of Nursing (DON). The DON indicated that the entry of 3/19/2026 at 1:13 PM was a checking document that translated the check marks into a narrative document. The DON reported that the documentation of the addition of the pressure reducing devices and repositioning program did not result in implemented action.Review of the Physician Orders for R108 reflected an order dated 3/24/2026 for an APM mattress. This was twelve days after the recommendation was documented by the Medical Provider (3/12/2026).Review of the EMR Progress Notes for R108 revealed an entry dated 3/26/2026 at 11:34 AM that Skin issue is resolved.Review of the Care Plan for R108 reflected Stage 2 Pressure Injury was not revised to indicate the issue was resolved.Review of the EMR did not reflect any Progress Note, Skin Assessment, or Care Plan changes of actions implemented or conducted to prevent recurrence of a pressure injury.Review of the EMR document dated 4/4/2026 at 12:05 PM titled Skin-total Body Eval revealed an open, measurable area on the coccyx of R108. Neither this entry nor the Progress Notes revealed the guardian had been notified.Review of the Care Plan did not reflect any revisions or that it had been updated as of 4/7/2026.

This citation pertains to intake #2719938 Based on interview and record review, the facility failed to 1.) promptly identify and treat a resident in hypoglycemic crisis for 1 resident (Resident #1) and 2.) ensure medications were administered in accordance with physician orders for diabetic residents for 3 residents (Resident #1, #2, and #3) out of 3 residents reviewed for competent nursing staff.Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes.Review of R1's Order Summary dated 1/10/2026-1/21/2026 revealed, Obtain Blood Sugar before meals and at bedtime before meals and at bedtime for blood glucose monitoring If BGL (blood glucose level) is less than 60 or over 300, (provider). To be completed at 7:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM.Review of R1's Order Summary dated 1/11/2026 revealed: Glucose Oral Tablet Chewable 4 GM (Dextrose (Diabetic Use)) Give 4 tablet by mouth every 24 hours as needed for hypoglycemia for 14 Days and Glucagon Nasal Powder 3 MG/DOSE (Glucagon) 1 spray Alternating nostrils as needed for Diabetes for 14 Days Use as needed for hypoglycemia.Review of R1's Nursing Progress Note dated 1/19/2026 at 06:48 AM written by Licensed Practical Nurse (LPN) B revealed, Note Text: Patient's AM BS (blood sugar) 69 nurse encouraged patient to eat her cookies. R1's Blood Sugar Summary revealed the blood glucose result of 69 was not documented.Per the facility policy for hypoglycemia, LOW BLOOD GLUCOSE (55-69 MG/DL) PROCEDURE.Repeat blood glucose check in approximately 15 minutes.Continue to repeat blood glucose check and simple sugar/carbohydrate snack until blood sugar is 70 or greater. Examples of simple sugar/carbohydrate snack were 4 ounces of juice, 4 ounces of regular soda/pop, 1/2 banana, 6 saline or Ritz crackers, 3 [NAME] crackers. Review of R1's Electronic Medical Record (EMR) revealed no documentation that licensed nurses reevaluated R1's blood sugar or ensured R1 was medically stable until a vital sign assessment was completed at 08:26 AM (approximately 1 hour 45 minutes later).Review of R1's O2 Sats (oxygen saturation) Summary dated 1/19/2026 at 08:26 AM revealed an oxygen level of 84% on room air (no supplemental oxygen). Per Fundamentals of Nursing, normal pulse oximetry values range between 92% and 100% saturation.Review of R1's Blood Sugar Summary dated 1/19/2026 at 08:32 AM revealed a blood sugar of 46.Review of R1's SBAR Summary (Situation/Background/Assessment/Recommendation) dated 1/19/2026 at 08:29 AM and completed by Unit Manager (UM) C revealed, um entered room noting bp (blood pressure) at 189/100 =asking for bs (blood sugar) which was noted at 46, call had already been made for 911 with bp and unresponsiveness. an attempt to pull gluc (glucagon) out not successful r/t (related to) user error. education is being completed. ems (Emergency Medical Services) took bs while they attempted to put in iv for a reading of 24 .Primary Care Provider responded with the following feedback: send out 911 with unresponsive and elevated bp.Review of R1's Nursing Progress Note dated 1/19/2026 at 09:14 AM and written by LPN A revealed, Resident BS was 46 and eyes were rotating back and forth ok to send to ER VS (vital signs) were unstable 02 was 84%.Review of R1's EMR revealed no documentation that facility staff applied oxygen following the identification of the low oxygen level or that the emergency glucagon was administered Review of R1's Incident Note dated 1/19/2026 revealed, blood sugar noted by noc (night) floor nurse at 69, snack was given, vs taken on day shift early with note resident was not responding and had elevated bp, um asked floor nurse to get bs while um called dr on call, dr said to sent (sic) r/t (related to) non responsive and elevated bp, bs noted to be at 48 um had a floor nurse get ready to send out, um attempted to get gluc from back up however it was done in error thus not give (sic) prior to ems/ 911 arrival, fire noted bs at 46, ems attempted to get line in for greater then (sic) 15 min, next bs taken at 24 by fire with ems doing im (intramuscular) for glucagon, line was in after many attempts and d5 was started per ems. Education for all nursing staff being completed.During an interview on 01/28/2026 at 12:30 PM, UM C reported that R1's blood sugars would have significant fluctuations, and she had required the use of glucagon to correct the low blood sugars on multiple occasions. UM C reported she was not present when LPN B assessed R1's blood sugar as it was typically assessed prior to 7AM. UM C reported that LPN B was proactive about low blood sugars and likely encouraged R1 to consume the cookies as it was known that R1's sugars could drop drastically, however, UM C was not notified of any concerns related to R1's blood sugar when she arrived to the facility. UM C reported she was notified by LPN A that R1 was unresponsive with a critically low blood sugar which was when she went to the automated medication dispenser to pull glucagon. UM C reported there was a user error but there was no glucagon available in the dispenser anyway. The DON reported that there was glucagon available in the dispenser, but UM C but her attempt to remove was done incorrectly.During an interview on 01/28/2026 at 12:49 PM, LPN B confirmed R1 had a history of low blood sugars and she was concerned with R1's blood sugar level when she obtained it the morning of 1/19/26 stating, that's why I wanted her to eat her cookies. LPN B reported R1 was alert and sitting up in her bed with snacks and cookies in front of her on her tray table and was starting to eat her cookies when LPN B exited the room to finish her rounds. LPN B reported she did not obtain a follow up blood sugar level or reassess R1 prior to giving report to LPN A. LPN B reported she informed LPN A of R1's low sugar and stated she him you're going to want to check her right away.On 01/28/2026 at 12:04 PM a message was left for LPN A to validate the timeline of events. There was no return call prior to survey exit.Review of R1's Complaint/Incident Investigation Report received 1/20/26 revealed, Per an EMS (Emergency Medical Services) report .Pt (patient) was given cookies instructed to eat them and staff left the room. At 08:10 (AM) staff found patient unresponsive and called EMS. EMS arrived at 08:20 (AM) and patient was still unconscious and when EMS evaluated her blood glucose it was 24. EMS also found patient to be hypoxic with oxygen in the low 80s. Pt was placed on a non-rebreather and was given 1mg glucagon by EMS .EMS informed me that staff at (facility) stated they didn't have glucagon or glucose to give the patient. After patient arrived in the emergency department, Pt was stable. RN (Registered Nurse) noticed Pt has 2 separate orders for glucose when experiencing low blood sugar, an oral glucose tablet and a glucose nasal spray despite the staff telling EMS they did not have any to give her. When another RN contacted (facility), she asked why they patient was left alone with a low blood glucose and they did not give an answer .Review of R1's EMS Patient Care Report revealed the emergency call was made at 8:10 AM and EMS arrived to the facility at 8:15 AM. EMS arrived on scene to find female subject laying supine in her hospital bed at skilled facility with staff and (omitted) PD (police department) on scene. Pt's skin was pale, cool and clammy and she was unresponsive. (omitted) FD (fire department) had pt on oxygen via NRB (nonrebreather) due to pt's RA (room air oxygen level) being 80%. Per staff, they noticed pt's sugar was low around 0740 (7:40 AM) and staff told pt to eat. Nurse stated I came back 30 minutes later and found her unconscious, I attempted to find Glucagon and couldn't find any in the building and then called 911 .Pt received 1mg IM Glucagon with improvement. Pt's mentation continued to improve after glucagon administration .Review of R1's Hospital Records dated 1/19/26 revealed, Chief Complaint: Blood Sugar Problem .Pt was told she needs to eat cookies and staff left the room. Staff returned around 08:10 and Pt was unconscious. EMS arrived at 08:20 and Pt's BG was 24 .(R1) is a 37 y.o. (year old) female who presents to the emergency department by EMS from assisted living facility because of low blood sugar. The patient was checked and found to have a low blood sugar this morning before 8:00 of around 60. Patient was advised to eat. She did not and was found 40 minutes later with a blood glucose of 24. The facility did not have glucagon to provide .During an interview on 01/28/2026 1:50 PM, LPN E reported that glucagon and other related emergency products are kept on the medication carts. They are also available in the medication room in the automated medication dispenser. LPN E reported the facility had not run out of glucagon that she was aware of.During an interview on 01/28/2026 at 9:06 AM, the Director of Nursing (DON) reported that R1's blood sugars would range from 40's to 500's and could drop suddenly requiring the use of glucagon. The DON reported R1 did not receive glucagon prior to EMS responding due to a nurse user error with the automated medication dispenser (where additional medications are held) and the nurse reported there was no glucagon available. The DON reported by the time she was made aware of the situation and the inability for the licensed nurses to retrieve the glucagon, EMS had already arrived.During an interview on 01/28/2026 at 10:26 AM, the DON reported she immediately began education for all licensed nurses to ensure they had the knowledge of how to pull emergency medication from the automated medication dispenser. The education included the licensed nurses completing a return demonstration to verify they understood the process. The DON reported the nurses were also educated on the facility's hypoglycemia policy and procedure and an audit was completed to ensure that all residents receiving insulin had ordered parameters.Resident #2 (R2)Review of an admission Record revealed R2 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 2 Diabetes.Review of R2's Order Summary dated 12/20/25 revealed, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 22 unit subcutaneously at bedtime for iddm (insulin dependent diabetes mellitus).Hold Lantus if BGL (blood glucose level) less than 100. To be administered at 9:00 PM.Review of R2's Blood Sugar Summary revealed there were no blood sugars assessed on 1/1/26, 1/3/26, 1/4/26, 1/6/26, 1/8/26, 1/13/26, 1/17/26, 1/18/26, 1/20/26, 1/22/26, 1/24/26, 1/25/26, or 1/27/26.Review of R2's January Medication Administration Record revealed all doses of Lantus from 1/1/26 through 1/27/26 were administered.Review of R2's EMR revealed no rationale for the lack of blood sugar assessments prior to the administration of the Lantus for the dates listed above.During an interview on 01/28/2026 at 4:00 PM, the DON confirmed a blood sugar assessment was not completed prior to the administration of the Lantus and reported that R2 did not want her blood sugar to be assessed every evening. It was confirmed that there was no documentation to reflect blood sugar refusals. The DON reported that her care plan was updated to reflect her preference.Resident #3 (R3)Review of an admission Record revealed R3 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 2 Diabetes.Review of R3's Order Summary dated 12/27/25 revealed, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously at bedtime.Hold Lantus is BGL is less than 100.Review of R3's Order Summary revealed no order for routine blood glucose assessments.Review of R3's Blood Sugar Summary from 1/8/26-1/28/26 revealed only 4 blood sugars were assessed: On 1/8/26, 1/17/26, 1/25/26, and 1/26/26.Review of R3's Medication Administration Record revealed that from 1/8/26-1/27/26 all doses of Lantus were administered except on 1/24/26 and 1/26/26 (due to low blood sugar).During an interview on 01/28/2026 at 4:00 PM, the DON confirmed blood sugars had not been assessed prior to the administration of the Lantus and reported that the licensed nurses were to review the full order summary to ensure provider ordered parameters were followed.Review of the State Operations Manual revealed, Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as.Communication.Basic nursing skills.Medication management.Identification of changes in condition.Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents.Review of the facility policy, Medication Administration dated 8/7/23 revealed, To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs .Vital Signs are taken prior to the administration of vital sign dependent medications in accordance with medical practitioner's orders. Laboratory values are validated prior to the administration of laboratory dependent medications in accordance with medical practitioner's orders.Review of the facility's Hypoglycemia Procedure last revised 5/2/24 revealed, It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode.LOW BLOOD GLUCOSE (55-69 MG/DL) PROCEDURE:Recognize hypoglycemic symptoms.Obtain Blood Glucose result.If resident is alert and able to swallow, administer simple sugar/carbohydrate snack if the resident's diet and fluid consistency allows, examples include: 4 ounces of juice, 4 ounces of regular soda/pop, 1/2 banana, 6 saline or Ritz crackers, 3 [NAME] crackers.If resident refuses the snacks or their diet or fluid restrictions prohibits the use of those snacks, obtain and/or follow physician's orders for administration of glucose gel.Repeat blood glucose check in approximately 15 minutes. If blood glucose is 55 -69 mg/dL and resident continues to be alert and able to swallow, repeat simple sugar/carbohydrate snack and/or glucose gel administration per physician orders.Continue to repeat blood glucose check and simple sugar/carbohydrate snack until blood sugar is 70 or greater, then have resident eat a nutritious meal or long-acting source of sugar/carbohydrate snack such as cheese and crackers, 8 ounces of milk, sandwich with meat or cheese, peanut butter and crackers, peanut butter sandwich, etc.If the resident is not alert, is unable to swallow, or their diet or fluid consistency prohibits the use of simple sugar/carbohydrate snack or glucose gel administration, obtain and/or follow physician orders for hypoglycemia treatment (i.e. Glucagon IM - reconstitute is in the back up box/Omnicell from pharmacy, G-Voke SQ, IV Dextrose - check IV supplies for availability, etc.)Notify the resident's medical practitioner and relay assessment, symptoms, blood sugar results, interventions, and response to interventions. Obtain and document any new medical practitioner orders.SEVERE LOW BLOOD GLUCOSE (54MG/DL OR BELOW) PROCEDURE:Repeat blood glucose check.Evaluate clinical condition including vital signs and signs and symptoms of hypoglycemia, do not leave the resident unattended.Follow physician orders for hypoglycemia that resident already has in place: Glucose Gel (if resident is alert and able to swallow), Glucagon IM, G-Voke SQ, Dextrose IV, etc.In lieu of physician orders, notify medical practitioner of clinical condition including signs and symptoms, vital signs, and blood glucose level and obtain orders.Administer physician's orders for emergency treatment, i.e. Glucose Gel (if resident is alert and able to swallow), Glucagon IM - reconstitute is in the back up box/Omnicell from pharmacy, IV Dextrose - check IV supplies for availability, and orders for frequency of blood glucose monitoring, labs, etc.).Recheck blood glucose in 15 minutes or per practitioner order.If acceptable blood glucose level is not reached or condition deteriorates, contact practitioner for further orders and/or hospital transfer.SUGGESTED DOCUMENTATION:Document blood glucose levels, vital signs, clinical condition, interventions provided for low blood glucose, resident's response, communications with practitioner, any orders as applicable, and notification to the resident's Guardian, DPOA, representative, as applicable.

Based on interview and record review, the facility failed to prevent a fall in two of two residents (Resident #1 and Resident #51) and secure hazardous materials and biologicals in one of one salon and for one resident (Resident #43) reviewed for accidents and hazards, resulting in fractures for R1 and R51 residents and the potential for R43 to ingest hazardous materials.Findings Include: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of pneumonia and repeated falls. Review of a Facility Investigation initiated for R1 after a fall with a major injury on 12/30/25 concluded the following: the evening of 12/30/25 Certified Nurse Aide (CNA) LL was in R1's room providing care. CNA LL did not use a second staff person for safe bed mobility and R1 fell from the bed onto the floor causing a cut to the forehead and a broken right distal femur (above the knee). After the incident, CNA LL reported knowing that R1 required two people for safe bed mobility but proceeded anyway. This incident represents a failure to follow the resident's care plan. Review of a Care Plan for R1 reflected the following safety intervention: Bed mobility: two-person assist. During an interview on 01/06/26 at 3:29 PM, the Director of Nursing indicated that CNA LL had not followed facility policy, and the resident centered care plan, and those actions led to the fall and fractured femur for R1. Resident #51 (R51)Review of an admission Record revealed R51 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of cognitive communication deficit, difficulty walking, muscle weakness, and lack of coordination. Review of a Fall Report provided by the facility, revealed R51 sustained an unwitnessed fall in her room on the evening of 12/20/25. The report also indicated that R51 was transferred back to bed via a mechanical hoyer lift before she received a complete head-to-toe assessment by nursing staff. After being transferred back to her bed, R51 complained of right hip pain. R51 was sent to the emergency room and diagnosed with a right proximal femur fracture (just below the hip). During an interview on 01/07/26 at 4:07 PM, the Director of Nursing stated that Licensed Practical Nurse (LPN) HH had moved R51 from the floor to the bed while R51 complained of right hip pain and without first assessing R51 for injury. Review of the facility policy Fall Management Guidelines revealed the following procedure for a post-fall evaluation: if a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries of the head, neck, spine, and extremities (arms and legs). During an observation on 01/06/25 at 08:46 AM, the beauty shop door sat open, and the white cabinets were unlocked and contained an aerosol can of [NAME] Cool Air Plus, labeled as a coolant, disinfectant, lubricant, cleaner, and rust preventative that was hazardous to humans. Also, in an unlocked cabinet sat a can of hair spray. Resident #43 (R43) Review of an admission Record revealed R43 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of insomnia, anxiety disorder, and repeated falls. During an observation on 01/05/26 at 10:52 AM a bottle of Dermal Wound Cleaner, that read call poison control if swallowed, sat on the round table in R43's room. Also, in R43's room were a 7.5-ounce bottle of Kleen peri cleaner and a prescription bottle of Miconazole 2% powder.

Based on interview and record review, the facility failed to treat a urinary tract infection in a timely manner for one of one resident's (Resident #1) reviewed for the quality of care. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of pneumonia and limitation of activities due to disability and use of a foley catheter (a system that drains urine from the bladder into a collection bag) long term. Review of a physician communication book revealed that nursing staff had left a note for the facility prescribers on 12/07/25 that R1 was complaining of pain in his penis area. Review of a prescriber note for R1, written on 12/08/25 by Nurse Practitioner (NP) W reflected the following concern: (R1) is seen today for penile pain. He feels it is related to the catheter. Resident has a chronic indwelling foley .white to green drainage noted around the foley catheter and dark cloudy urine in the foley collection bag. Plan: check a urinalysis with culture and sensitivity if indicated. Resident with penile pain. Foley needs to be changed every 30 days. Excessive amount of penile drainage, urine is cloudy and looks suspicious for a UTI (urinary tract infection). Review of an Order Summary for R1 revealed an order for the urinalysis (U/A) and culture and sensitivity (C&S) on 12/08/25. Review of a prescriber note for R1, written on 12/10/25 by NP W reflected the following concern: (R1) seen today for right flank pain, recent malodorous (bad smelling) drainage around the catheter, U/A is pending for this. Plan: will wait for U/A and C&S ordered earlier this week. PA W was not made aware by nursing that the urine had not yet been collected from R1 for the U/A and C&S. Per the Electronic Health Record (EHR) the U/A and C&S for R1 were not collected by staff until 12/11/25 and the C&S had been completed incorrectly and could not be resulted. Documentation could not be found that NP W was notified. Review of a physician note for R1, written on 12/12/25 by Medical Doctor (MD) PP reflected: (R1) had a urinalysis (U/A) with culture and sensitivity on 12/08, results not seen at this time. Review of a prescriber note for R1, written on 12/15/25 revealed that R1 was seen for redness to his right third toe. The note does not contain any information related to the U/A and culture and sensitivity that the lab was not able to complete. Review of a nursing progress note, dated 12/15/25 at 11:30 PM, reflected that R1 asked to be sent to the emergency room for care for penile pain and discharge. Review of an After Visit Summary for R1, dated 12/16/26, from the emergency room revealed that R1 had been diagnosed with a urinary tract infection and was prescribed an antibiotic.

This citation pertains to Intake 2629685Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 01/05/2026 at 9:06 AM, observed hand towels were not readily available at the handsink in the dishwashing room. This is the only designated handsink for the kitchen. According to the 2022 FDA Food Code section 6-301.12 Hand Drying Provision.Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with:(A) Individual, disposable towels; Pf (B) A continuous towel system that supplies the user with a clean towel; Pf or (C) A heated-air hand drying device; Pf or (D) A hand drying device that employs an air-knife system that delivers high velocity, pressurized air at ambient temperatures. PfOn 01/05/2026 at 9:10AM, observed filters were not in the face of the hood ventilation system, over the cookline. On 01/05/2026 at 9:20AM, during interview, Dietitian DD stated the filters have been out of the hood system for cleaning since Friday 1/2/2026. Dietitian DD stated the hood was not operational and Dietitian DD was observed turning off the hood. According to the 2022 FDA Food Code Section 4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings.On 01/05/2026 at 9:27AM, observed resident's food, an orange/brown colored sauce in foam takeout container, with a date of 12/31/2026. Resident's foods are stored in the pantry refrigerator. At that time interview with Dietitian DD stated that the facility policy was to hold the time/temperature controlled for safety food for 3 days and then discarded. On 01/05/2026 at 10:00AM, Vital therapeutic nutrition supplement product observed with an expiration date of 1 [DATE], product was sitting on shelving in back room with other therapeutic nutrition supplemental products. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .On 01/05/2026 at 9:34AM, observed in dining room, the handsink was leaking. The water that was leaking was cold water. Dietitian DD stated the faucet was repaired the week prior for same issue. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.On 01/05/2026 at 10:00AM, it was observed that various kitchen personnel were leaving other tasks and then handling clean dishes without washing their hands. Personnel were also observed taking off their gloves and not washing hands before putting on new gloves.On 01/05/2026 at 11:00AM, observed several kitchen personnel leave the kitchen area, come back into kitchen and begin working with equipment to prepare for lunch without washing their hands. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.On 01/05/2026 at 10:05AM, observation of dish machine operation, disclosed the sanitizing rinse was not reaching 180 degrees F on the gauge readout and not reaching a plate surface temperature of 160 degrees F. Plate surface temperature was tested using a DishTemp plate simulating tester. The reading on the tester was a maximum temperature of 146 degrees F. Interview with Dietitian DD at this time, regarding temperatures and procedures for dish machine operation, confirmed the minimum temperatures of 180 degrees F hot water at gauge readout and 160 Degrees F for plate surface temperature. According to the 2022 FDA Food Code Annex 3. Public Health Reasons/Administrative Guidelines section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. According to the 2022 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: (1) For a stationary rack, single temperature machine, 74C (165F); or (2) For all other machines, 82C (180F).

Based on interview and record review, the facility failed to 1) implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, 2.) ensure appropriate personal protective equipment (PPE) for a resident in contact precautions, and 3.) ensure residents at risk of MDRO (multi-drug resistant organisms) acquisition were placed in enhanced barrier precautions for 3 residents (Resident #36, #58, and #40) out of 18 residents reviewed for infection prevention and control.Findings: Review of the December Employee Illness Log revealed: Certified Nursing Assistant (CNA) OO called off of work with an onset date of 12/4/25 for the reason of just said not feeling well. There was no documentation of specific symptoms or a return to work date. CNA LL called off of work with an onset date of 12/26/25 for the reason of none listed. There was no documentation of specific symptoms or a return to work date. CNA MM called off of work with an onset date of 12/27/25 for the reason of unknown. There was no documentation of specific symptoms or a return to work date. CNA NN called off of work with an onset date 12/31/25 for says stomach bug. There was no documentation of specific symptoms or a return to work date. All 32 employee illness call-offs for the month of December did not have a return to work date. During an interview on 01/07/2026 at 10:14 AM, Infection Control Preventionist (ICP) Z and the Director of Nursing (DON) reported that the process for employee call-offs was for the facility staff to fill out a slip with the employee name, shift, and illness/symptoms and place that in the schedulers bin. The scheduler would then document that absence and provide ICP Z with the slip. ICP Z reported call-offs were tracked in real time and discussed each morning. If the reason for the call-off was vague she was responsible for following up to obtain accurate symptoms and provide a return to work date. During an interview on 01/08/2026 at 11:16 AM, the Director of Nursing (DON) reported that the Infection Control Preventionist (ICP) was new to the position and there had been some areas missed. The DON was notified that specific illnesses and return to work dates were not completed/acted upon and she confirmed that the investigation of specific symptoms and a return to work date should have been completed. Resident #36 (R36) Review of an admission Record revealed R36 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: surgical wound to the right foot. Review of R36's Order Summary dated 11/3/25 revealed, Right foot surgical site: cleanse with saline and gauze, apply dry gauze over the site, secure with kerlix then ACE wrap. Change daily. note and s/s of infection. every day shift for surgical site care Note there is a skin substitute stapled to the wound base, DO NOT REMOVE THIS! Just cleanse gently over the top and around the wound. Further review of R36's Order Summary revealed no order for R36 to be in Enhanced Barrier Precautions (EBP) due to her right foot wound. Resident #58 (R58) Review of an admission Record revealed R58 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke, abnormal weight loss, and cerebral palsy. Review of the Provider Communication Log dated 12/24/25 revealed R58 had (left) buttock-open area and (right) buttock-nearly open with a foam border applied. Review of R58's Order Summary dated 12/25/25 revealed, foam border dressing to bilat. (bilateral) buttocks wounds, change daily and prn (as needed) dysruption (sic) every day shift for wound care. Further review of R58's Order Summary revealed no order for R58 to be in EBP due to the wound on her coccyx. During an observation on 01/07/2026 at 1:25 PM, there was no EBP signage posted outside of R36 and R58's room. During an observation on 01/08/2026 at 10:52 AM, there was no EBP signage posted outside of R36 and R58's room. During an interview on 01/08/2026 at 10:56 AM, Licensed Practical Nurse (LPN) U reported that R58 was not in EBP, and if she was, there would be signage on her door to alert staff to wear appropriate PPE (personal protective equipment) when performing tasks. LPN U reported that the ICP was responsible for apply the signage on the doors. During an interview on 01/08/2026 at 11:16 AM, the DON was notified that R58 and R36 both required wound care but were not in EBP. The DON confirmed the ICP is responsible for ensuring residents were placed in EBP and that appropriate signage and PPE was placed outside of the room. Review of the CDC guidance (dated 6/28/24), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. Review of the facility policy Infection Control Surveillance last revised 9/25/24 revealed, .The infection preventionist or designee will utilize surveillance tools to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics/ monitor employee infection, monitor adherence to infection prevention and control practices, and detect unusual pathogens with infection control implications. On 1/7/26 at 11:48 AM a request for policy for employee call-offs was requested. The policy did not include tracking off illnesses or return to work criteria. Review of the State Operations Manual revealed the infection control surveillance, Establishes facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. NOTE: For purposes of this guidance, staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Enhanced Barrier Precautions (EBP) EBP are used in conjunction with standard precautions and expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. R40 A review R40's admission Record, dated 1/6/26, revealed R40 was a [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R40's admission Record revealed multiple diagnoses that included contacted with and suspected exposure to COVID-19. A review of a sign posted onto the outside of R40's door on 01/06/2026 at 8:45 AM, revealed R40 was in isolation and Special Droplet Contact Precautions (gown, gloves, face shield, and N95 respirator) were to be followed for anyone entering R40's room. During an observation on 01/06/2026 at 8:45 AM, Maintenance Assistant (MA) A was observed going into Resident #40's room with a blue surgical mask on. The sign posted on the outside of Resident #40's room door revealed, Special Droplet Contact Precautions and advised anyone entering the room to wear a gown, gloves, face shield, and N95 respirator. MA A also left the room door open approximately 3 inches so the surveyor could see him standing next to R40's bed talking with him. The sign on the door also instructed staff, visitors, and physicians (doctors) to keep the room door closed. MA A was in R40's room for approximately 5 minutes. During an interview on 01/06/2026 at 8:50 AM, MA A stated he was aware that R40 had a sign on his door revealing he was in Special Droplet Contact Precautions. MA A verbally confirmed that anyone going into R40's room should wear a gown, glove, N95 respirator, and face shield. During an interview on 01/06/2026 at 8:55 AM, Certified Nursing Assistant (CNA) B verified that R40 was in isolation and Special Droplet Contact Precautions were to be followed for anyone entering R40's room. CNA B also stated R40 was in isolation for COVID-19. A review of R40's Provider encounter note, dated 12/20/25, revealed, Patient is seen for COVID-19 infection. Patient diagnosed over the weekend with COVID-19 tested positive on rapid testing here in facility due to symptoms of cough and nasal drainage. Patient is in bed. He does continue to complain of cough; his oxygen saturations are stable. Meds reviewed and vital signs are stable.

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of ceilings and ventilation covers of resident restrooms 11, 12 and 13. Findings Include:On 01/15/2026 at 2:00PM, observed cobwebs on the vent's cover in the restrooms for rooms 11,12,13. Record review of Healthcare Services Group, Housekeeping schedule, states, Cleaning resident rooms using the 5 and 7 step cleaning process. The 5 and 7 step cleaning process lists what needs to be cleaned and cleaning methods for those steps, such as horizontal surfaces, vertical surfaces, dust mop and damp mop. On 1/05/2025 at 2:00PM, observed in room [ROOM NUMBER]'s restroom, the ceiling tile is sagging and partially off the ceiling grid tracks allowing for an accessible space of half inch between the tile and the track. On 01/05/2026 at 3:15PM, interview with Maintenance CC disclosed they were unaware of the ceiling tile sagging in room [ROOM NUMBER]'s restroom.

This citation pertains to intake #2665891Based on observation, interview, and record review, the facility failed to follow professional guidelines for two of two resident's (resident #72 and Resident #91) reviewed for peripheral and central intravenous fluids. Findings:Resident #72 (R72)Review of an admission Record revealed R72 was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses of a right femur fracture. R72 was most recently hospitalized on [DATE] to 12/10/25 for an infected prosthesis in the right femur and had a central catheter placed to receive intravenous antibiotics. During an observation on 01/05/26 at 11:30 AM, R72 sat in a chair with an IV (intravenous) antibiotic hanging on an IV pole and the antibiotic was connected to a PICC (percutaneously inserted central catheter) in R72's right arm. R72 stated that the tubing that delivered the antibiotic fluid to the PICC was stuck inside the lumen (opening) of the PICC and nursing could not get it out. They have called in a specialty nurse for it. During the same observation, it was noted that a folded-up gauze dressing was covering the catheter at the site it entered the skin, this dressing was visible through the clear dressing (opsite) covering the entry site of the PICC. R72 stated that the dressing for the PICC line had just been changed by nursing. Review of an Electronic Treatment Administration Record (Etar) for R72, dated January 5th, 2026, revealed that there was not a measurement of the PICC external catheter for nursing to monitor daily. The measurement would alert nursing if the catheter had been moved at all from its original placement. During an interview on 01/05/26 at 11:49 AM, Unit Manager/Licensed Practical Nurse (UM/LPN) II indicated that she had completed a PICC line dressing change that morning for R72 and also reported that there were no measurements available regarding the length of R72's PICC. UM/LPN II stated that a specialty vascular access nurse had been called in the evaluate the tubing that had been stuck into the lumen of the PICC. Antibiotic therapy for R72 had been paused until the PICC was evaluated further. During an interview on 01/05/26 at 2:20 PM, Vascular Access specialty Registered Nurse (RN-VA) BB evaluated R72's PICC and indicated that the IV tubing had been incorrectly pushed into the opening of the PICC instead of using a needless connector. RN-VA BB was able to safely remove the IV tubing from the opening of the PICC and then proceeded to remove the dressing. The end of the catheter was coiled up and covered by a folded gauze dressing, and the insertion site at the skin could not be seen without removing the dressing. RN-VA BB indicated that the gauze dressing should not be under the clear sterile PICC dressing as it was a medium (a good environment) for bacterial growth. The gauze dressing also obscured (blocked) the nurses from seeing how long the PICC was from the skin to the needless connector (which would let nursing know if the catheter had moved). RN-VA BB stated this was an important measurement for nursing to know because the tip of the PICC was placed in a blood vessel very near to heart and if it moved, it could have serious consequences. Resident #91 (R91) Review of an admission Record revealed R91 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of metabolic encephalopathy (altered mental status) due to sepsis (a blood infection) and had a central catheter placed to receive intravenous (IV) antibiotics. Review of an admission assessment dated [DATE], for R91 revealed the resident was admitted to the facility with a PICC placed in the left arm. The Assessment did not have any information regarding the size and length of the catheter, the circumference of the arm at the catheter insertion site, and how the PICC line site appeared, ie was the dressing intact, any redness or other signs of infection etc. Review of an Electronic Medication Administration Record (Emar) revealed an order for R91 to receive IV antibiotics every 8 hours for 28 days until 11/25/25. Review of an Etar for R91 dated October 2025 revealed there were no orders for nursing to monitor the PICC site, to change dressings weekly and as needed, to monitor for signs and symptoms of infection, monitor the length of the catheter, and flushing the catheter. During an interview on 01/08/26 at 10:30 AM, Physician Assistant (PA) W stated that if the hospital does not sent orders regarding the monitoring of the catheter (PICC), flushing, etc the nurses should recognize this and call for orders. Review of a Nursing Progress Note for R91, dated 11/1/25 revealed .per report, PICC pulled by Registered Nurse/Unit Manager/Infection Control Preventionist Z because IV med was discontinued. During the same interview on 01/08/26 at 10:30 AM, Physician Assistant (PA) W indicated that an order to stop IV antibiotics and pull the PICC line were not given. Review of the facility policy IV Therapy Peripherally Inserted Central Catheter (PICC) reflected .Length of the catheter is specific to the resident. The length needs to be documented in the medical record .this is a very fragile catheter and can be broken easily .and the upper arm circumference should be measured on admission and weekly to monitor for infiltration.

Based on observation, interview, and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development of a injuries and 2.) assess, monitor, and provide ordered treatment for residents with pressure injuries/wounds for 2 residents (Resident #58 and #43) out of 18 residents reviewed for pressure injury prevention/management.Findings:Resident #43 (R43) Review of an admission Record revealed R43 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of a stroke causing paralysis and weakness on the resident's left side. During an observation on 01/07/26 at 9:45 AM, Certified Nurse Aide (CNA) P provided morning care for R43 and a dressing on R43's coccyx area was in place. The dressing had writing on it in blue maker, the date 1/4, and also written on the dressing in black marker were the dates 1/6 and 1/7. The Director of Nursing was called to R43's room to observe the multiple dates written on the dressing. The DON observed the dressing and stated that it looked like the dates had been changed on the dressing so that it wouldn't have to be changed. Review of an Electronic Treatment Administration Record (Etar) for R43, dated January 2026, revealed an order to clean open area on coccyx with normal saline, pat dry, and apply Optiform for protection every night shift every other day starting 01/04/26. There was no documentation that showed the dressing had been changed on 01/06/26. Review of a Care Plan for R43 reflected: Resident has pressure ulcer and . administer treatments per physician orders. Resident #58 (R58) Review of an admission Record revealed R58 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke, abnormal weight loss, and cerebral palsy. Review of R58's Braden Scale-for Predicting Pressure Ulcer Risk Evaluation dated 12/5/25 indicated R58 was a High Risk for developing a pressure injury. The evaluation dated 12/14/25 and 12/21/25 revealed R58 was a moderate risk for developing a pressure injury. During an observation on 01/05/2026 at 9:31 AM, R58 was in bed on her back with her heels elevated off the bed. There were no pillows/offloading devices behind her left or right side to reduce pressure and prevent the worsening of her skin injury. During an observation on 01/05/2026 at 11:23 AM, R58 was in bed on her back with her heels elevated off the bed. There were no pillows/offloading devices behind her left or right side. During an observation on 01/05/2026 at 1:12 PM, R58 was in bed on her back with her heels elevated off the bed. There were no pillows/offloading devices behind her left or right side. During an observation on 01/05/2026 at 2:26 PM, R58 was in bed on her back with her heels elevated off the bed. There were no pillows/offloading devices behind her left or right side. During an observation on 01/05/2026 at 4:04 PM, R58 was in bed on her back with her heels elevated off the bed. There were no pillows/offloading devices behind her left or right side. During an observation on 01/06/2026 at 8:38 AM, R58 was in bed with her heels elevated. There was a pillow slightly under her left side. R58 was not positioned in a way to fully offload pressure on her buttocks. During an observation on 01/06/2026 at 11:46 AM, R58 was in bed with her heels elevated. There was a pillow slightly under her left side. R58 was not positioned in a way to fully offload pressure on her buttocks. During an observation on 01/06/2026 at 9:47 AM, R58 was in bed with her heels elevated. There was a pillow slightly under her left side. R58 was not positioned in a way to fully offload pressure on her buttocks. Review of R58's Skin-Total Body Eval (to be completed weekly) revealed the last evaluation was completed on 7/27/25. Review of R58's Hospice Note dated 12/24/25 revealed, .skin open of left side (about 1 inch diameter) of buttocks near coccyx. LPN (Licensed Practical Nurse [name omitted]) and this RN (Registered Nurse) assess, and foam dressing applied. (LPN) to update plan of care, and alert doctor . Review of R58's Nursing Progress Note dated 12/24/2025 revealed, hospice rn in, open area noted lt. (left) buttock, nearly open rt. (right) buttock, (provider group) and wound team notified, foam border dressing applied. Review of the Provider Communication Log dated 12/24/25 revealed R58 had (left) buttock-open area and (right) buttock-nearly open with a foam border applied. Review of R58's Electronic Medical Record revealed no documentation that a comprehensive wound assessment was conducted at the time the skin breakdown/pressure injury was identified. (Comprehensive wound assessments are to include location, dimensions, description of wound bed, exudate type, exudate amount, presence of odor, wound edges, peri-wound assessment, tunneling/undermining, and pain.) Review of R58's Order Summary dated 12/25/25 revealed, foam border dressing to bilat. (bilateral) buttocks wounds, change daily and prn (as needed) dysruption (sic) every day shift for wound care. Review of R58's January Treatment Administration Record (TAR) revealed the foam boarder dressing change was not completed on 1/2/26 or 1/3/26. Review of R58's Skin Issues (wound evaluation) dated 1/8/26 at 11:39 AM revealed a new wound, In-house acquired, Open lesion on the left coccyx measuring 1.8 cm (length) x 1.38 cm (width) x 0.1 cm (depth). (Completed 15 days after the wound was discovered.) Review of R58's Care Plan revealed no documentation of the pressure injury identified on 12/24/25 or any newly implemented interventions to prevent further breakdown. R58's skin integrity Care Plan was last updated on 10/22/23. Review of R58's Care Plan revealed: Focus: (R58) has limited physical mobility r/t: -Comorbidities: Cerebral palsy, left-sided weakness and dysarthria following intracerebral hemorrhage (stroke), and history of left hip fracture. Interventions/Task.BED MOBILITY: (R58) requires extensive assist by 2 staff to turn and reposition in bed. Date Initiated: 02/14/2023 (Confirming R58 relied on staff assistance to offload pressure to prevent a pressure injury). AND Focus: (R58) has potential for impairment to skin integrity Goal: (R58's) skin integrity breaks will exhibit healing by next review date. Date Initiated: 03/16/2023 (Indicating R58 had a history of skin breakdown. Additionally, R58's Care Plan had not been updated when the previous skin injuries healed. Interventions/Task.Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (Medical Doctor). Date Initiated: 11/21/2022. R58's Care Plan did not include a turning/repositioning schedule or the use of offloading devices. (No new interventions implemented since 10/22/23.) On 01/08/2026 at 10:40 AM a request was made via email for interventions implemented for R58's skin breakdown identified on 12/24/25 was requested. No documentation was received prior to survey exit confirming R58's care plan had not been updated. During an interview on 01/08/2026 at 12:55 PM, the Director of Nursing (DON) reported skin assessments were to be completed weekly on all residents and confirmed R58 had not had a skin assessment since July. During an interview on 1/8/25 2:22 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) II reported she had not been made aware that R58 had a skin injury identified on 12/24/25 and the expectation was for licensed nurses to notify her and the management team of any new skin injuries. UM/LPN II reported that weekly skin assessments were now scheduled in R58's Electronic Medical Record, a comprehensive wound assessment was completed, and R58 would be evaluated by the wound provider. UM/LPN II reported education would be implemented regarding wound management and a facility wide audit was initiated for any missing treatments. Review of the facility policy Skin and Wound Guidelines last revised 3/20/24 revealed, Skin alterations and pressure injuries are evaluated and documented by the licensed nurse. Weekly evaluation of the skin alteration in the resident's medical record by the wound team or licensed nurse per state and federal regulations. Weekly evaluation of the pressure injury in the resident's medical record by the wound team or licensed nurse per state and federal regulations.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. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base and the factors influencing the patient's risks for poor healing so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue.Measurement of the wound size provides information on overall changes in dimensions, which is an indicator for wound-healing progress ([NAME], 2016). This includes measuring the length and width of a wound, as well as determining its depth (see Skill 48.2). Use a disposable wound-measuring device to measure wound width and length. This approach offers a uniform, consistent method for measuring meaningful comparisons of wound status across time (EPUAP/NPIAP/PPPIA, 2019b). Measure depth by using a cotton-tipped applicator in the wound bed. Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Normally a closed surgical wound has minimal serosanguineous drainage immediately after surgery (see Chapter 50). Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality, and intensity, and any aggravating or relieving factors also should be assessed ([NAME], 2016) (see Chapter 44). Examine the skin around a wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1333). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Early identification of high-risk patients helps prevent pressure injuries (see Chapter 48). Interventions aimed at prevention include turning and positioning and the use of therapeutic support surfaces and devices (e.g., low air loss mattresses, heel boots, flotation mattresses) to relieve pressure. Regular skin care (cleansing of soiled areas and use of moisturizers) aims to maintain the condition of the skin. Change the immobilized patient's position according to his or her activity level, perceptual ability, treatment protocols, and daily routines. For example, an obese patient or a very thin patient, both of whom have bowel incontinence, will require more frequent turning than standard practice. Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown.Chair-bound patients may benefit from a pressure-relief cushion such as an air, viscous fluid/ foam, or gel/ foam cushion that reduces pressure. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 845). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to ensure fluids were within reach for one of three residents (Resident #43) reviewed for hydration. Findings:Resident #43 (R43)Review of an admission Record revealed R43 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of a stroke causing left sided paralysis and protein-calorie malnutrition. During an observation and interview on 01/05/26 at 12:19 PM, R43 sat up in bed eating lunch with the use of her right hand. When asked if R43 could reach the styrofoam cup of water positioned on the left side of the over bed table, R43 responded no but if you move that cup over here (pointed to the right side of the over bed table), I can reach it. During an observation on 01/06/26 at 9:35 AM, R43 laid in bed resting with her eyes closed. The styrofoam cup of water sat on the far-left corner of the over bed table, out of reach of the resident. During an observation on 01/06/26 at 11:14 AM, R43 laid in bed resting with her eyes open and the styrofoam cup of water sat on the far-left corner of the over bed table, out of reach of R43. During an observation on 01/06/26 at 3:20 PM, R43 laid in bed resting with her eyes open. The styrofoam cup of water sat on the far-left corner of the over bed table out of reach. When asked if she could reach the water cup, R43 attempted to reach across her body with her right arm and demonstrated that she could not reach the water cup. During an observation on 01/07/26 at 8:20 AM, R43 activated the call light system and stated that she was thirsty and wanted a drink but could not reach the cup of water that sat on the left side of the over bed table. Review of R43's Care Plans revealed she did not have a treatment plan in place that addressed her left sided paralysis and inability to reach with her left hand and her need to have hydration positioned so R43 could reach it with her right hand.

Based on observation, interview, and record review, the facility failed to follow physician orders for one of two resident's (Resident #93) reviewed for tube feeding. Findings:Resident #93 (R93)Review of an admission Record revealed R93 was a 65- year-old female, admitted to the facility on [DATE], with pertinent diagnoses of a new PEG (percutaneous endoscopic gastrotomy) tube placed on 12/29/25, following a stroke that caused right sided weakness and difficulty swallowing. During an observation on 01/05/26 at 12:32 PM, the 60-milliliter (ml) syringe used for tube feed flushes sat in the graduated basin with the barrel in the syringe and not separated, after cleaning it to air dry. R93 stated I need a drink. During an observation on 01/05/26 at 4:04 PM, R93's tube feed ran and the head of the bed (HOB) was positioned at 10 degrees. The tube feed formula bag did not have the date and time the feed was initiated nor the physician ordered rate. During an interview on 01/06/26 at 8:47 AM, R93 asked for something to drink. During an observation on 01/06/26 at 3:40 PM, R93 sat up in a Broda chair near the nurse's desk. R93 stated she was very thirsty. During an observation on 01/07/26 at 8:16 AM, R93 laid in bed resting with her eyes closed. The tube feed ran at the physician ordered rate and was almost empty. However, the kangaroo flush bag (how the resident receives hydration) was full. Per the infusion pump (an electronic device that was programmed by nursing to deliver tube feed nutrition and water flushes at a physician ordered rate) a flush rate had not been set and R93 was not receiving any hydration since the tube feed was initiated at 4 PM on 01/06/26. The previous tube feed run ended at 8:00 AM on 01/06/26 and R93 had not received any fluids/hydration in the past 24 hours. The 60-milliliter syringe used for tube feed flushes sat in the graduated basin with the barrel in the syringe, not separated, and the graduated container was dated 01/06. During an interview on 01/07/26 at 8:59 AM, Licensed Practical Nurse (LPN) T reported having started the tube feed and hydration flush for R93 yesterday (01/06) afternoon and did not double check to ensure the hydration flush was programmed and running. During an observation on 01/08/26 at 8:17 AM, R93 laid in bed resting with her eyes closed and the tube feed running. The syringe and graduated basin for flushes was dated 01/06 and the barrel was in the syringe. The tube feed formula bag did not have the date and time the feed was initiated nor the physician ordered rate. Review of an Electronic Medication Administration Record (Emar) for R93 dated January 2026 reflected the following physician orders: (a) Tube feed order .flush with water 50 ml's every 1 hour while tube feed is infusing and flush with 60 ml's of water after each feeding, and (b) elevate HOB to 30 to 45 degrees at all times during tube feed. There was no documentation on the Emar that indicated nursing signed off on these two orders the evening of 01/02/26. Review of the facility policy Tube Feeding reflected .the tube feed formula/flushing 60 ml (milliliter) syringe will be dated and changed every 24 hours .after using the 60 ml syringe, clean with warm/hot water and dry. The plunger is not reinserted into the barrel and is stored dry in a container for the next use .on the formula bag document the date and time the formula was hung/administered and the physician ordered rate of administration .position the head of the bed at least 30 degrees for tube feeding.

Based on interview and record review, the facility failed to account for controlled substances in one of one medication carts reviewed for narcotic reconciliation. Findings:Review of the Controlled Medication Shift Change Log for the medication cart Medbridge 1 revealed an incorrect total was documented on 1/3/26 at 7:30 AM. That incorrect total was carried forward through the next four shift change counts. Review of the Controlled Substance Shift Inventory sheets for the medication cart Medbridge 1 dated 11/22/25 to 12/30/25 revealed the following:Two nurses' signatures were not documented on (a) 11/25 at the 7 PM count, (b) 11/30 at the 7 AM count, (c) 12/04 at the 3 PM count, (d) 12/8 at the 3 PM count 12/16 at the 7 PM count, and on 12/19 at the 7 AM count. An end of shift total was not documented on (a) 11/25 at 11:15 PM, (b) 11/29 at 7 AM, (c) 12/1/ at 3 PM, (d) 12/3 at 7 PM, (e) 12/4 at 3 PM, (f) 12/10 at 7 PM, and (g) 12/11/ at 7 AM. Incorrect counts were noted on (a) 11/22 at 7 PM, (b) 11/28 at 7 PM, (c) 12/1 at 7 PM, (d) 12/2 at 7 AM, (e) 12/18 at 7 am, and (f) 12/29 at 7 PM. During an interview on 01/08/26 at 1:40 PM, the Director of Nursing (DON) indicated that Unit Manager/RN Z was in charge of auditing the controlled substance documentation on the medication carts. The DON also stated, after reviewing the above findings, that the documentation was not the policy nor expectation of the facility. Review of the facility policy Controlled Medication Guidelines reflected: .A physical inventory of all controlled medications is completed by two licensed nurses and is documented on the shift-to-shift form at shift exchange or whenever a nurse relinquishes their keys to another nurse and .the two nurses sign the shift-to-shift count sheet acknowledging that the actual count of controlled medication matches the quantity documented.

This citation pertains to intake #: 2664254Based on interview and record review, the facility failed to notify the provider of 1.) a change in condition and 2.) abnormal vital signs for 2 of 18 residents (Resident #90 and #81) reviewed for notification of change.Findings:Resident #90 (R90)Review of an admission Record revealed R90 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: type 1 diabetes mellitus with hyperglycemia.Review of a Facility Reported Incident (FRI) dated 9/17/25 revealed, (Hospital) patient navigator emailed facility to inform us that (R90) alleged he was being abused at our facility regarding his insulin management.Review of R90's Order Summary dated 8/6/25 revealed, Obtain Blood Sugar before meals and at bedtime before meals and at bedtime for blood glucose monitoring Less than 60 or greater than 200, notify physician.Review of R90's Blood Sugar Summary revealed:On 8/11/2025 at 9:49 PM, R90's blood sugar was 533 On 8/11/2025 at 10:50 PM, R90's blood sugar was 508 On 8/12/2025 at 1:27 AM, R90's blood sugar was 490 On 8/15/2025 at 11:23 PM, R90's blood sugar was 433 On 8/16/2025 at 7:14 AM, R90's blood sugar was 409 On 8/18/2025 at 10:09 AM, R90's blood sugar was 418 On 8/18/2025 at 10:20 AM, R90's blood sugar was 400 On 8/29/2025 at 7:44 AM, R90's blood sugar was 419 On 9/5/2025 at 11:15 PM, R90's blood sugar was 551 On 9/9/2025 at 11:29 AM, R90's blood sugar was 400 On 9/10/2025 at 4:52 PM, R90's blood sugar was 400Review of R90's Electronic Medical Record revealed no documentation that the provider was notified of the elevated blood sugar.During an interview via email on 01/08/2026 at 11:47 AM, a request for documentation that the provider had been notified of R90's elevated blood sugars was made. On 01/08/2026 at 12:15 PM, Nursing Home Administrator (NHA) stated, Unfortunately, we do not see anything documented either.During an interview on 01/08/2026 at 12:55 PM, the Director of Nursing (DON) reported that the expectation was for the licensed nurses to notify the provider of elevated blood sugars and that was typically done when a blood sugar reading was greater than 450.Resident #81 (R81)Review of an admission Record revealed R81 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease and presence of cardiac pacemaker.Review of R81's Medication Administration Record revealed a dose of Nitroglycerin Sublingual Tablet was administered on 1/5/25 at 1:49 AM.Review of R81's Nursing Progress Note dated 1/5/2026 at 01:50 AM revealed, Patient complained of chest pain on left side nitroglycerin given. BP (blood pressure) 158/90 P(pulse) 73 R (respirations) 18 T (temperature) 97.3 Sats (Oxygen Saturation) 93% at room air. Nurse notified patient's wife of patient's condition and she stated to continue to monitor and she will be in this morning. Per Fundamentals of Nursing ([NAME] and [NAME]) 11th edition a myocardial infarction (heart attack) in men is usually described as crushing, squeezing, or stabbing. The pain is often in the left chest and sternal area.Review of R81's Nursing Progress Note dated 1/5/2026 at 2:31 AM revealed, Received call back from patient's wife CNA (Certified Nursing Assistant) reports patient resting quietly in bed. Patient's wife stated that if he becomes worse to send him to (name omitted) Hospital for evaluation.Review of R81's provider Progress Note dated 1/6/26 at 8:59 AM revealed he was assessed by the provider for elevated sugars.Review of R81's provider Progress Note dated 1/6/26 at 10:33 AM revealed he was assessed by the provider for emergency room and UTI (urinary tract infection) follow-up.Review of R81's Electronic Medical Record revealed no documentation that the provider had been notified of the episode of chest pain despite R81's complex history of heart disease and other comorbidities.Review of the Provider Communication Log revealed no documentation that the episode of chest pain was documented for provider follow-up.On 01/07/2026 at 2:07 PM, the Director of Nursing (DON) confirmed that there was no documentation that the provider had been notified of the episode of chest pain.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Be aware of the following common negligent acts that have resulted in lawsuits against hospitals and nurses (Frank and [NAME], 2019; Grant and [NAME], 2018): Failure to follow the standard of care Failure to communicate (e.g., failure to notify the health care provider of abnormal assessment data or significant changes in a patient's status) Failure to document care and evaluation of care provided to the patient Failure to assess and/or monitor, including making a nursing diagnosis. [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, interview, and record review, the facility failed to ensure call lights remained within reach for three of three resident's (Resident #43, Resident #93, and Resident #10) reviewed for accommodation of needs. Findings:Resident #43 (R43)Review of an admission Record revealed R43 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of a stroke that caused left sided weakness and paralysis, a history of falls, and lack of coordination. During an observation on 01/05/26 at 8:58 AM, R43 laid in bed with her eyes open. When asked if she could locate her call light, R43 looked around her bed and stated that she could not find it. The call light sat on the floor under the head of the bed, out of sight and out of reach of R43. During an observation on 01/05/26 at 10:57 AM, R43's call light remained on the floor under the head of the bed, out of sight and out of reach. During an observation on 01/05/26 at 12:01 PM, R43's call light laid on the floor under the head of the bed, out of reach and out of sight. Review of a Care Plan for R43 reflected the following intervention: (R43) will use the call light to call for assistance. Resident #93 (R93) Review of an admission Record revealed R93 was a 65- year-old female, admitted to the facility on [DATE], with pertinent diagnoses of a new PEG (percutaneous endoscopic gastrotomy) tube placed on 12/29/25, following a stroke that caused right sided weakness and difficulty swallowing. During an observation on 01/06/26 at 8:30 AM, R93 laid across the bed, legs off the right side of the bed, gown partially pulled up and stated, I want a drink. The call light laid on the floor at the right side of the head of bed, out of reach and out of sight of R93.During an observation on 01/08/26 at 8:25 AM, R93 laid in bed with her eyes closed, the tube feed ran, and the call light hung off the left side of the bed half-way to the floor, caught on the tube feed tubing pulling it taught from the resident to the infusion pump. The call light sat out of sight and out of reach of R93. Resident #10 (R10)Review of an admission Record revealed R10 was an [AGE] year-old female. During an observation on 01/05/26 at 1:58 PM, R10 sat up in bed awake and stated that if she needs anything she uses the call light system. R10 could not locate the call light at that time. The call light sat on the floor near the head of the bed out of sight and out of reach of the resident. During an interview on 01/08/2026 at 10:55 AM, Certified Nurse Aide (CNA) LP stated that the expectation for checking call light availability was that call lights were checked each time staff enter a room. Review of the facility policy Call Light Accessibility and Timely Response reflected .staff will be educated in the proper use of the resident call system, including how the system works and ensuring residents have access to the call light.

This citation pertains to intake #: 2641157Based on interview and record review, the facility failed to 1.) prevent misappropriation of resident medication and 2.) monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 2 residents (Resident #38 and #41) out of 7 residents reviewed for the misappropriation of medications, resulting in the diversion of medications and the potential for ongoing diversion of medications. Findings:Resident #38 (R38)Review of an admission Record revealed R38 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes.Review of R38's Facility Reported Incident (FRI) dated 10/29/25 revealed, .Verified The allegation was supported by evidence collected during the investigation.On 10/28/25 (Registered Nurse [RN] GG) accepted the Ozempic from the pharmacy at 11:30pm and had it in her possession. She received the medication from pharmacy then attempted to get (Licensed Practical Nurse [LPN] KK) to co-sign with her. This was concerning to (LPN KK) as it was already in (RN GG's) possession. (LPN KK) reported this to the DON (Director of Nursing) at 06:40am on 10/29/25. When first shift arrived at 0700am the medication was unable to be located. (RN GG's) statement was that she couldn't be responsible for the Ozempic because it was not her assigned resident. Packing slips for all meds delivered were recovered-except for the Ozempic.(RN GG) was stated by multiple co-workers that she was often communicating/inquiring about medications for weight loss.RCA highlighted the need for controlled access to GLP1s (type of medication) due to cost which was immediately implemented and all licensed nurses were re-educated on the process.(RN GG) was called on 10/31/25 and 1/03/25. Messages were left and there was no response to the facility. This was an isolated incident in which the facility responded promptly and replaced the Ozempic at facility cost. There were no missed doses or delays. There was no harm to the resident (R38).Resident #41 (R41)Review of an admission Record revealed R41 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain in left and right knees.Review of a Minimum Data Set (MDS) assessment for R41, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R41 was cognitively intact. Review of R41's Order Summary dated 11/15/24 revealed, HYDROcodone-Acetaminophen (Norco) Tablet 5-325 MG Give 1 tablet by mouth every 12 hours as needed for breakthrough pain management.Review of R41's Controlled Drug Receipt/Record/Disposition Forms revealed that from 10/25/25-1/4/26 only 1 nurse (LPN HH) dispensed the Norco to R41. No other licensed nurses dispensed any tablets of Norco to R41.An entry between 12/22/25 and 1/3/26 indicated a correct count was completed indicating a tablet of Norco was missing and could not be accounted for.During an interview on 01/07/2026 at 8:31 AM, R41 reported she took pain medication at night which was effective in controlling her leg pain. R41 confirmed the medication was Tylenol and was scheduled (not administered as needed). R41 reported she did have an order for as needed pain medication (Norco) but never asks for it as her pain was controlled without it.During an interview on 01/07/2026 at 2:20 PM, the DON reviewed R41's Controlled Drug Receipt/Record/Disposition Forms and confirmed that only 1 nurse dispensing a narcotic appeared suspicious for narcotic diversion.During an interview on 1/7/26 at 3:47 PM, the NHA confirmed what R41 had reported of the scheduled evening Tylenol being effective for her pain control and not requiring the as needed Norco. The NHA reported LPN HH would be suspended pending a misappropriation/diversion investigation.Review of the facility policy, Controlled Medication Guidelines last revised 3/20/24 revealed, .Suspected tampered packages (i.e. vials without tamper evident caps or taped punch cards) and unresolved discrepancies in the count must be reported immediately as follows: Notify the DON, charge nurse/ or designee and the pharmacy. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted. The DON, charge nurse, or designee must also report any loss of controlled medications where theft is suspected to the appropriate authorities such as local law enforcement. Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators.

This citation is related to intake #2674209Based on interview and record review, the facility failed to treat one resident (Resident # 72) in a dignified manner, out of three residents reviewed for dignity and respect. Findings: Resident #72 (R72) Review of an admission Record revealed R72 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of an infected right hip replacement and difficulty walking. During an interview on 01/05/26 at 11:26 AM, R72 reported the following details regarding an incident that occurred very early in the morning on 11/12/25, that involved R72 and Certified Nurse Aide (CNA) Y: (a) during the night/early morning of 11/12/25 CNA Y came into her room and told R72 to stop putting on her call light and that CNA Y had been into R72's room multiple times tonight and was not coming back again, (b) R72 stated that CNA Y then messed around with her bed control and call light and left the room, (c) R72 fell back asleep, woke up sometime around 5 AM and needed to go to the bathroom, (d) R72 looked for and could not find her call light, (e) R72 had a bowel movement and urinated in her undergarments because she could not find the call light to alert staff that she needed help, and (f) R72 reported that she was devastated and embarrassed by the incident and was tearful when recounting the details of the incident. It felt like she (CNA Y) didn't come back on purpose to punish me. R72 stated that she finally got help from CNA S after shift exchange. During an interview on 01/06/25 at 12:35 PM, CNA S reported that entering R72's room the morning of 11/12/25 and could smell feces and that R72 was very upset. CNA S indicated that R72's sheets were saturated with urine and feces and that the call light was wrapped up with the bed remote, on the floor, out of sight and out of reach of the resident. CNA S recalled that R72 was embarrassed about the incident. CNA Y no longer worked at the facility and could not be reached for comment.

Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure injuries for 1 resident (Resident #6), out of 3 residents reviewed for pressure injuries, resulting in the worsening of a pressure injury and prolonged healing time without new interventions added to the treatment/care plan to address pressure reduction to the affected area and areas at risk for pressure injury. Findings: Resident #6 (R6) Review of an Admission Record reflected R6 admitted to the facility with diagnoses that included diabetes, osteomyelitis, unsteadiness on feet, peripheral vascular disease, protein calorie malnutrition, heart failure, non-pressure chronic ulcer to bilateral lower extremities and dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected that R6 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6/15 and needed extensive assistance from one person for bed mobility, transfers and dressing. R6 was coded as being at risk for pressure ulcers based on clinical assessment and was coded as having one unstageable pressure ulcer due to coverage of wound bed by slough (a yellow or white material in the wound bed) and/or eschar (a type of necrotic tissue that can develop on severe wounds). Review of an Encounter note dated 6/9/23 indicated R6 was being followed by NP G for treatment of chronic venous stasis ulcers. Additionally, the progress note specified .Resident (R6) also had a wound on the left heel measuring 4.0 x 7.5 x 0.1cm (centimeters), the wound was a large bullous lesion that had ruptured, I did remove the overlying epithelial tissue, underneath the wound base is 100% epithelial tissue with moderate serosanguinous drainage, no odor, wound edges are intact and attached . The Plan in the note reflected Resident (R6) also with a new wound on the left heel which appears to be a pressure injury, I am concerned it may have been caused by the Unna boot (a compression dressing that was being used to treat R6's venous stasis ulcers; a gauze that is applied wet, similar to a cast, and dries to form a semirigid mold) so I am going to discontinue the Unnaboots. Review of Encounter notes documented by PA G indicated that R6's left heel pressure ulcer was not seen again until 6/23/23 when it was noted .Ulcer on the left heel measures 2.5 x 5.0cm, there is a depth of 0.1cm though this is not a true depth due to the presence of eschar (necrotic tissue), the wound base is 40% eschar, 40% granulation tissue and 20% epithelial tissue, there is moderate serosanguineous drainage with no odor, wound edges are intact and attached . The note indicated the pressure injury on the left heel was smaller than previously documented but unstageable due to the presence of eschar. Staff were instructed to continue encouraging R6 to lay down a couple of times a day to elevate her legs. Review of an Encounter note dated 7/7/23 reflected that the pressure ulcer on R6's heel was improved since the prior evaluation. Review of an Encounter noted dated 7/19/23 reflected R6 had been hospitalized from 7/8/23-7/13/23 for hyperkalemia (high potassium) and hypoxia (low blood oxygen) and was put on an antibiotic for her left heel wound which was NOT found to be related to osteomyelitis (a bone infection) and it was noted R6 did NOT have peripheral artery disease (PAD). PA G debrided (cut away) loose eschar from the left heel pressure ulcer which remained unstageable due to the presence of slough over 90% of the wound bed. PA G indicated Continue pressure relieving boots when in bed. Review of an Encounter note dated 8/18/23 reflected PA G assessed the pressure ulcer on R6's left heel and noted Pressure injury on left heel is bigger today and the granulation tissue is non-blanchable purple discoloration and is at risk of becoming nonviable, will consider the wound unstageable at this time .Resident should have pressure relieving boots on whenever she is in bed (this is in her Kardex). Review of an Encounter note dated 8/25/23 reflected PA G again noted the left heel pressure ulcer had gotten bigger, Pressure injury on the left heel is bigger today, there is also an odor noted today and erythema to the peri wound concerning for cellulitis, will start Keflex (antibiotic) 500mg (milligrams) three times a day for 10 days. PA G discontinued the previous dressing change order, implemented a different treatment and again specified Resident should have pressure relieving boots on whenever she is in bed (this is in her Kardex) . Further review of the remaining Encounter notes from 8/25/23-10/20/23, documented by PA G reflected that the pressure ulcer on R6's left heel would show signs of improvement, then worsen, then show signs of improvement again. PA G consistently documented the need for R6 to have pressure relieving boots on whenever she was in bed with each progress note. The most recent Encounter note dated 10/20/23 indicated the wound was 19 weeks old and continued to reflect R6's left heel pressure ulcer was unstageable due to the base of the wound was 60% slough. During an observation on 10/23/23 at 8:01 AM, R6 appeared to be asleep in the bed, no pressure relieving boots are in place, right and left heels are on the mattress. During an observation on 10/23/23 11:00 AM, R6 is in the bed with both heels resting on the mattress, pressure relieving boots were not in place. During an observation on 10/24/23 at 7:55 AM, R6 was lying in bed, both heels resting on the mattress, pressure relieving boots were not in place. During an observation on 10/24/23 at 9:39 AM, R6 was resting in bed, both heels resting on the mattress, pressure relieving boots were not in place. During an observation and interview on 10/24/23 beginning at 10:07 AM, Licensed Practical Nurse (LPN) H completed an ordered dressing change to R6's left lower leg and heel. LPN H did not apply pressure relieving boots per PA G's instructions. During an interview on 10/24/23 at 10:23 AM, R6 said she didn't think that staff ever tried to keep her heels off the mattress when she was in bed. During a follow-up interview on 10/24/23 at 10:32 AM, LPN H reported that she did not know why staff weren't elevating R6's heels off the bed but would talk to Unit Manager (UM) I and get an order for a heels up intervention. Per LPN H, floating/relieving pressure to R6's heels should be done even without an order. During an interview on 10/24/23 at 10:45 AM, UM I and the Director of Nursing (DON) said that R6 will often refuse to elevate her heels off the bed. UM I and the DON said that staff did not document when R6 would refuse to keep pressure off her heels. During an observation on 10/24/23 at 11:39 AM, R6 was observed with a pillow under her left lower leg, but the heel was still making full contact with the pillow. R6's right heel was resting on the mattress. During an interview on 10/24/23 at 11:43 AM, Certified Nursing Assistant (CNA) J said she thought R6 had blue boots (pressure relieving boots) at one time but reported one of them was missing and wasn't sure if the boots were still supposed to be used. CNA J indicated she had just placed a pillow the long way under R6's left lower leg. CNA J agreed that R6's left heel was still making contact with the pillow and turned the pillow to support floating R6's heel off the bed. CNA J was not observed floating R6's right heel which was still resting on the mattress. Review of a Care Plan initiated on 6/12/2023 reflected (R6) has an actual impairment to skin integrity r/t (related to): recurrent vascular ulcers on bilateral lower extremities; unstageable PI (pressure injury) to the left heel. The goal of the care plan focus area was that R6's skin integrity breaks will exhibit healing by the next review date (1/24/2024). Interventions to meet the goal included Follow physician orders for treatment of skin impairments. Refer to eTAR (electronic Treatment Administration Record) for specifics. The intervention Elevate heels off bed surface while at rest in bed had not been added to the care plan until 10/23/23 and was revised on 10/24/23. Alternative interventions to meet R6's need to keep pressure off the left heel were not noted as it related to reports that R6's refused to off-load pressure while in bed or in her wheelchair. Review of another Care Plan focus area indicated R6 had the potential for impairment to skin integrity r/t comorbidities (two or more diseases or medical conditions and is associated with worse health outcomes) that included a history of a healed right heel deep tissue injury. The intervention Pressure relieving boots to BLE (bilateral lower extremities) when in bed was Resolved (discontinued) on 10/12/2023. No other interventions on the care plan addressed R6's need to relieve pressure were present or added after the pressure relieving boots were discontinued. Review of the Treatment Administration Records for the months of June-October 2023 did not reflect an order for applying pressure relieving boots or alternate means to relieve pressure areas for R6.

This citation pertains to MI00136207: Past non-compliance was accepted for this citation. Corrective actions identified below. Based on observations, interview and record review the facility failed to follow a resident's (R1) plan of care resulting in R1 falling and sustaining fractures, bruising, emotional distress and pain. Findings include: Review of R1 face sheet dated 5/10/23 and MDS (minimum data set) revealed R1 initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnosis that included: Hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke) affecting left non-dominant side, asthma, anxiety, pain and depression. R1 was their own responsible party and their most recent MDS assessment on 4/20/23 revealed a BIMS (Brief interview for Mental Status) score of 12/15 indicating mild cognitive impairment. Review of facility reported incident and attachments revealed on 4/22/23 staff A was assisting R1 with a brief change and R1 rolled off the bed. R1 sustained a fracture of the right tibia plateau and left great toe along with multiple contusions (bruises). R1 was care planned to be extensive assist of two people for bed mobility, toileting and transfers however during the incident, staff A was assisting R1 alone. Per facility interview with R1 dated 4/24/23 (no time documented) I was being changed by (staff A). She did not have anyone else in the room helping her. When she rolled me to the right (towards the window) I fell off the bed and landed on my face. Interviews with 5 other staff working during the time of the incident revealed staff A had not requested assistance to complete R1's care. On 5/9/23 at approximately 10:20 AM an observation and interview was completed with R1 in her room. R1 stated that a couple weeks ago she had fallen when a staff member rolled her out of bed. R1 stated it was really scary at the time. R1 stated overall her care is really good and it was not normal for only one staff member to assist her with care. R1 stated it had happened occasionally, but she had never fallen before. R1 stated staff A rolled her off the bed and she hit her face and broke her leg and toe. R1 stated it hurt so bad and I thought I was going to lose teeth too, luckily I did not. R1 stated since the incident two staff have always been present. R1 stated she has experienced pain and bruising from the fall but the pain is under control now. Review of the facility investigation and past noncompliance documentation during an abbreviated survey on 5/9/23-5/11/23 reflected the facility implemented the following interventions that resolved the non-compliance: 1. Staff were educated regarding following the plan of care, transfers and neglect 2. Like residents were interviewed 3. Staff A's employment was terminated 4. R1's injuries were treated and care plan revised 5. QAPI will assess ongoing compliance The facility stated compliance with this action plan was achieved as of 4/28/23

Based on observation, interview, and record review, the facility failed to follow CDC (center for disease control and prevention) infection control guidelines and practices, for 9 of 9 residents reviewed, resulting in an immediate jeopardy when staff (a) did not use proper PPE (personal protective equipment) on Covid units, (b) did not complete respiratory assessments on residents, (c) did not sanitize and clean multi-resident use equipment, (d) independently screened themselves in and at times failed to screen before starting work, (e) handled garbage from a Covid unit without gloves, (f) distributed meal trays to residents without proper hand hygiene and PPE (g) cut through Covid units to access other parts of the facility, and (i) did not have correct signage on doors to alert persons they were entering a restricted Covid unit and what PPE was required on the unit. This deficient practice placed all 82 residents at risk for the transmission of Covid 19 and other [MEDICAL CONDITION] and bacterial diseases spread via airborne, droplet, or contact transmission. During an observation on 11/16/20 at 7:50 A.M., Certified Nurse Aid (CNA) Q (a) left the Covid unit with a gown still on, (b) did not perform hand sanitizing before or after leaving the Covid unit, (c) approached Licensed Practical Nurse (LPN) Y and asked a question, (d) straightened the front of the gown with bare hands, and (e) returned to the Covid unit without changing the gown or performing hand sanitization. During an interview on 11/16/20 at 7:56 A.M., LPN Y stated that the assignment for this shift included Covid + (rooms [ROOM NUMBER]) and Covid - rooms. During an observation on 11/16/20 at 7:58 A.M., LPN Y was observed wearing a gown at the medication cart outside room [ROOM NUMBER]. LPN Y answered the call light for room [ROOM NUMBER] (a room that was identified to have Covid + residents), exited room [ROOM NUMBER], did not remove the gown, and continued to pass medications and answer a call light in room [ROOM NUMBER] (a Covid - room). During an observation on 11/16/20 at 8:08 A.M., LPN S exited the Covid unit, did not remove the gown that had been worn on the unit, did not perform hand sanitization, asked this surveyor of the where abouts of LPN Y, and returned to the Covid unit without changing gowns or performing hand hygiene. During an observation on 11/16/20 at 8:20 A.M., the food cart used to deliver breakfast trays was outside room [ROOM NUMBER] and the door to the cart was open. During an observation on 11/16/20 at 8:30 A.M., maintenance worker S was on the Covid unit without a gown on. During an observation on 11/16/20 at 8:34 A.M., CNA Q was observed (a) on the Covid unit without a gown on, (b) carrying a bundle of gowns, and (c) exited the Covid unit and placed the bundle of gowns in the PPE (personal protective equipment) tower outside room [ROOM NUMBER]. During an observation on 11/16/20 at 8:38 A.M., CNA G (a) removed two breakfast trays from the food cart outside of room [ROOM NUMBER], (b) took the food trays onto the Covid unit without donning a gown, (c) exited the Covid unit and returned to the food cart for two more trays without performing hand hygiene between the handling of food trays, (d) took the additional two food trays onto the Covid unit (e) once on the unit, donned a gown but no gloves and delivered the breakfast tray to the last room on the left (later identified as a resident room), (f) CNA G exited the Covid unit and did not remove the gown or perform hand hygiene, (g) CNA G removed a breakfast tray from the cart and went to room [ROOM NUMBER] ( a Covid + room), (h) in the doorway of room [ROOM NUMBER] and while holding the breakfast tray, CNA G removed the gown that had been worn on the Covid unit and hung it over the hand rail outside the door, and entered the Covid + room without a gown or gloves on, (i) CNA G exited room [ROOM NUMBER], and proceeded to put back on the gown that was hung on the hand rail, (j) CNA G realized that the gown was on inside out and removed the gown and donned it again, (k) no hand hygiene was performed by CNA G before continuing to pass meal trays. During an observation on 11/16/20 at 8:50 A.M., a set of closed double doors that led to the Covid + unit did not have any signage on the doors to alert persons that they were entering a restricted area nor that any specific precautions or PPE were required to enter the unit. During an observation on 11/16/20 at 8:54 A.M., medical records clerk (MRC) E exited the Covid unit wearing a jacket and carrying a purse and appeared to be just coming into the building for the start of a shift. During an interview on 11/16/20 at 9:00 A.M. MRC E indicated just getting to work, screened self in and went directly to the office. MRC E acknowledged cutting through the Covid unit (without donning any additional PPE) to get to the office. During an observation on 11/16/20 at 8:59 A.M., a food cart was noted to be on the Covid unit next to room [ROOM NUMBER]. During an interview on 11/16/20 at 9:40 A.M., the Administrator reported that respiratory assessments are being done on all residents; every shift if the resident is Covid - and every 8 hours if the resident is Covid+. During an observation on 11/16/20 at 9:52 A.M., environmental service worker (ES) L was noted to be cleaning floors on the Covid unit without a gown on. During an interview with ES L at 9:56 A.M., the worker reported that there was not a requirement to wear a gown when on the Covid + unit, only if the worker entered a resident room on the Covid unit. During an observation on 11/16/20 at 9:55 A.M. a staff person exited the Covid unit with a bag of garbage, was not wearing gloves, stopped at room [ROOM NUMBER] and 132 (rooms not on the Covid unit), collected garbage from each room without gloves on and then took the garbage to a location not observed. During an observation on 11/16/20 at 10:05 A.M., a Covid + resident, residing in room [ROOM NUMBER] (not on the Covid unit), stood in the doorway to the room without a mask on and was talking with staff. During the same observation, a Covid - resident, who resides on same hallway across from room [ROOM NUMBER], was in the hallway self-propelling in a wheelchair. The Covid- resident did not have a mask on and was within 2 feet of the Covid+ resident who was standing in the doorway talking to staff. During an interview on 11/16/20 at 10:09 A.M., Infection Control Preventionist (ICP) A indicated that all staff who enter the Covid units must wear required PPE. (gown, N95, goggles or face shield, gloves) During an observation on 11/16/20 at 10:18 A.M., a Covid + resident residing in room [ROOM NUMBER] (not on the Covid unit) wore a surgical mask pulled down below the nose and mouth and self-propelled into the next room (room [ROOM NUMBER]) where two Covid- residents resided. During an interview on 11/16/20 at 10:20 A.M., ICP A indicated that (a) staff working on the Covid units do not care for other residents outside of the unit, (b) garbage generated on the Covid unit gets placed in a red biohazard bag for double bagging and for identification, and is removed from the unit directly to the dumpster outside, and (c) gowns must be removed and hand hygiene performed each time staff exit the Covid unit. During an observation on 11/16/20 at 10:24 A.M., LPN Y was on the Covid unit without a gown or face shield on. When asked to put on a gown by ICP A, LPN Y indicated not being aware that a gown was required on the Covid unit. During an observation on 11/16/20 at 10:27 A.M., maintenance worker S was on the Covid unit without a gown on. When asked to put on a gown by ICP A, Maintenance worker S indicated not being aware that a gown was required on the Covid unit. During an observation on 11/16/20 at 10:40 A.M., outside vendor F was on the Covid unit without a gown on. During an interview on 11/16/20 at 11:00 A.M., ICP A stated there would be no reason for staff to cut through the Covid unit as a short cut to an office. They could pick up stuff and carry it to the office and then to other areas of the building. During an interview on 11/16/20 at 11:45 A.M., Director of Dietary Services (DDS) U reported the following: (1) kitchen staff bring food carts to the outer doors of the Covid units and do not go on the units, (2) what they do with it when it's (the food cart) on the unit, you will have to ask nursing about that, (3) the kitchen initiated last week that all meals throughout the facility to be served on disposable trays and with all disposable eating utensils., (4) the food carts returned from the Covid unit are sanitized the same as all other food carts, (5) dietary aid AA worked on 10/19/20, reported body aches that were attributed to having received the flu vaccine, and then tested positive for Covid 19 on 10/20/20. During an observation on 11/16/20 at 1:35 P.M., CNA G (1) went onto the Covid unit without a gown or gloves on, (2) brought a sit to stand with a sling draped across it off the unit and to room [ROOM NUMBER] without sanitizing the equipment, (3), entered room [ROOM NUMBER] with the sit to stand and sling without gloves on, (4) assisted Unit Manager (UM) O with placing the sling on the Covid - resident in bed 2, (5) transferred the resident to the wheelchair while the resident held onto the bar of the sit to stand bare handed, (6) did not offer the resident hand hygiene, and (7) removed sit to stand from room [ROOM NUMBER]. It was observed that the sheets of 109 bed 2 were soaked with urine (resident had been cleaned up and placed in clean clothes while still in bed). During an observation on 11/16/20 at 1:50 P.M., UM O removed a garbage bag from Covid + room [ROOM NUMBER] without gloves on and took the garbage out the double doors leading to the outside of the building. During an observation on 11/16/20 at 1:53 P.M. housekeeper X came out of room [ROOM NUMBER] ( a Covid+ room) with a gown and gloves on, opened the cleaning cart, removed supplies, and returned to inside room [ROOM NUMBER]. During an observation on 11/16/20 at 2:30 P.M. a Covid+ resident residing in room [ROOM NUMBER] was noted to be in the hallway outside of the room with a mask below the nose and mouth. During an interview on 11/16/20 at 3:10 P.M. the Director of Nursing (DON) indicated that staff screen themselves in at the start of each shift by (1) taking their own temperature, (2) answering the questions on the Start of Shift Daily Employee Screening Log (SSDESL), and (3) if staff answer yes to any of the questions then they are to go find a nurse and have the positive symptoms reviewed to determine if they are able to work. The DON indicated that it was her responsibility to review the SSDESL's for completeness and follow up. The DON also stated that there was not a log or record keeping system in place that cataloged each time a staff person had positive symptoms and spoke with a nurse. Review of a Smartlinx time sheet for CNA Z revealed that the CNA worked on 11/13/20, 11/14/20 and 11/15/20. Review of SSDESL's dated 11/13/20, 11/14/20, and 11/15/20 revealed that CNA Z screened in on 11/14/20. During an observation on 11/17/20 at 10:50 A.M., the Covid+ resident residing in room [ROOM NUMBER] (not a Covid unit) was out in the hallway with a mask on below the nose and mouth. During an observation on 11/17/20 at 11:05 A.M., physical therapy assistant (PTA) J and certified occupational therapy assistant (COTA) K were observed cutting through the Covid unit to access a side hallway. Resident #103 (R103) Review of an Admission Record reflected that R103 was a [AGE] year-old male that was Covid -. Review of respiratory assessments for R103 revealed no assessments had been completed on 10/24/20, 10/25/20, 10/27/20, 10/28/20, 11/5/20, 11/7/20, 11/12/20, 11/14/20, 11/15/20, and 11/16/20. Resident #104 (R104) Review of an Admission Record reflected that R104 was a [AGE] year-old Covid- female with pertinent [DIAGNOSES REDACTED]. Review of respiratory assessments for R104 revealed no assessments had been completed on 11/1/20, 11/2/20, 11/3/20, 11/9/20, and 11/14/20. Only one of the two required daily respiratory assessments were completed on 10/31/20, 11/4/20, 11/5/20, 11/6/20, 11/7/20, 11/8/20, 11/11/20, 11/12/20, 11/13/20, 11/15/20, and 11/16/20. R104 tested positive for Covid 19 on 11/18/20. On 11/17/20 at 12:05 P.M., the Administrator was verbally notified and received written notification that Immediate Jeopardy was identified at F-880, starting on 11/16/20 at 7:45 A.M. when the facility staff failed to: use proper PPE on Covid units, complete respiratory assessments on residents, sanitize and clean multi-resident use equipment, conduct employee screens as directed by the CDC, handle garbage from the Covid unit with gloves on, distribute meal trays to residents using correct hand hygiene, limit traffic on Covid units, and post signage identifying the restricted Covid unit. This deficient practice had the potential to affect all 82 residents residing in the facility. On 11/17/20 the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: 1. On 11/16/20 all staff education began regarding (a) Guidance-Covid 10 Core Practices, (b) Proper PPE usage in the facility, (c) Covid waste management, (d) Management/Care of Covid residents, (e) Equipment cleaning standards, and (f) limiting foot traffic on the Covid units. As of 11/17/20 38 out of 90 staff members have been educated. 2. All Covid units and rooms have been identified with appropriate CDC language and signage. 3. The vendor was educated on proper PPE use when in a Covid unit. 4. A staff member was assigned to screen in all staff at the start of each shift. 5. Two non-complaint Covid positive residents were moved to a Covid unit. 6. On 11/17/20 all residents' records were audited and a respiratory screening was completed by nursing staff. 7. The facility alleges the immediacy with the deficient practice has been removed on November 17th, 2020. Although the Immediate Jeopardy (IJ) was removed on 11/17/20, the facility remained out of compliance at a scope of widespread and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

This citation pertains to intake number MI 971. Based on observation, interview, and record review, the facility failed to ensure an infection control prevention program that accurately monitored, tracked, trended, reported and followed up infections included [REDACTED].#5, #14, #15, #16 and #17) reviewed for infection control. This deficient practice placed residents, staff and visitors at risk for the potential spread of COVID-19 and other contagious infections. Findings include: The facility provided a copy of the policy/procedure for Infection Prevention and Control adopted 8/20/20 for review. The policy reflected, 10. The facility will have a plan for managing new admissions and re-admissions whose COVID-19 status is unknown. Resident placed in a single person room or in separate observation area. Staff members will wear an N95 or higher level respirator (or facemask if a N95 or respirator is not available), eye protection (eye goggles or face shield that covers the front and sides of the face), gloves and gown when caring for these residents. Resident will be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after admission . The facility provided a copy of the policy/procedure for Infection Prevention and Control for COVID-19 adopted 4/20/20 for review. The policy reflected, The decision to accept a nebulizer dependent resident from the hospital, or whether to transfer a resident to the hospital should be based on the following: If nebulized medications are necessary for a resident with COVID-19, the safest practice is for the staff member to wear an N-95 or higher-level respirator AND eye protection (along with the rest of CDC recommended PPE for Transmission-Based Precautions during COVID-19) . Resident #14 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #14 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents Resident #14 had moderate cognitive impairment. Resident #15 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 6 out of 15 which represents Resident #15 had moderate cognitive impairment. Resident #16 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 14 out of 15 which represents Resident #16 was cognitively intact. Resident#17 Review of the Face Sheet dated 9/9/20 revealed Resident #17 admitted to the facility on [DATE]. During an interview on 9/08/2020 at 11:53 AM, Registered Nurse (RN) A reported that residents who admit to the facility are placed on transmission based precautions (TBP) on the COVID-19 observation unit (rehabilitation unit) in a private room and staff were to don (wear/apply) a gown, gloves, surgical mask and goggles for the care of these residents for the first 72 hours of their stay. After 72 hours, the only personal protective equipment (PPE) staff need to don would be a surgical mask and goggles. RN A reported the residents are served meals on disposable trays, dinnerware and utensils. During an observation on 9/09/2020 at 8:00 AM, RN K was observed through an open-door doffing (removing) a disposable isolation gown, gloves and surgical mask, placing the items into a trash can inside the room. Resident #17 was observed in bed, a nebulizer treatment (a procedure known to generate aerosols) running. RN K was not wearing an N-95 mask and reported that Resident #17 had just returned from a hospitalization and was in 72-hour transmission based precautions which she explained meant that staff were to don a surgical mask, gown, face shield or goggles and gloves whenever they entered the room to provide care. During an observation on 9/9/2020 at 10:58 AM, Speech Language Pathologist (SLP) N was observed entering the room of Resident #17 holding a cup of pudding and wearing a surgical mask, gown, gloves and goggles. SLP N was observed moments later exiting the room, doffing the gown, gloves and mask into a trash can inside Resident #17's room. SLP N was asked if she had worn an N-95 mask and she said she had. SLP N then walked down the hall to the therapy room where two other residents were exercising without a mask on, the goggles were on her head not covering her eyes. SLP N was asked to show the surveyor where she discarded the N-95 mask she reported she wore while in Resident #17's room. SLPN N then went to Resident #17's room, donned a gown, gloves, face shield and an N-95 she retrieved from a supply of PPE outside the room. SLP N looked in the trash and a surgical mask was discovered along with the pudding cup, gown and gloves she had just doffed and discarded moments before. No evidence of an N-95 was found. SLP N said she thought she had worn an N-95, but must not have. During an observation on 9/9/2020 at 8:15 AM, Certified Nurse Aide (CNA) L entered Resident #15's room wearing a surgical mask and goggles she wore while interacting with another resident across the hall. A sign posted outside Resident #15's room indicated staff were required to wear a mask (did not specify what type of mask), faceshield, gloves and gown prior to entry into the room. No PPE was observed outside of Resident #15's room. CNA L was asked about this observation and reported that someone must have forgotten to take down the sign outside the door to Resident #15's room and removed the sign. CNA L reported she worked at the facility 4 days a week and would get report daily regarding the residents on the COVID-19 observation unit and just knew what residents required what type of TBP. This surveyor noted the fire doors to the observation unit were open and contained a sign taped to the door that reflected, Stop, required to enter: Mask, faceshield, gloves and gown. There were 2 staff members observed in the hall wearing only a surgical mask on 9/9/20 at approximately 11:45 AM. On 9/9/20 at approximately 11:50 AM, this surveyor observed CNA L pass the lunch meals on the observation unit. The entire time CNA L passed all the lunch trays for the hall she was wearing a surgical facemask (not a N95) and protective eye wear resting on the top of her head (not covering her eyes). CNA L pulled the tray for Resident #14 and entered her room wearing a surgical mask and no eye protection. The facility served the residents on disposable trays, dinnerware, and utensils. CNA L removed the insulated plate cover (non-disposable) from the plate, placed it on the over the bed table, set up the tray and picked up the insulated cover and returned it to the cart in the hall. CNA L then pulled Resident #15's lunch tray and entered Resident #15's room wearing just a surgical mask, placed the tray on the over the bed table, removed the insulated lid and returned it to the cart in the hall. CNA L pulled Resident #16's tray, entered her room wearing only a surgical mask, placed her tray on the over the bed table, removed the insulated cover, placed it on the bed, set up the tray and then picked up the insulated cover, and placed the lid back into the food cart in the hall. According to record review Resident #14 admitted on [DATE], Resident #15 admitted on [DATE] and Resident #16 admitted on [DATE]. According to the policy all residents who are new admissions and readmissions will be placed in Transmission-Based Precautions for 14 days and the appropriate PPE (personal protective equipment) worn to enter their rooms. During an interview on 9/9/20 at 12:50 PM, the DON stated that the facility requires a COVID19 test on all admissions/readmission at least 72 hours prior to entry to the facility. The DON stated that all new admissions/readmissions are placed in Transmission-Based Precautions for 72 hours after admission then precautions are discontinued and the resident remains on the observation unit for the remainder of the 14 days before moving to the long term care halls. When asked if a new resident could be tested at the hospital on a Monday, test negative and still be admitted on Thursday (within the 72-hour window) and the DON stated, Yes. When asked if the resident could potential be exposed to COVID-19 after being tested and before presenting to the facility, the DON stated, Yes. When asked where the facility policy/procedure reflects a new admission/readmission could be removed from Transmission-Based Precautions prior to 14 days, the DON was unable to locate that within the policy/procedure. During an interview and record review on 9/9/20 at 3:25 PM, the two Surveyors met with the NHA and the DON to review CDC guidance and the facility policy/procedure for all new admissions/readmissions to be placed in Transmission Based Precautions for 14 days and the PPE required to provide care.

This citation pertains to intake 7 Based on interview and record review, the facility failed to ensure one resident (Resident #11) out of 17 residents reviewed, was assessed prior to discharge to an emergency room (ER) for replacement of a malfunctioning nasogastric tube, resulting in an unrecognized change in condition and potential for a delay in treatment. Findings include: Review of a facility policy Change in Resident's Condition or Status adopted 7/11/2018 The facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The procedure specified 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Resident #11 Review of an Admission Record reflected Resident #11 originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Record indicated that Resident #11 was hospitalized from [DATE] until 8/07/20. Review of a hospital History and Physical dated 7/27/2020 at 11:38 PM reflected Resident #11 had been sent to the hospital from the facility on 7/27/2020 for mental status depression, was diagnosed with [REDACTED]. According to the hospital record, Resident #11 became hypoxic (low oxygen) while in the ER and required intubation and mechanical ventilation. During an interview on 9/08/2020 at 2:41 PM, Emergency Medical Technician (EMT) H reported he was dispatched to the facility in the early morning hours of 8/14/20 on a low priority call to transport Resident #11 to the emergency room (ER) for replacement of a malfunctioning nasogastric (NG) tube. According to EMT H, upon arrival to Resident #11's bedside, Resident #11 was unresponsive and lethargic with audible breath sounds, elevated heart rate and appeared feverish. EMT H reported nursing staff were not available to assist in coordinating the transfer, waiting 20 minutes to get the required paperwork necessary for the ordered ER visit. When a nurse did arrive at Resident #11's bedside, she told EMT H she was not assigned to care for Resident #11 was under the impression Resident #11 was just being transferred out to the ED to replace the malfunctioning NG tube and that the transfer had been ordered and started the night before. EMT H reported that the call to the facility was changed to a priority one (highest priority), requiring lights and sirens to get Resident #11 to the hospital as soon as possible where Resident #11 was found to have a fever of 103.8 degrees Fahrenheit, intubated and placed on a ventilator (mechanical breathing). Review of the ambulance company Patient Care Report dated 8/14/2020 reflected that at 2:03 AM, an ambulance was dispatched to the facility without lights and siren (low priority), arriving at the facility at 2:09 AM, at patient bedside at 2:11 AM leaving the facility with Resident #11 36 minutes later at 2:45 AM with lights and siren on, arriving at the hospital ER at 2:58 AM. The Narrative included in the report reflected the following: Dispatched for a patient with a blocked NG tube. ATF (unapproved abbreviation, 'at the facility') patient sleeping in bed and snoring. Nurse aid who brought EMS (Emergency Medical Services) to room stated that the patient is getting sent out due to her NG tube being blocked, but that is all she knew because she doesn't work on that part of the facility. Aid also stated that she would get paperwork as well. EMS crew went into patient room to wake patient. Patient was found to be unresponsive, GSC 3 (Glascow Coma Scale, a score of 3 is indicative of severe [MEDICAL CONDITION]) warm to touch, [MEDICAL CONDITION] (elevated heart rate) and tachypneic (abnormally rapid breathing). EMS crew talked to nurse at facility who stated that they tried to wake (patient) earlier to inform her of going to the hospital but was lethargic and not able to wake. Nurse states that she just got on at midnight and does not know much about the patient. Nurse also stated that she did not know when the patient was last seen normal. EMS crew sheet lifted patient from bed to cot and was secured. Patient vitals and assessment completed enroute. Patient was immediately placed on oxygen at 15 LPM (liters per minute) via NRB (Non-rebreather mask). Enroute EMS crew contacted (hospital) for (priority) 1 report. Patient was found febrile with a temp ranging from 102-104 degrees. Patient was found to be sweaty in the face and head. Upon arrival at (hospital) patient was sheet lifted from cot to bed. Patient care transferred to RN (Registered Nurse). During a telephone interview on 9/9/20 at 1:55 PM, RN S reported she worked from 7:00 PM - 11:00 PM on 8/13/2020 to help with the evening medication pass and was not assigned to care for Resident #11. RN S said Licensed Practical Nurse (LPN) V did not report to work until almost 8:00 PM and requested her assistance with Resident #11 because the NG tube was clogged. RN S said that they were not able to unblock the NG tube. RN S said an order was obtained to send the resident to the ER to have the NG tube replaced. RN S said she did not notice anything unusual about Resident #11 but admitted she did not physically assess her or document anything pertaining to Resident #11 on 8/13/20. During a telephone interview on 9/9/20 at 8:56 AM, LPN V reported she was assigned to care for Resident #11 on 8/13/20-8/14/20 and discovered her NG tube was clogged when she attempted to give her medication. LPN V said she asked RN S to help unclog Resident #11's NG tube but was unsuccessful. LPN V said she was unfamiliar with how to send a resident to the ER for an NG tube replacement and RN S said she would have the nurse working on the rehabilitation unit (RN R) take care of it for her. LPN V said she did not physically assess Resident #11, did not enter a progress note, did not speak to a physician and obtain the order for transfer and had no further interaction with Resident #11 until EMS arrived to transport her to the hospital after 2:00 AM on 8/14/20. During a telephone interview on 9/9/20 at 1:34 PM, Registered Nurse (RN) R reported she was not the nurse assigned to care for Resident #11 on 8/14/20, but said she was asked to help LPN V transfer Resident #11 to the ER per the order that had been received the night before. RN R reported she did not address the order for transfer until she was finished with the residents she was assigned to. RN S thought it was odd that they were sending Resident #11 out to the hospital in the middle of the night instead of waiting until morning but did not want to call and bother the on-call physician to question the order. RN R said she did not assess Resident #11 and did not know if RN S or LPN V had conducted a physical assessment either. RN R said she called the hospital ER and gave report over the phone despite not having assessed Resident #11, indicating Resident #11 was being sent for replacement of the malfunctioning NG tube. Review of a Progress Note dated 8/14/2020 at 3:10 AM reflected (Resident #11) NG tube clogged, received an order to transfer resident out for tube replacement, contacted (hospital ER) for nurse to nurse report. Sent resident via (ambulance company). Bed hold policy sent with resident. The progress note did not reflect any assessment findings. Review of Progress Notes for the date range 8/13/2020-8/14/2020 did not reveal when Resident #11's NG tube stopped working. Review of a Temperature Summary and O2 Sats Summary reflected the last temperature and oxygen saturation were measured on Resident #11 at 9:03 AM on 8/13/2020. A Blood Pressure Summary reflected that Resident #11 had not had her blood pressure monitored at the facility since 8/8/2020 at 3:21 p.m. During an interview on 9/14/20 at 9:40 AM, Nurse Practitioner (NP) X reported she was the provider on call on 8/13/20-8/14/20 and did not have documentation related to which nurse called her about Resident #11. NP X said that if an order for [REDACTED].#11's clogged NG tube and no other assessment findings. Review of the hospital records Emergency Department documentation dated 8/14/2020 reflected History of Present Illness (HPI) (Resident #11) is a [AGE] year-old female who presents from a nursing home facility. The patient has previous history [MEDICAL CONDITION](stroke) and is nonverbal at baseline. Originally, we received a phone call that the patient would be coming to the emergency department because her [MEDICATION NAME] (NG tube) was plugged. It is uncertain how long this has not been working. According to EMS, when they arrived, the patient was unresponsive. There is no reported [MEDICAL CONDITION] activity visualized. EMS does report that they noted the patient's gaze to be deviated . The patient was also noted to be febrile per EMS staff . Objective findings reflected Resident #11 had a rectal temperature of 103.6 degrees Fahrenheit, a heart rate of 117 beats per minute, 24 breaths per minute, and a blood pressure of 193/84 on 8/14/20 at 3:00 AM. The hospital record included notes from the Intensive Care Unit (ICU) which reflected Tonight, the patient's nursing facility contacted the hospital requesting assistance with exchanging the patient's nasal [MEDICATION NAME] due to it being clogged. When EMS arrived, they found the patient obtunded (altered mental status, difficult to arouse) with a GCS of 3. They were unable to get any information from the nursing facility as to how long the patient had been in that condition. She was brought to (hospital), where she was intubated.

This citation pertains to MI 739, MI 49, MI 969 and MI 067 Based on interview and record review, the facility failed to prevent physical abuse for 1 (Resident #1) of 7 residents reviewed for abuse, resulting in a resident being physically abused and the potential for continued abuse. Findings include: Resident #1 According to a facility face sheet dated 8/18/20 at 12:37 PM, Resident #1 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Resident #2 According to a facility face sheet dated 8/18/20 at 3:42 PM, Resident 32 was a [AGE] year-old admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Resident #2 no longer resided in the facility. Review of a facility investigation on an intake reported to the State Agency dated 3/4/2020 at 3:32 AM reflected, 3/4/2020 at 12:00 AM .Incident Summary: A CNA (Certified Nurse's Aide) answered (Resident #1's) call light and observed both Resident #1 and #2 in their beds. Resident #1 was upset and stated Resident #2 had hit her and pulled her hair. Resident #2 was immediately moved to a private room and the incident was report (sic) to the Administrator. Resident #1 was assessed, and the nurse observed a small light pink area on Resident #1's cheek and two superficial scratches on her neck . Review of a facility document titled, 5 Day Report no date noted reflected, Event Timeline created through Interviews with Staff: At approximately 11 pm, (name of Licensed Practical Nurse or LPN K) was in the residents room assist Resident #1 to get ready for bed. Resident #2 was laying quiet in her bed. Resident #1 told the nurse that Resident #2 had called her a b***h (an offensive derogatory term). When asked about this, Resident #2 stated, she called me a [***] and I am one, so I didn't take offense to it. Resident #1 then made kissing sounds and told the nurse she told Resident #2 that they needed to get along like 'kissing cousins'. (Name of LPN K) asked Resident #2 if she if she called her roommate a b***h and Resident #2 stated, 'yes'. When asked why she stated, 'I don't know, I just did.' Through additional question (name of LPN K) learned that Resident #2 thought the TV was too loud and wanted to go to sleep. (name of LPN K) said she adjusted the TV volume making sure it was quiet enough for Resident #2 and loud enough for Resident #1 to still hear it. Both residents confirmed they were good with the volume and verbally voiced they had no additional concerns with each other. A little after 11:30 PM, (Name of Certified Nurse's Aide or CNA A) answered the call light and Resident #1 asked her to turn down the TV. She turned down the volume and asked if they needed anything else. Resident #1 didn't. Resident #2 was lying in bed, appeared to be asleep and did not answer. Around midnight, this CNA answered the call light again and Resident #1 wanted ice, the TV turned off and her music turned on for the night. Resident #2 was still lying in bed and appeared to be asleep. The CNA left the room to get ice. When she came out of the pantry with the ice, she saw (name of LPN J) walking Resident #2 down the hall. (Name of LPN J) stated they were moving Resident #2 to another room. A little after midnight (less than 10 minutes after CNA left room for ice Name of LPN K) answered the call light. She found the room door pulled around, but not shut tightly. Resident #2 was lying in bed and appeared to be asleep. Resident #1 was upset and said her roommate had just hit her and pulled her hair. Resident #1 assessment: Resident #1 was assessed for injury, pain, vital signs and neurological checks started. (Name of Resident #1) vitals were within normal limits except for O2 (oxygen) saturation which was 86 % (percent, 93% and above is normal) and immediately went up to 92% with 2L (liters) of O2. She had pain on the right side of her face and her left arm and rated it a '4' out of '10'. She declined pain medication but agreed to an ice pack. Initial skin assessment showed a pinkness to the side of face and scratches, one on her forehead and a couple on her neck. The skin assessment continued to change as time progressed. The pinkness changed to red blotchy and then to light purple with petechiae type red dots. There was some swelling in the cheek area, a purple bruising to right upper lip and right eye and a red dot to her sclera (white part of the eye), right eye Resident #2 assessment: Resident #2 was assessed and we found some bruising on the top of her hands. She was interviewed to better understand what happened. Resident #2 maintained a calm, nonchalant demeanor throughout the interview. Each time Resident #2 was asked why she hit her roommate she answered with one of the following responses: 'I don't like her', 'she made me mad', 'the TV was too loud and I wanted to sleep', and 'I don't know.' . Review of a typewritten statement of Resident #2 signed by the Nursing Home Administrator (NHA) dated 3/4/2020 at 2:00 AM reflected, What happened earlier tonight? 'I was mad at her.' Who were you made (sic) at? 'That woman in (room number).' Why were you mad at her? 'I don't remember. What did you do? 'I don't remember.' Did you hit her in the face? 'Yes'. Did you put a pillow in her face? 'Yes.' Why did you do this? 'I don't remember but I was mad at her.' .Second Interview 3/4/2020 at 11:00 AM Do you remember hitting her? 'Yes.' Do you remember putting a pillow on her face? 'Yes.' Were you trying to hurt her? 'No.' How many times did you hit her? '3 times.' Review of a typewritten statement of LPN K dated 3/4/2020 (no time noted) but signed by the NHA and LPN K reflected, I answered (Name of Resident #1) call light, both resident's were in bed. Lights were off. (Name of Resident #1) stated, 'she f****n' hit me.' And then started to cry. I asked who hit her and (Name of Resident #1) stated, 'she did over there'. I asked where did she hit you? (Name of Resident #1) said, 'she hit me in the face and pulled my hair.' I turned on the overhead light and saw the right side of her face was red. I called for help and (Name of LPN J) came into the room. I assessed (Name of Resident #1) vitals and they were within normal limits but her O2 sat was low. O2 sat was initially 85 to 86% so I started 2L of O2 (oxygen) NC (by nasal cannula) and it came up to 92%. (Name of Resident #1) told me as I was assessing her, 'she put the pillow over my face.' I observed a pillow on (Name of Resident #1) chest and she usually has pillows under both elbows and head, and those were in place. (Name of Resident #2) pillow was on her bed . Another facility typewritten statement for LPN K dated 3/4/2020 at 3:40 PM signed by the NHA reflected, After further investigation of the incident I needed to ask (name of LPN K) additional questions. Did (Name of Resident #1) tell you that (Name of Resident #2) called her a 'b***h'? 'Yes, she did when I was helping her with her oral care before she went to bed.' Approximately 11 pm. (Name of Resident #1) started making 'kissing sounds' and I asked her what that meant. (Name of Resident #1) said, 'I told (Name of Resident #2) we need to be like like (sic) kissing cousins and get along.' I asked (Name of Resident #2) if anything was bothering her and (Name of Resident #2) said she wanted to go to bed and the TV is too loud. I talked with both of them and they agreed on a volume for the TV so (Name of Resident #2) could sleep and (Name of Resident #1) could still hear it .How much time elapsed between the time you help (Name of Resident #1) get ready for bed and her light came on? 'Around an hour.' Was the resident room door closed when you answered the light? 'No, I don't believe so. I believe it was pulled around but not closed shut.' 'I answer the light and (Name of Resident #2) was in bed and I didn't note the TV was off and the music was on low. I didn't do this so I think the CNA probably had already been in her room. The CNA always tucks (Name of Resident #1) in at night and gets her comfortable with pillows and regularly checks on her.' How long do you think the call light was on? 'I think 5 - 10 minutes at the longest.' On 8/19/2020 at 8:44 AM during a review of the typewritten and signed statement and phone interview with LPN K, she confirmed that Resident #1 had told her that Resident #2 had called her a b***h before Resident #2 had hit Resident #1. LPN K stated this was verbal abuse and she stated she had reported this to her charge nurse LPN J. LPN K confirmed that she had not separated the residents after this event of verbal abuse. LPN K did not separate the residents because LPN J had told her to keep an eye on them, no one was upset or offended. During an interview with LPN J on 8/19/2020 at 10:35 AM, she confirmed she was house supervisor the evening of 3/3 to 3/4/2020. LPN J confirmed that LPN K had informed her that Resident #2 called Resident #1 a b***h. LPN J stated she was going to call the Director of Nursing (DON) and then go check on the residents. When she returned to Resident #1 and #2's room, Resident #1 was crying and stated Resident #2 had punched her in the face. LPN K told her that Resident #2 tried to smother Resident #1 with a pillow. LPN J confirmed that calling someone a b***h was a form of verbal abuse. LPN J also confirmed that normal procedure was to separate residents when exhibiting verbal abuse. LPN J confirmed that LPN K had left the residents room after the report of verbal abuse, leaving Resident #1 and #2 alone. During a phone interview with the NHA on 8/19/2020 at 11:13 AM, she stated she immediately left her home when she was called about the resident to resident incident on 3/4/2020 and arrived ½ hour later at the facility. When asked when the local law authorities were called, she stated she thinks it was around 8:00 AM but was not sure of the time. When asked what facility policy was regarding reporting a crime to local law enforcement, she stated it was to be done as soon as possible. NHA was not aware of the 2-hour reporting parameter. NHA stated she was unaware of the residents calling each other b***h. NHA confirmed that this would be considered verbal abuse and the residents should have been separated. NHA stated Resident #1 was laughing the name calling off, making a kissing noise, kissing cousin's and did not seem to be offended being called a b***h according to her interviews. NHA was asked if she was aware of Resident #2's history before her admission into the facility and how they review possible admissions for appropriateness of admission into the facility. NHA stated that the intake and admissions departments review and red flag any items of concern and use this when considering room placement and care needs. This was to include a criminal background check. NHA stated she was not aware of any concerns before admission. NHA stated Resident #2 was admitted into a semiprivate room without a roommate and had not displayed any behaviors during her first few days in the facility. Review of a facility document for Resident #2 dated 3/3/2020 (no time noted) reflected, (Name of Resident #2 and Resident #2 legal guardian) that (Name of Resident #2 will be moving to LTC (Long Term Care) side. This document reflected the room change was completed on 3/3/2020. The resident to resident incident occurred on 3/4/2020 at approximately midnight, less than 24 hours later. Review of a document for Resident #1 and #2 titled, (Name of City) Police Department dated reported 3/4/2020 at 9:21 AM and dispatch time was 3/4/2020 at 9:24 AM, description: assault. This document reflected that the initial report was made by the facility 9 ½ hours after the approximate time of the resident to resident physical abuse. Review of a document in Resident #2's electronic medical record contained a facsimile transmittal sheet from a local acute care hospital dated 1/14/20 at 10:10 AM (across the top for transmittal) to the facility with the message, Please call (Name of personnel) with questions and concerns (phone number). On page 11 of this transmitted document, encounter notes for Resident #2 dated 12/27/19 reflected, Per Legal Guardian, patient had a TBI ([MEDICAL CONDITION]) as a child. She believes this is why the patient has spontaneous outbursts where she becomes irritable and agitated. Per guardian she has poor self control. She is tearful throughout the visit as she misses her spouse .See recent notes regarding history of abuse to her husband. APS is involved and there is a court separation at this time. Spouse is also living at AFC (Adult Foster Care) home . Resident #2 has a history of having spontaneous outbursts and was easily irritable and agitated and had a history of [REDACTED]. During an interview with the Director of Nursing (DON) on 8/19/2020 at 11:55 AM, the DON was asked how they are screening incoming potential residents for appropriateness to reside in the facility and for the facility to meet their needs. The DON she was part of this process and stated they do background checks and check the sexual offenders list. The DON confirmed she was not aware of Resident #2's history of having spontaneous outbursts and was easily irritable and agitated and had a history of [REDACTED]. The DON stated that Resident #2's guardian had not expressed any concerns about Resident #2 having a roommate. The DON stated she was not aware of the facsimile and if she had been aware, she would have investigated this further. Review of a facility policy and procedure titled, Resident Rights, Abuse and Neglect dated revised 6/17/19 reflected, Policy: It is the policy of this facility to provide professional care and services in a environment that is free from any type of abuse .The guidelines include compliance with the seven (7) federal components of prevention and investigation .There are seven types of abuse: Abuse includes 1) physical 2) verbal .Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means. Examples: hitting, slapping, kicking, squeezing, pinching, poking, twisting, roughly handling. Any person may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employees, family members, guardian, and other visitors. Verbal: Verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to resident within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc .If abuse/neglect is suspected the facility will: Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care .notify law enforcement authorities and press charges, if indicated .In situations in which resident to resident misconduct is being evaluated the facility will follow the steps delineated at #3 (above). An internal investigation will be conducted along with a report to the appropriate State Agencies as part of the facility quality improvement/quality assurance program. Situation s that appear to be 'behavioral altercations' which sometimes result from disagreements and living in an environment in close quarters with other individuals will be addressed and resolved .Steps of Prevention: Screening, training, prevention, identification, investigation, protection, reporting/response .Prevention: Identify, correct and intervene in situations in which abuse, neglect, and/or misappropriation of resident properly (sic) is more likely to occur .Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and determine the direction of the investigation .Investigate all allegations of abuse. Protection: Have procedures to: Protect residents from harm during the investigation. If the allegation of abuse involves 2 or more residents, they will be all immediately separated for the protection of all residents involved and those potentially affected by the abuse .Reporting: have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately .if the event that results in allegations of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency .In the event that the cause of the reasonable suspicion of a crime .B) does not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion, UNLESS IT INVOLVES ABUSE.

This citation pertains to MI 739, MI 49, MI 969 and MI 067 Based on interview and record review, the facility failed to prevent resident to further resident physical abuse after an incident of verbal abuse for 2 residents (Resident #1 and #2), out of 7 residents reviewed for abuse, resulting in physical abuse with injuries. Findings include: Resident #1 According to a facility face sheet dated 8/18/20 at 12:37 PM, Resident #1 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Resident #2 According to a facility face sheet dated 8/18/20 at 3:42 PM, Resident 32 was a [AGE] year-old admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Resident #2 no longer resided in the facility. Review of a facility investigation on an intake reported to the State Agency dated 3/4/2020 at 3:32 AM reflected, 3/4/2020 at 12:00 AM .Incident Summary: A CNA (Certified Nurse's Aide) answered (Resident #1's) call light and observed both Resident #1 and #2 in their beds. Resident #1 was upset and stated Resident #2 had hit her and pulled her hair. Resident #2 was immediately moved to a private room and the incident was report (sic) to the Administrator. Resident #1 was assessed, and the nurse observed a small light pink area on Resident #1's cheek and two superficial scratches on her neck . Review of a facility document titled, 5 Day Report no date noted reflected, Event Timeline created through Interviews with Staff: At approximately 11 pm, (name of Licensed Practical Nurse or LPN K) was in the residents room assist Resident #1 to get ready for bed. Resident #2 was laying quiet in her bed. Resident #1 told the nurse that Resident #2 had called her a b***h (an offensive derogatory term). When asked about this, Resident #2 stated, she called me a [***] and I am one, so I didn't take offense to it. Resident #1 then made kissing sounds and told the nurse she told Resident #2 that they needed to get along like 'kissing cousins'. (Name of LPN K) asked Resident #2 if she if she called her roommate a b***h and Resident #2 stated, 'yes'. When asked why she stated, 'I don't know, I just did.' Through additional question (name of LPN K) learned that Resident #2 thought the TV was too loud and wanted to go to sleep. (name of LPN K) said she adjusted the TV volume making sure it was quiet enough for Resident #2 and loud enough for Resident #1 to still hear it. Both residents confirmed they were good with the volume and verbally voiced they had no additional concerns with each other. A little after 11:30 PM, (Name of Certified Nurse's Aide or CNA A) answered the call light and Resident #1 asked her to turn down the TV. She turned down the volume and asked if they needed anything else. Resident #1 didn't. Resident #2 was lying in bed, appeared to be asleep and did not answer. Around midnight, this CNA answered the call light again and Resident #1 wanted ice, the TV turned off and her music turned on for the night. Resident #2 was still lying in bed and appeared to be asleep. The CNA left the room to get ice. When she came out of the pantry with the ice, she saw (name of LPN J) walking Resident #2 down the hall. (Name of LPN J) stated they were moving Resident #2 to another room. A little after midnight (less than 10 minutes after CNA left room for ice Name of LPN K) answered the call light. She found the room door pulled around, but not shut tightly. Resident #2 was lying in bed and appeared to be asleep. Resident #1 was upset and said her roommate had just hit her and pulled her hair. Resident #1 assessment: Resident #1 was assessed for injury, pain, vital signs and neurological checks started. (Name of Resident #1) vitals were within normal limits except for O2 (oxygen) saturation which was 86 % (percent, 93% and above is normal) and immediately went up to 92% with 2L (liters) of O2. She had pain on the right side of her face and her left arm and rated it a '4' out of '10'. She declined pain medication but agreed to an ice pack. Initial skin assessment showed a pinkness to the side of face and scratches, one on her forehead and a couple on her neck. The skin assessment continued to change as time progressed. The pinkness changed to red blotchy and then to light purple with petechiae type red dots. There was some swelling in the cheek area, a purple bruising to right upper lip and right eye and a red dot to her sclera (white part of the eye), right eye Resident #2 assessment: Resident #2 was assessed and we found some bruising on the top of her hands. She was interviewed to better understand what happened. Resident #2 maintained a calm, nonchalant demeanor throughout the interview. Each time Resident #2 was asked why she hit her roommate she answered with one of the following responses: 'I don't like her', 'she made me mad', 'the TV was too loud and I wanted to sleep', and 'I don't know.' . Review of a typewritten statement of Resident #2 signed by the Nursing Home Administrator (NHA) dated 3/4/2020 at 2:00 AM reflected, What happened earlier tonight? 'I was mad at her.' Who were you made (sic) at? 'That woman in (room number).' Why were you mad at her? 'I don't remember. What did you do? 'I don't remember.' Did you hit her in the face? 'Yes'. Did you put a pillow in her face? 'Yes.' Why did you do this? 'I don't remember but I was mad at her.' .Second Interview 3/4/2020 at 11:00 AM Do you remember hitting her? 'Yes.' Do you remember putting a pillow on her face? 'Yes.' Were you trying to hurt her? 'No.' How many times did you hit her? '3 times.' Review of a typewritten statement of LPN K dated 3/4/2020 (no time noted) but signed by the NHA and LPN K reflected, I answered (Name of Resident #1) call light, both resident's were in bed. Lights were off. (Name of Resident #1) stated, 'she f****n' hit me.' And then started to cry. I asked who hit her and (Name of Resident #1) stated, 'she did over there'. I asked where did she hit you? (Name of Resident #1) said, 'she hit me in the face and pulled my hair.' I turned on the overhead light and saw the right side of her face was red. I called for help and (Name of LPN J) came into the room. I assessed (Name of Resident #1) vitals and they were within normal limits but her O2 sat was low. O2 sat was initially 85 to 86% so I started 2L of O2 (oxygen) NC (by nasal cannula) and it came up to 92%. (Name of Resident #1) told me as I was assessing her, 'she put the pillow over my face.' I observed a pillow on (Name of Resident #1) chest and she usually has pillows under both elbows and head, and those were in place. (Name of Resident #2) pillow was on her bed . Another facility typewritten statement for LPN K dated 3/4/2020 at 3:40 PM signed by the NHA reflected, After further investigation of the incident I needed to ask (name of LPN K) additional questions. Did (Name of Resident #1) tell you that (Name of Resident #2) called her a 'b***h'? 'Yes, she did when I was helping her with her oral care before she went to bed.' Approximately 11 pm. (Name of Resident #1) started making 'kissing sounds' and I asked her what that meant. (Name of Resident #1) said, 'I told (Name of Resident #2) we need to be like like (sic) kissing cousins and get along.' I asked (Name of Resident #2) if anything was bothering her and (Name of Resident #2) said she wanted to go to bed and the TV is too loud. I talked with both of them and they agreed on a volume for the TV so (Name of Resident #2) could sleep and (Name of Resident #1) could still hear it .How much time elapsed between the time you help (Name of Resident #1) get ready for bed and her light came on? 'Around an hour.' Was the resident room door closed when you answered the light? 'No, I don't believe so. I believe it was pulled around but not closed shut.' 'I answer the light and (Name of Resident #2) was in bed and I didn't note the TV was off and the music was on low. I didn't do this so I think the CNA probably had already been in her room. The CNA always tucks (Name of Resident #1) in at night and gets her comfortable with pillows and regularly checks on her.' How long do you think the call light was on? 'I think 5 - 10 minutes at the longest.' On 8/19/2020 at 8:44 AM during a review of the typewritten and signed statement and phone interview with LPN K she confirmed that Resident #1 had told her that Resident #2 had called her a b***h before Resident #2 had hit Resident #1. LPN K stated this was verbal abuse and she stated she had reported this to her charge nurse LPN J. LPN K confirmed that she had not separated the residents after this event of verbal abuse. LPN K did not separate the residents because LPN J had told her to keep an eye on them, no one was upset or offended. During an interview with LPN J on 8/19/2020 at 10:35 AM, she confirmed she was house supervisor the evening of 3/3 to 3/4/2020. LPN J confirmed that LPN K had informed her that Resident #2 called Resident #1 a b***h. LPN J stated she was going to call the Director of Nursing (DON) and then go check on the residents. When she returned to Resident #1 and #2's room, Resident #1 was crying and stated Resident #2 had punched her in the face. LPN K told her that Resident #2 tried to smother Resident #1 with a pillow. LPN J confirmed that calling someone a b***h was a form of verbal abuse. LPN J also confirmed that normal procedure was to separate residents when exhibiting verbal abuse. LPN J confirmed that LPN K had left the residents room after the report of verbal abuse, leaving Resident #1 and #2 alone. During a phone interview with the NHA on 8/19/2020 at 11:13 AM, she stated she immediately left her home when she was called about the resident to resident incident on 3/4/2020 and arrived ½ hour later at the facility. NHA stated she was unaware of the residents calling each other b***h. NHA confirmed that this would be considered verbal abuse and the residents should have been separated. NHA stated Resident #1 was laughing the name calling off, making a kissing noise, kissing cousin's and did not seem to be offended being called a b***h she had found during her interviews. Review of a facility policy and procedure titled, Resident Rights, Abuse and Neglect dated revised 6/17/19 reflected, Policy: It is the policy of this facility to provide professional care and services in a environment that is free from any type of abuse .The guidelines include compliance with the seven (7) federal components of prevention and investigation .There are seven types of abuse: Abuse includes 1) physical 2) verbal .Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means. Examples: hitting, slapping, kicking, squeezing, pinching, poking, twisting, roughly handling. Any person may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employees, family members, guardian, and other visitors. Verbal: Verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to resident within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc .If abuse/neglect is suspected the facility will: Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care .notify law enforcement authorities and press charges, if indicated .In situations in which resident to resident misconduct is being evaluated the facility will follow the steps delineated at #3 (above). An internal investigation will be conducted along with a report to the appropriate State Agencies as part of the facility quality improvement/quality assurance program. Situation s that appear to be 'behavioral altercations' which sometimes result from disagreements and living in an environment in close quarters with other individuals will be addressed and resolved .Steps of Prevention: Screening, training, prevention, identification, investigation, protection, reporting/response .Prevention: Identify, correct and intervene in situations in which abuse, neglect, and/or misappropriation of resident properly (sic) is more likely to occur .Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and determine the direction of the investigation .Investigate all allegations of abuse. Protection: Have procedures to: Protect residents from harm during the investigation. If the allegation of abuse involves 2 or more residents, they will be all immediately separated for the protection of all residents involved and those potentially affected by the abuse.

Based on observation, interview and record review, the facility failed to meet Professional Standards of Practice for Nephrostomy care and Tube Feedings for 1 (Resident #2) of 2 residents reviewed, resulting in potential for infections and the malfunction of Tube Feedings and Nephrostomy tube. Findings include: Review of a Face Sheet revealed Resident #2 originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] for Resident #2 revealed she had a Brief Interview for Mental Status (BIMS) indicating she is severely cognitively impaired and requires extensive assistance of 2 staff for dressing and hygiene and has a nephrostomy tube and a feeding tube. The resident also has bilateral upper and lower extremity impairment. According to Fundamentals of Nursing, Potter and Perry, (2005) the nurse monitors the patency of the urinary drainage system to prevent pooling of urine within the tubing. Urine in the drainage bag is an excellent medium for microorganism growth. Bacteria can track up drainage tubing to grow in pools of urine. If this urine flows back into the client's bladder, an infection will likely develop. The drainage bag should not be above the level of the bladder. If it become necessary to raise the bag above the level of the bladder, the tubing should be clamped or emptied into the drainage bag first. According to Fundamentals of Nursing, Potter and Perry, (2005) the nurse is to flush gastrostomy tubing with 30 ml (milliliters) of water every 4 to 6 hours and before and after administering medications to maintain patency of the tube. Small jejunal tubes are very prone to clogging and are difficult to replace. When the tube feedings are not being administered, cap or clamp the proximal end of the gastrostomy/jejunostomy tube. Rinse container and tubing with warm water after all intermittent feedings. This clears feeding from tubing and reduces bacterial growth in container and tubing. Review of a Policy titled Enteral Feeding Administration-Tube Flushing last revised 9/18/19 revealed: It is the policy of this facility to maintain patency of feeding tube and/or to restore patency, to provide free water and to maintain adequate hydration in resident. Tubes should be irrigated before and after administration of medications, before initiating a feeding or when there's an interruption of feeding. Review of orders for Resident #2 revealed: Enteral Feed Order every shift Continuous Enteral Feeding: Formula: [MEDICATION NAME] 1.2 ; Rate: 85cc/hr (milliliters/hour); Start at 100 time and run until 1100 mLs has infused; Tube Type: j tube (jejunostomy). During an observation on 10/31/19 at 8:40 a.m., Resident #2 observed in bed with tube feeding infusing and lights off and her television was very close to her face and on her back. Resident #2 opened her eyes and answered questions appropriately and denied any concerns at this time. Resident #2 had visible caked on debris on her teeth and had noticeable phlegm in her lungs/throat. Her hair is matted and dirty. During an observation and an interview on 10/31/19 at 1:46 p.m., Licensed Practical Nurse (LPN) [NAME] reported Resident #2 has poor output with her nephrology bag and it was reported the day before this day. LPN [NAME] said she was going to flush it, but the connections were too tight, and the hospital is to call back when they had a time available to replace or fix the current tube. LPN [NAME] reported she seems to have problems every couple of months with her nephrostomy tubing and usually drains about 100 to 200 milliliter (mls) on the day shift. The nephrostomy tubing and drain bag observed laying on the bed on the right side of Resident #2 with scant amount of drainage noted. When queried, LPN [NAME] shrugged her shoulder and reported the nephrostomy bag should be drained to gravity and went to the supply room to get a drain bag holder and hung it to the side of the bed. LPN [NAME] reported she was going to give her antibiotics for her respiratory infection through her PEG tube (Percutaneous endoscopic gastrostomy) and reported it did not have any problems. LPN [NAME] then flushed PEG tube before and after medication. During an observation and an interview on 10/31/19 at 2:04 p.m., CNA C and CNA F went to Resident #2's room for care. CNA C reported Resident #2 is combative with care and does not get showers, only bed baths and that the beauticians cleaned her hair. Resident was cooperative with care this day during her bed bath. Resident #2 kept scratching her hair. Resident #2's roommate said they needed to clean Resident #2's hair because she keeps on picking at it. When the CNA's turned her to the left side to continue cleaning the resident, CNA F picked up the nephrology drain bag and raised it to her shoulder height and did not clamp the bag, then moved it out of the way to proceed with care. Resident #2's brief was saturated with urine. CNA #2 then reported the restorative aide usually cleaned Resident #2's hair but she was not there today. Both CNA's proceeded to put pants on Resident #2 and the nephrostomy tubing was pulled up to the residents' waist and over her pants, then they place an abdominal binder over the PEG tube and the nephrostomy tube. CNA C reported the resident had a blockage in her nephrostomy tube about a month ago and that she always places her nephrostomy tube on the seat or the bed next to the resident. Neither CNA attempted to provide oral care. Both CNA's then transferred the resident to her special chair. During an observation on 11/1/19 at 10:20 a.m., Resident #2 observed in bed and her mouth was dirty with debris, nephrostomy drain bag was on the bed next to the resident and the tube feeding machine alarmed indicating it was complete. During an observation and an interview on 11/1/19 at approximately 11:15 a.m., Unit Manager (UM) I reported everyone's new tubes in the facility seemed to have issues. UM I reported Resident #2 did not like water or baths. UM I and this surveyor walked to Resident #2's room together and observed Resident #2 in bed and her teeth were filthy, nephrostomy bag on the bed next to the resident and the PEG tube was disconnected from the tube feeding machine and capped off. Tube feeding observed still in the PEG tube connected to the Resident. UM I reported it should be flushed with water when disconnected because it can clog the tube. UM I then flushed it with water and the tube became clear. At this time, Resident #2 reported she wanted to be out of bed and the UM I reported the resident is usually in the common area visiting with other residents at this time of the day. In an interview on 11/1/19 at 1:00 p.m., Physician Assistant (PA) J reported Resident #2 went to the hospital on [DATE] and a couple other times because [MEDICATION NAME] Radiology (IR) had to change her nephrostomy tubing because it was not draining, and staff were not to flush the nephrostomy tubes now. PA J reported Resident #2 has copious amounts of sputum and started her on antibiotics to help clear her respiratory congestion. When this surveyor shared her observations with the PA and the management staff in the room, and queried if that was optimal for draining of the nephrostomy tubing or if there were follow up to find the root causes with problems with the nephrostomy tubing, there was no answer and a couple shook their heads no. Review of hospital orders for Resident #2 dated 10/17/19 revealed: Send to IR ([MEDICATION NAME] Radiology) for replacement of feeding tube, clogged. Review of a Hospital Discharge Summary dated 10/18/19 for Resident #2 revealed; Patient tolerated nephrostomy exchange and feeding tube evaluation well with no complications.Review of a Hospital Nursing Progress note for Resident #2 revealed: Myself and (Patient Care Technician) washed hair which she (Resident #2) was not fond of at first but when we placed a warm towel around her hair for a few minutes and then removed it and combed her hair she was fine, than used oral wet toothete (oral swab) and cleansed mouth and patient allowed us to using small amount of water while wetting toothettes, several light and dark brown green thick mucous was removed from patients mouth and tongue, also along her top and bottom gum line, mouth odor appears to have had a sour odor, bathed her including between fingers which had crusty light flaky that did fall off while bathing, did wash under arms and applied deodorant, also changer her attends (brief) small amount of dry gold brown stool dry on buttocks and diaper, no open sores noted . IR Feeding Tube Replacement 10/18/19: Indication: tube clogged. IR Drain (Tube) Exchanged 10/18/19. Indication: IR to Replacement of Nephrostomy Tube, very little output. Hydro[DIAGNOSES REDACTED] with renal and [MEDICAL CONDITION] calculous obstruction. Comparison 9/27/19. Review of an Order Summary for Resident #2 revealed: Stop feeding, no intake prior to having her tube changed 7/26/19 one time only until 07/26/2019. Ordered 7/25/19. Nephrostomy tube is dislodged, please set patient up with IR for replacement dx nephrolithiasis. Active 09/25/20. Please have IR eval feeding tube, has come out approx. 5 inches dx dysphagia, MS, ordered 09/26/2019. Ultrasound right kidney dx hydro[DIAGNOSES REDACTED], dec nephrostomy tube output. Ordered 10/14/19. Send to IR for replacement of feeding tube, clogged dx (diagnosis), advanced MS, dysphagia. Ordered 10/17/19. Enteral Feed Order every shift Continuous Enteral Feeding: Formula: [MEDICATION NAME] 1.2; Rate: 85cc(milliliters)/hr (hour); Start at 2100 time and run until 1100 mLs (milliliters) (1320kcal) has infused; Tube Type: j tube. Flush with water: Amount: 60cc q 1hr while TF running Monitor Q Shift, start 10/28/19. Please have IR replace nephrostomy tube, no output in 24 hrs (hours) dx (diagnosis): hydro[DIAGNOSES REDACTED], renal stones. Ordered 10/30/2019. [MEDICATION NAME]-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Give 5 milliliter via J-Tube three times a day for bacterial infection, clinical aspiration pneumonia, fever for 10 Days. Ordered 10/29/19. Review of Hospital Discharge Instructions dated 7/9/19 for Resident #2 revealed: Type of Procedure performed: Right nephrostomy and cholecystostomy tube exchange. Review of a Care Plan for Resident #2 revealed: Resident has nephrostomy drain related to renal [MEDICATION NAME], date initiated 6/7/17, last revised 4/19/18. Interventions: . Maintain drainage bag below bladder level. Urinary Incontinence related to advance disease process . last revised 3/15/18, Goal: Will be maintained in as clean and dry dignified state as possible. (sic) ADL Self care deficit limited mobility, limited ROM (range of motion) Last revised 4/19/18. Interventions: Abdominal binder to be applied during transfers and repositioning at all times to maintain patency and placement of Nephro/Chole tubes and then released or removed carefully after activity completed. (sic) Dementia and lack of understanding or personal preference. Date Initiated: 08/03/2019. Goal: The resident will cooperate with care through next review date.

Based on observation, interview, and record review, the facility failed to provide appropriate intervention for nephrostomy care in 1 (Resident #2) of 1 resident reviewed for nephrostomy care, resulting in frequent trips to the hospital to change them out. Findings include: Review of a Face Sheet revealed Resident #2 originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] for Resident #2 revealed she had a Brief Interview for Mental Status (BIMS) indicating she is severely cognitively impaired and requires extensive assistance of 2 staff for dressing and hygiene and has a nephrostomy tube and a feeding tube. The resident also has bilateral upper and lower extremity impairment. In an interview on 10/29/19 at 12:19 p.m., Complainant AA reported Resident #2 frequently visited the hospital for post operation problems and the last time Resident #2 came to the hospital on (MONTH) 18, 2019, the hospital staff were concerned that her appearance was overall dirty, unkempt and looked like she had not had a bath in a long time. She has been observed to have poor hygiene and smelly. Her hair is very unkempt, and her mouth has a thick mucus with a foul smell, likely due to no oral care. The hospital staff used several mouth swabs to clean the thick dried brown mucous that was in her mouth. Complainant AA described how Resident #2 had old dirt in her fingernails and between her toes which were contracted and required Activities of Daily Living (ADL's). Complainant AA reported her hands were contracted and there was no way the resident could pull out her nephrostomy tube which was replaced on 10/18/19. Complainant AA reported she is always coming to the hospital to get her nephrostomy tubes replaced and her feeding tube was clogged because the facility is not flushing the tube after the feedings. During an observation on 10/31/19 at 8:40 a.m., Resident #2 observed in bed with tube feeding infusing and lights off and her television was very close to her face and on her back. Resident #2 opened her eyes and answered questions appropriately and denied any concerns at this time. Resident #2 had visible caked on debris on her teeth and had noticeable phlegm in her lungs/throat. Her hair is matted and dirty. During an observation on 10/31/19 at 10:10 a.m., Resident #2 observed in bed in the same as seen earlier. The lights were off, and her eyes closed. During an observation on 10/31/19 at 11:39 a.m., Resident #2 observed in bed with the lights off in the same position and her tube feeding was off. No morning cares noted and Resident #2 tried to talk and her mouth was still filthy. In an interview on 10/31/19 at approximately 12:30 p.m., Certified Nursing Assistant (CNA) B reported CNA C was taking care of the residents on the hall where Resident #2 is and is on break at this time. In an interview of 10/31/10 at 1:40 p.m., CNA C reported she last changed Resident #2's brief around 7:30 a.m. and that the resident had a respiratory infection and did not know if she could get her up or not and was going to find out. During an observation and an interview on 10/31/19 at 1:46 p.m., Licensed Practical Nurse (LPN) [NAME] reported Resident #2 has poor output with her nephrology bag and it was reported the day before this day. LPN [NAME] said she was going to flush it, but the connections were too tight, and the hospital is to call back when they had a time available to replace or fix the current tube. LPN [NAME] reported she seems to have problems every couple of months with her nephrostomy tubing and usually drains about 100 to 200 milliliter (mls) on the day shift. The nephrostomy tubing and drain bag observed laying on the bed on the right side of Resident #2 with scant amount of drainage noted. When queried, LPN [NAME] shrugged her shoulder and reported the nephrostomy bag should be drained to gravity and went to the supply room to get a drain bag holder and hung it to the side of the bed. During an observation and an interview on 10/31/19 at 2:04, CNA C and CNA F went to Resident #2's room for care. CNA C reported Resident #2 is combative with care and does not get showers, only bed baths and that the beauticians cleaned her hair. Resident was cooperative with care this day during her bed bath. Resident #2 kept scratching her hair. Resident #2's roommate said they needed to clean Resident #2's hair because she keeps on picking at it. When the CNA's turned her to the left side to continue cleaning the resident, CNA F picked up the nephrology drain bag and raised it to her shoulder height and did not clamp the bag, then moved it out of the way to proceed with care. Resident #2's brief was saturated with urine. CNA #2 then reported the restorative aide usually cleaned Resident #2's hair but she was not there today. Both CNA's proceeded to put pants on Resident #2 and the nephrostomy tubing was pulled up to the residents' waist and over her pants, then they place an abdominal binder over the PEG tube and the nephrostomy tube. CNA C reported the resident had a blockage in her nephrostomy tube about a month ago and that she always places her nephrostomy tube on the seat or the bed next to the resident. Neither CNA attempted to provide oral care. Both CNA's then transferred the resident to her special chair. During an observation on 11/1/19 at 10:20 a.m., Resident #2 observed in bed and her mouth was dirty with debris, nephrostomy drain bag was on the bed next to the resident and the tube feeding machine alarmed indicating it was complete. During an observation and an interview on 11/1/19 at approximately 11:15 a.m., Unit Manager (UM) I reported everyone's new tubes in the facility seemed to have issues. UM I reported Resident #2 did not like water or baths. UM I and this surveyor walked to Resident #2's room together and observed Resident #2 in bed and her teeth were filthy, nephrostomy bag on the bed next to the resident and the PEG tube was disconnected from the tube feeding machine and capped off. Tube feeding observed still in the PEG tube connected to the Resident. UM I reported it should be flushed with water when disconnected because it can clog the tube. UM I then flushed it with water and the tube became clear. At this time, Resident #2 reported she wanted to be out of bed and the UM I reported the resident is usually in the common area visiting with other residents at this time of the day. In an interview on 11/1/19 at 1:00 p.m., Physician Assistant (PA) J reported Resident #2 went to the hospital on [DATE] and a couple other times because [MEDICATION NAME] Radiology (IR) had to change her nephrostomy tubing because it was not draining, and staff were not to flush the nephrostomy tubes now. PA J reported Resident #2 has copious amounts of sputum and started her on antibiotics to help clear her respiratory congestion. When this surveyor shared her observations with the PA and the management staff in the room, and queried if that was optimal for draining of the nephrostomy tubing or if there were follow up to find the root causes with problems with the nephrostomy tubing, there was no answer and a couple shook their heads no. Review of a Hospital Discharge Summary dated 10/18/19 for Resident #2 revealed; Patient tolerated nephrostomy exchange and feeding tube evaluation well with no complications.Review of a Hospital Nursing Progress note for Resident #2 revealed: Myself and (Patient Care Technician) washed hair which she (Resident #2) was not fond of at first but when we placed a warm towel around her hair for a few minutes and then removed it and combed her hair she was fine, than used oral wet toothete (oral swab) and cleansed mouth and patient allowed us to using small amount of water while wetting toothettes, several light and dark brown green thick mucous was removed from patients mouth and tongue, also along her top and bottom gum line, mouth odor appears to have had a sour odor, bathed her including between fingers which had crusty light flaky that did fall off while bathing, did wash under arms and applied deodorant, also changer her attends (brief) small amount of dry gold brown stool dry on buttocks and diaper, no open sores noted . IR Feeding Tube Replacement 10/18/19: Indication: tube clogged. IR Drain (Tube) Exchanged 10/18/19. Indication: IR to Replacement of Nephrostomy Tube, very little output. Hydro[DIAGNOSES REDACTED] with renal and [MEDICAL CONDITION] calculous obstruction. Comparison 9/27/19. Review of an Order Summary for Resident #2 revealed: Nephrostomy tube is dislodged, please set patient up with IR for replacement dx nephrolithiasis. Active 09/25/20. Ultrasound right kidney dx hydro[DIAGNOSES REDACTED], dec nephrostomy tube output. Ordered 10/14/19. Please have IR replace nephrostomy tube, no output in 24 hrs (hours) dx (diagnosis): hydro[DIAGNOSES REDACTED], renal stones. Ordered 10/30/2019. Review of a Care Plan for Resident #2 revealed: Resident has nephrostomy drain related to renal [MEDICATION NAME], date initiated 6/7/17, last revised 4/19/18. Interventions: . Maintain drainage bag below bladder level.

Based on observation, interview and record review, the facility failed to provide appropriated tube feeding care for 1 (Resident #2) of 2 residents reviewed, resulting in the potential for poor patency and tube replacement. Findings include: Based on observation, interview, and record review, the facility failed to provide appropriate intervention for nephrostomy care in 1 (Resident #2) of 1 resident reviewed for nephrostomy care, resulting in frequent trips to the hospital to change them out. Findings include: Review of a Face Sheet revealed Resident #2 originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] for Resident #2 revealed she had a Brief Interview for Mental Status (BIMS) indicating she is severely cognitively impaired and requires extensive assistance of 2 staff for dressing and hygiene and has a nephrostomy tube and a feeding tube. The resident also has bilateral upper and lower extremity impairment. Review of a Policy titled Enteral Feeding Administration-Tube Flushing last revised 9/18/19 revealed: It is the policy of this facility to maintain patency of feeding tube and/or to restore patency, to provide free water and to maintain adequate hydration in resident. Tubes should be irrigated before and after administration of medications, before initiating a feeding or when there's an interruption of feeding. In an interview on 10/29/19 at 12:19 p.m., Complainant AA reported Resident #2 frequently visited the hospital for post operation problems and the last time Resident #2 came to the hospital on (MONTH) 18, 2019, the hospital staff were concerned that her appearance was overall dirty, unkempt and looked like she had not had a bath in a long time. She has been observed to have poor hygiene and smelly. Her hair is very unkempt, and her mouth has a thick mucus with a foul smell, likely due to no oral care. The hospital staff used several mouth swabs to clean the thick dried brown mucous that was in her mouth. Complainant AA described how Resident #2 had old dirt in her fingernails and between her toes which were contracted and required Activities of Daily Living (ADL's). Complainant AA reported her hands were contracted and there was no way the resident could pull out her nephrostomy tube which was replaced on 10/18/19. Complainant AA reported she is always coming to the hospital to get her nephrostomy tubes replaced and her feeding tube was clogged because the facility is not flushing the tube after the feedings. During an observation on 10/31/19 at 8:40 a.m., Resident #2 observed in bed with tube feeding infusing and lights off and her television was very close to her face and on her back. Resident #2 opened her eyes and answered questions appropriately and denied any concerns at this time. During an observation and an interview on 10/31/19 at 1:46 p.m., Licensed Practical Nurse (LPN) [NAME] reported she was going to give her antibiotics for her respiratory infection through her PEG tube (Percutaneous endoscopic gastrostomy) and reported it did not have any problems. LPN [NAME] then flushed PEG tube before and after medication. During an observation and an interview on 11/1/19 at approximately 11:15 a.m., Unit Manager (UM) I and this surveyor walked to Resident #2's room together and observed Resident #2 in bed and her teeth were filthy, nephrostomy bag on the bed next to the resident and the PEG tube was disconnected from the tube feeding machine and capped off. Tube feeding observed still in the PEG tube connected to the Resident. UM I reported it should be flushed with water when disconnected because it can clog the tube. UM I then flushed it with water and the tube became clear. Review of a Hospital Discharge Summary dated 10/18/19 for Resident #2 revealed; IR Feeding Tube Replacement 10/18/19: Indication: tube clogged. IR Drain (Tube) Exchanged 10/18/19. Review of an Order Summary for Resident #2 revealed: Stop feeding, no intake prior to having her tube changed 7/26/19 one time only until 07/26/2019. Ordered 7/25/19. Send to IR for replacement of feeding tube, clogged dx (diagnosis), advanced MS, dysphagia. Ordered 10/17/19. Enteral Feed Order every shift Continuous Enteral Feeding: Formula: [MEDICATION NAME] 1.2; Rate: 85cc(milliliters)/hr (hour); Start at 2100 time and run until 1100 mLs (milliliters) (1320kcal) has infused; Tube Type: j tube. Flush with water: Amount: 60cc q 1hr while TF (tube feeding) running Monitor Q Shift, start 10/28/19. Please have IR eval feeding tube, has come out approx. 5 inches dx dysphagia, MS, ordered 09/26/2019.

This citation pertains to intake # MI 4398 Based on observation, interview, and record review, the facility failed to provide services that were necessary to avoid physical harm, pain, mental anguish and emotional distress for 3 residents (Resident #402, Resident #403, and Resident #408), investigated for abuse/neglect, resulting in Resident #402 & Resident #403 being left for hours in urine soaked briefs and Resident #408 sustaining a fall with multiple serious injuries. Findings include: Resident #402 Review of a Face Sheet revealed R402 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed 05/03/19, revealed that R402 required extensive assistance from staff for bed mobility, personal hygiene, and transfers. The MDS assessment also indicated that R402 was always incontinent of bowel and bladder and was at risk for developing pressure ulcers/injuries. A Brief Interview for Mental Status (BIMS), also completed 05/03/19, revealed a score of 15 out of 15 which indicated that R402 had no cognitive impairment. Review of a Occupational Therapy Evaluation & Plan of Treatment, dated 050/9/19, revealed the following evaluation summary: Patient presents with impairments in balance, problem solving, mobility, and strength resulting in limitations and/or participation restrictions in the areas of mobility, self care, and general tasks and demands. During an interview on 07/10/19 at 10:00 A.M., Family Member (FM) Q stated that she had visited R402 many times in the past and found R402 in urine soaked briefs. They just let her lay there like that until someone makes a scene. During an interview on 07/10/19 at 10:25 A.M., R402 stated that she called FM Q last night crying because no one would change her and she was wet from urine. R402 also stated that after she put on her call light, 5 people came in to check on her, she told them she was wet, and each left saying they would be back with help and never returned. It's bullshit that they treat me that way. R402 indicated that she was left lying in a urine soaked brief for 2 hours. R402 then reported that this has happened to her a lot in the past. Review of a CNA Care Guide revealed that R402 required assist x 2 for toileting needs. Not indicated on the CNA Care Guide were any guidelines as to how frequently staff should check to see if R402 was incontinent or needed to be changed. Review of R402's Care Plan, revealed the following Goal: will be maintained in as clean and dry dignified state as possible within the confines of urinary dysfunction. No Interventions were listed as to how staff were going to meet that goal. Resident #403 Review of a Face Sheet revealed R403 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed 06/20/19, revealed that R403 required extensive assistance from 2 staff persons for bed mobility. The MDS assessment also indicated that R403 was always incontinent of bowel and bladder and was at risk for developing pressure ulcers/injuries A Brief Interview for Mental Status (BIMS), also completed 06/20/19, revealed a score of 15 out of 15, which indicated that R403 had no cognitive impairment. Review of a CNA Care Guide for R403 revealed : 2 assist with bed mobility turning and positioning, provide assist x 2 for toileting needs, and check frequently for incontinence and provide incontinence care as needed. Review of R403's Care Plan revealed the following Goal and Intervention: Goal- will be maintained in as clean and dry dignified state as possible. Intervention- check frequently for incontinence and provide incontinence care as needed. During an interview on 07/09/19 at 10:00 A.M., R403 stated that staff had not been in to change her brief since 12:30 A.M. They like to leave me in my diapers for a long time, and stated that this happens frequently. R403 indicated that she thinks someone will be in to get her cleaned up for the day and change her brief within the next 30 minutes. When asked for clarification that she had been in the same brief for the past 9.5 hours, R403 stated yes. What can I do about it, I need their help. During an interview on 07/09/19 at 11:45 A.M., R403 stated that staff returned to get her cleaned up around 10:10 A.M. R403 also stated that there are times when she is sopping wet in the early morning and she will try to catch an aide to change her real quick. Sometimes I go all night without an aide. Review of a Skin Observation Tool for R403, dated 05/26/19, revealed an open area to R gluteal fold. Subsequent Skin Observation Tool sheets for 06/10/19, 06/17/19, and 06/24/19 indicated the same findings. Skin Observation Tool sheets were requested from 07/01/19 forward but were not provided by the facility. Resident #408 Review of a Face Sheet revealed R408 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed 04/15/19, revealed that R408 required extensive assistance from 2 staff persons for bed mobility. A Brief Interview for Mental Status (BIMS), also completed 04/15/19, revealed a score of 15 out of 15 which indicated that R408 had no cognitive impairment. Review of a CNA Care Guide, printed 06/24/19, revealed Bed mobility x 2 was needed for R408. Review of R408's Care Plan, printed 06/24/19, revealed the intervention of Bed Mobility x 2 was indicated. During an observation on 07/10/19 at 11:20 A.M., R408 was in bed with significant bruising noted to the left side of her face. R408's left elbow to mid forearm was bruised as well as her left wrist which was covered by a small 3 x 3 border dressing. The right ankle and foot were swollen, skin shinny and taught, no brace was noted on the right foot and the foot was resting on a pillow in the plantar flexed position. During an interview on 07/10/19 at 11:25 A.M., R408 stated the following related to the fall sustained on 06/24/19 : The aid was getting me cleaned up, I was laying on my right side too close to the edge, they know I hate that, it makes me nervous. The aid was doing something on my back side, I couldn't see what, and I felt her push me and over I went. R408 states that the aid was alone, there were not 2 staff persons present on this occasion. R408 stated that before she fell , they only used one person to move me around in bed, since I fell , they use 2 now. During an interview on 07/11/19 at 12:39 A.M., Certified Nurse Aid (CNA) C stated that on 06/24/19 she was caring for R408 by herself. Everybody did it that way, nobody never did her with two persons. CNA C indicated that she charted one person care for this resident in the past and no one ever corrected her or told her different. It was not anywhere that she was a two person. She (R408) had a BM and I had to change the sheets because it was all over. She was on her side and I was about to have her come back the other way and she just fell off the bed. During an interview on 07/11/19 at 12:59 P.M., CNA F stated that the expectation for aids was to know resident care interventions and if the aid was not familiar with the resident, then the information could be located on the CNA Care Guide or staff could speak with a nurse or OT/PT for information. Review of emergency room records and radiology reports from the local Hospital, dated 06/24/19, revealed R408 had sustained a subdural hematoma, nondisplaced fractures of the right tibia and fibula, and a moderate sized left anterior frontal scalp hematoma from her fall at the facility earlier that day.

This pertains to intakes M 3570, M 3437, and M 3696 Based on interview and record review, the facility failed to prevent abuse in 3 (Resident #101, Resident #102, and Resident #103), from a resident with known dementia with behaviors (Resident #106), a visitor and a volunteer, resulting in potential for harm and the potential for more harm and psychosocial distress. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #101 had a Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact and was totally dependent on 2 staff for transfers, and Activities of Daily Living (ADL). Resident #106 Review of a Face Sheet revealed Resident #106 was a [AGE] year old female admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] from previous facility revealed Resident #106 had a BIMS that indicated she was severely cognitively impaired and primary language was Spanish and required an interpreter to communicate with staff. She had delusions, behaviors, and wandering, and could ambulate independently with supervision Review of the MDS discharge assessment dated [DATE] for Resident #106 indicated she was severely cognitively impaired and had behaviors affecting others. In an interview on 5/29/19 at 1:30 p.m., Family Member (FM) R reported staff were being mentally and emotionally abusive to Resident #101 by leaving her soiled in her briefs for long periods of time and not answering her call light in a timely manner. Said staff will ask resident how many times she urinated in her briefs and tell her to go 1-2 more times before they change her. FM R reported she had to call the facility on a 3 way call every 10 minutes for about an hour to get someone to attend to Resident #101. FM R reported the call light is left out of residents reach sometimes. FM R reported on 5/21/19 Resident #101 received a roommate and a CNA (Certified Nursing Assistant) told her the new roommate was violent and getting into Resident #101's things and did not understand how the facility could place someone like that in a room with Resident #101 who cannot defend herself. Resident #101 does not want male care givers and the facility forced her to give it a try. FM R reported one of the CNA's listened to their conversation and went into Resident #101's room and threatened her. Said staff turnover is all the time and they do not talk to Resident #101 like she is a human. During an observation and an interview on 5/29/19 at 3:02 p.m., Resident #101 was in bed and her wheelchair had urine soaked through onto the lined cushion that embraced the inside of the chair. At this time, the wheelchair was soaked with urine from the night before and still was not cleaned. She was still in bed because of it. Resident #101 said the CNA who transferred her to the bed last night knew about it. Resident #101's mother was at the resident's bedside and said she reported it about an hour ago to the staff. Resident #101 reported the staff were lazy. During an observation and an interview on 5/30/19 at 9:12 a.m., Resident #101 was in bed with soiled brief and put the call light on. CNA [NAME] entered room to care for the resident. CNA [NAME] gathered supplies and turned Resident #101 to the left side with no other staff to assist. The resident was unable to assist and observed on the very edge of the bed with her neck contracted and her extremities with no support. CNA [NAME] cleaned the resident up, using the same gloves, CNA [NAME] tucked a new clean brief under the resident and pulled the resident on her back. CNA [NAME] then went to the other side with the same gloves on and turned the resident on to her right side to finish cleaning her up, and the resident was on the very edge of the bed with no support. CNA [NAME] finished care, then removed her gloves, and placed a neck brace on Resident #101 with no hand hygiene. The CNA observed a bruise on the resident's right upper thigh, with the surveyor present and observing, washed hands and left the room. Resident #101 had a baseline of cussing while conversing with staff and family. Resident #101 reported that not all staff like the way she talks and her daughter was in the room and said that is just how she talks. Review of a Transition of Care Report for Resident #106 from the previous facility revealed: Care Plan: Focus: Potential for agitation/aggression (verbal and physical) related to dementia, [MEDICAL CONDITION] diagnoses. Pt does not like others to alter her environment thus highest potential for behavior is when staff attempt to clean room i.e. remove hoarded linens, clothes that need to be laundry Intervention: . When agitation/aggression is present; provide calming presence, assess for needs Focus: Behavior: Patient demonstrates pilfering/scavenging behaviors . at times may barricade door with room furniture . Progress notes: dated 5/11/19: Pt continues to pace up and down the hallway peering into other pts rooms and occasionally trying to take items. Pt struck housekeeping staff who were attempting to clean her room this a.m. Staff were not a familiar face to the pt. This nurse explained that they were there to clean and pt then allowed the service Nursing Progress note dated 5/15/19: Resident observed during 5 a.m. and 6 a.m. rounds with room door closed, when staff attempted to open the door, resident was observed sitting in a chair in front of the door and leaning backwards pressing her back to door preventing staff from entering. This nurse re attempted to enter at 630 a.m. but again, resident still observed sitting in chair preventing entry into room Social Services Progress note dated 5/15/19: .She does have a [DIAGNOSES REDACTED]. She did have an increase in packing her belongings and refusing care after a GDR (gradual dose reduction) of [MEDICATION NAME] and it was considered failed on 5/10/19. Nursing Progress note dated 5/17/19: CNA's reported that they noticed 2 pain of shoes in residents' room which belonged to other residents . Nursing Progress note dated 5/21/19: Called report to . facility. Spoke with (staff) in regard to transfer of resident. They do not have a private room so the transfer may be an issue per nurse . (sic) Review of a Nursing Progress Note dated 5/21/19 at 2:53 p.m. for Resident #106 revealed: 12:40 p.m. resident admitted to room [ROOM NUMBER]-1, ambulated to the facility, her daughter was with her, resident and daughter speak very little English . resident with HX (history) of dementia with wondering, came with wondergaurd on right ankle, resident has Hx of agitation per family and will take others things (sic) Review of a Nursing Progress Note dated 5/21/19 at 6:22 p.m. for Resident #106 revealed: 6:40 pm resident agitated at times even with daughter . constantly walking around in halls, going into others room and taking things such as someones glasses and lipstick and any laundry laying on the beds . (sic) Review of a Baseline Care Plan for Resident #106 dated 5/21/19 revealed no interventions for dementia or behaviors. Review of an incident report for Resident #101 dated 5/21/19 revealed: At approximately 0100, this nurse observed roommate at residents' bedside, removing sheet from said residents' body. This nurse attempted to redirect, and resident became agitated and began speaking aggressively in Spanish and lightly shoving this nurse aside. Then roommate walked to the other side of the room and attempted to take items from room that belonged to resident. At that time resident became upset and began to shout, NO NO NO! Roommate turned around, went over to resident's bed, stood over her, pointed at her and began speaking aggressively in Spanish (unable to understand) and open-hand slapped her on top of her foot. This nurse immediately directed roommate and calmly walked her out of the room together for residents' safety. Roommate became increasing agitated, then began hitting, attempting to bite, scratching, punching, swearing (per Spanish-speaking nurse), swinging a towel she was carrying and attempting to hit staff (sic) Review of an incident report for Resident #106 dated 5/22/19 revealed: At approximately 0100, this nurse observed resident at roommate's bedside, removing sheet from said roommates' body. This nurse attempted to redirect, and resident became agitated and began speaking aggressively in Spanish and lightly shoving this nurse aside. Then resident walked to other side of the room and attempted to take items from room that belonged to roommate. At that time roommate became upset and began to shout, NO NO NO! Resident turned around, went over to roommates' bed, stood over her, pointed at her and began speaking aggressively in Spanish (unable to understand) and open-hand slapped her on the top of her foot. This nurse immediately directed resident and calmly walked her out of the room together for roommate's safety. Resident became increasingly agitated, then began hitting, attempting to bite, scratching, punching, swearing (per Spanish-speaking nurse), swinging a towel she was carrying and attempting to hit staff. Physician notified. 1:1 initiated per IPC. DON made aware. Family contacted, but not available at this time. Residents' room changed at this time. Family notified of room move. Police report filed. (sic) Review of an unsigned typed statement dated 5/29/19, Registered Nurse (RN) N revealed: I was semi in the room and was standing back. One resident (Resident #106) was fumbling into the other resident (Resident #101s) items. We kept trying to redirect her (Resident #106) and she was agitated. I did not see the covers being pulled but the other nurse saw her pulling at the covers and trying to take blankets over the other resident's head. When I got in there she was fumbling with the television and fumbling with other items of (Resident #101) and picking up items. The resident (Resident #106) was upset and yelling in Spanish. (Resident #101) did not want her to touch her stuff. (Resident #106) smacked her (Resident #101's) leg/foot area. We were finally able to remove her from the room. (Resident #101) did not cry and states she was not hurt. We did not see any physical injuries at the time. (Resident #106) kept trying to get back into the room and kept hitting us with towels and yelling and biting staff. She left a bruise on one nurse. (Resident #106) noted to be wandering and restless the whole day. Review of an unsigned typed statement dated 5/29/19, NHA interviewed Resident #101 and revealed: Resident was interviewed with guardian present. Resident lying in bed and smiling. Resident states she feels safe in the facility and she did not feel any harm from the event. Resident's guardian was agreeable with the statement. Resident laughed during the interview regarding the incident. No further concerns were noted during the interview. Review of an unsigned typed statement dated 5/30/19, RN O revealed: I came in after to assist. She (Resident #106) kept trying to go back into the room and saying she is my daughter (referring to Resident #101). We did not allow her to go back into the room, but she was really confused. During an observation and an interview on 5/30/19 at 9:12 a.m., Resident #101 was in her room in bed and turned on the call light for incontinence care. While waiting, Resident #101 reported she called a CNA the B word the night before because she was in a wet, soiled brief for an hour while in her wheelchair, without a pad under her and she had soaked through her brief onto her wheelchair. Resident #101 reported the CNA was lazy and called her a name. Resident #101 reported LPN I entered the room after that and told the resident not to talk to staff like that. In an interview on 5/30/19 at 2:06 p.m., Licensed Practical Nurse (LPN) I reported Resident #101 can be demanding and if she didn't get her way, she would cry. If Resident #101 did not like a person she would give them a harder time, but if the staff knew her routine there would not be a problem. When Resident #101 gets mad at staff, she calls them explicit names and did not think the resident should treat staff like that since they were taking care of her. When this Surveyor queried about being professional and trained to deal with residents with behaviors, LPN I was silent. LPN I did not want to say which staff members had problems with Resident #101 and said this Surveyor should talk to the DON or the NHA if I wanted to know that information. LPN I reported she did not know why Resident #101 had a bruise on her right upper thigh and expected the CNA's to tell her about it. During an observation and an interview on 5/31/19 at approximately 12:00 p.m., Resident #101 was in bed, her neck contracted toward the left, her bilateral lower extremities contracted and unable to move and had limited ability in hands to push the call light and use the remote control for her television. Resident #101 reported she did not receive notification of getting a new roommate on 5/21/19. Resident #101 reported when Resident #106 arrived, she could not speak English and was unable to communicate with her. Resident #106 ambulated to her side of the room and went through Resident #101's things, walked next to her bed and tried to speak to Resident #101 in Spanish, and smacked her legs. Resident #101 reported she was not scared but felt sorry for Resident #106 because she seemed confused. Resident #101 denied any items missing or any injuries from the incident. In an interview on 5/31/19 at 10:34 a.m., Hospital Liaison and Administrator in Training (AIT) L reported she assisted Central Intake with resident placement in the facility. AIT L reported that their other facility was undergoing some remodeling and that was how Resident #106 ended up at this facility. AIT L reported at the other facility, Resident #106 had a private room at the end of the hall and would sit in a chair in the hallway all the time. Even though the resident had dementia, the family wanted the resident to transfer temporarily to this facility because the construction at the other place could be disturbing to Resident #106. AIT L reported Resident #106 did not have behaviors with other residents at the previous facility, only with staff and did wander into other resident rooms because she was a collector and a little intrusive. AIT L reported the staff were prepared for her arrival. When this surveyor asked about the transferring of a dementia care resident to another facility and behaviors that could be associated with the disturbance, as well as transferring from a private room to a room with a roommate that was totally dependent, AIT L reported the benefits outweighed the risks, and Resident #101 could use the call light to call for help. Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had a Brief Interview for Mental Status (BIMS) that indicated he was cognitively intact and required limited assistance of one staff for transfers and no documented behaviors. Resident #103 Review of a Face Sheet for Resident #103 revealed a [AGE] year old male admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] from the previous facility, revealed Resident #103 had a BIMS that indicated he was cognitively intact and required extensive assistance of 2 staff for transfers and had verbal behaviors directed toward others. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had a BIMS that indicated he was severely cognitively impaired and required extensive assistance of 2 staff for bed mobility, hallucinations and no behaviors. Review of an incident report dated 4/21/19 for Resident #103 revealed: Nurse was at her cart getting resident's medications ready when she was alerted to resident calling for help. Noted resident on floor with legs still in bed . Mental Status: disoriented, no witnesses . Incomplete investigation and follow up/interventions to incident. Review of an incident report dated 4/22/19 for Resident #103 revealed: Observed on floor with legs on bed back on floor. Denied hitting head. Resident poor historian. Neuro checks unremarkable. No complaints of new pain Mental Status: Alert, Confused, Oriented to Person, Oriented to Time, disoriented . Attempting to get out of bed . Witness: (no name), relation: Staff . Incomplete investigation and follow up/interventions to incident. Review of an incident report dated 4/25/19 for Resident #103 revealed: Resident kicked over bedside table. The table scraped his left lateral foot, just below the pinky toe and he sustained a 1 cm (centimeter) x 1 cm skin tear. Immediate Action Taken: Site was cleansed Boots had been off because he'd be restless and trying to take them off, and they were reapplied to feet . Other Info: Resident confused to time of day and place. Continually asking about meals, specifically breakfast. Restless while in bed and while moving around, kicked over bedside table. Bedside table moved away from bed. Incomplete investigation and follow up to incident. Review of an incident report dated 4/25/19 for Resident #103 revealed: Resident out to nurse's desk with bloody paper towel requesting help. Observed skin tear to right forearm. Incomplete investigation and follow up/interventions to incident. Review of an incident report dated 5/10/19 at 7:40 a.m. for Resident #102 revealed: CNA (Certified Nursing Assistant) observed (Resident #102) outside of room in wheelchair with an odd look on his face. CNA checked on roommate (Resident #103) and found him crying and he stated that (Resident #102) had thrown water on him and beat him. Review of an incident report dated 5/10/19 at 7:39 a.m. for Resident #103 revealed: Resident was lying in bed when this nurse entered his room. We initiated neuro checks after resident to resident. Resident (#103) in bed one was lying in bed, face on the left side above the eye was red. He reported a pain of 8 on his neck, head, and knee After making few phone calls, this nurse went to his room, noticed face turn purple with more swollen above the left eye. He reported same pain on the head, neck and legs and change in speech Pt was sent out to the hospital for evaluation. Resident was agitated with staff calling out and being very vocal . (sic)

Based on interview and record review, the facility failed to revise the care plan for 1 (Resident #57), resulting in worsened pressure ulcers. Findings include: Review of a Face Sheet revealed Resident #57 was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] after hospitalization and had pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #57 revealed: .Section M0150: Is this resident at risk for pressure ulcers? Yes. Section M0210: Does this resident have 1 or more unhealed pressure ulcer(s) at a Stage 1 or higher? No. Section M1200: Skin and Ulcer Treatments. A. Pressure reducing device for chair. B. Pressure reducing device for bed. Section V0200: CAAs (Care Assessment Areas) and Care Planning: A. Care Area Triggered .Pressure Ulcers .B. Addressed in Care Plan . Pressure Ulcers. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) that indicated he was severely cognitively impaired, required the extensive assist of 2 staff for transfers, no behaviors, and no pressure ulcers. Section M1200 Skin and Ulcer Treatments revealed no turning and repositioning program. Weight was 165 pounds. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) that indicated he was severely cognitively impaired, required the extensive assist of 2 staff for transfers, no behaviors, and one unstageable pressure ulcer. Section M1200 Skin and Ulcer Treatments revealed no turning and repositioning program. Weight was 160 pounds. Review of Wound Measurement documentation for Resident #57 revealed measurements and treatments for an acquired pressure wound on coccyx. The following revealed: 10/17/18, Stage II, L (length) 3.0, W (width) 1.6, D (depth) 0.1, Tissue Type: [MEDICATION NAME], Surrounding Skin: Intact Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Pressure ulcer care. Treatment: Skin prep peri-wound. Cleanse and cover with border gauze. Change BID and PRN. 10/25/18, Stage II, Tissue Type: Slough, L 2.8, W 1.4, D UTD (unable to determine), Surrounding Skin: Intact, Last Debridement date: 10/25/18, Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Pressure ulcer care. 11/21/18, Stage II, Tissue Type: Slough, L 2.2, W 1.6, D UTD, Surrounding Skin: intact, Last Debridement 11/21/18, Skin & Ulcer Treatment: Pressure reducing device for bed. 11/29/18, Stage II, Tissue Type: Slough, L 2.5, W 1.2, D UTD, Surrounding Skin: Intact + Maceration, Skin & Ulcer Treatment: Pressure reducing device for bed. Pressure ulcer care. Treatment: thera honey to wound bed. 12/6/18, Stage II, Tissue Type: Slough, L 2.5, W 0.8, D UTD, Surrounding Skin: Intact + Maceration. Treatment: therahoney to wound bed, cover with boarder foam. 12/13/18, Stage II, L 3.0, W 1.8, D UTD, Surrounding Skin: Maceration. Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Pressure ulcer. Treatment: thera honey to wound bed cover with 4X4. 12/20/18, Unstageable, L 2.8, W 2.0, D (no entry), Surrounding Skin: Intact. Skin & Ulcer Treatment: Pressure reducing device for chair/ Pressure reducing device for bed/ Pressure ulcer care. Treatment: Therahoney to wound bed. 12/27/18, Unstageable, L 2.8, W 1.7, D UTD, Surrounding Skin: [DIAGNOSES REDACTED]/Redness-Blanchable + Maceration. Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Nutrition or hydration intervention/Pressure ulcer care. 1/3/19, Unstageable, L 5.0, W 4.3, D 0.0, Surrounding Skin: [DIAGNOSES REDACTED]/Redness-Non-Blanchable + Hardness/Induration + Other. Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Turning/repositioning program/Nutrition or hydration intervention/Pressure ulcer care. Treatment: Cleanse ulcers on sacrum and left medial buttock with saline and gauze and cover with silicone foam border dressing. Review of the Care Plan for Resident #57 revealed: Focus: The resident has unstageable pressure ulcer on the coccyx area and potential for pressure ulcer on the Left distal coccyx/buttocks area r/t MASD and Immobility. Date Initiated: 10/15/2018. Revised 12/27/18. Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 10/15/2018. Revision on: 01/05/2019. Interventions revealed no APM (air pressure mattress), no pressure reducing device for chair, repositioning resident at least every 2 hours, and no new pressure ulcer interventions after 10/4/18 to address worsening of pressure ulcers until 12/27/18. In an interview on 3/14/18 at 3:30 p.m. Corporate Consultant/Registered Nurse (RN) I reported that Resident #57 had behaviors sometimes and liked to be in his wheelchair and was also hard to reposition because he would move back to his previous position. RN I reported that his advanced [MEDICAL CONDITION] made it difficult too because of his tremors and when the resident returned from the hospital, he had some weight loss. RN I provided all documentation related to Resident #57's pressure ulcer.

Based on interview and record review, the facility failed to document, and implement interventions to prevent pressure ulcers in 2 (Resident #57 and Resident #22) resulting in Resident #57 developing an unstageable pressure ulcer on the coccyx area and Resident #22 having the potential to develop a pressure ulcer when the facility did not utilize pressure relieving interventions. Findings include: Review of a Face Sheet revealed Resident #57 was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] after hospitalization and had pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #57 revealed: .Section M0150: Is this resident at risk for pressure ulcers? Yes. Section M0210: Does this resident have 1 or more unhealed pressure ulcer(s) at a Stage 1 or higher? No. Section M1200: Skin and Ulcer Treatments. A. Pressure reducing device for chair. B. Pressure reducing device for bed. Section V0200: CAAs (Care Assessment Areas) and Care Planning: A. Care Area Triggered .Pressure Ulcers .B. Addressed in Care Plan . Pressure Ulcers. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) that indicated he was severely cognitively impaired, required the extensive assist of 2 staff for transfers, no behaviors, and no pressure ulcers. Section M1200 Skin and Ulcer Treatments revealed no turning and repositioning program. Weight was 165 pounds. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) that indicated he was severely cognitively impaired, required the extensive assist of 2 staff for transfers, no behaviors, and one unstageable pressure ulcer. Section M1200 Skin and Ulcer Treatments revealed no turning and repositioning program. Weight was 160 pounds. Review of Physician order [REDACTED].#57 revealed: Admit to Hospice . Review of a Skin Observation Shower Record for Resident #57 dated 9/27/18 revealed: Resident received a bed bath by Certified Nursing Assistant (CNA) and documented there were red areas and rashes and circled the buttocks on a body diagram. Review of a Skin Observation Shower Record for Resident #57 dated 10/1/18 revealed: Resident received a bed bath by Certified Nursing Assistant (CNA) and noted red areas to the side of the neck and a scratch on the right eye. Review of a General Progress Note dated 10/4/2018 for Resident #57 revealed: blanchable discolored area noted on coccyx, orders for z-guard and side lying repositioning received, guardian notified. (sic) Review of a Skin Progress Note dated 10/15/2018 for Resident #57 revealed: Wound rounds completed this date with PA. Res has coccyx alteration 3 cm x 1.6 cm with darkened center approx. 1.5 cm x 0.6 cm. TX started per PA this date. Res has MASD to distal coccyx 0.5 cm x 0.2 cm x less than 0.1 cm 100 percent pink [MEDICATION NAME] tissue, leave open to air. MASD to left distal buttock 0.4 cm x 0.5 cm 100 percent slough, leave open to air. Res has air mattress in place, is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. (sic) Review of a physician progress notes [REDACTED].#57 revealed: .Patient is seen with staff present for new open area on coccyx near rectum. Admits to pain near his rectum, esp (especially) with wiping and cares, but also sitting in wc (wheelchair) .Skin: Wound at coccyx 3.0 cm (centimeters) X 1/6 cm with 100% slough on wound bed, unstageable, surrounding tissue pink and blanchable, no maceration of the wound edges, no drainage or odor noted, some pain with cleansing wound, etc. In measuring 1.5 cm X 0.6 cm. 2 smaller wounds on either side of upper buttocks, left measure 0.4 x 0.5 cm, stage 2 100% wound bed pink granulation, not macerated and blanchable. On the right upper buttock, a similar appearing wound measures 0.5 cm x 0.2 cm, again pink granulation at its wound bed, stage 2 .Plan: Three wounds, add foam border dressing and skin prep to coccyx wound, the other two buttock wounds, cover with zgaurd (skin protectant paste) and monitor closely (sic) Review of a Skin Progress Note dated 10/18/2018 at 12:42 p.m. for Resident #57 revealed: The resident has unstageable pressure ulcer on the coccyx area. And potential for pressure ulcer on the Left distal coccyx/buttocks area r/t MASD (Moisture-associated skin damage) and Immobility .IDT (Interdisciplinary Team) Wound rounds completed this date with PA (Physician Assistant). Res has coccyx alteration 3cm x 1. 3cm 85 percent slough, 15 percent granulation, scant seros drainage, edges intact and attached. TX changed to santyl to wound bed, foam boardered dressing. Res has MASD to distal coccyx 0.5 cm x 0.2 cm x less than 0.1 cm 100 percent pink [MEDICATION NAME] tissue, leave open to air. MASD to left distal buttock 0.4 cm x 0.5 cm 100 percent slough, leave open to air. Res has air mattress in place, is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. Review of a General Progress Note dated 10/18/2018 at 1:42 p.m. for Resident #57 revealed: received report from cena that resident was grabbing and twisting cena's wrist during feeding at lunchtime, also that he kicked her in the back after she had laid him down in bed after lunch, had completed cares, and had turned to leave the room. (sic) Review of a Skin Progress Note dated 10/18/2018 at 1:48 p.m. for Resident #57 revealed: The resident has unstageable pressure ulcer on the coccyx area. And potential for pressure ulcer on the Left distal coccyx/buttocks area r/t MASD and Immobility Note Text: IDT Wound rounds completed this date with PA. Res has coccyx alteration 3cm x 1. 3cm 85 percent slough, 15 percent granulation, scant seros drainage, edges intact and attached. TX changed to santyl to wound bed, foam boardered dressing. Res has MASD to distal coccyx healed. MASD to left distal buttock 0.4 cm x 0.7 cm 85 percent slough, 15 percent granulation scant serous drainage edges intact and attached, apply z-guard. Res has air mattress in place, is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. MD (Medical Director) aware and agrees with P[NAME]. (sic) Review of a physician progress notes [REDACTED].#57 revealed: he has developed ulcers on his coccyx and left buttock. It appears the wounds were first noted on 10/15/18 .He admits that the wounds are painful .Skin: Superior ulcer on coccyx measures 3.0 x 1.3 cm, there is a depth of 0.1 cm, but this is not a true depth d/t (due to) the presence of slough, the wound base is 15% granulation tissue and 85 % slough, there is scant serous drainage with no odor, the wound edges are intact and attached. Inferior ulcer on coccyx appears to be resolved, there is healthy pink [MEDICATION NAME] tissue where the ulcer had been present. The ulcer on the left buttock measures 0.4 x 0.7 cm there is a depth of 0.1 cm, but this is not a true depth d/t the presence of slough, the wound base is 15% granulation tissue and 85% slough, there is scant serous drainage with no odor, the wound edges are intact and attached Plan: Unstageable ulcer, coccyx: will have staff cleanse the wound with saline and gauze .it is noted that resident is on Hospice forend stage [MEDICAL CONDITION], he does have an APM (alternating pressure mattress), according to his charting he is eating well. Localized skin desquamation: MASD to the left buttock, resident is incontinent of bowel and bladder, staff to continue to apply zinc cream to the buttock, avoiding the dressing on the coccyx, every shift and PRN (as needed) for incontinence . Review of a Skin Progress Note dated 10/25/2018 at12: 31 p.m. for Resident #57 revealed: IDT Wound rounds completed this date with PA. Res has coccyx alteration 2.8 cm x 1.4 cm 60 percent slough, 40 percent granulation, moderate serous drainage, edges intact and attached. TX santyl to wound bed, foam boardered dressing. MASD to left distal buttock healed. Res has air mattress in place, w/c cushion in place is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. MD aware and agrees with P[NAME]. (sic) Review of a Skin Progress Note dated 11/1/2018 at 3:15 p.m. for Resident #57 revealed: Note Text: IDT Wound rounds completed this date with PA. Res has coccyx alteration 3.0 cm x 1.7 cm 90 percent slough, 10 percent granulation, scant seros drainage, edges intact and attached with purple discoloration. TX santyl to wound bed, foam boardered dressing. Res has air mattress in place, w/c cushion in place, is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. MD aware and agrees with P[NAME]. (sic) Review of a Skin Progress Noted dated 11/8/2018 at 1:56 p.m. for Resident #57 revealed: IDT Wound rounds completed this date with PA. Res has coccyx alteration 2. 3cm x 1.6 cm 85 percent slough, 15 percent scattered granulation, moderate serous drainage, edges intact and attached. TX santyl to wound bed, foam boardered dressing. Res has air mattress in place, w/c cushion in place, is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. MD aware and agrees with P[NAME] (Plan of Care). (sic) Review of a Skin Progress Note dated 11/15/2018 at 11:25 a.m. for Resident #57 revealed: IDT Wound rounds completed this date with PA. Res has coccyx ulcer 2.2 cm x 1.6 cm 85 percent slough, 15 percent scattered granulation, moderate serous drainage, edges intact and attached. TX santyl to wound bed, foam boardered dressing. Res has air mattress in place, w/c cushion in place, is incontinent of bowel and bladder which could delay wound healing. Nursing to apply z-guard to buttocks. MD aware and agrees with P[NAME]. (sic) Review of a Nutrition/Weight Progress Note dated 12/4/2018 at 1:56 p.m. for Resident #57 revealed: .Weight Change Note. Resident triggered for significant weight loss of -18.2# (-10.2%) over previous 6 months. Current body weight 159.8#, BMI 23.6 (Healthy). Resident remains weight stable over the previous ~4-5 months. Resident continues with good appetite, meal intakes 75-100%, supplement intakes 75-100% (Nutritional Treat BID). Resident continues to require feeding assistance with meals, snacks, drinks. RD placed in IPC book, notified guardian and hospice. Goal for weight to remain stable within healthy BMI range. On hospice with goal for comfort measures, with no tube feeding interventions. (sic) Review of a General Progress Note dated 12/26/2018 at 4:16 p.m. for Resident #57 revealed: IPC in, new wound orders received, order received for abx (antibiotics) for [MEDICAL CONDITION] of sacral area (sic) Review of a Skin Progress Note dated Progress Notes 12/27/2018 at 8:03 a.m. for Resident #57 revealed: IDT wound rounds completed 12-26-18. Sacrum wound 2.8 cm x 1.7 cm with 85 percent slough, 15 percent granulation moderate serous drainage edges intact and macerated with tissue breakdown peri-wound with [DIAGNOSES REDACTED] and induration. Left side buttock MASD 2.6 cm x 1. 3cm x 0.1 cm 10 percent granulation, 90 percent [MEDICATION NAME] scant serous drainage, edges macerated with tissue breakdown. D/C (discontinue) previous treatment, change to cover with foam. ATB (antibiotic) started for wound infection. P[NAME] updated. (sic) Review of a General Progress Note dated 12/27/2018 at 2:42 p.m. for Resident #57 revealed: LS (lung sounds) remain clear, cont. with coughing at meal times, cont. on po abx (antibiotics) for tx (treatment) of [MEDICAL CONDITION] of sacral wound area . Review of a General Progress Note dated 12/31/18 for Resident #57 revealed: . Resident has area of skin on wound that is black. Hard bump under skin approximately size of a golf ball. Review of a General Progress Note dated 1/3/2019 1:41 p.m. for Resident #57 revealed: .The resident was started on a new antibiotic today to help treat his wound on his bottom . The resident treatment was done by the wound care nurse today. The resident is being repositioned from side to side and did not get out of bed today . Review of Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Wound Measurement documentation for Resident #57 revealed measurements and treatments for an acquired pressure wound on coccyx. The following revealed: 10/17/18, Stage II, L (length) 3.0, W (width) 1.6, D (depth) 0.1, Tissue Type: [MEDICATION NAME], Surrounding Skin: Intact Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Pressure ulcer care. Treatment: Skin prep peri-wound. Cleanse and cover with border gauze. Change BID and PRN. 10/25/18, Stage II, Tissue Type: Slough, L 2.8, W 1.4, D UTD (unable to determine), Surrounding Skin: Intact, Last Debridement date: 10/25/18, Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Pressure ulcer care. 11/21/18, Stage II, Tissue Type: Slough, L 2.2, W 1.6, D UTD, Surrounding Skin: intact, Last Debridement 11/21/18, Skin & Ulcer Treatment: Pressure reducing device for bed. 11/29/18, Stage II, Tissue Type: Slough, L 2.5, W 1.2, D UTD, Surrounding Skin: Intact + Maceration, Skin & Ulcer Treatment: Pressure reducing device for bed. Pressure ulcer care. Treatment: thera honey to wound bed. 12/6/18, Stage II, Tissue Type: Slough, L 2.5, W 0.8, D UTD, Surrounding Skin: Intact + Maceration. Treatment: therahoney to wound bed, cover with boarder foam. 12/13/18, Stage II, L 3.0, W 1.8, D UTD, Surrounding Skin: Maceration. Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Pressure ulcer. Treatment: thera honey to wound bed cover with 4X4. 12/20/18, Unstageable, L 2.8, W 2.0, D (no entry), Surrounding Skin: Intact. Skin & Ulcer Treatment: Pressure reducing device for chair/ Pressure reducing device for bed/ Pressure ulcer care. Treatment: Therahoney to wound bed. 12/27/18, Unstageable, L 2.8, W 1.7, D UTD, Surrounding Skin: [DIAGNOSES REDACTED]/Redness-Blanchable + Maceration. Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Nutrition or hydration intervention/Pressure ulcer care. 1/3/19, Unstageable, L 5.0, W 4.3, D 0.0, Surrounding Skin: [DIAGNOSES REDACTED]/Redness-Non-Blanchable + Hardness/Induration + Other. Skin & Ulcer Treatment: Pressure reducing device for chair/Pressure reducing device for bed/Turning/repositioning program/Nutrition or hydration intervention/Pressure ulcer care. Treatment: Cleanse ulcers on sacrum and left medial buttock with saline and gauze and cover with silicone foam border dressing. Review of the Care Plan for Resident #57 revealed: Focus: The resident has unstageable pressure ulcer on the coccyx area. and potential for pressure ulcer on the Left distal coccyx/buttocks area r/t MASD and Immobility. Date Initiated: 10/15/2018. Revised 12/27/18. Goal: The resident's will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 10/15/2018. Revision on: 01/05/2019 Interventions revealed no APM (air pressure mattress), no pressure reducing device for chair, repositioning resident at least every 2 hours, and no new pressure ulcer interventions after 10/4/18 to address worsening of pressure ulcers until 12/27/18. In an interview on 3/14/18 at 3:30 p.m., Corporate Consultant/Registered Nurse (RN) I reported that Resident #57 had behaviors sometimes and liked to be in his wheelchair and was also hard to reposition because he would move back to the previous position. RN I reported that his advanced [MEDICAL CONDITION] made it difficult too because of his tremors and when the resident returned from the hospital, he had some weight loss. RN I provided all documentation related to Resident #57's pressure ulcer. Resident #22 Review of Resident #22 Minimum Data Set (MDS), nursing assessment tool dated 1/18/19 revealed Resident #22 was an [AGE] year old female admitted to the facility on [DATE] and was on hospice care. Resident #22 required extensive assistance of one person for bed mobility, extensive assistance of 2 people for dressing, extensive assistance of 2 people for toilet use and extensive assistance of one person for hygiene. Resident #22 was observed flat in bed on 3/12/19 at 2:19 PM and Certified Nurse Aides (CNA) F and H were providing care. When CNA's changed Resident #22's brief, Resident #22 had a dime size open area over the coccyx area that was open and bleeding. When asked if they were aware of this open area before this brief change, CNA F and H responded this was the first time they did care with Resident #22 today because the hospice aide provided the morning care. CNA F and H did not get any report from the hospice aide or assist the hospice aide with any care. CNA F and H were not aware if the hospice aide reported any care concerns. During an interview with Unit Manager (UM) U on 3/12/19 at 2:42 PM, U was asked for the hospice care plan and charting for Resident #22. UM U could not find and hospice aide notes in the facility and could not locate any documentation that showed what care or services the hospice aide was scheduled to provide 3/12/19. No information was located to indicate what care the hospice aide was expected to do when she came to see Resident #22. During an interview with the Hospice Registered Nurse (RN) FF on 3/12/19 at 3:57 PM, she said she did not know what care the hospice aide had provided on 3/12/19 because there was no documentation kept in the facility. RN FF did not confirm what care she expected the hospice aide to do 3/12/19. During an interview with the Director of Nursing (DON) and UM U on 3/13/19 at 12:13 PM, they confirmed Resident #22 started hospice care on 1/9/19. They were not able to locate a detailed note of a care conference with hospice in the facility medical record. UM U said the hospice aide had reported verbally to Licensed Practical Nurse (LPN) G on 3/12/19 before leaving that she had done comfort care for Resident #22 that day. LPN G thought that the hospice aide did all of Resident #22 morning care from that report but found out after the Surveyor questioned the care that the hospice aide did not do all the morning care. UM U said, hospice is going to give the aide more education. UM U confirmed Resident #22 had been observed drinking some juice that morning, and facility staff did turn and reposition Resident #22 around 10:00 to 10:30 AM. UM U could not confirm Resident #22 had received any care or assistance the morning of 3/12/19 other than being turned around 10:00 to 10:30 AM. The DON confirmed Resident #22 was dependent on staff for reposition and that should occur every 2 hours even if not care planned as that is the standard of care for dependent residents. There was no information provided that showed Resident #22 had received turning and repositioning care every two hours on 3/12/19. (Facility CNA's provided turning care around 10:00 to 10:30 and again at 2:19 PM, this is twice in an 8 hour shift. ) During an interview on 3/14/19 at 11:01 AM with UM U, UM said the hospice aide was in on 3/12/19 at 8:30 AM and did not provide the expected care by repositioning the resident. She also stated that hospice was handling her education and the facility was working on the hospice care, and hospice documentation, to keep track of services provided each day of service. UM U provided two handwritten staff statements dated 3/13/19 for Resident #22. The first statement was from CNA L and documented, I remember before lunch (name of CNA FF) and me went in there and checked her and turned her. She was dry, and I knew she was dry because the brief turns color when wet. The brief will turn color even when soiled with poop. So the hospice Aide told LPN G and I was right there that, oh yeah I just did complete bed bath on her. She was swallowing okay. The hospice Aide was telling me thinking I was name of Resident #22 Aide. The hospice Aide did not say anything about skin. The next time I went in to help was about 2 PM when LPN G, me and CNA F went in to help and turn and LPN G was measuring her buttock. The second statement was from CNA F and documented, On 3/12/19 I repositioned Resident #22 at about 10:00 to 10:30. The pillow was on the right side, and I took it out so I could help with feeding, her. CNA L was in with me. I lifted the gown to check her brief, and she was dry. There was no discoloration on the brief. I didn't see any poop in the back of the brief. Then me and CNA L were back in there to reposition her, and the State Surveyor was in there about 1:40 PM, 2 PM. She was wet, and at this time I wiped the periguard, and there were 2 spots starting to bleed. I put the periguard on and went to report to LPN G, and by this time the State Surveyor had reported to LPN G Than me, LPN G and CNA L went back LPN G measured and put on a patch. (statement confirmed Resident #22 received assistance with turning twice between 7:00 AM and 2:19 PM, not every 2 hours). Review of Resident #22's care guide dated 3/13/19 revealed no indication Resident #22 was on hospice and did not indicate hospice was providing any care listed on the guide. Under ADL's (activities of daily living)/Restorative Care documented, Bed mobility x (times) 2 for any incontinence care and hygiene, Assist x 2 with any grooming, dressing every Am and PM, Bed bath only. Review of Physician Assistant note dated, 3/13/19 documented: Skin: right upper inner buttock medially there is a 0.3 cm (centimeters) x 0.2 cm very superficial skin sloughed are and just later to this is a 0.1 cm similar appearing superficial sloughed area. Wound beds are pink and moist, and tissue is blanchable. Surrounding this area is dry desquamated skin that extends up towards the coccyx as well. Again tissue is blanchable at coccyx as well. Under ICD Codes: documented 709.8 Open area buttock not consistent with pressure area, consistent with desquamated skin, area is blanchable, cont offloading by turns in bed, patient is declining overall, very as increased weakness and bed bound status, incontinence. Cont(tinue) periguard bid (twice a day) and prn (as needed) with brief changes. During a telephone interview with Nurse Practitioner NP O on 03/14/19 at 11:08 AM, O said she had been following Resident #22 due to right leg venous changes and the need to treat her right foot with dressing changes. She said she had not seen Resident #22 in a while because she was comfort measures only and the right foot was stable. Healing to Resident #22's buttock wound was revealed by NP O after seeing the resident per request by the facility. When asked about Resident #22's turning and repositioning needs, she said turning every 2 hours was sufficient at this time.

This citation pertains to MI 959. Based on observation, interview and record review, the facility failed to implement measures to prevent facility acquired pressure ulcers for 1 resident (#3), of 3 reviewed for pressure ulcers, from a total sample of 9 residents, resulting in the development of facility acquired pressure ulcers and the potential for delayed wound healing. Findings include: Review of the facility Face Sheet, dated 3/27/18 at 2:30 PM, reflected that Resident #3 was a [AGE] year old male, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 12/23/17, reflected that Resident #3 was non-ambulatory and required one person extensive assist with bed mobility, dressing and hygiene. He required two person extensive assist with transfers and toileting and total assist of two people for bathing. The assessment reflected that the resident was at risk for pressure ulcers and that the resident had moisture associated skin damage (MASD). Review of the medical record reflected the following progress notes: -On 1/18/18 at 1:25 PM, Physician's Assistant (PA) J documented that an unstageable pressure ulcer (an ulcer where the extent of tissue damage could not be determined due to the wound base being covered with slough or eschar) was noted to the left heel that day. Treatment was initiated, and pressure relieving boots while in bed were put in place. The resident also had an ulcer to the buttock secondary to MASD. -On 1/25/18 at 10:50 AM, PA J documented that the unstageable pressure ulcer to the left heel was stable. The treatment and pressure relieving boots while in bed were continued. The ulcer to the buttock was improved. -On 2/1/18 at 1:05 PM, PA J documented that the unstageable pressure ulcer to the left heel was stable. The treatment and pressure relieving boots while in bed were continued. A stage 1 pressure ulcer (intact skin that was red and non-blanchable) of the left ankle was noted. The resident was wearing shorter socks, and the top of the sock rested in about the same area as the wound. PA J recommended that the resident got different socks that went higher up the leg. The ulcer to the buttock measured larger, but the wound base improved. -On 2/8/18 at 12:10 PM, PA J documented that the unstageable pressure ulcer to the left heel was stable, and treatment continued. The pressure ulcer of the left ankle was documented as unstageable and stable. An unstageable pressure ulcer of the right ankle was noted. The ulcer on the buttock was closed. The note reflected, .again recommend resident get different socks as he was noted to be wearing ankle socks again, will also d/c (discontinue) pressure relieving boots in the event that the straps may be contributing to the ankle wounds, will have staff float his heels on pillows . -On 2/15/18 at 2:40 PM, PA J documented that the wound to the left ankle was noted on 2/1/18, and the wound to the right ankle was noted on 2/8/18. .I had asked that resident stop wearing ankle socks, and last week we also d/c'd his pressure relieving boots in the event that the straps for the boots were putting pressure on theankles (sic) . The unstageable pressure ulcer to the left heel was stable. The unstageable pressure ulcers to the left and right ankles were improved. -On 2/22/18 at 12:25 PM, PA J documented that the unstageable pressure ulcer to the left heel was stable. The note reflected that the unstageable pressure ulcer to the left ankle measured larger and that the reason was unclear. The unstageable pressure ulcer to the right ankle was stable. -On 3/1/18 at 12:00 PM, PA J documented that it appeared the resident was still getting pressure to the unstageable pressure ulcer of the left heel. The documentation reflected, .we had discontinued the pressure relieving boots out of concern that the straps may have been contributing to the ankle wounds, however last week the wounds had worsened without the boots, so I no longer suspect the boots played a role and will restart pressure relieving boots to both feet whenver (sic) he is in bed . The note also reflected that the unstageable pressure ulcer to the left ankle .improved, however I did note that resident was wearing ankle socks again today, staff to be reminded that he is not to wear these type of socks . The unstageable pressure ulcer to the right ankle .improved, again will need to remind staff that he is not to wear ankle socks . -On 3/8/18 at 10:05 AM, PA J documented, .I had asked that the resident stop wearing ankle socks .last week I reinitiated the boots as his ankle wounds had worsened,indicating it wasn't the boots .I also examined his buttocks as he has a hx (history) of MASD to the buttocks, he did have a wound on the right upper buttock .the wound edges are macerated (softening and breakdown of skin resulting from prolonged exposure to moisture) . The unstageable pressure ulcer of the left heel was stable. The unstageable pressure of the left ankle was improved, and the unstageable pressure ulcer of the right ankle was stable. -On 3/22/18 at 9:35 AM, PA J documented that the ulcer on the right buttock was closed, and the unstageable pressure ulcer to the left heel had resolved. The note reflected that the unstageable pressure ulcer to the left ankle measures bigger this week, however he was noted to be wearing ankle socks today .again I recommend he does not wear ankle socks . The unstageable pressure ulcer to the right ankle also measured slightly bigger. -On 3/22/18 at 1:04 PM, Social Worker (SW) R documented that she spoke with Resident #3's Durable Power of Attorney to request taller socks for the resident. -On 3/27/18 at 2:13 PM, SW P documented that the family had purchased new crew socks for the resident. Review of the Kardex Report, dated 3/27/18, reflected that Resident #3 was to wear prevalon boots (boots to lift the heels off the mattress) bilaterally (to both feet) when he was in bed. Review of a Care Plan History document printed by the facility on 3/28/18, reflected: - .SPECIAL NEED: no ankle socks to be worn. r/t (related to) sore on bil (bilateral) ankles, pressure relieving boots bilat. (bilaterally) while in bed . with a Resolved Date of 3/25/18 and a Revision Date of 3/25/18. - .SPECIAL NEED: no ankle socks to be worn. r/t sore on bil ankles, pressure relieving boots bilat. while in bed . with a Revision Date of 3/1/18. - .SPECIAL NEED: no ankle socks to be worn. r/t sore on bil ankles . with a Revision Date of 3/1/18. Review of the Care Plan with a Focus titled, At risk for alteration in skin integrity related to: impaired mobility, incontinence . reflected that it was initiated on 6/15/17 and was revised on 1/19/18. The Interventions area of the care plan reflected that prevalon boots bilaterally (on both feet) while in bed was initiated on 3/1/18. During an interview and observation on 3/28/18 at 1:54 PM, Resident #3 was in bed with gripper socks on both feet. His heels and ankles were resting on the bed, and his prevalon boots were not in place as ordered. Certified Nursing Assistant (CNA) E stated that the resident was supposed to wear moon boots while in bed. During an interview and observation on 3/28/18 at 2:18 PM, CNA K stated that he put pressure relieving boots on Resident #3 whenever he was in bed. Resident #3 was observed lying in bed with his heels and ankles resting on the mattress. His prevalon boots were on his nightstand in the corner of the room. CNA K acknowledged that Resident #3 did not have his pressure relieving boots on. He stated that he had put the resident to bed about 20 minutes prior. When informed of the observation on 3/28/18 at 1:54 PM, CNA K then stated he put the resident in bed around 1:45 PM that day. On 3/29/18, two unsuccessful attempts were made to speak to PA J while PA J was present in the facility that day. Upon the third request, the facility stated that PA J had left the facility and was available by phone. An attempt to speak to PA J via phone on 3/29/18 at 4:04 PM was unsuccessful.

Based on observation, interview and record review, the facility failed to perform clean dressing changes, hand hygiene and assess for protein needs to heal pressure ulcers for one resident (Resident #44), out of 3 residents reviewed for pressure ulcers, from a total sample of 28 residents, resulting in an infection of a wound and underlying boney structures and the potential for slow healing wounds and further skin breakdown. Findings include: According to a facility face sheet dated 2/8/18 at 10:56 AM, Resident #44 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. According to a document titled Medication Review Report dated 2/2/18 for Resident #44 reflected, Stage 4 ulcer to left ischium .Stage 4 ulcer to sacrum . A Stage 4 Pressure Injury: Full-thickness skin and tissue loss full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) During an observation of Resident #44's wound care on 02/07/18 01:34 PM it was observed that Certified Nurse's Aide (CNA) O donned gloves and emptied the Foley indwelling catheter bag (drains urine from the bladder) of a clear yellow urine into a graduated container. No cleansing with alcohol was noted of the Foley drainage spout. CNA O then with her dirty gloved hand, was observed to pull at the top of the dressing cart to move it to the side to be able to walk by it to the bathroom. Clean dressing supplies were observed on top of this cart, no barrier was observed under the clean dressings. No preparation of the top of the cart such as disinfection was observed. Resident #44 was positioned lying in bed on her right side and 2 pressure wounds were observed, one under left buttock and one at the sacrum. Resident #44 stated she was admitted with the wounds. Resident had a bowel movement, and this was cleansed by the CNA's with adult disposable wipes and removed with the brief. No barrier observed placed under Resident #44 on bed after cleansing of the bowel movement by CNA O. LPN X donned gloves washed the wounds with a saline squirt (a single use small saline plastic container) and gauze. The buttock wound was observed to be washed from the outside skin into the base of the wound (dirty skin to clean base of the wound). Dirty dressing supplies were discarded open trash bag on the bed. LPN X was observed to prop up the saline squirt on an item in the dirty garbage bag so that the spout wouldn't leak saline. LPN X removed her gloves and was observed to cut the calcium alginate dressing needed. This cut piece was placed on top of the open dressing sleeve. LPN X was not observed to perform hand hygiene after removing her gloves. Alcohol hand gel was observed on top of the dressing cart. LPN X applied clean gloves. No hand hygiene was observed before donning new gloves. LPN X pulled out packing gauze from a container, applied saline to the gauze and placed in the lower left buttock wound. LPN X was then observed to cut the packing gauze with her scissors near the residents body after it had been packed in the resident's wound and then pulled more packing gauze from a new vial and cut this with her used scissors. LPN X was not observed to have cleaned her scissors before cutting a clean piece of packing gauze. LPN X was observed to have applied dermaskin (a skin protectant) spray to peri (around) wound AND wound packing areas then applied an occlusive foam dressing to the buttock wound. LPN X then discarded her used gloves into the garbage bag and was observed to use alcohol hand gel and applied clean gloves. The sacral wound was then observed cleansed by LPN X with the use of the propped up saline squirt applied to gauze (with clean gloves on). Again LPN X cleansed from the outside skin to the inner wound, from outside of wound in. LPN X took off her dirty gloves and applied new gloves, no hand hygiene observed. LPN X cut a calcium alginate piece with the uncleansed scissors and applied it to the wound bed. This sacral wound was observed sprayed with dermaskin around the wound AND over the wounds calcium alginate. LPN X then took off gloves and no hand hygiene observed, applied new gloves and applied foam dressing over the sacral wound. No dates were observed to be placed on either ischial or sacral wound dressings. CNA O was then observed to remove the garbage bag with gloved hands from the bed. No hand hygiene was observed after removal of CNA O's gloves. CNA O asked LPN X if the calcium alginate needed to be saved. LPN X replied, Yes, it's expensive and CNA O was observed to place the dressing with her ungloved and un cleansed hands into the original open package and placed the dressing in the dressing cart. CNA O was observed to have pulled the dressing cart out of the room and into the hall. Review of a facility policy titled, Skin Practice Guide dated issued 1/2013 reflected, Wound Management: .Dressing changes are performed using a non-sterile, clean technique unless otherwise ordered by the attending physician. In general, the following guidelines are considered when performing treatments: adhere to principles of infection control - separate clean and dirty, provide a barrier filed for treatment supplies, appropriate use and changing of gloves, maintain appropriate precautions, appropriate cleaning of the wound bed (center of wound to outside perimeter), cleansing of scissors, hand washing, disposal of soiled dressings .Dressings are dated and initialed. Review of a facility policy titled, Dressing Change: Non sterile (Clean) dated revised 4/2016 reflected, .Perform hand hygiene (each time you are entering or leaving a room and when you are going form dirty to clean) .Set up area: disinfect over bed table using an EPA approved disinfectant. While over bed table (surface) is drying, gather supplies and bring them to the patients room .perform hand hygiene upon entering. Place a clean barrier on the over bed table (surface) then place hand sanitizer, equipment and supplies on top of barrier. Do no open supplies at this point. Place waste receptacle, with leak proof bag under the over bed table .Perform hand hygiene Place procedure towel (wound drape) or clean towel under the area for treatment. Perform hand hygiene and apply latex free non-sterile drugs. Remove soiled dressing and discard in trash bag .Remove soiled gloves, discard and perform hand hygiene. Prepare a clean filed: arrange supplies on table, open packages to reveal supplies, if dressing need to be cut to size, use cleans scissors (disinfect the scissors with an EPA approved disinfectant before and after using), label tape used to secure dressing with caregiver initials and date. Perform hand hygiene and apply latex free non sterile gloves. Cleanse wound per physician's orders [REDACTED]. Clean wound then peri wound. Removed soiled gloves, discard. Perform hand hygiene and apply latex free non sterile gloves. Apply dressing per physician's orders [REDACTED]. Remove procedure towel from under patient and discard. Dispose of soiled and used disposable equipment and supplies in waste bag. Remove soiled gloves and discard. Perform hand hygiene .Return equipment and used supplies to designated area. Clean, sanitize, disinfect or dispose as indicated. Perform hand hygiene after disposing waste and or cleaning equipment. Review of a facility policy titled, Hand Hygiene dated 12/2009 reflected, Purpose: To decrease spread of infection .When to wash hands or use hand rub: before applying and after removing gloves .after contact with body fluids or excretions. Mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . During an Infection Control interview on 02/07/18 at 02:10 PM with DON B, Corporate Quality Assurance (CQA) Y and Unit Manager (UM) CC, DON B stated she has been DON at the facility for a little over a week. DON B has had formal training on Infection Control facility surveillance. It was asked if hand hygiene audits have been done. UM CC confirmed she has watched handwashing but does not have documentation of who she watched, when or if any follow up training was required. UM CC and DON BB was asked about dressing change procedure and hand hygiene. DON B stated hand hygiene needs to be done before and after donning your gloves, remove dressing you wash your hands. Scissors are to be cleansed before and after each use. Dressings that are open and cut are considered used and need to be thrown away. A barrier needed to be on top of cart, under the dressing supplies. All three confirmed that propping saline squirts inside dirty garbage bag on bed was not a good infection control practice. UM CC stated that the Foley spout needed to be cleansed with alcohol before emptying, and touching the clean dressing cart touch with dirty gloves should not have occurred. On 02/07/18 at 03:49 PM during a review of medical records the records reflected, OSTEO[DIAGNOSES REDACTED] OF VERTEBRA (back bones), SACRAL AND SACR(NAME)(NAME)CYGEAL REGION (lower back and tail bone area, where Resident #44 pressure ulcer is located) 12/8/2017. [DIAGNOSES REDACTED] (is): Inflammation of the bone due to infection . Both the bone and the bone marrow may be infected. Symptoms include deep pain and muscle spasms in the area of inflammation, as well as fever. Treatment includes bed rest, use of antibiotics, and sometimes surgery to remove dead bone tissue. (https://www.medicinenet.com/script/main/art.asp?articlekey=4681) Review of a document for Resident 344 titled, EMAR (electronic medication administration record) dated 10/1 to 10/31/17 reflected, [MEDICATION NAME] Capsule (an antibiotic). Give 100 mg (milligrams) via G (gastric) tube every 12 hours for [MEDICAL CONDITION] (wound) for 20 administrations) on 10/18/17 and changed on 10/19/17 to [MEDICATION NAME] Mono (an antibiotic) 100 mg cap Give 100 mg via G tube every 12 hours for [MEDICAL CONDITION] for 20 administrations. On 02/08/18 11:40 AM during an interview with Director of Nursing (DON) B, DON B confirmed there were no blood protein levels (indicates level of protein in the body so that the body can heal properly) that have been checked since Resident #44's admission. Stephanie stated she, has been doing her job long enough to know that a protein level would be warranted. An acute care document titled, Comprehensive Metabolic Panel dated 6/16/17 reflected, [MEDICATION NAME] 3.1 g/dl (grams per deciliter which is low. Normal is 3.5 to 5.7 g/dl). Resident #44 has the [DIAGNOSES REDACTED]. Review of a facility policy titled, Skin Practice Guide dated issued 1/2013 reflected, Tests: .Laboratory tests including hematocrit (number of red blood cells in relation to the blood sample), hemoglobin (red blood cells carrying oxygen), [MEDICATION NAME] (protein level), hemoglobin A1C (history by blood of what glucose levels have been) and coagulation studies (how well a residents blood clots) .Phase 3: Implement .Protein: Increased protein intake is often emphasized in patients with non-healing wounds. Provide adequate protein for positive nitrogen balance, 1.25 to 1.5 gm (grams)/kg (per kilogram) body weight is recommended for nutritionally compromised patients. Reassess protein needs as condition changes and adjust for formula based on renal and liver function . Review of a document titled, Medication Review Report dated 2/2/18 for Resident #44 reflected, ProMod Liquid (Nutritional Supplement which provides 100 Calories and 10 grams of protein per ounce or 30 ml) Give 30 ml (milliliters) via PEG (stomach feeding tube) tube three times a day for wound healing. This intervention was dated as ordered 12/28/17, over 5 months after Resident #44's admission with two stage 4 pressure ulcers. Good nutritional status is essential for wound healing to take place. Ignoring nutritional status may compromise the patient's ability to heal and subsequently prolong the stages of wound healing. Glucose provides the body with its power source for wound healing and this give energy for angiogenesis and the deposition of new tissue. Therefore, it is vital that the body receives adequate amounts of glucose to provide additional energy for wound healing. Fatty acids are essential for cell structure and have an important role in the [MEDICAL CONDITION] process. Wound healing is dependent on good nutrition and the presence of suitable polyunsaturated fatty acids in the diet. Protein deficiency has been demonstrated to contribute to poor healing rates with reduced collagen formation and wound dehiscence (re opening of a wound). High exudate (a mass of cells and fluid that has seeped out of blood vessels especially in inflammation) loss can result in a deficit of as much as 100g of protein in one day. This subsequently needs to be replaced with a high protein diet. Vitamins are also important in wound healing. Vitamin C deficiency contributes to fragile granulation tissue. There is a correlation between low serum [MEDICATION NAME] and body mass index (BMI) and the development of pressure ulcers. Also, low serum [MEDICATION NAME] and high Waterlow (a scale used to assess pressure ulcer risk) score have a positive association. (https://www.ncbi.nlm.nih.gov/pubmed/ 399) The recommended amount of 0.8 g protein/kg body weight is based on the needs of healthy adults. Elderly patients may require a higher baseline protein intake of 1 g/kg. However, many patients, including those with wounds, don't fall into the healthy adult category and have even higher protein needs. It's known that adequate protein is crucial for proper wound healing, but the precise amount isn't established .For patients with pressure ulcers, the recommendation is also 1 to 1.5 g/kg; those with deep ulcers or multiple pressure-ulcer sites may need 1.5 to 2 g/kg .When determining the protein needs of a wound patient, it's necessary to consider additional factors, such as preexisting protein-energy malnutrition, renal impairment, or other critical illnesses. The best strategy is to evaluate the patient as a whole and use clinical judgment based on: o a physical examination for signs of catabolism (degradative metabolism involving the release of energy and resulting in the breakdown of complex materials (such as proteins or lipids) within the organism according to Merriam-Webster Dictionary) o a dietary history to determine typical protein intake (Resident #44 was receiving a gastric tube feedings) o a weight history to find out if unintended weight loss has occurred o laboratory values, such as serum [MEDICATION NAME], to identify catabolism and inflammation. It's also necessary to consider the depth and total body surface areas of the patient's wounds. (https://woundcareadvisor.com/how-dietary-protein-intake-promotes-wound-healing-vol2-no6/)

Based on interview and record review, the facility failed to notify the Durable Power of Attorney (DPOA) and physician of a change in condition for 1 resident (Resident #42) and failed to promptly notify the DPOA of a change in condition for 1 resident (Resident #13) of 2 reviewed for notification of change, from a total sample of 28, resulting in absence of treatment and delay of treatment. Findings include: Resident #42 Review of the medical record reflected that Resident #42 was a [AGE] year old female, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record and advance directive reflected that Resident #42 was a full code, which indicated that her wishes were for life-saving measures. Record review of a progress note dated [DATE] at 10:00 AM reflected, called into room by cena (competency evaluated nurse aide) at 7:40 am, resident noted with no resp.(respirations) or pulse, code blue called and CPR was initiated, 911, (Physician Group), family and manager on call all contacted, (ambulance company), fire and police arrived, code continued until 8:06am when it was stopped and time of death was pronounced after (paramedics) contacted hospital and order was made to stop CPR, family, (Physician group), manager notified of death, police in contact with M.E. (medical examiner) and ok to release body to funeral home, daughter here at 9:15am, awaiting funeral home staff for release of body. Record review of a progress note by Physician's Assistant (PA) VV on [DATE] at 11:21 PM reflected that the resident was seen for [MEDICAL CONDITION]. The note reflected that her Brain Natriuretic Peptide (BNP) was over 3,000 (BNP is a laboratory test that measures levels of a protein made by the heart and blood vessels. The reference range for the result is less than or equal to 99). The note also reflected that her Creatinine was 3.4 (Creatinine is a laboratory test that measures a waste product from the normal breakdown of muscle tissue that is filtered through the kidneys. The reference range for the result is 0.600 to 1.200). Documentation reflected that the resident was more confused than her baseline and that a care conference would need to be set up with the daughter to discuss options, including hospice versus renal consult and [MEDICAL TREATMENT]. A progress note documented by Social Worker (SW) W on [DATE] at 12:05 PM, reflected that the PA requested to speak with the DPOA (durable power of attorney) regarding the plan of care and medical status. A teleconference was set up with DPOA UU for [DATE]. During a phone interview on [DATE] at 2:13 PM, DPOA UU reported that she had not been notified of changes of changes in condition at all times. She reported that the SW had called her (on [DATE]) to say that someone wanted to talk to her about the resident's [MEDICAL CONDITION]. DPOA UU acknowledged that someone was going to call her back on [DATE] because the timing was not good that day. She reported she had not been notified that the resident's condition was declining and that nobody had suggested to send the resident to the hospital. DPOA UU reported that she would have wanted the resident sent to the hospital for evaluation and treatment if she had known of changes in condition. She stated, I have always sent her to the hospital. She re-stated that SW had stated they wanted to talk about changes. Referring to [DATE], DPOA UU reported, They called me at 8:00 AM to let me know there was a change in condition. They called me at 8:14 AM to let me know that my mom was dead. Record review of laboratory testing reflected that a Comprehensive Metabolic Panel (CMP) was drawn on [DATE] at 12:20 PM. Creatinine was 2.454 and the carbon [MEDICATION NAME] level was 22.0 (the reference range was 21.0 to 31.0). On [DATE] at 6:30 AM, a CMP was drawn and reflected a creatinine of 3.140 and a carbon [MEDICATION NAME] of 16.0. A BNP test on [DATE] at 6:30 AM reflected a result of 1,715.0. A CMP was drawn on [DATE] at 6:50 AM. The creatinine level was 3.694 and carbon [MEDICATION NAME] was 16.0. The BNP result was 3,594.3. The lab report reflected a handwritten note by PA VV that a care conference with the family was needed. During an interview on [DATE] at 3:14 PM, Medical Doctor (MD) V reported that an elevated BNP was considered a change in condition. During a phone interview on [DATE] at 4:20 PM, PA VV reported that in the few weeks prior to her passing away, Resident #42 had been declining and overall was not doing well. PA VV reported that she completed her documentation from home and had not seen the patient at the actual time her progress note for [DATE] was documented. She reported she wanted to set up a conference with the daughter to discuss hospice. PA VV reported she spoke to the SW about setting up a care conference with the daughter (DPOA), and she passed away over the weekend, before the care conference. PA VV stated, I was moving towards making this patient comfortable. She was declining. When asked if an elevated BNP would have necessitated a call to the DPOA, PA VV reported, Yes, that is what I did. Documentation in the medical record reflected that SW W, who was not qualified to discuss laboratory results or medical conditions, made a phone call to the daughter. During a phone interview on [DATE] at 9:18 AM, Licensed Practical Nurse (LPN) X reported that earlier in the week of Resident #42's death, if she was having difficulty breathing, oxygen was put on her. She reported that on [DATE], she received report that the resident had some respiratory problems and to monitor her oxygen saturation levels. During a phone interview with Registered Nurse (RN) OO on [DATE] at 9:39 AM, she reported that she received report from LPN WW on the morning of [DATE] that the resident had pursed lip breathing during the night and that maybe she was short of breath. She was also told that oxygen was applied during the night, which gave her a little relief. During a phone interview on [DATE] at 10:23 AM, LPN WW reported that she worked with Resident #42 overnight on [DATE] and into the morning of [DATE]. She reported that the resident did pursed lip breathing sometimes. LPN WW stated that Resident #42 began pursed lip breathing on her shift. She applied oxygen and told the Certified Nursing Assistant's (CNA) to keep an eye on her and tell her if there was anything different. She reported that the oxygen saturation was at 96% that night, so she was not personally worried about the resident. LPN WW reported the resident seemed more comfortable, and the pursed lip breathing had resolved. She reported that she had not contacted the DPOA during her shift that night and stated, I assumed that was already done. LPN WW reported she did not personally report a change in condition to the doctor because she did not feel pursed lip breathing was a change for the resident. LPN WW stated she had first noticed pursed lip breathing that Thursday ([DATE]). Review of the medical record did not include documentation that the resident had pursed lip breathing for the time surrounding [DATE]. During an interview on [DATE] at 12:47 PM, MD V reported that he would have expected to be notified during the night about pursed lip breathing if he was on call. He stated, Honestly they should have sent her out .If someone has pursed lip breathing, they need to be sent out (to the hospital). MD V reported that the conversation with the survey team was the first time he had been notified that the resident had pursed lip breathing. Review of the facility policy titled, CHANGE IN CONDITION with a date of ,[DATE], reflected the purpose was to provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications. The policy also reflected, .immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed . Resident #13 A review of Resident #13's admission record dated [DATE], revealed Resident #13 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:29 AM, Resident #13 stated she had a fall that morning. A laceration was observed above left eye, and a bruise on left knee. Resident #13 was observed to be in significant amount of pain. Registered Nurse (RN) P entered the resident's room at this time and stated that Resident #13 also had pain and range of motion issue on left hip. Resident #13 stated she fell because no one came to answer her call light and she had to go to the bathroom. RN P stated that she observed that the resident's wheel chair was behind her when she fell around 7:15 AM. on [DATE]. RN P stated that the call light was not on. When asked if Resident #13 had any fractures, RN P stated they are waiting for an x-ray. During an interview on [DATE] at 11:25 AM, Resident #13's Durable Power of Attorney (DPOA) ZZ stated she was just notified approximately 30 minutes ago (about 11 am) that the resident had a fall at 7 AM that morning. DPOA ZZ stated if she had known that Resident #13 had fallen she would have come to the facility hours ago. DPOA ZZ stated they notified her brother when he came to visit about 8 AM but he was not the DPOA. DPOA ZZ was also upset because they were just now doing an x-ray. On [DATE] at 12:36 PM, Paramedics were observed outside the door of Resident #13's room. When questioned as to what was happening, RN P reported they are transferring Resident #13 to the hospital because she was calling out in pain. RN P revealed that Resident #13's hip x-ray came back negative. RN P revealed she was going to be checked out and have a CT scan done. DPOA ZZ came out and stated that she had requested the resident be sent out. During an interview on [DATE] at 02:45 PM, Nursing Home Administrator (NHA) A was asked when a DPOA should be notified of a fall. NHA A stated that the DPOA should have been notified of the fall right away. On [DATE] at 03:30 PM, NHA A reported that RN P told the son about the fall when he came in at 8 o'clock. NHA A stated RN P did not call the DPOA until about 10:15 AM because RN P stated she was waiting for the doctor. NHA A stated it was an issue that the DPOA had not been notified and they were aware of it. Review of Resident #13's After Visit Summary (a report of Resident #13's hospital visit) on [DATE] reflected the following Diagnoses: [REDACTED]. -Closed fracture of left inferior pubic ramus, initial encounter (HCC) -Nondisplaced zone i fracture of sacrum, initial encounter for closed fracture (HCC) A review of the progress notes from [DATE] to [DATE] reflected the following information: -On [DATE] at 07:15, res (resident) observed on floor at foot of bed in front of w/c (wheelchair) with back against wall. laceration above left eye noted measuring 2.5 cm. Res assisted to bed via mechanical lift. c/o pain in left hip and head. ROM (ange of motion) performed WNL (within normal limits); able to flex/extend BLE (bilateral lower extremities). Scheduled [MEDICATION NAME] (a narcotic) given for pain. Bruise noted to left knee; denies pain in knee. laceration above eye cleansed with NS (normal saline). Approximated edges. Steri-strips applied. Wound continued to bleed. placed Band-Aid over steri-strips. -On [DATE] at 08:40, Note by Director of Nursing (DON) B, Approached by nurse (RN P's name). who stated resident was found on the floor by her bed, and assisted back to bed. Stated residents vitals were stable, neuro's initiated without current concern, full range of motion noted w/o pain at this time, although bruising noted to hip area. Nurse (RN P's name) noted laceration above eye, site cleaned and SS (steri-strips) and Band-Aid in place, bleeding did subside. Instructed nurse to order x-ray to hip, and inform of change in condition from current status. -On [DATE] at 09:47 Note by RN P, (Physician Group) ordered stata AP/Lat (anterior, posterior and lateral) Left hip X-ray. Awaiting (mobile x-ray company). -On [DATE] at 10:15, Note by DON B, Informed by Clinical Coordinator (name of Registered Nurse (RN) CC) , resident had increased pain during hygiene care. Mobile x-ray completed, PA (Physician's Assistant)assessed resident and awaiting x-ray interpretation, instructed CC (RN CC) resident would need to be transferred out for evaluation, CC (RN CC) stated she would speak to physician for transfer to ER. -On [DATE] at 11:25, Note by RN P, Res in severe pain. Radiology reveals no fracture of dislocation. Laceration to left eye continues to swell despite putting ice to area. MD assess res at bedside. MD recommends ER visit for eval. - On [DATE] at 22:42, Returned from ER accompanied by daughter, closed pelvic fx r/t fall. Bruising around left eye. new order for [MEDICATION NAME] 15 mg PRN and 10 mg PRN (as needed). Neuros within normal limits. -On [DATE] at 17:39, Resident is alert and orientated x2 with some confusion noted. c/o pain and gave PRN effective. continues neuro check for fall. some small amounts of swallowing difficulty noted-reported findings, therapy to eval [DATE]. resting in room, call light in reach. -On [DATE] at 09:41, SLP downgraded residents diet texture from regular to mechanical soft texture. Continue to monitor meal intakes. Follow up as needed. During an interview on [DATE], DPOA ZZ revealed that since the fall with fracture Resident #13 is on bed rest, is on oxygen (previously not on), and the diet has been downgraded from a regular diet to mechanical soft.

Based on observation, interview and record review, the facility failed to keep one resident free from restraints and maintain physical function for one resident (Resident #57), out of 1 resident reviewed for restraints, from a total sample of 28 Residents, resulting in the restraint and physical decline of Resident #57 and the potential for psychological harm. Findings include: Review of Resident #57's Face Sheet dated 2/6/18, revealed Resident #57 was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #57 was not his own responsible party. On 02/05/18 at 11:06 a.m., Resident #57 was observed up in a geriatric style chair (reclined chair with foot rest) in hall. Resident #57 was asked if chair was comfortable and he said no. Resident #57 could not say how long he was up or why he was uncomfortable. Resident #57 said he wanted to go to bed. Certified Nurse's Aide (CNA) O was asked if Resident #57 needed to go to bed because he was uncomfortable and CNA O said, no, if he goes to bed he will stand up, walk and fall. CNA O readjusted the Geri chair to a more reclined position. On 02/08/17 at 9:20 am., CNA O and CNA RR put Resident #57 in bed from his geriatric style chair. CNA's O and RR provided hygiene care. CNA's O and RR said Resident #57 could not stay in bed because he would get up and fall. Resident #57 was placed back in his Geri Chair, in a reclined position in the hall after care. During an interview with the Minimum Data Set (MDS) Registered Nurse (RN) QQ on 2/12/18 at 9:50 a.m., RN QQ said Resident #57 received his geriatric style chair from hospice in July 2017 and she completed a significant change assessment at that time. RN QQ was asked why the geriatric chair was not coded as a restraint at that time and QQ responded she did not think of it. Review of Resident #57's Physical Therapy Discharge Note dated 6/8/17 (prior to receiving the geri-chair) reflected Resident #57 could walk 170 feet with a 2 wheeled walker and minimal assist of one person. During an interview on 2/12/18 at 2:00 PM, Therapy Director SS confirmed Resident #57 could walk 170 feet with a 2 wheeled walker and one person assist when Physical Therapy discharged him on 6/8/17. SS could not find the standard documentation that provided nursing with instructions to help maintain a Residents function when discharged from therapy. SS could not locate any documentation that would explain why nursing did not receive any instructions to continue to walk with Resident #57 when discharged from therapy on 6/8/17. Review of Resident #57's Physical Restraint assessment dated [DATE] and signed by RN CC documented the brand name of the geriatric chair is for positioning, it is not a restraint. During an interview with RN CC on 2/12/18 at 2:00 PM, Resident #57's Restraint Assessment completed by CC was reviewed along with fall incident reports that documented the intervention on 2 occasions to prevent falls was to recline Resident #57 in his geriatric wheelchair. RN CC said she was not aware Resident #57 was able to get out of a wheelchair or geriatric chair and when it was reclined he could not get out. CC said that was why she assessed the chair as a positioning device on 7/7/18 and the geriatric chair was not assessed again. CC said she was not aware Resident #57 was able to walk with one person assist in June and did not know why Resident #57's functional status was not maintained after he was discharged from Physical Therapy. Review of Resident #57's Incident Report dated 8/28/17 at 12:30 PM, reflected Resident attempted to get out of his recliner then staff assisted him to the floor as resident was sliding off the recliner. Did not hit head to the floor. Under corrective action documented, Staff will have name of geriatric style chair tilted back whenever resident is in name of geriatric style chair unless resident is eating or drinking (This made the geriatric style chair a restraint as evidenced by documentation that Resident #57 could get out of the chair when sitting up and stand when it was not reclined, no order for this restraint or restraint evaluation was located at this time). Review of Resident #57's Incident Report dated 12/1/17 at 7:01 PM, revealed Res (resident) at nurse's station in name of geriatric style wheel chair. Observed attempting to stand from chair, Resident's knee buckled and ended up on both knees on floor with feet in chair. Under corrective action documented, Must remain reclined between meals. (Restraining resident #57 to prevent falls, without an evaluation, orders or release times). Review of the facility Restraints policy dated 5/17, documented under procedures. 1. Prior to utilization of any restraint, the interdisciplinary group completes an evaluation of the patient including a review of hospital discharge records, transfer reports of other documents; an interview with the patient, family or patient representative about the patient's history and risk factors, previous interventions utilized and any medical evaluation of the presenting medical symptom necessitating the use of the restraint. (This information was not located, the restraint evaluation was not completed by the interdisciplinary group. The evaluation was completed by one person. The geriatric style chair was determined not to be a restraint by that one person not the group. None of the other steps in the facility policy were followed).

Based on observation, interviews and record review, the facility failed to complete an accurate restraint assessment for one resident (Resident #57), of 1 Resident Reviewed for restraints, from a total sample of 28 Residents, resulting in Resident #57 being physically restrained and declining in physical function. Findings include: Review of Resident #57's Face Sheet dated 2/6/18, revealed Resident #57 was a [AGE] year old male admitted to the facility on [DATE] and had the following diagnose: [MEDICAL CONDITION], delusional disorders, muscle weakness, difficulty walking and lack of coordination. Resident #57 was not his own responsible party. On 02/05/18 at 11:06 a.m., Resident #57 was observed up in a geriatric style chair (reclined chair with foot rest) in hall. Resident #57 was asked if chair was comfortable and he said no. Resident #57 could not say how long he was up or why he was uncomfortable. Resident #57 said he wanted to go to bed. Certified Nurse's Aide (CNA) O was asked if Resident #57 needed to go to bed because he was uncomfortable and CNA O said, No, if he goes to bed he will stand up, walk and fall. CNA O re-adjusted the Geri chair to a more reclined position. On 02/08/17 at 9:20 a.m., CNA O and CNA RR put Resident #57 in bed from his geriatric style chair. CNA's O and RR provided hygiene care. CNA's O and RR said Resident #57 could not stay in bed because he would get up and fall. Resident #57 was placed back in his Geri Chair, in a reclined position in the hall after care. During an interview on 2/12/18 at 9:50 a.m., the Minimum Data Set (MDS) Registered Nurse (RN) QQ said Resident #57 received his geriatric style chair from hospice in July 2017 and she completed a significant change assessment at that time. RN QQ was asked why the geriatric chair was not coded as a restraint at that time and QQ responded she did not think of it. RN QQ was not aware Resident #57 was able to walk in June 2017 with one assist and was not aware the geri chair prevented Resident #57 from standing when reclined. Resident #57 was in a standard wheelchair prior to the significant change in July. RN QQ reviewed the Care Area Assessment (CAA) part of MDS that gives assessment details to address decline. RN QQ could not locate any additional information on why Resident #57 was no longer able to use a standard wheel chair and was place in a chair he could not move. Review of Resident #57's Physical Therapy Discharge Note dated 6/8/17, reflected Resident #57 could walk 170 feet with a 2 wheeled walker and minimal assist of one person. During an interview on 2/12/18 at 2:00 PM, Therapy Director SS confirmed Resident #57 could walk 170 feet with a 2 wheeled walker and one person assist when Physical Therapy discharged him on 6/8/17. Therapy Director SS could not find the standard documentation that was to be provided to nursing staff with instructions to help maintain a resident's function when discharged from therapy. Therapy Director SS could not locate any documentation that would explain why nursing did not receive any instructions to continue to walk with Resident #57 when discharged from therapy on 6/8/17. Review of Resident #57's Physical Restraint assessment dated [DATE] and signed by RN CC documented the brand name of the geriatric chair is for positioning, it is not a restraint. During an interview on 2/12/18 at 2:00 PM with RN CC, Resident #57's Restraint Assessment completed by CC was reviewed along with fall incident reports that documented the intervention on 2 occasions to prevent falls was to recline Resident #57 in his geriatric wheel chair. RN CC said she was not aware Resident #57 was able to get out of a wheel chair or geriatric chair and when it was reclined he could not get out. RN CC said that was why she assessed the chair as a positioning device on 7/7/18 and the geriatric chair was not assessed again. RN CC said she was not aware Resident #57 was able to walk with one person assist in June and did not know why Resident #57's functional status was not maintained after he was discharged from Physical Therapy. Review of Resident #57's Incident Report dated 8/28/17 at 12:30 PM, reflected, Resident attempted to get out of his recliner then staff assisted him to the floor as resident was sliding off the recliner. Did not hit his head to the floor. Under corrective action documented, Staff will have name of geriatric style chair tilted back whenever resident is in name of geriatric style chair unless resident is eating or drinking (This made the geriatric style chair a restraint as evidenced by documentation that Resident #57 could get out of the chair when sitting up and stand when it was not reclined, no order for this restraint or restraint evaluation was located at this time). Review of Resident #57's Incident Report dated 12/1/17 at 7:01 PM, reflected, Res (resident) at nurse's station in name of geriatric style wheel chair. Observed attempting to stand from chair, Resident's knee buckled and ended up on both knees on floor with feet in chair. Under corrective action documented, Must remain reclined between meals. (Restraining resident #57 to prevent falls, without an evaluation, orders or release times). Review of the facility Restraints policy dated 5/17, documented under procedures. 1. Prior to utilization of any restraint, the interdisciplinary group completes an evaluation of the patient including a review of hospital discharge records, transfer reports of other documents; an interview with the patient, family or patient representative about the patient's history and risk factors, previous interventions utilized and any medical evaluation of the presenting medical symptom necessitating the use of the restraint. (This information was not located, the restraint evaluation was not completed by the interdisciplinary group. The evaluation was complete by one person. The geriatric style chair was determined not to be a restraint by that one person not the group. (None of the other steps in the facility policy were followed).

Based on observation, interviews, and record review, the facility failed to provide the care and services to prevent physical decline for 1 resident (Resident #57), out of 28 residents reviewed for care, from a total sample of 28 residents, resulting in Resident #57 having an avoidable decline in walking and physical movement. Findings include: Review of Resident #57's Face Sheet dated 2/6/18, revealed Resident #57 was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #57 was not his own responsible party. Review of Resident #57's Physical Therapy Discharge Note dated 6/8/17 revealed Resident #57 could walk 170 feet with a 2 wheeled walker and minimal assist of one person. During an interview on 2/12/18 at 2:00 PM, Therapy Director SS confirmed Resident #57 could walk 170 feet with a 2 wheeled walker and one person assist when Physical Therapy discharged him on 6/8/17. SS could not find the standard documentation that was provided to nursing with instructions to help maintain a Residents function when discharged from therapy. SS could not locate any documentation that would explain why nursing did not receive any instructions to continue to walk with Resident #57 when discharged from therapy on 6/8/17. Review of Resident #57's Minimum Data Set (MDS), a nursing assessment, dated 1/1/18 revealed Resident #57 was no longer able to walk and required extensive assistance of 2 people for transfers. Resident #57 was observed being transferred with an electronic lift (total assist with transfer requiring 2 people on 2/8/18 at 9:20 a.m. This should be coded as total assist of 2 on the MDS). On 2/05/18 at 11:06 a.m., Resident #57 was observed up in a geriatric style chair (reclined chair with foot rest) in hall. Resident #57 was asked if the chair was comfortable and he said no. Resident #57 could not say how long he was up or why he was uncomfortable. Resident #57 said he wanted to go to bed. Certified Nurse's Aide (CNA) O was asked if Resident #57 needed to go to bed because he was uncomfortable and CNA O said, no, if he goes to bed he will stand up, walk and fall. CNA O readjusted the Geri chair to a more reclined position. On 2/08/17 at 9:20 am. CNA O and CNA RR put Resident #57 in bed from his geriatric style chair using a electronic lift. CNA's provided hygiene care. CNA's said Resident #57 could not stay in bed because he would get up and fall. Resident #57 was place back in his Geri Chair, in a reclined position in the hall after care. During an interview on 2/12/18 at 9:50 a.m., Minimum Data Set (MDS) Registered Nurse (RN) QQ said Resident #57 received his geriatric style chair from hospice and in July 2017 and she completed a significant change assessment at that time. RN QQ was asked why the geriatric chair was not coded as a restraint at that time and QQ responded she did not think of it. RN QQ reviewed the significant change documentation and could not find any information on Resident #57 ability to walk in June or reason for placing Resident #57 in a geri chair verses a standard wheel chair. Review of Resident #57's Physical Restraint assessment dated [DATE] and signed by RN CC documented the brand name of the geriatric chair is for positioning, it is not a restraint. During an interview with RN CC on 2/12/18 at 2:00 PM Resident #57's Restraint Assessment completed by CC was reviewed along with fall incident reports that documented the intervention on 2 occasions to prevent falls was to recline Resident #57 in his geriatric wheel chair. RN CC said she was not aware Resident #57 was able to get out of a wheel chair or geriatric chair and when it was reclined he could not get out. CC said that was why she assessed the chair as a positioning device on 7/7/18 and the geriatric chair was not assessed again. CC said she was not aware Resident #57 was able to walk with one person assist in June and did not know why Resident #57's functional status was not maintained after he was discharged from Physical Therapy. Review of Resident #57's Incident Report dated 8/28/17 at 12:30 PM, documented, Resident attempted to get out of his recliner then staff assisted him to the floor as resident was sliding off the recliner. Did not his head to the floor. Under corrective action documented, Staff will have (name of geriatric style chair) tilted back whenever resident is in (name of geriatric style chair) unless resident is eating or drinking (This made the geriatric style chair a restraint as evidenced by documentation that Resident #57 could get out of the chair when sitting up and stand when it was not reclined, no order for this restraint or restraint evaluation was located at this time). Review of Resident #57's Incident Report dated 12/1/17 at 7:01 PM, documented, Res (resident) at nurse's station in (name of geriatric style wheel chair). Observed attempting to stand from chair, Resident's knee buckled and ended up on both knees on floor with feet in chair. Under corrective action documented, Must remain reclined between meals. (Restraining resident #57 to prevent falls, without an evaluation, orders or release times).

Based on interview and record review, the facility failed to perform complete neurological assessments after falls for 2 residents (Resident #38 and #53) and failed to appropriately assess and monitor 2 residents (Resident #15 and #42) of 28 reviewed for quality of care, from a total sample of 28, resulting in residents not receiving care and treatment in accordance with professional standards of practice and unrecognized changes in condition. Findings include: Resident #42 Review of the medical record reflected that Resident #42 was a [AGE] year old female, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record and advance directives reflected that the resident was a full code, which indicated that her wishes were for life-saving measures. Record review of a progress note dated [DATE] at 10:00 AM reflected, called into room by cena (competency evaluated nurse aide) at 7:40 am, resident noted with no resp.(respirations) or pulse, code blue called and CPR was initiated, 911, (Physician Group), family and manager on call all contacted, (ambulance company), fire and police arrived, code continued until 8:06am when it was stopped and time of death was pronounced after (paramedics) contacted hospital and order was made to stop CPR, family, (Physician group), manager notified of death, police in contact with M.E. (medical examiner) and ok to release body to funeral home, daughter here at 9:15am, awaiting funeral home staff for release of body. Record review of a progress note by Physician's Assistant (PA) VV on [DATE] at 11:21 PM reflected that the resident was seen for [MEDICAL CONDITION]. The note reflected that her Brain Natriuretic Peptide (BNP) was over 3,000 (BNP is a laboratory test that measures levels of a protein made by the heart and blood vessels. The reference range for the result is less than or equal to 99). The note also reflected that her Creatinine was 3.4 (Creatinine is a laboratory test that measures a waste product from the normal breakdown of muscle tissue that is filtered through the kidneys. The reference range for the result is 0.600 to 1.200). Documentation reflected that the resident was more confused than her baseline and that a care conference needed to be set up with the daughter to discuss options, including hospice versus renal consult and [MEDICAL TREATMENT]. A progress note documented by Social Worker (SW) W on [DATE] at 12:05 PM reflected that the PA requested to speak with the DPOA (durable power of attorney) regarding the plan of care and medical status. A teleconference was set up with the DPOA for [DATE]. During a phone interview on [DATE] at 2:13 PM, DPOA UU reported that she had not been notified of changes of changes in condition at all times. She reported that the SW had called her (on [DATE]) to say that someone wanted to talk to her about the resident's [MEDICAL CONDITION]. DPOA UU acknowledged that someone was going to call her back on [DATE] because the timing was not good that day. She reported she had not been notified that the resident's condition was declining and that nobody had suggested to send the resident to the hospital. DPOA UU reported that she would have wanted the resident sent to the hospital for evaluation and treatment if she had known of changes in condition. She stated, I have always sent her to the hospital. She re-stated that SW had stated they wanted to talk about changes. Referring to [DATE], DPOA UU reported, They called me at 8:00 AM to let me know there was a change in condition. They called me at 8:14 AM to let me know that my mom was dead. Record review of laboratory testing reflected that a Comprehensive Metabolic Panel (CMP) was drawn on [DATE] at 12:20 PM. Creatinine was 2.454 and the carbon [MEDICATION NAME] level was 22.0 (the reference range was 21.0 to 31.0). On [DATE] at 6:30 AM, a CMP was drawn and reflected a creatinine of 3.140 and a carbon [MEDICATION NAME] of 16.0. A BNP test on [DATE] at 6:30 AM reflected a result of 1,715.0. A CMP was drawn on [DATE] at 6:50 AM. The creatinine level was 3.694 and carbon [MEDICATION NAME] was 16.0. The BNP result was 3,594.3. The lab report reflected a handwritten note by PA VV that a care conference with the family was needed. During a phone interview on [DATE] at 4:20 PM, PA VV reported that in the few weeks prior to her passing away, Resident #42 had been declining and overall was not doing well. PA VV reported that she completed her documentation from home and had not seen the patient at the actual time her progress note for [DATE] was documented. She reported she wanted to set up a conference with the daughter/DPOA to discuss hospice. PA VV reported she spoke to the SW about setting up a care conference with the daughter/DPOA, and she passed away over the weekend, before the care conference. PA VV stated, I was moving towards making this patient comfortable. She was declining. When asked if an elevated BNP would have necessitated a call to the DPOA, PA VV reported, Yes, that is what I did. (Documentation in the medical record reflected that SW W, who was not qualified to discuss laboratory results or medical conditions, made a phone call to the daughter.) During the same interview on [DATE], PA VV stated that diuresing the resident (giving medication to remove excess fluid from the body) would not have made a difference. PA VV reported that [MEDICAL TREATMENT] would have made a difference for the resident and that it could have been started in the hospital. PA VV stated that she would have been on board with sending the resident to the hospital but would have advocated that it was a Band-Aid. She stated that in the past, the DPOA did not want [MEDICAL TREATMENT], she wanted aggressive treatment. PA VV reported that at the time she evaluated the resident on [DATE], she was clinically stable. She reported clinical presentation that would have warranted a transfer to the hospital included increased respirations, low blood pressure, respiratory distress, increased heart rate and increased confusion. During a phone interview on [DATE] at 9:18 AM, Licensed Practical Nurse (LPN) X reported that earlier in the week of Resident #42's death, if she was having difficulty breathing, oxygen was put on her. She reported that on [DATE], she received report that the resident had some respiratory problems and to monitor her oxygen saturation levels. During a phone interview with Registered Nurse (RN) OO on [DATE] at 9:39 AM, she reported that she received report from LPN WW on then morning of [DATE] that the resident had pursed lip breathing during the night and that maybe she was short of breath. She was also told that oxygen was applied during the night, which gave her a little relief. RN OO reported that she saw the resident at approximately 6:30 AM on [DATE], as she was passing by Resident #42's room. RN OO stated that she could see the resident breathing at that time. RN OO reported that on the morning of [DATE], Certified Nursing Assistant (CNA) AAA was passing linens and told RN OO that something was not right with Resident #42 and to go to the room. RN OO reported that the resident was not breathing so she started the code process right away. RN OO stated, I knew she was declining a little but did not expect to walk into that. During a phone interview on [DATE] at 10:23 AM, LPN WW reported that she worked with Resident #42 overnight on [DATE] and into the morning of [DATE]. She reported that the resident did pursed lip breathing sometimes. LPN WW stated that Resident #42 began pursed lip breathing on her shift. She stated that she applied 1 liter of oxygen and told the CNA's to keep an eye on her and tell her if there was anything different. She stated she told the CNA's to notify her of any distress, if she was in more distress and increased confusion. She reported that the oxygen saturation was at 96% that night, so she was not personally worried about the resident. During the same interview, LPN WW reported the resident seemed more comfortable, and the pursed lip breathing had resolved after oxygen was applied. LPN WW reported that she elevated the head of the bed, checked the resident frequently and checked her vital signs and oxygen saturation level. She reported there was not a physical assessment of the resident during her shift because the resident was not in distress. LPN WW stated, I did not listen to her lungs because she was at 96% so I was not worried. She reported that she had not contacted the DPOA during her shift that night and stated, I assumed that was already done. LPN WW reported she did not personally report a change in condition to the doctor because she did not feel pursed lip breathing was a change for the resident. LPN WW stated she had first noticed pursed lip breathing that Thursday ([DATE]). LPN WW reported that she had not applied oxygen to Resident #42 in the past, prior to her shift on [DATE]. The medical record did not include documentation that the resident had pursed lip breathing. LPN WW had not documented any assessment of the resident in the progress notes. Review of the Medication Administration Record (MAR) and the Treatment Administration Records (TAR) for [DATE] and February 2018 reflected an order for [REDACTED]. Documentation did not reflect that the resident had been placed on oxygen at any time. Review of the vital signs summary reflected that vital signs of temperature, pulse, respirations and blood pressure had last been obtained on [DATE] at 8:05 PM. The last oxygen saturation was documented as 98% while breathing room air on [DATE] at 8:35 PM. During an interview on [DATE] at 3:14 PM, Medical Doctor (MD) V reported that an elevated BNP would be considered a change in condition. He reported that clinically, if the resident was short of breath, had a heart rate greater than 100 beats per minute, a respiratory rate greater than 20 breaths per minute or appeared to be in respiratory distress, he would have recommended that she was sent to the hospital. He further stated that with any one of the above mentioned symptoms, he would have likely sent her to the hospital. He stated that he would have wanted a current set of vital signs to make the determination. MD V also stated that a determination could not have been made regarding her clinical presentation without a recent set of vital signs. MD V stated that he last examined Resident #42 on [DATE], and at that time, he did not feel that she was end stage in her life. He also reported he did not feel she was a hospice candidate at that time. During an interview on [DATE] at 12:47 PM, MD V reported that he would have expected to be notified during the night about pursed lip breathing if he was on-call. He stated, Honestly they should have sent her out .If someone has pursed lip breathing, they need to be sent out (to the hospital). MD V reported that the conversation with the survey team was the first time he had been notified that the resident had pursed lip breathing. He stated that his expectations of a nurse in regards to monitoring someone with pursed lip breathing would have included monitoring respiratory rate and oxygen saturation levels while on and off oxygen, an assessment of the respiratory effort and listening to lung sounds. MD V stated, If I am called for respiratory distress, I send the patient out .We were treating her appropriately based on labs, but based on pursed lip breathing, I would have sent her out . Review of the facility policy titled, CHANGE IN CONDITION with a date of ,[DATE], reflected the purpose was to provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications. The policy also reflected, .immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed . During an interview on [DATE] at 10:08 AM, CNA SS reported that she cared for Resident #42 overnight on [DATE] and that she did not take any vital signs for the resident. She reported that the resident was breathing fine. During an interview on [DATE] at 10:15 AM, CNA AAA reported that she got report from RN OO that the resident had oxygen on and had trouble breathing during the night. When AAA entered Resident #42's room, she turned the light on and called Resident #42's name. She reported the resident was not moving so she called for RN OO. AAA reported, she was gone, her lips were blue. During an interview on [DATE] at 11:45 AM, CNA SS reported that Resident #42 had her oxygen on more towards the morning, but the nurse did not say anything about keeping an eye on the resident. She reported her first observation of oxygen use was around 3:00 AM and that the resident was awake all night. She stated that she had not checked the oxygen saturation for the nurse and had not been asked to do anything extra. Review of the death certificate reflected that Resident #42 died from natural causes and that an autopsy was not performed. The causes of death were listed as cardiorespiratory arrest, [MEDICAL CONDITION], hypertension and diabetes mellitus. Resident #53 Review of the facility Face Sheet, dated [DATE], reflected that Resident #53 was an [AGE] year old female, re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an incident report by LPN S on [DATE] reflected that Resident #53 was observed lying on the floor between her bed and nightstand. The resident had reported that she was reaching for her phone, which was on the nightstand. The resident had bleeding over her right eye and was sent to the hospital for evaluation. Review of a progress note by LPN S on [DATE] at 10:11 PM reflected that the resident was observed on the floor at 5:10 PM. The note reflected vital signs had been taken but did not reflect that a complete neurological assessment had been performed. Record review for a CT scan of the head reflected that on [DATE] at 7:27 PM, a small left-sided subdural hematoma (a pool of blood between the brain and its outermost covering and is most often the result of a severe head injury) measuring up to 8 millimeters (mm) in thickness with approximately 2 to 3 mm of rightward midline shift was identified. Record review of a Post-Acute Care Transfer Form for [DATE] at 6:10 PM reflected a primary visit [DIAGNOSES REDACTED]. Review of a progress note by LPN NN on [DATE] at 7:13 PM, reflected that the resident had returned from the hospital with 7 stitches and a right sided black eye. A progress note by LPN MM on [DATE] at 1:50 PM reflected that the resident had a laceration by the right eyebrow, bruising around the right eye and was not able to fully open her right eye. The note reflected that the resident continued on fall precautions and neurological checks. A progress note by LPN BBB on [DATE] at 6:36 AM reflected that the neurological assessment was within normal limits. A progress note by LPN MM on [DATE] at 1:54 PM reflected that the resident continued on fall precautions and neurological checks. A progress note by LPN S on [DATE] at 12:48 PM reflected that the resident continued to complain of a headache. There was no double vision, blurred vision or nausea. A progress note by LPN S on [DATE] at 2:21 PM reflected that the resident complained of a headache after third shift had given Tylenol. On first shift she had complained of feeling dizzy and lightheaded with the headache. There was no nausea, blurred vision or double vision. A progress note by LPN S on [DATE] at 11:00 AM reflected that (Name of Physician's group) requested that the resident was sent to the emergency room for evaluation of a recent subdural hematoma. Record review of an After Visit Summary, dated [DATE], reflected that the reason for the visit was Altered Level of Consciousness. Review of progress notes for [DATE] through [DATE] did not reflect that complete neurological checks were performed on the resident. A neurological check flow sheet was not found in the medical record. During an interview on [DATE] at 2:19 PM, Director of Nursing (DON) B reported that there were no neurological checks for the fall that Resident #53 had on [DATE]. She reported if there was an unwitnessed fall, neurological checks had to be initiated. Record review of the facility document titled, .Neurological Evaluation Flow Sheet reflected, .Directions: Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent monitoring may be necessary .Complete episodic charting for at least 72 hours including any pertinent evaluation findings related to the neurological evaluation. Review the most recent evaluation on the medical record and notify the physician of any changes from previous evaluation . The Neurological Evaluation Flow Sheet included assessment areas of, Level of Consciousness .Orientation (orientation to person, place, situation) .Pupils (pupil size of both eyes and reaction) .Motor Movement Evaluation (extremity movement and facial symmetry) .Communication/Language .Unusual/New Observations (such as weakness, dizziness, headache and vision changes) .Vital Signs . Resident #15 According to a facility face sheet dated [DATE] at 4:11 PM, Resident #15 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Fall #2 [DATE] Review of a facility investigation for Resident #15, a document titled Incident Report - Patient Involved dated [DATE] at 8:30 PM (same time of day as fall #1) reflected, CNA transferring patient in sit to stand (mechanical lift) machine from shower chair to bed. Patient observed slowing letting go of handles and sliding down to floor. CNA and nurse lowered patient to the floor. Patient unresponsive for a few seconds and could not say where she was at or how she got to the floor. This document reflected, Corrective Action: Sent out to the emergency room for further evaluation. On [DATE] at 09:37 AM during an interview with Unit Manager (UM) CC she was asked if Resident #15 had any syncopal ([MEDICAL CONDITION] or dizziness) episodes before the fall from the sit to stand mechanical lift. UM CC confirmed that Resident #15 had a few low blood pressures (B/P) before that fall on [DATE]. UM CC was asked if any serial orthostatic blood pressures (lying, sitting, standing blood pressures to detect a change) done. UM CC stated, No. No previous [MEDICAL CONDITION] before that episode on [DATE]. UM CC stated Resident #15 was hanging in the sit to stand lift sling and the nurse and CNA unhooked the sling and lowered her to the floor. UM CC stated this was from her interviews with the two staff members. The nurse took vital signs, assessed Resident #15, called the physician and received an order to have go to the emergency room . UM CC was asked if there was any injury and she replied that per Resident #15's progress notes, septic UTI and bilateral clavicle fractures. Resident #15 returned on [DATE]. UM CC stated that [MEDICATION NAME] (a medication that is used to treat low blood pressure or [MEDICAL CONDITION]. It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. As a result, blood pressure is increased. https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 821) was started on [DATE] and increased on [DATE]. On [DATE] [MEDICATION NAME] (a hypertension/heart medication) was discontinued. Orthostatic B/P's were to be done for 3 days in September, 2017. Review of the blood pressures in the EMR did not reflect any or orthostatic blood pressures or under vital signs or in progress notes per UM CC. UM CC reviewed the MAR (medication administration record) and there was a check that orthostatic B/P's were done on, ,[DATE], ,[DATE] and [DATE] but not documented on the MAR (medication administration record). No documentation of orthostatic blood pressures were found by UM CC. UM CC stated she was not sure if Resident #15 was having problems with dizziness. The facility failed to assess Resident #15's orthostatic blood pressures as ordered in [DATE] and as an assessment to determine if orthostatic [MEDICAL CONDITION] was occurring for safety with transfers. Review of facility documents for Resident #15 titled, [MEDICAL TREATMENT] Communication Form reflected that the Section 1 Completed by (Name of Facility Staff) (Send with patient to [MEDICAL TREATMENT] center) was not completely filled out to inform the [MEDICAL TREATMENT] center of any changes with Resident #15 regarding vital signs, access site, patient status, lab tests, change in diet order, current medication changes or an significant changes. Review of these sheets: [DATE] There was no documentation regarding pressure areas/wounds, [MEDICAL TREATMENT] and patient status. [DATE] There was no vital signs, [MEDICAL TREATMENT] assessment documented or pressure areas/wounds or nurse signature [DATE] There was no documentation on pressure area/wounds, significant changes, [MEDICAL TREATMENT], patient status or nurse signature. [DATE] There was no documentation regarding wounds/pressure areas, [MEDICAL TREATMENT] [DATE] There was no documentation regarding pressure areas/wounds, [MEDICAL TREATMENT] or nurse signature [DATE] A handwritten notation on the side of the facility assessment, Section 1, Please fill out. There was no documentation about wounds/pressure areas, significant change, vital signs, [MEDICAL TREATMENT], patient status, labs, diet, current medications or nurse signature. All fields in section 1 was blank. [DATE] There is no documentation regarding wounds or pressure areas or [MEDICAL TREATMENT] [DATE] There is no documentation regarding wounds or pressure areas or [MEDICAL TREATMENT] [DATE] There is no documentation regarding wounds or pressure areas, [MEDICAL TREATMENT] site and the form is not signed by a nurse [DATE] There is no documentation regarding wounds or pressure areas, [MEDICAL TREATMENT] site or patient status [DATE] There is no documentation regarding wounds or pressure areas or [MEDICAL TREATMENT] site [DATE] There is no documentation regarding wounds or pressure areas, vital signs, [MEDICAL TREATMENT], or nurse signature [DATE] There is no documentation regarding wounds or pressure area, vital signs, [MEDICAL TREATMENT], patient status or nurses signature. These documents were the only documents provided when the facility was asked for communications with Resident #15's [MEDICAL TREATMENT] unit. A pre [MEDICAL TREATMENT] nursing assessment should consist of, Assess vital signs, including orthostatic blood pressures (lying, sitting, and standing), apical pulse, respirations, and lung sounds. These data provide baseline information to help evaluate the effects of [MEDICAL TREATMENT]. Hypertension may indicate excess fluid volume. The client who is hypotensive may not tolerate rapid fluid volume changes during [MEDICAL TREATMENT]. Abnormal heart sounds (e.g., a gallop or murmur) and changes in heart rate or rhythm may indicate excess fluid volume or electrolyte imbalance. Fluid overload may also cause dyspnea, tachypnea, and rales or crackles in the lungs. Record weight. Weight changes are an effective indicator of fluid volume. Assess vascular access site for a palpable pulsation or vibration and an audible bruit and for inflammation. Infection and thrombus formation are the most common problems affecting the access site in [MEDICAL TREATMENT] clients. (http://wps.prenhall.com/wps/media/objects/,[DATE]/[MEDICAL TREATMENT].pdf) According to skin progress notes dated [DATE] at 7:45 AM, Resident #15 began to have an area from her right leg prosthesis, Traumatic dermal hemorrhage right medial (middle) mid buttock obliquely (slanting) measures 2.0 cm (centimeters) by 1.3 cm. Area fairly well defined except for interior (inside) and lateral (sideways) where there is moderate dusky red color. Otherwise very dark red blood in skin with blanching or refill. Peri wound very irregular and somewhat poorly defined measures 6.5 cm by 5.0 cm. and pale/mod pink with good blanch and measures 3.2 cm by 0.4 cm . According to skin progress notes (IDT or interdisciplinary team) dated [DATE] at 11:24 AM, Right medial mid buttock assessed. Mild serosanguinous (serum and blood) spotting noted. No debris but mild bleeding with swabbing. Area measures 1.2 cm by 1.4 cm. 70 % (percent) pale yellow necrotic dermis (dead skin) and 20 % red dermis. Skin split noted over mid coccyx level midline crease measures 0.4 cm by 0.1 cm with surrounding pale pink scaring. No significant depth. Wound bed with pale pink dermis. Per wound for both pink/violet with good blanch and refill except for area to left which is irregular old blood in skin 2.5 cm by 2.0 cm. Minimal discomfort. New area to right medial inguinal crease which obliquely measures 0.3 cm by 0.2 cm by 0.3 cm with mild bleeding. Undermining from 9:00 to 12:00 (o'clock) up to 1.0 cm at 10:00 (o'clock). Peri wound pale dusky violet due to sub Q bleeding and obliquely measures 1.5 cm by 1.0 cm. Area with no blanch and refill. [DIAGNOSES REDACTED]. Also has area to right posterior medial upper thigh. Traumatic dermal hemorrhage. Area very irregular up to 0.7 cm by 7.6 cm. Area not open but wound moderate red blood in skin from stump shrinker. Therapy notified (Name of rehabilitation center) related to skin alterations secondary to stump shrinker. Resident #15 had wounds from her prosthesis, stump shrinker and then a stage 2 pressure area to her coccyx area. Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. When this happens, a pressure ulcer may form. (https://medlineplus.gov/ency/patientinstructions/ 7.htm) There was no communication regarding Resident #15's wounds or pressure area so that bleeding may be monitored for (Resident #15 was on a blood thinner), or measures could be taken in the [MEDICAL TREATMENT] chair to relieve pressure like a pressure reducing pillow and/or frequent repositioning. Resident #38 According to a facility face sheet dated [DATE] at 1:32 PM, Resident #38 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Fall #1 [DATE], no time noted Review of progress notes dated [DATE] at 11:28 AM reflected, Patient Safety Note Text: IDT note post fall on [DATE]. Patient explains she was attempting to get out of bed and bend to pick something up at the same time. She denies injury and could verbalize how to remain safe such as, wearing grippy socks, not trying to do two things at a time, using reacher for items on floor, asking for help when needed. Fall #2 [DATE] at 6:30 AM Review of a facility investigation for Resident #38, a document titled Incident Report - Patient Involved dated [DATE] at 6:30 AM reflected, Heard yelling for help, upon entering the room, the resident (#38) stated she fell ing trying to get her drink. Drink was on the tray table at upper right side of bed. Resident states severe pain in right shoulder and she states hitting her head on the floor, so did not move resident from position .send to hospital for evaluation. This was the only Incident document provided when Incident/Accident forms for falls were requested from UM CC. Review of another progress note for Resident #38 reflected, [DATE] at 3:58 PM Patient Safety Note Text: IDT post fall review for fall on [DATE]: resident was ambulating in her room without walker. She reports reaching to put her water down and fell forward, hitting her head and hurting her right shoulder. Witness to the fall reports that she was reaching to either grab or put something down and she fell forward. Resident was sent out to the ED and returned to the facility with dx with a fracture of right clavical and urinary tract infection and started on antibiotics. BIMS (Brief interview for mental status) 11 (indicating Resident #38 is cognitively intact). She was educated by DOR regarding asking for assistance with transfers/care needs. Nurse was updated with her change in care plan. New Intervention: PT/OT (physical therapy/occupational therapy) to eval(uate) and treat, education to patient and staff, U/A (urinalysis if not completed by hospital), medication review by IPC (Neudexta, an antipsychotic medication was discontinued). Care reviewed and updated. Transfer status changed to 1 assist with gait with transfers and w/c (wheelchair) for transportation until therapy assesses. Resident #38 experienced a fall on [DATE] and [DATE]. Review of a facility document for Resident #38 titled, Neurological Evaluation Flow Sheet dated started on ,[DATE] (no year written) at 12:45 PM. This form reflected, Complete Neurological evaluation with vital signs initially, then every 30 x (times) 4, then every 4 hours x 4, then every 8 hours x 9 (72 hours) . This form was completed for the first 30 x 4. The next every 4 hours x 4 was not completed. This form documentation last notation is [DATE] at 8:30 PM. 72 hours from the first assessment is [DATE] at 12:45 PM. Neurological assessment were not done per facility policy. Resident #15 also fell again on [DATE] at 6:30 AM. This neurological assessment should have started over and neurological assessments be done again for another 72 hours until [DATE] at 6:30 AM. Per the Falls/Fall Risk Process Guidelines (MDCH, 2001) residents who have fallen are at risk for delayed consequences which may occur within several days after the fall; occasionally they can occur several weeks later. Acute subdural hematomas (bleeding under the covering of the brain) develop within 48 hours of injury and have an organized clot. Subacute subdural hematomas develop within 3 days to 2 weeks after a head injury. The chronic subdural hematoma can produce symptoms from about 3 weeks to several months after the injury. The damaged area is filled with fluid rather than an organized clot. (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.) The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide .Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count - not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care. https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current st (TRUNCATED)

Based on observation, interview and record review, the facility failed to supervise and failed to perform a safe sit to stand mechanical lift transfer for one resident (Resident #15), out of 7 residents reviewed for falls, from a total sample of 28 residents, resulting in two falls with fractures. Findings include: Resident #15 According to a facility face sheet dated 2/8/18 at 4:11 PM, Resident #15 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Fall #1 - 11/8/17 Review of a facility investigation for Resident #15, a document titled Incident Report - Patient Involved dated 11/8/17 at 8:30 PM reflected, Resident (#15) was witnessed sitting on the floor in her bathroom. She stated she was trying to get up and fell . Prior to the incident resident was asked if she was ready for bed, she said no. When Certified Nurse's Aide (CNA) went to get her ready she put her in the bathroom, and told her (Resident #15) to call when she was done, but instead of resident putting on the call light when she was done, she tried to stand up on her own and fell on buttocks, skin tear on left elbow when checked her vitals (vital signs) B/P (blood pressure) was 69/40 (low). Resident was responding but couldn't hold herself up and keep conversation. She was very lethargic and she (Resident #15) as leaning to the right side. Physician notified. Orders received to send to ER (emergency room ) for evaluation. Review of a document for Resident #15 titled, [MEDICAL TREATMENT] Communication Form dated 11/6/17 (no time noted) reflected, Completed by [MEDICAL TREATMENT] center: .B/P 77/41, pulse 79 (pre [MEDICAL TREATMENT]) .B/P 93/38, pulse 53 (post [MEDICAL TREATMENT]). Low blood pressure, also called [MEDICAL CONDITION], is blood pressure low enough that the flow of blood to the organs of the body is inadequate and symptoms and/or signs of low blood flow develop shock. Low pressure alone, without symptoms or signs, usually is not unhealthy. The symptoms of low blood pressure include lightheadedness, dizziness, and [MEDICAL CONDITION]. These symptoms are most prominent when individuals go from the lying or sitting position to the standing position (orthostatic [MEDICAL CONDITION]). Low blood pressure that causes an inadequate flow of blood to the body's organs can cause [MEDICAL CONDITIONS], and kidney failure. It's most severe form is shock . The range of systolic blood pressure for most healthy adults falls between 90 and 120 millimeters of mercury (mm Hg). Normal diastolic blood pressure ranges between 60 and 80 mm Hg (millimeters of mercury). Current guidelines define normal blood pressure range as lower than 120/80. (https://www.medicinenet.com/low_blood_pressure/article.htm) On 02/12/18 at 11:38 AM, a review of a general progress note for Resident #15 dated 11/9/2017 at 02:51 AM reflected, General Progress Note. Note Text: Returned from ER. Received report from nurse in ER. Stated a CT (CAT scan) of head and neck were done that were negative as well as an x-ray of pelvis and R (right) leg which were also negative. (Resident #15) Received a 500 ml (milliliter) fluid bolus (intravenously). Was answering all questions appropriately in the ER (emergency room ). Resident (#15) shared with ER nurse that she had attempted to transfer herself from the toilet to her w/c by herself because she wanted the staff here at (Name of facility) to be proud of her. But that's when she fell . Returned from ER at 0200 (AM). LS CTA (lung sounds clear to auscultation) throughout. BS (bowel sounds) positive x4 (quadrants). Neuro check wnl (within normal limits). Resident (#15) very tired. C/O (complained of) R (right) leg pain. Medicated with prn (as needed) [MEDICATION NAME] (a pain medication). V.S. (vital signs) (B/P) 98/48, (Heart rate) 75, (respirations) 16, (Temperature) 97.7 , (Pulse oximetry) 97% (percent). Resident #15's blood pressure remained low even though she had received intravenous fluids in the emergency room . On 02/12/18 at 12:06 PM, review of a note dated 10/31/2017 23:21, a Medical Practitioner Note reflected, Patient seen for low bp (blood pressure) and dizziness per staff, patient is seen with dtw (daughter) present. Patient sbp (systolic blood pressure) in the 90's, patient is HD ([MEDICAL TREATMENT]) dep (dependent), denies dizziness herself, in bed, patient admits she is non-compliant with therapy recs (recommendations) with transfers . On 02/12/18 at 03:10 PM, during an interview with Director of Nursing (DON) B, if cognitive level is good to ask for assistance, they can be in the bathroom by themselves. DON B was asked even if a resident was being non-compliant with therapy recommendations, not following therapy directions and experiencing dizziness could a resident be left alone in the bathroom? DON B stated she understood the concern. According to an MDS (Minimum Data Set) quarterly assessment dated with the assessment reference date of 11/8/17, Resident #15 required a 3/3 or extensive assist of 2 to transfer from surfaces such as bed, chair or wheelchair, and 3/3 or extensive assist of 2 to toilet. Assessment Reference Date (ARD) refers to the last day of the observation (or look back) period that the assessment covers for the resident. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also cover this time period. The facility is required to set the ARD on the MDS Item Set or in the facility software within the required timeframe of the assessment type being completed. This concept of setting the ARD is used for all assessment types (OBRA and Medicare-required PPS) and varies by assessment type and facility determination. Most of the MDS 3.0 items have a 7 day look back period, according to the Long Term Care Facility Resident Assessment Interment 3.0 User's Manual version 1.14, October 2016. The 7 days preceding a fall in the bathroom on 11/8/17, Resident #15 required extensive assist of 2 persons to transfer and to toilet. This MDS assessment also reflected Resident #15 had a history of [REDACTED]. Review of a document for Resident #15 titled, Weights and Vital Signs dated printed on 2/8/18 at 8:20 AM, reflected no orthostatic blood pressures (lying, then sitting, then standing to detect orthostatic [MEDICAL CONDITION] or a drop in blood pressure with each position). On 11/4/19 at 10:21 PM, B/P was 95/38 (no notation what position this was taken in), 11/5/17 at 7:31 PM 94/46 (no notations on position), 11/8/17 (day of fall #1) at 8:54 PM 69/40 sitting right arm, 11/9/17 at 4:46 AM 98/48 (no notation on what position), 11/10/17 at 4:14 AM 93/46 (no notation on what position). Fall #2 11/23/17 Review of a document for Resident #15 titled, [MEDICAL TREATMENT] Communication Form the day before the second fall dated 11/22/17 (no time noted) reflected, Completed by [MEDICAL TREATMENT] center: .B/P 101/52, (no heart rate was noted) Pre [MEDICAL TREATMENT]. Vitals signs Post [MEDICAL TREATMENT] B/P 98/43, heart rate 92. The communication for the [MEDICAL TREATMENT] unit was that Resident #15 was experiencing low blood pressure after [MEDICAL TREATMENT]. Review of a facility investigation for Resident #15, a document titled Incident Report - Patient Involved dated 11/23/17 at 8:30 PM (same time of day as fall #1) reflected, CNA transferring patient in sit to stand (mechanical lift) machine from shower chair to bed. Patient observed slowing letting go of handles and sliding down to floor. CNA and nurse lowered patient to the floor. Patient unresponsive for a few seconds and could not say where she was at or how she got to the floor. Review of a handwritten document in the facility investigation, no date noted, no signature of writer reflected, 12/1(17) [MEDICAL TREATMENT] calls said then sent her out to hospital alter(ered) mental status. 12/5 Arrived AMR .purple bruising under bilateral breast and arms. 12/6(17) NP noted she spoke with hospital and that Pt. had not experienced a traumatic injury here at CV (Crestview) (even though she had on 11/9 (17), fall in bathroom that was not noted on this handwritten note). 12/3(17) Final Report: Hospital. Last admit found to have right clavicular fx (fracture) and left scapular fracture. On this visit found to have asymptomatic pelvis fractures likely due to initial fall. Some ecchymosis on right arm/axillary present prior. Right clavicular fracture/L(eft) scapular fracture due to traumatic pelvic fracture due to fall PTA with likely underlying [MEDICAL CONDITION] metabolic bone disease. [MEDICAL CONDITION], Vit D : Chronic [MEDICAL TREATMENT] related? 12/8(17) Mobile X (a mobile xray company). On 02/08/18 at 12:05 PM, Review of another hand written note in the facility investigation, no date noted, no signature noted, reflected, 11/23(17) After shower CNA at back to bed with stand up lift, CNA and nurse lowered to floor after she began to slip off lift and let go of handles. Pt. unresponsive for short time. 11/23(17) AMR (ambulance service), hypotensive. 11/24(17) (Name of acute care hospital) calls (Resident #15 is) hypoxic (poor oxygenation). 11/29(17) ED (Emergency Department) Report to ICU (Intensive Care Unit) increased WBC (white blood cells), purulent urine (pus in urine) (did not fall). Next progress note in center is 11/30/17 admitted septic UTI (urinary tract infection). 11/30(17) Now Hoyer transfer (total mechanical lift). 11/28(17) Right shoulder mildly displaced mid shaft, R(ight) clavicle fracture. 11/28 there is suggestion of a possible non displaced fracture though scapula glenoid suggestion of rotator cuff disease. pain/trauma. 11/28(17) fell on shoulder 6 days ago. Review of a radiology report for Resident #15 dated 12/8/17 reflected, Clavicle complete right Conclusion: Mid clavicular fracture (collar bone) as described .Pelvis complete minimum 3 views Conclusion: .no pelvic or [MEDICAL CONDITION]. Shoulder Complete, minimum 2 views .Conclusion: .no acute fracture. Review of an acute care hospital document for Resident #15 titled, Patient Discharge Instructions dated 11/30/17 at 1:53 PM reflected, Updated Medications: .[MEDICATION NAME] 3 mg (milligrams) 1 tab by mouth daily. [MEDICATION NAME] or [MEDICATION NAME] is a blood thinner. On 02/12/18 at 12:14 PM, during a phone interview with Licensed Practical Nurse (LPN) JJ she stated she remembers the incident on 11/23/17 with Resident #15. I was in the room with her neighbor (roommate). The CNA was putting resident to bed after a shower. The CNA asked me when Resident (#15) up in sling, look at her bottom, as I went to look, she (Resident #15) began to slide. We tried to get her to bed. Bottom went to the floor, too late. Guided her down to the floor. LPN JJ stated there was no fall (a change in plane is a fall) just a lowering. LPN JJ stated Resident #15 was unresponsive, she got vital signs. LPN JJ revealed Resident #15 couldn't breathe wanted to go to sleep. Resident #15 could move her arms and legs. Resident #15 was still going in and out (of consciousness) so EMS (emergency medical services or ambulance) was called. A Hoyer mechanical lift was used to get Resident #15 from floor to bed LPN JJ stated, and Resident #15 was more coherent at that time. Resident #15 had no complaints of pain. EMS arrived in 15 to 20 minutes. During an observation of a sit to stand transfer with Resident #44 from chair to bed on 02/07/18 at 01:31 PM with CNA XX, CNA she revealed she cannot do the transfer by herself, the transfer requires two staff. Review of a facility document titled, Injury Prevention: Lifts and Injury - Reducing Devices Manual dated 9/2017 reflected, Number of employees required when operating a lift. Although one person can operate most models of hydraulic lists, it's advisable to have two staff members present to stabilize and support the patient . Review of a document for Resident #15 titled, Weights and Vital Signs dated printed on 2/8/18 at 8:20 AM reflected no orthostatic blood pressures (lying, then sitting, then standing to detect orthostatic [MEDICAL CONDITION] or a drop in blood pressure with each position). This document reflected, 11/21/17 at 10:21 AM 97/49 (no notation on what position this was taken), 11/23/17 (day of fall #2) at 4:33 PM 95/46. On 02/08/18 at 09:37 AM, during an interview with Administrator A, Unit Manager (UM) CC and Corporate Quality Assurance Y they were asked if Resident #15 had any syncopal ([MEDICAL CONDITION] or dizziness) episodes before the fall from the sit to stand mechanical lift. UM CC confirmed that Resident #15 had a few low blood pressures (B/P) before that fall on 11/23/17. UM CC was asked if any serial orthostatic blood pressures (lying, sitting, standing blood pressures to detect a change) done. UM CC stated, No. No previous [MEDICAL CONDITION] before that episode on 11/23/17. UM CC stated Resident #15 was hanging in the sit to stand lift sling and the nurse and CNA unhooked the sling and lowered her to the floor. UM CC stated this was from her interviews with the two staff members. The nurse took vital signs, assessed Resident #15, called the physician and received an order to have go to the emergency room . UM CC was asked if there was any injury and she replied that per Resident #15's progress notes, septic UTI and bilateral clavicle fractures. Resident #15 returned on 11/30/17. UM CC stated that [MEDICATION NAME] (a medication that is used to treat low blood pressure or [MEDICAL CONDITION]. It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. As a result, blood pressure is increased. https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 821) was started on 11/1/17 and increased on 11/9/17. On 10/17/17 [MEDICATION NAME] (a hypertension/heart medication) was discontinued. Orthostatic B/P's were to be done for 3 days in September, 2017. Review of the blood pressures in the EMR did not reflect any or orthostatic blood pressures or under vital signs or in progress notes per UM CC. UM CC reviewed the MAR (medication administration record) and there was a check that orthostatic B/P's were done on, 9/8, 9/9 and 9/10/17 but not documented on the MAR (medication administration record). No documentation of orthostatic blood pressures were found by UM CC. UM CC stated she was not sure if Resident #15 was having problems with dizziness. On 02/12/18 10:42 AM, during an interview with Physical Therapist (PT) LL. Resident #15 PT LL revealed that a lift assessment on 10/30/17, Resident #15 was walking with right leg prosthesis 20 feet with minimal assistance and a 2 wheeled walker. PT LL stated Resident #15 exhibited dizziness on 11/1/17 during physical therapy. On 11/1/17 PT visit note reflected that Resident #15 was having difficulties with dizziness. PT LL stated Resident #15 was unsafe, trying to get up on her own and not following directions. PT LL confirmed there was no change in transfer status at that time. Resident #15 remained a contact assist (requires a staff member to have contact with the resident) to transfer. On 11/2/17, PT LL stated therapy was working on walking with Resident #15. Resident #15 continued to have difficulties with dizziness. No mechanical lift was needed with right leg prosthesis. 11/3/17 Resident #15 was not feeling well and just sitting exercises were completed. On 11/6/17 Resident #15 continued to have dizziness and decreased safety awareness. PT LL stated Resident #15 was acting weird. I'm gonna get up anyway, Resident #15 was telling therapy. Added pressure relieving cushion to wheelchair. No lift transfers needed at this time for Resident #15. On 11/7/17, a home evaluation was completed for Resident #15. On 11/8/17 (day of fall #1 in the bathroom) Resident #15 was complaining of dizziness. Resident #15 could transfer edge of bed to wheelchair with stand by assist. PT LL stated she knew Resident #15 went to hospital but no changes related to that (for transferring/assistance/care needs). I think (Resident #15) went in by herself to toilet. Resident #15 wanted to see what she could do. PT LL confirmed that Resident #15 was not independent in the bathroom. On 11/9/17, Resident #15 required maximum need for assistance for transfers. PT LL stated Resident #15 still did not need mechanical lift transfers. On 11/14/17 Resident #15 was assessed to now need a sit to stand mechanical lift transfer with minimal assist. How many persons are needed to perform a sit to stand lift? PT LL stated, 2. PT LL stated Resident #15 could stand with minimum assist. On 11/16/17, Resident #15 was assessed to require moderate assist for transfers. On 11/21/17 during a care conference it was revealed that Resident #15 could stand with moderate assist of 1 person for 1 min. According to a facility document titled, Patient Transfer Screen Worksheet reflected, If yes to all of the criteria, patient is a candidate for using a sit to stand mechanical transfer device with appropriate weight capacity. If NO to any of these 3 criteria, patient is a candidate for full dependent mechanical lift with appropriate weight capacity. According to PT LL, Resident #15 met all the criteria for sit to stand use however this policy also reflected, There may be instances due to a unique clinical circumstance when a patient requires a different level of assist than determined from this guidance .Or a patient's condition, ability to transfer and amount of assistance required may vary over the course of the day. It may be necessary to use a higher level of assistance at those times. Resident #15 was experiencing dizziness and the need for moderate assist for transfers on 11/16/17 according to PT LL. On 11/21/17, two days before fall #2, Resident #15 could only stand with moderate assist of 1 person for only 1 minute. The sit to stand mechanical lift manual there is an assessment titled, Lift Program Skills Check Off Sheet Stand Assist Mechanical Lifts dated 9/2017. This check off reflected, Questions that need to be answered prior to using the Sara 3000 (or sit to stand mechanical lift): Can the individual bear weight on at least one leg? . Resident #15 could only do so for 1 minute. Review of an acute care hospital document for Resident #15 titled, Patient Discharge Instructions dated 11/30/17 at 1:53 PM reflected, Updated Medications: .[MEDICATION NAME] 3 mg (milligrams) 1 tab by mouth daily. [MEDICATION NAME] or [MEDICATION NAME] is a blood thinner. Resident #15 was taking this medication while experiencing the fall on 11/8 and 11/23/17. According the American Heart Association, [MEDICATION NAME] (brand names [MEDICATION NAME] and Jantoven) is a prescription medication used to prevent harmful blood clots from forming or growing larger. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a [MEDICAL CONDITION], stroke, [MEDICAL CONDITION] or [MEDICAL CONDITION] embolism. Because [MEDICATION NAME] interferes with the formation of blood clots, it is called an anticoagulant. Many people refer to anticoagulants as blood thinners; however, [MEDICATION NAME] does not thin the blood but instead causes the blood to take longer to form a clot .Some simple changes to decrease the risk of bleeding while taking [MEDICATION NAME] include the following: Use a soft-bristle toothbrush, Floss with waxed floss rather than un waxed floss, Shave with an electric razor rather than a blade, Take care when using sharp objects, such as knives and scissors, Avoid activities that have a risk of falling or injury (e.g., contact sports). The most prevalent [MEDICAL CONDITION] in our study was a subdural hematoma. As humans age, the brain begins to atrophy and therefore the bridging veins are stretched. This makes it more likely for the bridging veins to tear during a fall as the momentum of the brain provides a shearing force within the skull. One thing that is obvious in our study is that falls from a standing height is a cause of significant morbidity and disability, especially in patients on [MEDICATION NAME]. (https://www.clinmedjournals.org/articles/ijnn/ijnn-2-023.pdf). Resident #15 was at high risk for a severe injury such as an [MEDICAL CONDITION] such as a subdural hematoma because of the prescription [MEDICATION NAME]. Review of a facility policy titled, Falls Practice Guide dated 12/2011 reflected, Initial Evaluation: .Medication review. Medications side effects may predispose a patient for falls for fall risk. Such medication or medication classification may include but are not limited to: anti arrhythmic, anti-[MEDICATION NAME], anti-depressants, anti-epileptics, anti-hypertensives, anti-parkinsonian, diuretics, narcotic [MEDICATION NAME], benzodiazepines, anxiolytics, [MEDICAL CONDITION]. In addition to the above medications classifications, addition medication classifications that are more commonly associated with injury from fall include anticoagulants (such as [MEDICATION NAME]) . This policy also reflected, Laboratory or diagnostic tests may assist the physicians and clinicians in determining the root cause of falls and in identifying further fall risk. These test may include, but are not limited to: blood tests .bedside tests including oxygen saturation, orthostatic blood pressures . Review of an acute care hospital document for Resident #15 titled, Patient Discharge Instructions dated 11/30/17 at 1:53 PM reflected, Updated Medications: .[MEDICATION NAME] (an anticoagulant) 3 mg (milligrams) 1 tab by mouth daily .[MEDICATION NAME] (an anti-epileptic) 100 mg 1 capsule by mouth daily .[MEDICATION NAME] (an antiarrhythmic) 200 mg 1 tab by mouth once a day .[MEDICATION NAME] (an anti-hypertensive) 25 mg one tab by mouth daily .and [MEDICATION NAME] (classified as a narcotic in some states) 50 mg one every eight hours. Resident #15 was on 5 medications that put her at high risk for falls. Resident #15 was deemed at risk for a fall. Resident #15 was left in the bathroom alone when she was not deemed independent in the bathroom, while having a recent problem with dizziness, low blood pressure and poor compliance with directions and experienced a fall while on a blood thinner (fall #1). Resident #15 was transferred with a sit to stand lift by one person while continuing to have dizziness, low blood pressures and the inability to stand for over 1 minute in a sit to stand mechanical lift requiring the resident be able to bear weight on a leg, resulting in a fall with a fracture of her clavicle while on a blood thinner (fall #2). Review of Resident #57's face sheet dated 2/6/18, revealed Resident #57 was a [AGE] year old male admitted to the facility on [DATE] and had the following diagnose: [MEDICAL CONDITION], delusional disorders, muscle weakness, difficulty walking and lack of coordination. Resident #57 was not his own responsible party. 02/05/18 11:06 a.m. Resident 57 was observed up in a geriatric style chair (reclined chair with foot rest) in hall. Resident #57 was asked if chair was comfortable and he said no. Resident #45 could not say how long he was up or why he was uncomfortable. Resident #57 said he wanted to go to bed. Certified Nurse's Aide (CNA) O was asked if Resident #45 needed to go to bed because he was uncomfortable and CNA O said, no, if he goes to bed he will stand up, walk and fall. CNA O readjusted the Geri chair to a more reclined position. 02/08/17 9:20 am. CNA O and CNA RR put Resident #57 in bed from his geriatric style chair. CNA's provided hygiene care. CNA's said Resident #57 could not stay in bed because he would get up and fall. Resident #57 was place back in his Geri Chair, in a reclined position in the hall after care. Review of Resident #57's Physical Therapy discharge note dated 6/8/17 documented Resident #57 could walk 170 feet with a 2 wheeled walker and minimal assist of one person. During an interview with the Therapy Director EE on 2/12/18 at 2:00 PM, SS confirmed Resident #57 could walk 170 feet with a 2 wheeled walker and one person assist when Physical Therapy discharged him on 6/8/17. EE could not find the standard documentation that was provided nursing with instructions to help maintain a Residents function when discharged from therapy. EE could not locate any documentation that would explain why nursing did not receive any instructions to continue to walk with Resident #57 when discharged from therapy on 6/8/17. During an interview with RN CC, Director of Nursing (DON) B and Nursing Home Administrator A on 2/12/18 at 2:00 PM Resident #57's falls from 7/6/17 to 12/1/17 were reviewed (total of 14 falls). The facility could not locate a full investigation with a root cause analysis for all 14 falls. Interventions placed did not always provide increase assistance or supervision. Two falls 8/28/17 and 12/1/17 had the same intervention (restraint) and no orders, interventions to release, prevent decline or care plan for the restraint could be located. None of the interventions included increased supervision. Review of Resident #57's Incident Report dated 8/28/17 at 12:30 PM, documented, Resident attempted to get out of his recliner then staff assisted him to the floor as resident was sliding off the recliner. Did not his head to the floor. Under corrective action documented, Staff will have name of geriatric style chair tilted back whenever resident is in name of geriatric style chair unless resident is eating or drinking (This made the geriatric style chair a restraint as evidenced by documentation that Resident #57 could get out of the chair when sitting up and stand when it was not reclined, no order for this restraint or restraint evaluation was located at this time). Review of Resident #57's Incident Report dated 12/1/17 at 7:01 PM, documented, Res (resident) at nurse's station in name of geriatric style wheel chair. Observed attempting to stand from chair, Resident's knee buckled and ended up on both knees on floor with feet in chair. Under corrective action documented, Must remain reclined between meals. (Restraining resident #57 to prevent falls, without an evaluation, orders or release times).

Based on observation, interview and record review, the facility failed to maintain infection control practices to prevent infection for 4 residents (Residents #11, 28, 44 and 71), out of 25 residents reviewed for infection control practices, out of a total sample of 28 residents, resulting in infection of a wound and surrounding boney structures and a urinary tract infection (Resident #44) resulting in the potential for infection during a clean dressing change (Resident #71) and the potential for cross contamination from contaminated items (Residents #11 and 28). Findings include: Resident #44 According to a facility face sheet dated 2/8/18 at 10:56 AM, Resident #44 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. During an observation of Resident #44's wound care on 02/07/18 01:34 PM it was observed that Certified Nurse's Aide (CNA) O donned gloves and emptied the Foley indwelling catheter bag (drains urine from the bladder) of a clear yellow urine into a graduated container. No cleansing with alcohol was noted of the Foley drainage spout. CNA O then with her dirty gloved hand, was observed to pull at the top of the dressing cart to move it to the side to be able to walk by it to the bathroom. Clean dressing supplies were observed on top of this cart, no barrier was observed under the clean dressings. No preparation of the top of the cart such as disinfection was observed. Resident #44 was positioned lying in bed on her right side and 2 pressure wounds were observed, one under left buttock and one at the sacrum. Resident #44 stated she was admitted with the wounds. Resident had a bowel movement, and this was cleansed by the CNA's with adult disposable wipes and removed with the brief. No barrier observed placed under Resident #44 on bed after cleansing of the bowel movement by CNA O. LPN X donned gloves washed the wounds with a saline squirt (a single use small saline plastic container) and gauze. The buttock wound was observed to be washed from the outside skin into the base of the wound (dirty skin to clean base of the wound). Dirty dressing supplies were discarded open trash bag on the bed. LPN X was observed to prop up the saline squirt on an item in the dirty garbage bag so that the spout wouldn't leak saline. LPN X removed her gloves and was observed to cut the calcium alginate dressing needed. This cut piece was placed on top of the open dressing sleeve. LPN X was not observed to perform hand hygiene after removing her gloves. Alcohol hand gel was observed on top of the dressing cart. LPN X applied clean gloves. No hand hygiene was observed before donning new gloves. LPN X pulled out packing gauze from a container, applied saline to the gauze and placed in the lower left buttock wound. LPN X was then observed to cut the packing gauze with her scissors near the residents body after it had been packed in the resident's wound and then pulled more packing gauze from a new vial and cut this with her used scissors. LPN X was not observed to have cleaned her scissors before cutting a clean piece of packing gauze. LPN X was observed to have applied dermaskin (a skin protectant) spray to peri (around) wound AND wound packing areas then applied an occlusive foam dressing to the buttock wound. LPN X then discarded her used gloves into the garbage bag and was observed to use alcohol hand gel and applied clean gloves. The sacral wound was then observed cleansed by LPN X with the use of the propped up saline squirt applied to gauze (with clean gloves on). Again LPN X cleansed from the outside skin to the inner wound, from outside of wound in. LPN X took off her dirty gloves and applied new gloves, no hand hygiene observed. LPN X cut a calcium alginate piece with the uncleansed scissors and applied it to the wound bed. This sacral wound was observed sprayed with dermaskin around the wound AND over the wounds calcium alginate. LPN X then took off gloves and no hand hygiene observed, applied new gloves and applied foam dressing over the sacral wound. No dates were observed to be placed on either ischial or sacral wound dressings. CNA O was then observed to remove the garbage bag with gloved hands from the bed. No hand hygiene was observed after removal of CNA O's gloves. CNA O asked LPN X if the calcium alginate needed to be saved. LPN X replied, Yes, it's expensive and CNA O was observed to place the dressing with her ungloved and un cleansed hands into the original open package and placed the dressing in the dressing cart. CNA O was observed to have pulled the dressing cart out of the room and into the hall. The majority of articles emphasize the need for handwashing before and after contact with catheters and drainage bags, and the use of clean non-sterile gloves (Pratt et al, 2007; CPHVA, 2005; Pellowe and(NAME) 2004;(NAME) 1997) . Both(NAME)(1997) and NICE (2003) specify the use of disposable plastic aprons to protect clothing from exposure to body fluids, secretions or excretions.(NAME)(1997), Penfold (1999) and(NAME)and Lister (2004) recommend that the outlet tap should be cleaned with a 70% [MEDICATION NAME] alcohol swab before opening and after closing. (https://www.nursingtimes.net/evidence-care-of-urinary-catheters-and-drainage-systems/ 5.article) Review of a document for Resident #44, Urine Culture dated 10/18/17 at 3:45 AM reflected, Resulting lab: > (greater than) 100,000 CFU/ml (colony forming units per milliliter) Proteus (P.) mirabilis Strain 1 and > 100,000 CFU/ml Proteus (P.) mirabilis Strain 2. P. mirabilis is not a common cause of UTI in the normal host. Surveys of uncomplicated [MEDICATION NAME] or acute [MEDICAL CONDITION] show that P. mirabilis comprises only a few percent of cases. Even in patients with recurrent UTI, the incidence of infections by this organism is only a few percentage points higher. Why have we conducted and now are proposing to continue intensive studies of the pathogenesis of P. mirabilis? The answer lies in the fact that this organism infects much higher proportions (up to 44%) of patients with complicated urinary tracts; that is, those with functional or anatomic abnormalities or with chronic instrumentation such as long-term catheterization, making it the most common nosocomial (medical facility acquired) infection. While infecting the urinary tract, P. mirabilis has a predilection for the kidney (involving the kidney). Finally and importantly, not only does this bacterium cause [MEDICATION NAME] (bladder inflammation) and acute [MEDICAL CONDITION] (inflammation of the kidney), but the production of urinary stones, a hallmark of infection with this organism, adds another dimension to these already complicated urinary tracts. (http://www.umich.edu/~hltmlab/research/mirabillis/infection.htm) Proteus mirabilis is a common facility acquired infection. Review of a facility policy titled, Skin Practice Guide dated issued 1/2013 reflected, Wound Management: .Dressing changes are performed using a non-sterile, clean technique unless otherwise ordered by the attending physician. In general, the following guidelines are considered when performing treatments: adhere to principles of infection control - separate clean and dirty, provide a barrier filed for treatment supplies, appropriate use and changing of gloves, maintain appropriate precautions, appropriate cleaning of the wound bed (center of wound to outside perimeter), cleansing of scissors, hand washing, disposal of soiled dressings .Dressings are dated and initialed. Review of a facility policy titled, Dressing Change: Non sterile (Clean) dated revised 4/2016 reflected, .Perform hand hygiene (each time you are entering or leaving a room and when you are going form dirty to clean) .Set up area: disinfect over bed table using an EPA approved disinfectant. While over bed table (surface) is drying, gather supplies and bring them to the patients room .perform hand hygiene upon entering. Place a clean barrier on the over bed table (surface) then place hand sanitizer, equipment and supplies on top of barrier. Do no open supplies at this point. Place waste receptacle, with leak proof bag under the over bed table .Perform hand hygiene Place procedure towel (wound drape) or clean towel under the area for treatment. Perform hand hygiene and apply latex free non-sterile drugs. Remove soiled dressing and discard in trash bag .Remove soiled gloves, discard and perform hand hygiene. Prepare a clean filed: arrange supplies on table, open packages to reveal supplies, if dressing need to be cut to size, use cleans scissors (disinfect the scissors with an EPA approved disinfectant before and after using), label tape used to secure dressing with caregiver initials and date. Perform hand hygiene and apply latex free non sterile gloves. Cleanse wound per physician's orders [REDACTED]. Clean wound then peri wound. Removed soiled gloves, discard. Perform hand hygiene and apply latex free non sterile gloves. Apply dressing per physician's orders [REDACTED]. Remove procedure towel from under patient and discard. Dispose of soiled and used disposable equipment and supplies in waste bag. Remove soiled gloves and discard. Perform hand hygiene .Return equipment and used supplies to designated area. Clean, sanitize, disinfect or dispose as indicated. Perform hand hygiene after disposing waste and or cleaning equipment. Review of a facility policy titled, Hand Hygiene dated 12/2009 reflected, Purpose: To decrease spread of infection .When to wash hands or use hand rub: before applying and after removing gloves .after contact with body fluids or excretions. Mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . During an Infection Control interview on 02/07/18 at 02:10 PM with DON B, Corporate Quality Assurance (CQA) Y and Unit Manager (UM) CC, DON B stated she has been DON at the facility for a little over a week. DON B has had formal training on Infection Control facility surveillance. It was asked if hand hygiene audits have been done. UM CC confirmed she has watched handwashing but does not have documentation of who she watched, when or if any follow up training was required. UM CC and DON BB was asked about dressing change procedure and hand hygiene. DON B stated hand hygiene needs to be done before and after donning your gloves, remove dressing you wash your hands. Scissors are to be cleansed before and after each use. Dressings that are open and cut are considered used and need to be thrown away. A barrier needed to be on top of cart, under the dressing supplies. All three confirmed that propping saline squirts inside dirty garbage bag on bed was not a good infection control practice. UM CC stated that the Foley spout needed to be cleansed with alcohol before emptying, and touching the clean dressing cart touch with dirty gloves should not have occurred. On 02/07/18 at 03:49 PM during a review of medical records the records reflected, OSTEO[DIAGNOSES REDACTED] OF VERTEBRA (back bones), SACRAL AND SACR(NAME)(NAME)CYGEAL REGION (lower back and tail bone area, where Resident #44 pressure ulcer is located) 12/8/2017. [DIAGNOSES REDACTED] (is): Inflammation of the bone due to infection . Both the bone and the bone marrow may be infected. Symptoms include deep pain and muscle spasms in the area of inflammation, as well as fever. Treatment includes bed rest, use of antibiotics, and sometimes surgery to remove dead bone tissue. (https://www.medicinenet.com/script/main/art.asp?articlekey=4681) Review of a document for Resident 344 titled, EMAR (electronic medication administration record) dated 10/1 to 10/31/17 reflected, [MEDICATION NAME] Capsule (an antibiotic) Give 100 mg (milligrams) via G (gastric) tube every 12 hours for [MEDICAL CONDITION] (wound) for 20 administrations) on 10/18/17 and changed on 10/19/17 to [MEDICATION NAME] Mono (an antibiotic) 100 mg cap Give 100 mg via G tube every 12 hours for [MEDICAL CONDITION] for 20 administrations. Resident #44 required treatment of [REDACTED]. Resident #28 According to a facility face sheet dated 2/12/18 at 2:46 PM, Resident #28 was a [AGE] year old male admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. On 02/05/18 at 01:48 PM an observation was made of Resident #28's urinal. Resident #28 was not present. An empty hand held urinal was observed on over bed table. No barrier was observed under this urinal. On 02/07/18 at12:59 PM, an observation of the Resident #28's room, Resident #28 was not present. An empty hand held urinal was observed on the bedside dresser. During an observation on 02/08/18 at 08:46 AM Resident #28 was observed in bed. Over bed table was over his lap. An empty tray of food was in front of him. Resident #28 stated he is still hungry. Resident #28's empty hand held urinal was observed on the over bed table next to his food tray, again no barrier under the urinal was observed. During an interview on 02/08/18 at 01:22 PM with UM CC, she stated a urinal should be on a barrier on the table and care planned as such. UM CC stated the facility tries to teach residents about urinal placement after use. UM CC confirmed that there is no care planning regarding urinal placement for Resident #28. According to Mosby's Textbook for Nursing Assistants (5th ed., 2000), Remind men to not place urinals on over bed table and bedside stands. The over bed table is used for eating and as a work surface. Bedside stands are used for supplies. For these reasons, table surfaces must not be contaminated with urine. Resident #71 A review of Resident #71's admission record, dated 2/7/18, revealed Resident #71 was a [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an interview on 02/05/18 at 12:13 PM, Resident#71 stated her foot was infected and stinking, but it wasn't doing that any more. A white dressing was observed around the resident's lower right leg and foot. Resident #71 stated that it was caused because of some medication she was given and that it was painful. A Review of Resident #71's Medical Practitioner Note from Physician Assistant (PA) Z revealed that on 01/18/2018 the reason for the appointment was; 1. Wounds to right lower leg and foot PA Z documented that I have been consulted by Doctor V to evaluate (Resident #71) for multiple wounds to her right lower leg and foot. She was hospitalized from 12/27-1/4 at (name of hospital) for a [MEDICAL CONDITION] ([MEDICAL CONDITION] of the right lower extremity. In the hospital she was placed on Argatroban. She then developed bullous [MEDICAL CONDITION], so the medication was stopped and she was placed on [MEDICATION NAME]. Staff have been applying calcium alginate AG to the wounds daily. (Resident #71) has a history of [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) on HD ([MEDICAL TREATMENT]), type 2 diabetes and hypertension. Staff state her appetite has been good. At this time resident is lying in her bed. She states she has a lot of pain related to the wounds. Examination of Resident #71's skin revealed, Ulcer to the right lateral foot and ankle measures 13.0 x 7.0 cm, wound base is 40% necrotic eschar, 40% slough and 20% granulation tissue, there is moderate serous drainage with an odor, ulcer to the dorsom of the right foot measures 5.0 x 2.9 cm, the wound base is 80% eschar, 10% slough and 10% granulation tissue, there is scant serous drainage with an odor, ulcer to the right anterior lower leg measures 4.7 x 3.2 cm, the wound base is 85% eschar, 10% slough, and 5% granulation tissue, there is scant serousanguineous drainage with an odor, the ulcer to the right medial lower leg measures 8.5 x 2.8 cm, the wound base is 95% eschar and 5% granulation tissue, there is scant serous drainage with an odor, I note the skin to the distal right foot is thin and shiny with little subcutaneous fat as often seen in PAD Assessments 1. Generalized skin eruption due to drugs and medicaments Resident #71 treatment for [REDACTED]. currently on aspirin 81 mg daily, if her wounds are not improving we may need to consider increasing this to 325 mg. During a dressing change on 02/07/18 at 02:30 PM, for Resident #71, the following observations were made on Registered Nurse Supervisor (RNS) BB. During the removal of the residents old ABD pads dated 2/6/17 RNS BB stated he needed some saline from the his cart in the hallway. RNS BB removed gloves to exit room and get packages of saline. Did not perform hand hygiene after removing gloves. Opened room door and treatment cart. Returned to room, used hand sanitizer and applied new gloves. RNS BB continued to cleanse wound with gauze and soap and water. The nurse reached into an open package of gauze pads several times with gloved hands while cleansing the wound. Resident #71 wound covers top of right foot and lateral malleolus, a yellow wound bed to top of foot and the wounds extended up anterior and bilateral aspects of right shin and towards posterior aspect of extremity. RNS BB removed old barrier towels from beneath RLE and replaced, the replacement towel had sanguinous drainage. RNS BB removed his gloves and used hand sanitizer. RNS BB then dried the residents wounds with gauze. RNS BB removed gloves, applied hand sanitizer then new gloves. RNS BB used multiple cotton tipped applicators to apply the Silvadine cream, however the same cotton tipped applicator was used to apply [MEDICATION NAME] cream to multiple wound beds. RNS BB applied ABD pads over the residents wounds. RNS BB secured the ABD pads with a stretch gauze. The saturated dressing supplies thrown in the trash. RNS BB placed the saturated towels on floor at bedside. RNS BB used the same scissors that removed the old bandage to cut excess stretch gauze at the end of the dressing change. RNS BB dated and initialed the new dressing. Serosanguinous drainage noted to pillow case after RNS BB removed towels, Resident #71 placed her left foot and leg over the area of drainage on the pillow case along with her freshly bandaged right foot. Soiled barrier towels from floor were placed in a trash bag. Gloves removed, hand sanitizer used. RNS BB stated to Resident #71 that he would have a CNA come in and change her bedding and clothing. 2/12/18 02:20 PM During an Interview with Registered Nurse BB stated that he discarded all of the rest of the package of gauze that was left from the dressing change on 2/7/18. On 02/12/18 at 12:49 PM Certified Nurses Aide (CNA) O was observed providing hygiene care for Resident #11 in his bathroom. CNA O placed a wash cloth soiled with fecal matter in sink and preceded to take another wash cloth out of the sink to continue with hygiene care. CNA O washed Resident #11 face with a cloth that came out of the sink that had the cloth with fecal matter on it. CNA O did not disinfect Resident #11 sink when she was done providing hygiene.

This refers to MI 888 and MI 716. Based on observation, interview, and record review, the facility failed to prevent neglect for 1 of 11 residents (Resident #11) reviewed for abuse and neglect, from a total sample of 11 residents, resulting in Resident #11 sustaining multiple injuries to the body. Findings include: A review of Resident #11's admission record, dated 8/12/17, revealed Resident #11 was an [AGE] year old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #11's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 6/15/17, revealed Resident #11 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score was determined as moderately impaired. In addition, Resident #11's MDS revealed Resident #11 needed total dependence (full staff performance every time during entire 7- day period) with one person for transferring from one surface to another (e.g. wheelchair to bed) and bathing. Further review of Resident #11's MDS revealed that following activity did not occur for the resident: Moving from a seated to a standing position. Resident #11's MDS revealed a functional limitation in range of motion that interfered with daily functions or placed resident at risk of injury for an Upper extremity (shoulder, elbow, wrist, hand) and for a lower extremity (hip, knee, ankle, foot) impairment on one side of the body. A review of Resident #11's incident report for a bruise discovered on 8/12/17, dated 8/12/17, revealed Resident on LOA with husband. Upon return spouse indicated resident seemed to express more pain in her left hip (resident does have a painful hip). Upon obtaining an x-ray it was also noted her left knee was swollen with a bruise right below the knee. X-Rays obtained of hip and knee. Results shows [MEDICAL CONDITION] of knee and hip. Cause of bruise unknown Resident with swelling to the left knee and a bruise below left knee. Right upper arm shows a small bruise as well. Resident had a shower prior to LOA. Review of SKIN WORKSHEET dated 8/13/17 at 5:30 AM, revealed Resident #11 had an x in the box next abnormal (signifying the resident had broken, bruised or reddened areas.) The picture indicated bruises in the following areas: upper inner right arm, right big toe, and on the left shin. Swelling was indicated in the left knee area. Resident #11's Care Plan with a print date of 1/30/18, revealed that Resident #11 is at risk for falls due [MEDICAL CONDITION] L sided hemi-paresis and history of [MEDICAL CONDITION] disorder, impaired mobility, and weakness. (Revised on 10/12/17) Under interventions the plan revealed that, Only the residents husband is able to transfer with pivot transfer. (Revised on 11/22/16). Review of Resident #11's Kardex (a tool used by Certified Nurses Aides/staff on how to care for the Resident) revealed that Resident #11 was a One assist for transfers with Maxi lift. (Use Green Sling) Review of Statement dated 8/12/18 by the Spouse of Resident #11 revealed the following: Arrived at (the facility) about 11:00 AM. The aides were finishing up Resident #11 shower, she was dressed in her wheelchair so I took her out to breakfast as we do most Saturdays. I put her in the car and all seemed O.K. when I took her out of the car at the restaurant she moaned like her leg was hurting her bad, that was unusual. I became concerned. I was extra careful getting her back in and out of the car back to (the facility) and I laid her down and told them of Resident #11's pain in her leg so if the tried to move her they would be careful not to hurt her. I went home for for a couple of hours and returned to (the facility), Resident #11 needed to be changed and when I tried to turn her over just a touch of her left leg caused her to shutter with pain, I took off her shirt to put a gown on her I noticed bruises on her upper right arm (inner). I asked Resident #11 if something happened and said (nodded) yes. So I started asking Resident #11 questions and with a number of questions I formed an idea of what happened. I found RN FF and told her of Resident #11's severe leg pain, she came in Resident #11's room and helped me change Resident #11's brief. I showed RN FF the bruises on Resident #11's arm and RN FF told me the aide had called her into the showerroom during Resident #11's morning shower and found Resident #11 with her rearend just barely on her wheelchair so she bear hugged Resident #11 and lifted her fully on her chair. The answers I got from Resident #11 was that after the shower she was being transferred from shower chair to her wheelchair. Resident #11 said she went down to the floor. How it happened I don't fully know. Whether she slipped or tripped or the aide lost her hold on the pivot to the wheelchair. Resident #11 believed she landed on her knees, which would explain her bruised and swollen left shin and knee and her right big toe. The bruises on her inner right arm I think show that someone tried to keep her from falling or tried to pick her up .Upsets me most is that I wasn't told anything before I took Resident #11 out to eat and transferring her 4 different times in and out of the car. Possibly could hurt her even more, it did cause more pain. A review of Certified Nurses Aide (CNA) GG'statement of the incident dated 8/12/17, on 8/14/17 per telephone, revealed, I gave (Resident # 11's name) a shower after breakfast. I transferred her using a hoyer to the shower chair in her room. I transported her to the shower room while she was in the shower chair. After her shower I got her dressed then transferred her to her wheelchair. I put the wheelchair next to the showerchair and stood (Resident # 11's name) up then pivot her to the wheelchair. She was not in the wheelchair correctly because her back was not all the way to the chair so I called the nurse into the shower room to help boost her up. Registered Nurse (RN) FF came in and we boost her up into the wheelchair correctly. I then realized (Resident # 11's name) did not have on a brief so I took her to her room and asked for help to put her brief on. CNAMM and I stood her up to get the brief on her then put her back into the chair. CNA GG was asked if she knew how the patient should be transferred per Care Plan and Kardex. She stated, yes she transfers with a hoyer. During an interview on 1/30/17 at 12:10 PM, Certified Nurses Aide (CNA)GG was asked what she remembered during Resident #11's shower on 8/12/17. CNA GG stated she couldn't remembered, what does my statement say, read my statement. CNA GG did not answer any questions until her statement was read. (statement noted above) CNA GG was asked how many people it requires to transfer using the the hoyer. CNA GG stated two, and CNAGG thought she had help using the hoyer when she transferred the resident into the shower chair but she could not remember who. CNA GG stated she had done a pivot transfer to get the resident from the shower chair to back in her wheel chair, but I needed help getting (the resident) in the wheel chair so I grabbed the nurse (Registered Nurse (RN) FF). CNA GG voiced raised when she stated No the resident did not go down on her knees at anytime during the transfer, and she didn't slip out of the chair. CNA GG stated that she needed RN FF because the resident wasn't on the wheelchair all the way and we had to boost her. CNA GG believed RN FF was on the left side and she was on the right side during the boost. CNA GG stated that after the nurse left she realized the resident didn't have a brief on her,and that she received the help of 2 aides (CNA I and CNA MM) when she got Resident #11 back to her room an that it was quick, the resident did not fall, get hurt, or say anything during the transfer/change. CNAGG replied she did not know how Resident #11 got injured, but revealed she was wrote up for a bad transfer. Review of Employee Warning Notice marked as Third/Final Written Warning dated 8/16/17 for CNA GG, violation of work rule commitment Type B. The write up revealed, CNA did not comply with all health and safety standards, including infection control and/ or commit unsafe conduct or acts that result in minor injury to self or others. On 8/12/17 CNA transferred a resident in shower room without Hoyer lift. Residents Kardex states she is a Hoyer lift. CNA transported resident to her room and lifted her a second time with another CNA & 3rd CNA pulled up her brief. Resident knee is painful & swollen & her leg now has a bruise. CNA also on 8/12/17, lifted a resident off the floor who had fallen. CNA & Nurse did not use a Hoyer to get resident off the floor. During an interview on 1/30/18 at 11:40 AM with Registered Nurse (RN) FF, RN FF revealed the Resident #11 allegedly got her bruises after the aides transferred her wrong, but I didn't see that. CNAGG had called from the shower room to help her give Resident #11 a boost in the wheel chair, the resident had a top on, pants down and a towel around the waist. I was doing med pass, so I boosted and went out. Resident #11 is supposed to be a hoyer transfer according to her care plan. Resident #11's husband was complaining when he brought her back from LOA. RN FF stated she called the On call doctor to ask for an X-ray order for pain and range of motor issues. RN FF stated she got wrote up because, I was told I should have noticed their was no hoyer, I was the supervisor and I need to be more aware of my surroundings. RN FF was asked if she could explain how Resident #11 was injured, RN FF responded, the only 2 that know what happened are CNAGG and Resident #11. CNAGG won't tell and Resident #11 it's extremely difficult to get anything out of her, she has [MEDICAL CONDITION]. Review of Employee Warning Notice marked as First Written Warning dated 8/21/17 for RN FF, violation of work rule commitment Type C. The write up revealed, Observe written/oral instructions and carry out job responsibilities without errors. On 8/12/17, Nurse helped CNA reposition a resident in w/c while she was in the shower room. resident is a Hoyer lift, when nurse went into the shower room the CNA had transferred the resident incorrectly. Nurse did not address situation with CNA. Also on 8/12/17, Nurse & CNA incorrectly lifted patient from the floor who had fallen. During a interview on 1/30/17 at 1:15 PM with Certified Nurses Aide (CNA) G, CNA G revealed that Resident #11 was a hoyer transfer, and that they use a hoyer transfer for her all the time. CNA G also revealed that the resident can make her needs known by answering yes/no questions and shaking her head. The Resident (Resident #11) knows what is going on, she makes her needs known. During an interview on 1/30/17 at 1:35 PM with Certified Nurses Aide (CNA) I, CNA I revealed that CNA GG and CNA MM were in Resident #11's room after her shower. I didn't think about it when they asked me to pull up the residents pants up. The pants were at mid thigh, they stood her up, I pulled her pants up and then went to lunch. I didn't think, I know better, she's been a hoyer for at least 2 years for the CNA's. I did not help with the Resident in the shower, I don't think any aides helped her, the nurse (RN FF) did. I heard from management when I got called in for my write up that the resident had fallen. I'm preceptor I know better, I didn't think resident is a hoyer, a total mechanical lift of 2, she should never have been transferred using a pivot or stood up. Review of CNA MM written statement on 8/14/17 reflected the following information, CNA GG asked for help pulling up Resident #11's brief. I went into the room and CNA I came in about a minute later. I asked her to help us. I went underneath one arm and CNA GG under the other arm. We stood Resident #11 up and CNAI pulled up her brief. It was real quick. Resident #11 stood on her good leg. Resident #11 did not c/o any pain when we stood her up. Her leg did not bump her leg during the time I was in her room. During an interview on 1/30/17 at 1:05 PM with Resident #11, Resident #11 communicated by shaking head yes and no and pointing to areas. Resident #11 was asked if she remembered getting hurt back in August, Resident #11 responded by shaking head yes, and pointed to right arm, then left leg/knee, and then pointed towards right toe/foot. Resident shook her head yes when asked if she fell in the shower room. When asked if she fell getting in the shower the resident didn't move her head. Resident #11 shook her head yes, when asked if she fell going from the shower chair to her wheelchair. Resident #11 shook her head to No to reveal that their was not more than 1 person in the shower with her. Resident #11 shook her head No when asked if she used a hoyer in the shower that day. Resident stated yes' and shook her head yes when asked if she uses a hoyer to transfer. Resident shook her head No when asked did you fall or get hurt that day with your husband. Resident #11 stated YES when asked, did you just fall/get hurt in the shower with CNA GG. During a interview on 1/30/17 at 4:15 PM with Resident #11, Resident #11 revealed that she went down on her knees during her shower by shaking her head yes. Resident #11 was shook her head that yes she was on her knees when RN FF came in the shower room. Resident #11 revealed that RN FF helped pick her up off the floor by a head shake yes. The Resident also stated by shaking her head no that the CNA GG did not help her off of the floor. Just RN FF helped get her off the floor, Resident #11 confirmed statement by shaking her head yes, and CNA GG also helped shook head no. Progress Notes for Resident #11 revealed the following: -8/12/17 at 10:46 - Shower given with no skin alterations noted. Tolerated well. No noted s/s of distress, discomfort, or pain. Going on LOA with DPOA. -8/12/17 at 17:56 - New onset L hip pain. Pain aggravated with touch and or movement of any kind. No recent falls or trauma to L hip noted. On-call notified. Radiological tests ordered to r/o fx. Note left for IPC to eval. -8/13/17 at 00:20- While assisting X-ray tech with positioning of resident, bruising and swelling was noted to the left knee, called IPC to get ok for X-ray for knee while X-ray tech was still here, on-call notified, administrator notified, family aware. -8/13/17 at 15:59 [MEDICATION NAME]-[MEDICATION NAME] Solution 7.5-325 MG/15ML Give 15 ml via [DEVICE] as needed for pain BID. PRN Administration was: Effective -8/13/17 at 19:05- Resident was complaining of pain through out the day. it was reported that the resident had bruises on her left shin, right great toe, and right upper arm. Husband stated that he spoke to staff on Saturday concerning these bruises. Temp. was 101.2 Temp did come down at 2000 to 99.4. Husband will follow up during the week with management. -8/13/17 at 22:15- Resident continue on neuro checks & ROM to all extremities. Will continue to monitor & assess for changes. -8/14/17 at 17:04- Resident c/o pain [MEDICATION NAME] given at 1406 with moderate relief. Continue on post fall monitoring. Neuro checks & ROM to all extremities WNL. Resident remain with bruises to left shin, right great toe nail and right upper arm. Will continue to monitor assess for changes. -8/14/17 at 22:08- res cont on neuro checks and ROM checks. cont to have pain in left hip and left knee area. have given PRN's as needed. IPC called and [MEDICATION NAME] order to help relax the muscles of left leg. res appears to be resting comfortable with cares being down with care for limited moving. -8/16/17 at 05:19- Patient complains of left leg pain with left lower extremity bruising Patient has very limited ability to speak a response to yes and no questions by shaking her head An incident occurred the other day when patient was in the shower patient reports she lost her footing and hyperflexed her left leg which she typically does not fles anymore secondary to cerebral infarction and loss of motor control over this area. The following day patient and staff noticed some bruising of the left knee with increased pain. patient today has obvious left knee pain appears to be sensitive in nature. Question of left knee makes pain worse. X-ray obtained of left knee showing moderate [MEDICAL CONDITION] no acute fractures. . MUSCULOSKELETAL:Upper extremity muscle strength testing noted to be 3 out of 5. Lower extremity is noted to be diminished. Acute swelling about the left knee hematoma palpated distally at patella tendon insertion point distally. Bruising present, appears to be healing as there is good color change from bruising no longer purple more of a yellow type color. . Treatment 1. Left knee pain Notes: At this point mechanism of injury is unclear secondary to patient being relatively poor historian but is able to respond to yes and no questions. Patient feels that the knee pain was caused by episode of hyperflexion, given location of pain and acute swelling and bruising possible cause would be distal patellar tendon tear, versus and perhaps along with [MEDICAL CONDITION] flareup. -8/16/17 at 06:29- Cont with neuro checks. No changes noted. No breakthrough pain or discomfort noted. Cont with [MEDICATION NAME] and [MEDICATION NAME]. -08/17/17 at 09:17 [MEDICATION NAME]-[MEDICATION NAME] Solution 7.5-325 MG/15ML Give 15 ml via [DEVICE] two times a day for pain -08/18/17 at 15:20 Resident c/o headache at 9am, prn [MEDICATION NAME] was given & was effective. Resident remain with bruising to left hip, left shin, and right big toe. Swelling appear to have gone down, however left shin remain with slight discoloration . -08/18/17 20:30 Patient complains of continued left knee swelling and left knee pain. In discussion with nursing staff they feel knee is becoming more swollen and bruising of the left lateral distal aspect of her thigh. patient sustained a hyperflexion injury of left knee. X-ray was ordered at the time and shows no fractures. patient is painful over tibial plateau and tibial tubercle. Pain is sharp in nature. Otherwise patient denies chest pain, shortness of breath fever or chills. MUSCULOSKELETAL: Lower extremity muscle strength one out of 5 bilaterally left knee swollen bruising along the lateral aspect of distal thigh posterior knee patient very tender along inferior tendon, patient has more pain with passive range of motion with patellar glide. Warm to palpation along posterior fossa of left knee -08/21/17 at 12:56 Skin assessment complete for clarification. No bruising noted to left hip. Bruising noted to right upper arm, right great toe and left shin area. Bruises healing, left knee area swelling decreased. Hematoma to left shin resolving and surrounding tissue is absorbing blood/fluid. Bruising now yellowish. Bruising to right toe and right upper extremity light purple. Spouse present during assessment. Denies pain during assessment and movement. During an interview on 1/30/18 at 4:35 PM with the Nursing Home Administrator (NHA) A and the Director of Nursing (DON) B that after the incident they trained the staff on hoyer use, and following care plans. In response to whether or not Resident #11 was interviewed, NHA A and DON B state that Resident #11 was aphasic.

This citation pertains to Facility Reported Incident MI 739 Based on observation, interview and record review the facility failed to prevent the elopement of 1 resident reviewed for elopement (Resident #1) out of 1 resident sampled for elopement, from a total of 7 sampled residents, resulting in an Immediate Jeopardy when (Resident #1) who had been assessed as an elopement risk and wore a Secure Care bracelet eloped from the facility, unbeknownst to staff, after a visitor deactivated an audible door alarm, allowing Resident #1 to elope from the facility on 8/24/16 at 6:00 p.m. and was brought back to the facility 10 minutes later when staff members observed the resident outside the facility. This deficient practice placed Resident #1, and 6 other residents who were assessed to be elopement risks, at risk for serious harm, injury and or death from hazards outside the facility. Findings: Resident #1 was an [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and needed extensive assistance from one person for transfers, personal hygiene and bathing. Review of a Behavioral Symptoms Assessment dated 4/15/16 indicated Resident #1 demonstrated exit seeking behaviors and wandered without intent or purpose. A wander guard device was applied to Resident #1's ankle and checked daily for placement and function starting on 10/22/15. Review of a Care Plan for Resident #1 indicated he was at risk for elopement as evidenced by exit seeking tendencies related to Alzheimer's disease/dementia: statements about wanting to leave and go to Lansing, asking to leave, and making statements about not wanting to be in facility. During an observation on 9/01/2016 at 11:45 a.m. the route Resident #1 may have taken outside the facility was walked in the presence of the Director of Nursing (DON) B and the Maintenance Supervisor (MS) C. Several hazards were observed including access on the sidewalk to a parking lot which led to a busy 5 lane 40 mph thoroughfare. Review of a facility Incident Report dated 8/25/16 indicated Resident #1 was found outside the facility at 6:08 PM on 8/24/16 (Wed.), on the sidewalk in his wheelchair. The facility investigation indicated at approximately 6:00 PM the daughter of another resident came into the building via an exit door by entering a security code and deactivating the audible alarm. During an interview on 9/1/16 at 1:45 PM, RN G said she had noticed Resident #1 sitting close to the door he exited from but was not actively pushing on the door at approximately 4:30-4:45 PM on 8/24/16. RN G reported she told Licensed Practical Nurse F to keep a close eye on Resident #1. During an interview on 9/1/16 at 2:00 PM, CNA E reported she was one of two aides on duty on the unit where Resident #1 lived but was not assigned to his care on 8/24/16. CNA E reported she was never told that Resident #1 needed a wander buddy (a 1:1 care giver intended to prevent elopement of residents actively exit seeking) and would have known if her hall partner (CNA D) had been instructed to do so because they assisted one another with those residents who required 2 people for assistance. CNA E reported that she never heard an audible alarm sounding prior to Resident #1 being observed outside from a window in the room of a different resident both she and CNA D were getting ready to assist together. CNA E reported Resident #1 was heading toward the parking lot in his wheelchair. During an interview of 9/1/16 at 4:30 p.m., CNA D reported she was the aide assigned to care for Resident #1 and that she was keeping an eye on him. CNA D reported Resident #1 was acting like he wanted to go outside and even asked the nurse if she could walk outside but she discouraged it and reportedly indicated that if CNA D took Resident #1 outside, the resident might not want to come back inside. When asked, CNA D said she was not sure if a wander buddy and a resident who was on 1:1 supervision were the same thing. CNA D reported that the last place she saw Resident #1 prior to his elopement was in his wheelchair sitting in the hall outside his room. During an interview on 9/1/16 at 2:40 p.m., LPN H said she was the evening supervisor on 8/24/16 and reported that she had never been told that Resident #1 was on increased supervision. LPN H reported that after the elopement was discovered, she learned that LPN F had been watching Resident #1 closely. During an observation on 9/6/16 at 10:00 AM, this surveyor activated the audible alarm by pressing on the door jam on the door Resident #1 eloped from. No staff were observed nearby at the time the door alarm was activated and Visitor I walked over to the door, entered a code and deactivated the alarm. When asked, the visitor reported the door code was simply the month and the year and indicated she had never been told not to use that door. This surveyor verified that the code Visitor I used to turn off the alarm and open the door was indeed correct. The facility Nursing Home Administrator (NHA) A was informed of the Immediate Jeopardy (IJ) on 9/1/16 at 4:00 p.m., starting on 8/24/16 at approximately 6:00 p.m. for the facility's failing to prevent the elopement of 1 resident (Resident #1) who was a known elopement risk and wore a Secure Care bracelet and still, unbeknownst to staff, eloped from the facility after a visitor deactivated an audible door alarm, allowing Resident #1 to elope from the facility on 8/24/16 at 6:00 p.m. The facility implemented the following to remove the immediacy: -On 8/24/16 at 6:08 p.m. Resident #1 was observed by Certified Nursing Assistants (CNA's) D and E sitting in his wheelchair outside of the building through another resident's room window. Both CNA D and E notified the nurse and went outside to bring Resident #1 back into the center. Resident #1 was easily redirected back in. Registered Nurse (RN) F completed a head to toe assessment and pain evaluation with no abnormal findings. Resident #1 did not recall how he had gotten outdoors and within a short period of time did not recall ever being outside. Resident #1 was placed on 1:1 monitoring immediately, dinner tray was served and Resident #1 was assisted to bed at which he slept the rest of the evening/night. Physician and family were notified. -A Code Green was initiated on 8/24/16 at 6:10 p.m All residents were accounted for. -One to one supervision was implemented following incident on 8/24/16 at 6:10 p.m. -A complete physical assessment for any potential injuries completed with no abnormal findings on 8/24/16 at 6:15 p.m. -Investigation initiated to include interviewing employees in center on 8/24/16 starting at 6:30 p.m. -Evening shift supervisor completed a door check on ALL doors 8/24/16 at 6:30 p.m. with no negative findings. All doors and door alarms were functioning properly. -Residents with Secure Care device in place were checked for proper placement and functioning on 8/24/16 at 6:45 p.m. -Responsible party and Physician were notified of event on 8/24/16 at 7:45 p.m. and 7:33 p.m. respectively. -Door codes were changed on 8/25/16 at 6:00 a.m. and again on 9/6/16 at 10:30 a.m. due to visitors knowing how to figure out new codes due to past practices. -Interdisciplinary Team (IDT) established new signage on doors that stated Do not allow a resident to leave when you are exiting would be placed at all exit doors on 8/25/16 at 9:00 a.m. -On 8/25/16 at 10:00 a.m., Resident #1's care plan was reviewed and updated -Maintenance alone with Secure Care company service representative completed a door alarm check on ALL doors on 8/25/16 at 11:20 a.m. with no negative findings. -Incident report of occurrence completed on 8/25/16 at 3:08 p.m. -Review of Center Watch Binders/Boards completed and updated as needed on 8/25/16 at 8:00 a.m. -The residents identified as exit seekers received complete review of plan of care and updated exit seeking assessments as needed on 8/25/16. -All residents not currently identified as at risk for exit seeking in the facility were reassessed for current risk and assessments were completed on as indicated on 8/25/16. Plans of care were reviewed and revised if needed on 8/25/16. -Education provided to family member who used exit door to no longer enter or exit through the side door-completed by Director of Nursing (DON) B. -Education initiated to all licensed nursing staff regarding notifications to DON when initiating and discontinuing a 1:1 on 8/24/16 at 7:15 p.m. -Education initiated with all staff about not giving exit door codes no non-staff members on 9/01/16 at 12:45 p.m. -Re-education initiated with all staff on exit seeking behavior and 1:1 monitoring. -Completed education with both day shift unit managers and evening shift nurse supervisor on reporting off when leaving center 9/1/16 at 5:00 p.m. -Newly admitted residents continue to be evaluated for elopement risk during admission evaluation, with change in condition, quarterly and as needed with care plans being reviewed and revised as needed. Although the Immediate Jeopardy (IJ) was removed on 9/6/16, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO: IMPLEMENT AND EVALUATE INTERVENTIONS TO PREVENT A FALL WITH A FRACTURE (RESIDENT #4), RESULTING IN RESIDENT #4 EXPERIENCING A DECLINE IN ADL (ACTIVITIES OF DAILY LIVING) FUNCTION AND FAILED TO FOLLOW A CARE PLANNED TRANSFER TECHNIQUE (RESIDENT #14) RESULTING IN A FALL FOR 2 OUT OF 7 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 17 RESIDENTS. FINDINGS INCLUDE: A FACE SHEET DATED 7/20/12, REFLECTED RESIDENT #4 WAS A [AGE] year OLD FEMALE WHOSE INITIAL admitted WAS 8/19/2008. THE [DIAGNOSES REDACTED]. THE FACE SHEET DATED 8/6/12 REFLECTED RESIDENT #4 ALSO HAD THE [DIAGNOSES REDACTED]. IN A DOCUMENT DATED 8/6/12 TITLED, "NAME OF FACILITY, [DIAGNOSES REDACTED]. AN MDS dated [DATE] FOR RESIDENT #4 REFLECTED: THE STAFF ASSESSMENT FOR MENTAL STATUS RATED RESIDENT #4 AS A "1" OR MODIFIED INDEPENDENCE. RESIDENT #4'S FUNCTIONAL STATUS ON THIS MDS WAS A 2/2 (LIMITED ASSISTANCE WITH ONE PERSON PHYSICAL ASSIST) FOR WALK IN ROOM, TOILET USE AND TRANSFER ABILITY. AN MDS dated [DATE] FOR RESIDENT #4 REFLECTED A BRIEF INTERVIEW MENTAL STATUS SCORE (BIM) OF "6". A BIM SCORE OF 0-7 SUGGESTS SEVERE IMPAIRMENT OF COGNITION. A GENERAL PROGRESS NOTED DATED 7/11/12 AT 10:36 PM REFLECTS RESIDENT #4, "A&O (ALERT AND ORIENTED) TO SELF. CONFUSED/FORGETFUL (SIC) TO TIME, PLACE, SITUATION." AN INCIDENT/ACCIDENT REPORT ON 7/22/12, REFLECTED RESIDENT #4 EXPERIENCED A FALL IN HER BATHROOM AND SUFFERED A "SMALL SKIN TEAR TO RIGHT ELBOW." THE CORRECTIVE ACTION WAS "WILL REQUEST THAT THERAPY DEPARTMENT EVALUATE HER TRANSFERS." DURING AN INTERVIEW WITH PHYSICAL THERAPIST (PT) "D" ON 11/9/12 AT APPROXIMATELY 9:55 AM IN THE PHYSICAL THERAPY DEPARTMENT OFFICE, PT "D" WAS ASKED TO INTERPRET THE ABILITIES OF RESIDENT #4 AT HER DISCHARGE FROM PHYSICAL THERAPY ON 8/3/12 BEFORE HER SUSEQUENT FALL ON 8/6/12, RESULTING IN A FRACTURED RIGHT HIP. PT "D" STATED THAT RESIDENT #4 WAS A "STAND BY WITH ONE PERSON (ASSIST). WHEN YOU HOLD ON TO HER, SHE COULD TAKE A FEW STEPS TO THE WHEELCHAIR WITH HER AFO (A TYPE OF LEG BRACE)." RESIDENT #4 WAS "NOT ABLE TO PROPEL HER WHEELCHAIR DUE TO COGNITION." WHEN PT "D" WAS ASKED IF RESIDENT #4 WAS ABLE TO USE THE CALL LIGHT AT THAT TIME, PT "D" STATED SHE DID NOT FEEL RESIDENT #4 WAS COGNITIVE ENOUGH TO USE A CALL LIGHT. PT "D" STATED THEY HAD EDUCATED HER MANY TIMES TO USE THE CALL LIGHT WITHOUT SUCCESS. AN INTERVIEW WITH LPN "P" ON 11/9/12 AT APPROXIMATELY 3:50 PM, LPN "P" WHO HAS BEEN EMPLOYED IN THE FACILITY FOR 6 YEARS, WAS ASKED TO DESCRIBE RESIDENT #4'S ABILITIES BEFORE RESIDENT #4'S FALL ON 8/6/12. LPN "P" RELATED THAT RESIDENT #4 WOULD ATTEMPT TO SELF TRANSFER DURING THE TIME SHE WAS IN THERAPY AFTER 7/22/12. LPN "P" STATED THERE WERE NOTES ON RESIDENT #4 ' S TRAY TABLE TO NOT GET UP WITHOUT ASSISTANCE. LPN "P" WAS ASKED IF RESIDENT #4 COULD READ AFTER HER STROKE AND SHE STATED SOMETIMES RESIDENT #4 CAN READ, SOMETIMES RESIDENT #4 CAN'T READ, IT VARIES. AN INTERVIEW WITH CERTIFIED NURSING ASSISTANT (CNA) "Q" ON 11/9/12 AT APPROXIMATELY 4:05 PM, CNA "Q" WHO HAS BEEN EMPLOYED AT THIS FACILITY FOR 2 YEARS, WAS ASKED TO DESCRIBE RESIDENT #4'S ABILITIES BEFORE RESIDENT #4'S FALL ON 8/6/12. CNA "Q" DESCRIBED RESIDENT #4'S ABILITIES AS BEING A MINIMAL NEED FOR ASSIST WITH TRANSFERS. SHE STATED RESIDENT #4 DID NOT ALWAYS USE HER CALL LIGHT. CNA "Q" STATED RESIDENT #4 WAS FORGETFUL AND CNA "Q" WAS UNSURE IF RESIDENT #4 WAS "WITH IT" ENOUGH TO USE THE CALL LIGHT. CNA "Q" ALSO STATED RESIDENT #4 WAS CONTINENT (ABLE TO HOLD BOWEL AND BLADDER) AND THAT RESIDENT #4 WAS ABLE TO DRESS AND PERFORM ADL'S (ACTIVITIES OF DAILY LIVING) BY HERSELF. A CARE PLAN FOR RESIDENT #4 WITH THE FOCUS "AT RISK FOR FALLS DUE TO USE OF PSYCHOTROPIC MEDICATIONS, SEIZURES, HISTORY OF FALLS AND HURRIES AND FOCUSES ON HER TASK AND SOMETIMES FORGETS HER SAFETY NEEDS" WAS INITIATED ON 9/16/10 WITH A LAST REVISION ON 8/10/12. AN INTERVENTION DATED 9/16/10 REFLECTS "PROVIDE ASSIST TO TRANSFER AND AMBULATE (SIC) AS NEEDED." ANOTHER INTERVENTION DATED 10/24/11 REFLECTS, "REINFORCE NEED TO CALL FOR ASSISTANCE." AN INTERVENTION DATED 7/24/12 REFLECTS "PT (PHYSICAL THERAPY) EVALUATION AND TREATMENT PER MD ORDERS." THE MOST RECENT ENTRY RELATED TO FALLS WAS ON 8/10, DESCRIBING THE NEED TO USE A HOYER LIFT. THE INFORMATION NOTED BY THE CARE GIVERS REGARDING THE RESIDENTS FEAR OF WALKING IS NOT REFLECTED IN THE CARE PLAN. THERE IS NO INTERVENTION ADDRESSING RESIDENT #4'S CURRENT COGNITIVE ABILITY TO USE A CALL LIGHT FOR ASSISTANCE AND THERE IS NO INTERVENTION UPDATING RESIDENT #4'S CURRENT NEED FOR STAND BY ASSISTANCE OF ONE PERSON FOR TRANSFERS OR THE NEED FOR RESIDENT #4 TO USE HER AFO BRACE FOR TRANSFERS AND AMBULATION. THERE IS NO INTERVENTION FOR USE OF SIGNAGE TO REMIND RESIDENT #4 TO CALL FOR ASSISTANCE WITH AMBULATION. AN INCIDENT ACCIDENT REPORT DATED 8/6/12 AT 12:30 AM REFLECTS RESIDENT #4 EXPERIENCED A FALL IN THE BATHROOM. "CNA ENTERED ROOM TO FIND RESIDENT LAYING ON THE FLOOR BY THE TOILET." A GENERAL PROGRESS NOTED DATED 8/6/12 AT 12:28 AM REFLECTS THAT "RESIDENT (#4) ON FLOOR IN BR (BATHROOM). RESIDENT STATES SHE HAD TO GO TO THE BATHROOM. NO CALL LIGHT WAS ON.......1 CM ROUND ABRASION TO LEFT FOREHEAD......RESIDENT UNABLE TO MOVE RIGHT LEG AT THIS TIME." THERE IS NO MENTION ON THE INCIDENT ACCIDENT REPORT OF RESIDENT #4 WEARING HER AFO LEG BRACE. RESIDENT #4 WAS TAKEN TO THE HOSPITAL WITH THE [DIAGNOSES REDACTED]. DURING AN INTERVIEW OF RESIDENT #4 ON 11/9/12 AT APPROXIMATELY 9:30 AM IN RESIDENT #4'S ROOM, RESIDENT #4 WAS ASKED IF SHE REMEMBERED HER FALL WHEN SHE BROKE HER HIP. SHE STATED SHE REMEMBERED. RESIDENT #4 WAS ASKED IF SHE USED HER CALL LIGHT TO ASK FOR ASSISTANCE TO GO TO THE BATHROOM. SHE STATED, "YES, THEY CAME AND GOT ME AND TOOK ME TO THE HOSPITAL." RESIDENT WAS ONLY ABLE TO REMEMBER AFTER SHE WAS DISCOVERED IN HER BATHROOM." DURING AN INTERVIEW WITH PT "D" ON 11/9/12 AT APPROXIMATELY 10:30 AM, PT "D" WAS ASKED TO DESCRIBE RESIDENT #4'S ABILITIES AFTER HER FALL AND HIP FRACTURE ON 8/6/12. PT "D" STATED THAT RESIDENT #4 IS NOW: A "SIT TO STAND WITH ASSIST OF 2 PEOPLE. NURSING NOW UTILIZES A HOYER LIFT TRANSFER RESIDENT #4 DUE TO THE RESIDENTS FEAR OF FALLING. PT "D" STATED RESIDENT #4 COULD DO A STAND UP LIFT BUT WOULD SAY, "G** D****, PUT ME DOWN!" PT "D" STATED RESIDENT #4 WAS "TOO FEARFUL TO WALK, EVEN WITH PARALLEL BARS." PT "D" STATED PHYSICAL THERAPY CONTINUED FOR 2 MORE WEEKS THEN WAS DISCONTINUED BECAUSE OF A PLATEAU IN ABILITIES. DURING AN INTERVIEW WITH LPN "P" ON 11/9/12 AT APPROXIMATELY 3:50 PM, LPN "P" WAS ASKED TO DESCRIBE RESIDENT #4'S CURRENT ABILITIES AFTER HER 8/6/12 FALL. LPN "P" STATED RESIDENT #4 IS A "HOYER LIFT" (RESIDENT #4 REQUIRES A SPECIALTY LIFT WITH A SLING TO TRANSFER WHICH MAKES RESIDENT #4 TOTALLY DEPENDANT FOR TRANSFERS). LPN "P" DESCRIBED RESIDENT #4 AS HAVING MORE TROUBLE WITH COGNITION NOW, THAT RESIDENT #4'S COGNITION FLUCTUATES. LPN "P" STATED RESIDENT #4 "HAS TROUBLE FINDING CORRECT WORDS." DURING AN INTERVIEW WITH CNA "Q" ON 11/9/12 AT APPROXIMATELY 4:05 PM, CNA "Q" WAS ASKED TO DESCRIBE RESIDENT #4'S CURRENT ABILITIES. CNA "Q" STATED THAT RESIDENT #4'S "MEMORY WAS WORSE. (RESIDENT #4) HAS A LOT OF NEEDS AND IS NOW INCONTINENT." CNA "Q" ALSO STATED RESIDENT #4 COGNITIVE ABILITIES "HAS GONE DOWN." CNA "Q" STATED RESIDENT #4 NOW NEEDS ASSISTANCE WITH ADL'S AND DRESSING. RESIDENT WAS OBSERVED ON 11/7/12 AT 2:14 PM, 11/8/12 AT 9:35 AM AND 11/8/12 AT 11:05 AM DURING EACH OF THE OBSERVATIONS THE RESIDENT WAS LYING IN BED WITH HER EYES CLOSED. A FACILITY FACE SHEET DATED 6/13/12 REFLECTS RESIDENT #14, A [AGE] year OLD MALE, WAS admitted on [DATE] WITH THE [DIAGNOSES REDACTED]. ACCORDING TO A DOCUMENT TITLED "INCIDENT REPORT-PATIENT INVOLVED" DATED 5/3/12 AT 11:05 AM REFLECTS, "DESCRIPTION OF INCIDENT: PATIENT TRANSFERRED TO BED WITH CENA (CERTIFIED NURSING ASSISTANT). LEG BUCKLED AND fell TO FLOOR ON LEFT SIDE." ACCORDING TO A CARE PLAN DATED 4/23/12 WITH THE FOCUS REFLECTED AS "ANTICIPATED FALLS DUE TO LEFT SIDE PARALYSIS, CONFUSION, THROWS LEGS OVER SIDE OF BED, DOES NOT ACCEPT REDIRECTION WELL, EASILY FORGETS SAFETY GUIDANCE PROVIDED, LOSS OF SAFETY AWARENESS SECONDARY TO CVA...." AN INTERVENTION INITIATED ON 4/27/12 REFLECTS "STAND UP LIFT FOR TRANSFERS." THIS INTERVENTION WAS NOT FOLLOWED WHEN TRANSFERRING RESIDENT #14 ON 5/3/12, WHICH SUBSEQUENTLY RESULTED IN THE RESIDENT FALLING WHILE BEING TRANFERRED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE FOR 3 OUT OF 3 OF 17 SAMPLED RESIDENTS, BY FAILING TO MANAGE PAIN FOR RESIDENT #10, AND FAILING TO REPOSITION RESIDENTS #3 AND #14 RESULTING IN CONSTANT PAIN DUE TO INEFFECTIVE PAIN MANAGEMENT FOR RESIDENT #10 AND THE POTENTIAL FOR SHOULDER INJURY FOR RESIDENTS #3 AND #14. FINDINGS INCLUDE: RESIDENT #10 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. ON 1/4/11 AT 10:00 AM, RESIDENT #10 WAS OBSERVED WITH DARK RED SCALY SKIN FROM THE CALF DOWN, HER LEGS WERE VERY SWOLLEN, AND THE ASSISTANT DIRECTOR OF NURSING "J" STATED SHE HAD LOWER EXTREMITY [MEDICAL CONDITION]. RESIDENT #10'S QUARTERLY MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED THAT SHE WAS ALERT AND ORIENTED WITH NO COGNITIVE IMPAIRMENT AND SHE LIMITED HER ACTIVITIES, HAD DIFFICULTY SLEEPING DUE TO PAIN, AND WAS IN PAIN ALMOST CONSTANTLY. THE TELEPHONE ORDER DATED 1/4/11 REFLECTED THE [MEDICATION NAME] PATCH WAS DISCONTINUED PER RESIDENT #10'S REQUEST. DURING INTERVIEW ON 1/7/11, RESIDENT #10 STATED SHE REQUESTED THE [MEDICATION NAME] PATCH BE DISCONTINUED BECAUSE IT WAS CAUSING A RASH AROUND HER KNEE. SHE STATED SHE WAS IN PAIN, AND HER PAIN WAS AN "8" ON A SCALE OF 1 TO 10 WITH 10 BEING THE MOST SEVERE. SHE STATED THE NURSES DO NOT ASK HER IF SHE WAS IN PAIN WHEN THEY GIVE HER MEDICATION AND HER PAIN HAS BEEN AT THAT LEVEL SINCE SHE WAS admitted . RESIDENT STATED, "I FEEL LIKE THE STAFF JUST DON'T CARE". ON 1/7/11 NURSE "Z" HAS ADMINISTERED THE MORNING MEDICATIONS FOR UNITS "B" AND "C". ON 1/7/11 AT 11:00 AM NURSE "Z" STATED THAT RESIDENT #10 WAS NOT IN PAIN BECAUSE "SHE GETS [MEDICATION NAME] (A PAIN MEDICATION)". NURSE "Z" ALSO STATED SHE DID NOT THINK THE [MEDICATION NAME] PATCH WAS REPLACED WITH A NEW PAIN MEDICATION AND SHE WOULD HAVE TO ASK THE NURSE PRACTITIONER "AA." IN THE AFTERNOON ON 1/7/11, NURSE PRACTITIONER (NP) "AA" STATED SHE WAS GOING TO TRY [MEDICATION NAME] BECAUSE RESIDENT #10 WAS ALLERGIC TO SO MANY PAIN MEDICATIONS. NURSE PRACTITIONER "AA" EXPLAINED SHE WAITED UNTIL 1/7/11 TO REPLACE THE [MEDICATION NAME] PATCH WITH A NEW PAIN MEDICATION BECAUSE SHE THOUGHT THE [MEDICATION NAME] PATCH ORDER WAS DISCONTINUED 1/6/11. ALSO, IN THE AFTERNOON OF 1/7/11, NURSE "B" STATED RESIDENT #10 SAID THE [MEDICATION NAME] PATCH ONLY HELPED HER PAIN A LITTLE. THE MEDICATION ADMINISTRATION RECORDS FOR 10/10, 11/10, 12/10 AND 1/11 ALL REFLECTED RESIDENT #10 WAS EVALUATED FOR PAIN DAILY AND HAD NO PAIN, THIS WAS CONTRARY TO AN INTERVIEW WITH RESIDENT #10 ON 1/7/11, WHEN SHE STATED HER PAIN LEVEL WAS AN "8" "ALL THE TIME", STAFF DID NOT ASK WHAT HER PAIN LEVEL WAS PRIOR TO THE ADMINISTRATION OF HER MEDICATION OR FOLLOW UP FOR IT'S EFFECTIVENESS . IN ADDITION, HER PAIN RESULTED IN ISOLATING IN HER ROOM MOST OF HER TIME INCLUDING EATING HER MEALS IN HER ROOM. ( ) RESIDENT #14 WAS AN [AGE] year OLD COGNITIVELY IMPAIRED MALE WHOSE [DIAGNOSES REDACTED]. THE RESIDENT HAD CONTRACTURES OF THE FINGERS ON THE LEFT HAND, A STIFF LEFT ELBOW JOINT WITH THE ARM EXTENDED STRAIGHT OUT AND LEFT FOOT DROP (FOOT POINTED DOWN). ON 1/6/11 AT 11:20 AM THE RESIDENT WAS OBSERVED SEATED IN A BRODA CHAIR (HIGH BACKED ADJUSTABLE WHEELED CHAIR) IN HIS ROOM. THE RESIDENT HAD SLID DOWN IN THE CHAIR SO HIS BUTTOCKS WERE NEAR THE EDGE OF THE SEAT AND HIS FEET WERE OFF THE FOOT REST. THE RESIDENT'S LEFT SHOULDER WAS NEAR THE ARM REST SO HE WAS SIDEWAYS IN THE SEAT. AT 11:50 AM THE RESIDENT WAS REPOSITIONED IN THE CHAIR BY NURSING AIDE "X". NURSING AIDE "X" LOWERED THE BACK OF THE CHAIR TO A 45 DEGREE ANGLE AND STOOD BEHIND THE RESIDENT. NURSING AIDE "X" THEN PLACED HIS ARMS UNDER THE RESIDENT'S ARMPITS AND PULLED HIM TOWARD THE TOP OF THE CHAIRBACK. A SECOND ADJUSTMENT WAS NEEDED SO NURSING AIDE "GG" HELD THE RESIDENT'S LEGS WHILE NURSING AIDE "X" AGAIN PULLED THE RESIDENT TOWARD THE TOP OF THE CHAIRBACK WITH HIS ARMS UNDER THE RESIDENT'S ARMPITS. THE RESIDENT WAS AT RISK FOR INJURY TO HIS SHOULDERS WITH THE NURSING AIDE PULLING ON THEM AND SHEARING INJURY TO HIS BACK AND BUTTOCKS. ( ) ON 1/4/11 AT 1:30 PM, THE CLINICAL RECORD REVIEW WAS INITIATED FOR RESIDENT #3. ACCORDING TO THE FACILITY "ADMISSION SHEET" WITH A PRINT DATE OF 3/31/10 THE RESIDENT WAS admitted on [DATE]. HIS CURRENT [DIAGNOSES REDACTED]. ON 1/6/11 AT 11:45 AM, NURSING ASSISTANT - STAFF "Q" WAS OBSERVED COMPLETING A HOYER LIFT TRANSFER FROM RESIDENT #3'S BED TO THE WHEELCHAIR. FOLLOWING THE TRANSFER RESIDENT #3 WAS OBSERVED WITH HIS BUTTOCKS AND BACKSIDE NOT POSITIONED UP AGAINST THE CHAIRBACK. STAFF "Q" INFORMED RESIDENT #3 THAT HE NEEDED TO BE MOVED BACK INTO THE WHEELCHAIR. THE RESIDENT WAS OBSERVED PUSHING HIMSELF BACK WITH HIS LEFT FOOT WHILE STAFF "Q" REACHED UNDERNEATH THE RESIDENTS ARMPITS AND PULLED HIM UP AND BACK. A SECOND ATTEMPT AT REPOSITIONING THE RESIDENT IN THE SAME MANNER AS DESCRIBED ABOVE WAS OBSERVED. THE BRAKES ON THE WHEELCHAIR WERE NOT IN THE LOCKED POSITION DURING EITHER OF THE REPOSITIONING ATTEMPTS AND NO GAIT BELT WAS IN PLACE AROUND THE RESIDENT'S WAIST FOR USE DURING THE REPOSITIONING. THE NURSING ASSISTANT CARE PLAN UNDER THE SECTION "SAFETY/RESTRAINTS" DID NOT INCLUDE ANY INFORMATION REGARDING THE PROPER RE-POSITIONING PROCEDURE FOR THE RESIDENT. THE NURSING CARE PLAN LABELED "ADL SELF DEFICIT" INDICATED "...ENCOURAGE AND/OR ASSIST TO REPOSITION FREQUENTLY AND TRANSFER WITH MECHANICAL LIFT..." ( )

This citation pertains to intake number MI 556. Based on observations, interviews and record reviews the facility failed to (1) ensure the safety for 1 of 29 residents (Resident #500) who were leaving the facility on a regular basis without physician orders, resulting in an Immediate Jeopardy for Resident #500 when he eloped from the facility on 9/14/2010, sometime after 11:30am and was found when he returned to the facility at approximately 8:45pm, and (2) to ensure the safety of 1 of 6 residents (Resident #503) who were assessed to have "Exit Seeking Behaviors" and had a "Secure Guard Bracelet" (a bracelet that alarms when the person wearing it gets within a certain proximity of an alarmed door) on their wrist or ankle resulting in, an Immediate Jeopardy for Resident #503 when she signed herself out of the facility 12 times, from 7/26/2010 through 9/19/2010 and left without supervision from facility staff or a responsible party, nor a physician order to go out on a "Leave of Absence," placing residents #500 and #503 at high risk for serious harm or injury. Findings included: Resident #500: Per the facility face sheet, Resident #500 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an "Order Regarding Appointment of Temporary Guardian of Incapacitated Individual" from the court dated 8/19/2010 revealed that Resident #500 was granted a guardian. The court order revealed that the reason Resident #500 was granted a guardian was by reason of, mental deficiency and physical illness or disability. The court order was to be terminated only at the, "Further order of the court". Record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #500 had impaired vision. Record review of Resident #500's admission assessment dated [DATE] revealed that Resident #500 was not identified to have exit seeking behavior. Record review of care plans dated 8/ 0 revealed Resident #500 was at risk for dehydration or over hydration due to kidney disease which required staff to monitor his fluid intake. A care plan dated 8/26/2010 revealed Resident #500 was at risk for falls due to an unsteady gait. A care plan dated 8/26/2010 revealed Resident #500 required monitoring for hypertension due to cardiac disease. A care plan dated 8/26/2010 revealed Resident #500 required monitoring for his diabetes. The care plan revealed that Resident #500 was to receive hemodialysis three times per week. A care plan dated 8/26/2010 revealed Resident #500 received a special diet due to his diabetes. An intervention on the care plan was for staff to record the percentage of meals and supplements that Resident #500 consumed. A care plan dated 9/10/2010 revealed Resident #500 had impaired vision and only had to ability to see large bold print. Record review of a facility incident report dated 9/14/2010 revealed that at approximately 12:30pm Resident #500 was noted sitting at the bus stop, near the facility, by Staff Member #1 (the scheduler). The report revealed that at 1:00pm Staff Member #2, a Licensed Practical Nurse (LPN), noticed that Resident #500 had not eaten his lunch that was in his room. The report revealed that staff searched inside the facility for Resident #500 and when he was not found a "Code Green" (resident elopement) was called. The report revealed that staff then searched outside for Resident #500. The report revealed that a Physical Therapist remembered that Resident #500 had made a statement that he was going to the bank. Per the report the bank was phoned and it was verified that Resident #500 had made a transaction at the bank. Resident #500's family and guardian were notified as were the local police. Per the incident report, as of 7:00pm Resident #500 had not returned to the facility. Record review of nurses' notes dated 9/14/2010 at 11:30am revealed that Resident #500 was noticed to be missing. The notes revealed that another staff member (Staff Member #1) said that she saw Resident #500 sitting at the bus stop down the road. The nurses' notes revealed that Resident #500 did not report to any staff member that he was leaving the facility and he did he sign out of the facility on the sign out sheet. Nurses' notes dated 9/14/2010 at 8:45pm revealed that Resident #500 had returned to the facility and stated that he went shopping, out to eat, and to the bank. Record review of the facility "Wandering Patient Practice Guide" dated 4/2008 revealed if a resident chose to leave the facility without a physician's order to do so and was able to make decisions independently, the resident would need to be asked to sign a "Release from Discharge against Medical Advice" form. A resident who was able to make decisions to go outside and off premises, even with a physician's order, was asked to sign out upon leaving and sign in upon returning. The guide also revealed that an elopement was considered to have occurred when a resident left the premises or safe area without authorization. The guide also revealed that when an elopement or unsafe wandering risk was identified, a "Resident Assessment Protocol" was to be completed in order to determine the plan of care. No care plan was completed for Resident #500 after his elopement from the facility on 9/14/2010. The guide revealed that upon the elopement of a resident a "Behavioral Tracking Tool" was to be initiated and reviewed as needed to assist with ongoing adjustment to the care plan. No "Behavioral Tracking Tool" was started for Resident #500 or found to be with his medical records. Resident #500 was interviewed on 9/17/2010 at 1:50pm. He said that he went out the front door of the facility, went to the corner bus stop, and did not tell anyone that he was leaving the facility. He said that he did not know anyone. He said that he got on the bus and went to the bank and withdrew money. Then he went to the store and bought shoes and clothes and to shop for glasses. He also said that he went to a buffet to eat. He said that he took the bus back to the bus stop and walked back to the facility from the bus stop. He said that while walking back to the bus stop, he could only take three steps at a time. Then he had to stop and rest, because he was out of breath. He said that he told himself that he could make it and to keep going. He said it was hard to walk back. He said that he needed glasses. In another interview with Resident #500 on 9/28/2010 at 9:55am, Resident #500 said that if he had had the things he needed, he would never had left the facility. Observation of the route Resident #500 took on 9/14/2010 was done on 9/20/2010. Resident #500 walked approximately one block from the facility to the bus stop. He then rode the bus approximately 10 miles to the bank. He then rode the bus approximately 10 miles to the shopping stores. The bus stop was on the same side of the road that the store was. He then walked up and down a small plaza mall and rode the bus back to the bus stop near the facility. The walk from the facility to the bus stop and from the bus stop to the facility required Resident #500 to cross over a 4 lane road that was busy with a lot of traffic. Staff Member #1, a scheduler who sat at the desk by the front door, was interviewed on 9/20/2010 at 9:16am. She said she saw Resident #500 sitting at the bus stop approximately one block from the facility. She said she did not stop and talk with Resident #500. She said she did not tell any staff member that she saw Resident #500 at the bus stop when she returned to the facility. Staff Member #1 said Resident #500 was his own person, and she assumed he had signed himself out of the facility. She said Resident #500 was competent and had not ever left the facility before. She said Resident #500 did not have an order from the physician to leave the facility on a "Leave of Absence." She said after she saw Resident #500 at the bus stop, she returned to the facility about 45 minutes later. Staff Member #1 said Staff Member #2 asked if anyone had seen Resident #500. Staff Member #1 then told Staff Member #2 that she saw Resident #500 at the bus stop. Staff Member #1 said the alarm on the front door was routinely shut off from 7:00am to 5:00pm. She said she can usually see who goes in and out the front door from where she sat. Staff Member #2, a Licensed Practical Nurse (LPN) who was Resident #500's primary nurse, was interviewed on 9/17/2010 at 3:45pm. Staff Member #2 said she gave Resident #500 his medications at 11:30am. She said the driver of the transport bus had given Resident #500 some shoes because he felt bad for Resident #500 not having any shoes. She said Resident #500 made a comment that he was going to go try out his new shoes. Staff Member #2 said she did not see Resident #500 again after the comment that he made about his shoes. She said Resident #500 did not wander around the facility. Staff Member #2 said Resident #500 was to go to physical therapy and the staff from the therapy department could not find him. She said the therapy staff asked her if she knew where Resident #500 was. Staff Member #2 said when the therapy staff told her that Resident #500 was not in his room, she began an immediate search for him. Staff Member #2 said Staff Member #1 told her that she saw Resident #500 at the bus stop at around 1:20pm. Staff Member #2 said Staff Member #1 did not reveal to her that she saw Resident #500 at the bus stop until the "Code Green" (emergency search for resident elopement) was initiated. Staff Member #2 said she looked at the bus stop and a nearby store but was not able to locate Resident #500. Staff Member #2 said she then called the Director of Nursing (DON) and Resident #500's guardian. Staff Member #2 said the DON came into the facility and notified the police. Staff Member #2 said when she reported off to the oncoming nurse for the second shift, Resident #500 had not returned to the facility yet. Staff Member #3, an LPN who cared for Resident #500, was interviewed on 9/20/2010 at 2:00pm. Staff Member #3 said at the start of her shift, 2:45pm, Resident #500 was not in the facility. She said the police had been notified. Staff Member #3 said the Administrator of the facility told her to notify him when Resident #500 returned to the facility. Staff Member #3 said a Certified Nurse Aide (CNA, Staff Member #4) was on her break outside and saw Resident #500 walking up the parking lot. She said Staff Member #4 brought Resident #500 back into the facility, put him in a wheelchair, and brought him to the nurses' station. Staff Member #3 said when she met up with Resident #500, he was very tired. She said she asked Resident #500 where he had been, and he told her that he went out. Staff Member #3 said she told Resident #500 that he caused a lot of issues and told him that he could not leave the facility without telling someone and signing out. Staff Member #3 said Resident #500 received Lantus insulin at 8:00pm. She said she administered Resident #500's evening medications when he returned to the facility. She said Resident #500 told her he went to the bank, the store, and a restaurant to eat. She said he bought clothes, shoes, and a razor. Staff Member #3 said she did not place a "Secure Guard" bracelet on Resident #500. Staff Member #3 said there were no documented frequent checks done after Resident #500 returned to the facility on [DATE], in order to assure that he was still in the building. Staff Member #3 said the next evening on 9/15/2010 around 5:45pm, Resident #500 wanted to leave the facility again. He asked her where he needed to sign out in order to leave. She said Resident #500 left and returned at 9:30pm. She said his blood pressure was elevated (200/120) when he returned. Staff Member #3 said per the facility Policy and Procedure, a resident must sign out before leaving the facility. She said that no physician order was required. Staff Member #3 said she assumed Resident #500 was his own person. She said on 9/14/2010 she learned that Resident #500 actually had a guardian. She said when she thought back about it, Resident #500 should not have been able to sign himself out of the facility, due to having a court-appointed guardian. Staff Member #3 said the only thing she knew about the facility policy and procedure or guidelines was that a resident must sign out of the facility upon leaving the facility. She said a "Secure Care" bracelet was placed on Resident #500 on 9/17/2010, but he wanted it removed. She said she made a deal with Resident #500. She said she told him she would take the "Secure Care" bracelet off, but he had to agree to remain in the building. Staff Member #4, a CNA, was interviewed on 9/21/2010 at 1:20pm. She said she was on her break outside when she saw Resident #500 walking up the parking lot. She said it was about 8:30 or 9:00pm. She said it was dark outside and Resident #500 looked very tired. She said Resident #500 would take three steps, then stop and rest, then three steps and stop to rest. Staff Member #4 said Resident #500 was short of breath and breathing as though he had asthma. She said when she saw Resident #500 she did not speak to him or approach him. Instead, she followed him to the employee entrance door. She said Resident #500 had never walked that far since admission to the facility. She said Resident #500 went into the facility through the employee door, which required a code to access the door. Staff Member #4 said she approached Resident #500 when he got into the hallway. She said Resident #500 was standing up and breathing heavy. She said she asked Resident #500 if he wanted a wheelchair and he said yes with relief in his voice. She said she took Resident #500 to his room, and Staff Member #3 did an assessment on him. Staff Member #4 said Resident #500 had a plastic bag with him and told her that he went shopping for clothes, clippers, razor, and shoes. She said he had a bundle of money in his pocket. Staff Member #4 said there were several residents who left the facility everyday. Staff Member #8, a physical therapist who assisted Resident #500 with his therapy, was interviewed on 9/21/2010 at 10:35am. She said Resident #500 was able to walk greater than 200 feet without getting short of breath. She said Resident #500 needed to take extra time and frequent rest periods, because Resident #500 was generally weak and short of breath with activity. The Director of Nursing (DON), Staff Member #5, was interviewed on 9/17/2010 at 3:00pm. She said Resident #500 was not medically stable to leave the facility by himself. She said he had severe congestive heart failure. She said Resident #500 did not tell any staff members that he was leaving the facility on 9/14/2010. She said Resident #500's roommate would come and go as he pleased from the facility. She said Resident #500 did not know he was required to sign out before leaving the facility. She said she spoke with Resident #500 on 9/14/2010 and explained to him what he needed to do in order to leave the facility. She said Resident #500 verbalized that he understood the sign-out procedure. Staff Member #5 said the physician was contacted to obtain an order for [REDACTED]. She said the physician did not give the order. In another interview with the DON on 9/20/2010 at 11:00am, she said the "Wandering Patient Practice Guide" was just a guide and the facility did not necessarily have to follow the guide, per the "Quality Services Director." She said the "Wandering Patient Practice Guide" was the only (elopement) policy the facility had. The Regional Director of Quality Services was interviewed on 9/20/2010 at 1:35pm. She said the facility staff was expected to follow the "Wandering Patient Practice Guide." She said specifically the wandering patient guidelines were to be followed by the facility. Record review of the facility sign-out record for Resident #500 was done on 9/17/2010 at 1:00pm. The record indicated that Resident #500 did not sign-out on 9/14/2010. The record indicated that Resident #500 signed himself out of the facility on 9/15/2010 at 7:45pm. Observation of a sampled resident (Resident #501) leaving the facility on a leave of absence (LOA) was conducted on 9/20/2010 at 12:00pm. Resident #501's sister signed her out of the facility. Resident #501's medical chart was reviewed to identify a physician order for [REDACTED]. No physician order was found. Staff Member #6, a registered nurse (RN), was present during the observation and stated that she did not realize that a physician order was not on the medical chart. Staff Member #6 said that no resident in the facility had an order from the physician to leave the facility on a LOA. Resident #503 Per the facility face sheet, Resident #503 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Per the admission assessment completed on 7/12/2010, Resident #503 was not assessed to be at risk for elopement. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #503 had moderately impaired cognitive skills, impaired short-term memory problem, was resistive to care, and required assistance with ambulation. Record review of a care plan dated 4/5/2010 and revised on 7/19/2010 revealed Resident #503 was at risk for elopement based on Resident #503's comments that she wanted to go home. Interventions for Resident #503 were to avoid leaving her unattended or unobserved for long periods of time, check for placement and functioning of Resident #503's "Secure Care" bracelet every shift, "Secure Care" bracelet per physician order, and document Resident #503's behavioral history because she "may try to leave the facility unescorted." Record review of the list of residents who had exit-seeking behaviors and wore "Secure Care" bracelets revealed Resident #503 was listed as an exit-seeking resident. An observation of Resident #503 was conducted on 9/27/2010 at 10:50am. Resident #503 had a "Secure Care" bracelet on her right ankle. Record review of the "Leave of Absence" sign-out records for Resident #503 revealed that Resident #503 signed herself out of the facility on a LOA 13 times dating from 7/26/2010 through 8/4/2010. She signed herself back into the facility every time. Record review of Resident #503's medical record was conducted on 9/20/2010. No physician order was found for Resident #503 to leave the facility without a responsible person. On 9/20/2010 at 1:45pm, the DON and Administrator reported that they looked over every resident chart for residents who had been leaving the facility on LOA for a physician order. They indicated no physician orders were found on any of the residents' medical charts. Resident #503 was interviewed on 9/27/2010 at 10:50am. She said she attended hemodialysis three times per week. She said she rode the "Go Bus," which she said was public transportation. She said she obtained a round trip ticket on the day she needed to go to dialysis. Resident #503 said she went to the bus by herself. She said she used a walker. She said the "Go Bus" driver would watch her as she rode the lift up into the bus. She said she would hold onto her walker while the lift took her up into the bus. Resident #503 said while she rode the lift onto the bus she only had her walker to hold onto because there were no rails or walls to hold. She said the driver of the bus would watch her go into the dialysis building. She said the bus driver was a different driver every time. Resident #503 said she did not sign-out whenever she went to dialysis. The Administrator and Director of Nursing were notified on 9/27/2010 at 10:15am of the Immediate Jeopardy that began on 9/14/2010 due to (1) the facility's failure to ensure the safety of Resident #500, who had a court-appointed guardian, and who eloped from the facility, and (2) ensure the safety of Resident #503 who had a "Secure Guard" bracelet on her right ankle and who was signing herself out of the facility and leaving the facility without an escort from a responsible person. On 9/29/2010 at 10:50am, the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On 9/14/2010, Resident #500 was educated on the proper procedure for leaving the facility. 2. On 9/15/2010, the Quality Assessment and Assurance Committee met to review the incident. A 100% chart audit of residents who were leaving the facility on LOA was recommended to assure that valid physician orders where on resident charts, along with care plans on resident charts, and education for all staff regarding residents who leave the facility on LOA. 3. On 9/15/2010, an all staff in-service began regarding residents and a temporary leave of absence. The 20 remaining staff that had not received the in-service will not be allowed to work until they have received the in-service. 4. On 9/20/2010, the Quality Assessment and Assurance Committee met and reviewed progress with the established plan and reviewed the "Wandering Patient Guideline" book and deemed it appropriate. In addition, the "Center Watch" books (books with all resident's pictures that are at risk for elopement) were reviewed and updated and physician orders for LOA with escorts were in place. Additionally, training for licensed nurses was recommended by the Quality Assessment and Assurance Committee, to review the steps outlined in the LOA procedure, based on the "Wandering Patient Practice Guide" including the process for resident with guardians. As of 9/27/2010, 38 of 43 nurses received the additional education. The remaining 5 nurses will not be scheduled to work before receiving the training. 5. On 9/20/2010, all current residents have valid physician orders in place for LOA. Residents with guardians have orders for LOA with guardian permission, and residents with "Secure Care" bracelets have orders for LOA with and escort. 6. As of 9/27/2010, Resident #503 will have an escort and use medical transport for dialysis treatments. 7. Beginning 9/27/2010, all newly admitted residents will be evaluated for elopement risk during the nursing admission process and any identified risk reducing interventions will be put into place, including the appropriate orders for a LOA. The Interdisciplinary Team will review physician orders and care plans to further assure that elopement risks have been identified and assessed. All new admissions will be assessed for their ability to safely leave the facility and appropriate orders will be obtained at the time of admission. 8. Beginning 9/27/2010, residents will be required to see the licensed nurse to sign out for LOA. The licensed nurse will be responsible to assure that the appropriate authorization is in place and an escort is provided in indicated. Although the Immediate Jeopardy was removed on 9/27/2010, the facility remained out of compliance at a scope and severity of isolated with no actual harm, but the potential for more than minimal harm due to all staff had not received the educational in-service on the leave of absence policy and procedure and sustained compliance had not been verified by the State agency. ( )