Every finding on record at Ovid Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: On 04/01/2026 at 8:47am observed overhead spray nozzle hanging below the flood rim of the garbage disposal. During this observation, Dietary Manager E stated she was aware that the spray nozzle needs to be above the sink and maintenance knew about it as well. There was a zip tie around the hose, attempting to hold it up. On 04/01/2026 at 9:36am observed the drain line to the ice machine routed directly into drain in the nourishment room. On 04/01/2026 at 12:29 PM observed drain line to ice machine sitting inside drain in the main food storage room.According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings include:On 04/01/2026 at 9:41am observed an unused hose with a spray nozzle in the bathroom near the toilet in room [ROOM NUMBER]. During this observation, Maintenance Director C was interviewed on whether the hose near the toilet was flushed on a regular basis to prevent water stagnation, and he said they will flush unused fixtures in the empty rooms, but the hose near the toilet is not flushed. On 04/01/2026 at approximately 9:42am observed an unused hose with spray nozzle in bathroom near toilet in room [ROOM NUMBER]. On 04/01/2026 at approximately 9:44am observed an unused hose with spray nozzle in bathroom near toilet in room [ROOM NUMBER]. On 04/01/2026 at approximately 9:45am observed an unused hose with spray nozzle in bathroom near toilet in room [ROOM NUMBER]. On 04/01/2026 at approximately 9:46am observed an unused hose with spray nozzle in bathroom near toilet in room [ROOM NUMBER]. On 04/01/2026 at 9:49am observed a hopper in the housekeeping storage room. During this observation, Maintenance Director C was interviewed on whether the hopper is used and flushed regularly, and he said he wasn't sure if the hopper is being used and he wasn't sure if the hopper was flushed. On 04/01/2026 10:41 AM record review of the facility's water management plan on ways to intervene when control limits are not met, Remediation Activities establishing remediation activities and plans for addressing any breaches in control limits is crucial. This may involve flushing out stagnant water, adding disinfectant, or other corrective actions. In addition, the water management program policy states, The general principles of an effective water management program include: Preventing water stagnation. According to the facility's flushing logs, it states 1. Run water for a minimum of 3 minutes on all plumbing fixtures that do not get used regularly. Examples of this would be rooms off line, storage areas, mechanical rooms etc . The flushing logs were marked as completed for March, February, and January of 2026, and December 2025. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow.According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.

Through observation, interview and record review the facility failed to maintain the resident's dignity related to smoking for one resident (R2) of one evaluated for independent smoking based on unchanged smoking evaluations before and after appointed guardianship. Findings IncludeResident #2 (R2)Review of the medical record reflected that R2 was admitted to the facility on [DATE]. Diagnoses of paraplegia, migraines, bi-polar, contractors on left hip, right hip, right knee, left knee, muscles spasms, osteoarthritis and PTSD.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026 revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 was independent with eating, but maximal assistance on toileting, showering, dressing lower body, sit to stand and transferring from one surface to another.During an interview on 04/02/2026 at 9:13 AM, R2 asked writer about independent smoking because he has a new guardian and he was told he cannot be an independent smoker if you have a guardian. During an interview on 04/01/2026 at 3:13 PM, Activity Director (AD) was asked by writer who completed R2s smoking evaluation, stated it wasn't her, adding he should be supervised. In all previous assessments R2 was documented as being independent. AD stated because he had a guardian. Writer asked why that would prevent him from smoking independently, she stated because he's not safe. Record review revealed the smoking evaluations for R2 on the dates of 07/01/25, 07/02/25, 09/10/25, 11/28/25, 03/12/26, 04/01/26. Evaluation dated 04/01/26 documented that he was independent and a comment was written in by DON stating Supervised smoker by default due to inability to make consistent safe choices. Has guardian/DPOA/RP. Smoking policy stated it was a decision of the interdisciplinary team to make the decisions together, not one individual. R2 did not use a smoking vest/lap apron, safely holds a cigarette, he has not had to be re-evaluated due to violations or warning for not following the rules to smoke.During an interview on 04/02/2026 at 9:23 AM, DON B, stated they/management team did a smoking evaluation yesterday and R2 was deemed to not be an independent smoker, he was a supervised smoker, Supervised smoker by default due to inability to make consistent safe choices. Has guardian/DPOA/RP. Writer asked why that would stop him from smoking, DON stated he cannot wheel his wheelchair outside by himself, making him a supervised smoker. Writer asked if he had to wear a smoking vest/apron, DON stated no, writer asked if he had not followed the rules for smoking to make him supervised, DON B stated no. Writer asked if they had held an IDT team meeting to discuss this. DON B stated No. During an interview over the phone on 04/02/2026 at 10:17 AM, Guardian Angels P stated the facility had talked to her about another guardian within this facility, but he left the facility and then R2 went to supervised smoking, no explanation on where he went when he left the facility. Guardian Angels P stated she had not seen the policy for smoking and was going by what the facility told her. During an interview on 04/02/2026 at 1:30 PM, LNA A stated R2 had been a supervised smoker all along. LNA A stated it's the wording of the evaluation that says they are independent when we may feel they should be supervised. Writer asked LNA A about the facility smoking policy which says.Based on the interdisciplinary evaluation a decision will be made whether the resident is a safe or unsafe smoker.If the interdisciplinary team determines that the resident is an unsafe smoker, the resident may be required to wear a protective smoking vest/apron and is supervised while smoking.

Based on observation, interview, and record review the facility failed to ensure comfortable room temperatures for one (R13) with the potential to effect 60 residents. Findings include: On 3/31/2026 at 10:31 AM, Resident #13 (R13) was observed seated on the side of her bed. R13 motioned me to come into her room. Upon entry into R13's room, it was noticeably warmer from the ambient temperatures in the hallway. R13 had two fans on her and the window in her room was cracked open, however, the heater on the wall was running and blowing out hot air. R13 seemed anxious and began telling me that she felt very hot in her room. R13 explained that she has a diagnosis of Chronic Obstructive Pulmonary Disease and the high temperatures in her room are making her uncomfortable and making it more difficult for her to breath, causing increase discomfort. R13 stated that this has been reported to the facility, however, nothing had been done to address the heat issue in her room which had been ongoing for nearly a week. On 3/31/2026 at 10:35 AM, Maintenance Director C checked the ambient room temperature in the room. The ambient room temperature reached 81.6 degrees Fahrenheit. Maintenance Director C acknowledged this exceeded acceptable temperature ranges.

Based on observation, interview, and record review the facility failed to implement care planned interventions to prevent falls for one (Resident #56) out of 14 residents reviewed for care plans.Findings include: Resident #56 (R56)Review of the medical record reflected Resident #56 (R56) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included kidney disease anxiety disorder, restless leg syndrome, dementia, bipolar disorder, fracture of the nasal bones, and type two diabetes. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/15/2026, reflected R56 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/01/2026 at 11:29 AM, R56 was observed in his room lying in bed. R56 had bruising on his face that was mostly resolved. During conversation, R56 stated that the bruising occurred from a fight but later, stated it occurred from a fall. R56 had a regular, flat mattress on his bed and did not have any posted remind to use call light type signs on his walls. Review of a Fall Care plan revealed all fall interventions were in place at the time of observation expect an intervention for a sign placed in view to remind resident to utilize call light for assistance with transfers initiated on 11/15/2025 and an intervention for a perimeter/concave mattress implemented on 11/17/25. On 4/01/2026 at 12:49 PM, R56 did not have a perimeter mattress or a sign posted on the wall in his room,On 4/2//2026 at 2:10 PM, R56 did not have a perimeter mattress or a sign posted on the wall in his room On 4/3/2026 at 10:05 AM, R56 did not have a perimeter mattress or a sign posted on the wall in his room. In an interview on 04/03/2026 at 2:24 PM, Director of Nursing (DON) B confirmed that R56 had sustained a few falls during his admission at the facility. DON B stated that the Interdisciplinary Team discusses interventions and will often round to ensure fall interventions are in place. When asked if R56's concave mattress and sign reminding R56 to use his call light were in place, DON B stated that she did not think that those interventions were currently in place.

Based on observation, interview, and record review the facility failed to ensure orthostatic blood pressures were being monitored correctly (Resident #56) following professional standards.Findings Include Review of the medical record reflected R56 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included kidney disease anxiety disorder, restless leg syndrome, dementia, bipolar disorder, fracture of the nasal bones, and type two diabetes. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/15/2026, reflected R56 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/01/2026 at 11:29 AM, R56 was observed in his room lying in bed. R56 was alert but did not answer questions appropriately. Review of R56's Electronic Medical Record revealed a long history of prescribed antipsychotics for his medical diagnosis. Review of R56's Physician orders revealed active orders for check ortho bp (orthostatic blood pressure) active from 3/19/26 to 3/20/26. Another Physician Order stated take orthostatic BP (blood pressure) q (every) shift x 3 days (for three days) active from 3/21/26 to 3/23/26. Review of the Medication Administration Record (MAR) and the Vitals section in the Electronic Medical Record revealed inconsistent methods for obtaining the orthostatic blood pressures if they were obtained, and/or, no documentation depicting that the blood pressures were obtained. Review of the MAR for 3/19/26 revealed a y for yes in the section for check ortho BP and 3/20/26 revealed a single recorded blood pressure. Review of the Vitals Tab for the dates of 3/21/26 and 3/22/-26 revealed single blood pressure records.Review of the Vitals Tab for 3/23/26 showed two blood pressure recordings, 7 minutes apart, both noted to be in a seated position. In an interview on 4/03/2026 at 2:24 PM, Director of Nursing DON B stating that the procedure of obtaining orthostatic blood pressures would be to have the resident change positions from lying, sitting, and standing (if able) and obtain blood pressures with each position change. Per the Center for Disease Control and Prevention, the recommended method for obtaining orthostatic blood pressure would be to have the patient lie down for 5 minutes, measure blood pressure and pulse rate, then have the patient stand and repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes.

Based on observation, interview and record review, the facility failed to provide adequate pain management to one resident (R31) of one resident resulting in decline in activities of daily living related to uncontrolled pain. Findings IncludeResident #31 (R31)Record review on 03/31/2026 at 2:07 PM oxycodone HCl Oral Tablet 5 MG Give 2 tablet by mouth every 4 hours as needed for pain management.Observation on 03/31/2026 at 2:07 PM, R31 grimaced and jerked in place trying to explain his illness and the pain was unbearable. Observation on 04/02/2026 at11:05 AM from R31's door, R31 moaning out in pain, talking in his sleep. Writer asked R31 if he was in pain, he stated yes. Writer asked R31 if his pain medication was scheduled or he needed to ask for it. R31 stated he thought it was scheduled, rated it as #8 on scale of 0-10. R31 tried to reposition to try and get some relief on his right hip. Writer asked R31 if he needed something. R31 stated yes if they would give him something for pain, writer reminded R31 to push his call light, observed LPN S walking towards his room to ask about his pain. During an interview on 04/03/2026 at 8:01AM, RN T stated R31 has had a lot of pain especially in his right hip, when he fell, he reinjured it.RN T stated R31 had Tylenol ES 1000mg scheduled three times a day. Some days R31 does not have any pain. RN T stated she had asked provider for something long acting, but he hasn't ordered anything. RN T stated he did decline therapy related to pain. RN T stated they had recommended hospice, he was onboard, but his brother and therapy talked him out of it. RN T stated she had cared for him since his admission, he used to use walker, commode on his own, he could get around in his room independently. R31 rated his pain a #6 on a scale of 0-10, R31 received 2 Tylenol ES 1000mg plus Oxycodone 5mg as needed dose for right hip pain.RN T stated she gowns up for enhanced barriers PPE, doesn't have to gown up until she provides care but it's something she always does, better to be safe. RN T stated she was going to have the doctor come in and see him today. During an interview 04/03/2026 at 10:20 AM Interview with CNA U stated R31 frequently yells out like that, indication of pain, received report that he was more disoriented the last day or two. CNA U stated R31 cannot reposition himself related to his pain. CNA U also stated they pretty much do everything for him now, he yells out in pain. CNA U stated they had to change the linens and give him a bed bath because he misses using the urinal and the bedding is saturated with urine. CNA U stated therapy works with him and the restorative aide also works with him on range of motion. CNA U stated he seemed to always be in pain. During an interview on 04/03/2026 at 10:28 AM, LPN V stated the provider ordered labs. During an interview and observation on 04/03/2026 at 10:31 AM, LPN V reported the changes with R31 to NP W and stated R31 was using his scheduled mediations and prn medications and asked about a longer acting pain medication. NP W stated R31 had not said anything to him about that, but he didn't have a problem ordering that.During an interview on 04/03/2026 at 12:55 PM, Therapy Director O stated she was aware of R31 refusing therapy related to pain. Therapy Director O stated they try to coordinate pain medication administration with therapy. During an interview on 04/03/2026 at 2:06 PM, DON B stated NP W wrote new orders for Urinalysis with Culture & Sensitivity with the labs Complete Blood Count and Complete Metabolic Panel and that order for discontinued Pentoxifylline ER. Oxycodone 10mg tablet every 6 hours scheduled, Flexeril 5mg tablet every 8 hours for muscle pain.

Based on observation and intrview the facility failed to maintain safe food temperatures affecting all 61 residents with the potential for causing food-related illnesses. Findings include: On 1/6/25 at 12:45 PM during second tour of the facility kitchen the plating of food was observed. Following the plating of food done by the cook S the remaining food still on the steam table was immediately tested for temperature. The cook S utilized the kitchen thermometer. The food temperatures in degrees farenheight were as follows: Cream of Potato Casserole: 128 Peas: 90 Fish: 120 Green Beans 140 Mashed Potatoes 130 Gravy 135 Garlic Bread: 80 The cook S acknowledged the low readings and said the temperature readings would be addressed with administration. On 01/07/25 12:55 PM during interview the Consultant Dietician U said the low temperatures had been communicated (and the Dietary Manager (DM) T and CD U were communicating via email during the iterview) and CD U said DM T would address the problem of food being . not up to temperature. On 01/08/25 02:02 PM during observation of the pantry DM T was interviewed. DM T explained the refrigerator in the pantry is a main pantry used by all residents in the facility. The refrigerator temperature gauge was checked and showed a reading of 44 degrees. DM T was asked about the acceptable range which DM T stated as 32 to 41 degrees. DM T said that the temperature is monitored daily. A form secured to the refrigerator showed temperatures for the month of January consistently documented as 40 degrees. DM T was asked about actions to be taken when there is an out of range reading and responded by saying that there could be reasons the temperature was not at the required level. DM T said she would typically confirm the door was sealing shut and would return in an hour to check the temperature. If the temperature was found to be out of range the next step would be to transfer food to the backup refrigerator in therapy department. On 1/8/25 at 2:48 PM during second observation the pantry refrigerator temperature registered at 60 degrees. A dietary employee had just exited the room after having washed the inside of the refrigerator. On 1/8/25 at 2:55 PM the DM T and a dietary employee pulled a large plastic container of turkey sandwiches out of the refrigerator. DM T instructed the dietary employee that each layer of sandwiches would be checked for temperature and all products in the refrigerator would be checked and anything not within an acceptable level of temperature would be discarded and all food that was within range would be transferred to the backup refrigerator. The turkey sandwiches were testing at around 50 degrees F. Following that another container of cheese sandwiches was tested which tested at around 46 degrees F. DM T said these would all need to be discarded. The NHA A was present in the room. The testing continued. There were many products in the refrigerator. According to a facility policy titled Food Temperatures with a date of revision of 12/12/21 states in part, The temperature of holding hot foods at point of service will be > 130 degrees F. The temperature of holding cold foods at point of service will be < 41 degrees F. The cook is responsible for ensuring all food is at the proper serving temperature. Food temperatures will be taken and recorded for all TCS foods at all meals. According to an article on USDA.gov (United States Department of Agriculture) website the temperature of food at safe levels prevents foodborne illness.

Based on observation, interview and record review, the facility failed to 1) implement Enhanced Barrier Precautions for one (Resident #31); and 2) implement measures to mitigate the spread of COVID-19 infection to facility staff and residents. During an interview on 01/08/25 at 8:50 AM, with the Director of Nursing (DON) and Infection Preventionist (IP) I (in attendance via phone), it was reported that the facility's COVID-19 outbreak was believed to have started after Registered Nurse (RN) K tested positive for COVID-19 (on 12/30/24). It was reported that facility-wide COVID-19 testing was initiated for all residents and staff, as RN K had worked all over the facility, and they were unable to determine close contacts. It was reported the first residents tested positive for COVID-19 on 12/31/24. Review of a facility surveillance log reflected RN K had symptoms of stuffy nose, dry cough and body aches, which began on 12/28/24. RN K had a positive result on a COVID-19 test on 12/30/24. A time card report for RN K reflected they worked from 5:56 PM on 12/28/24 to 6:47 AM on 12/29/24, for a total of 12.25 hours. RN K worked from 5:56 PM on 12/29/24 to 7:38 AM on 12/30/24, for a total of 13.25 hours. According to Centers for Disease Control and Prevention (CDC), .Symptoms of COVID-19 .People with COVID-19 have a wide range of symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Symptoms may start as mild, and some people will progress to more severe symptoms .Possible symptoms include: .Cough .Sore throat .Muscle or body aches . (https://www.cdc.gov/covid/signs-symptoms/index.html In an interview with the Nursing Home Administrator (NHA) and DON on 01/08/25 at 3:48 PM, it was reported that RN K worked while experiencing symptoms that could have been consistent with COVID-19 but did not notify the facility. The facility became aware of RN K's symptoms after they tested for COVID-19 (on 12/30/24). According to the facility's COVID-19 infection surveillance logs, 31 residents had tested positive for COVID-19 between 12/31/24 and 1/8/25, and 23 staff had tested positive for COVID-19 between 12/30/24 and 1/7/25. During an interview with the DON and IP I (who attended via phone) on 1/08/25 at 1:43 PM, it was reported if staff were experiencing symptoms consistent with COVID-19, they were to notify the facility, which included the DON and IP I. It was reported that staff were to come to the facility for COVID-19 testing, outdoors. Staff were not to report to work if they were symptomatic. 45135 Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. During an interview and observation on 01/07/25 at 12:33 PM, Licensed Practical Nurse (LPN) B, stated she came in do oral care for R31, looked around for supplies, didn't have any in the room, she had to go out of the room to gather supplies. This writer could observed build up on his teeth, gum line puffy, same condition as yesterday, with stringy stuff hanging off his back teeth. LPN B returned to his room with oral care supplies. LPN B used a sponge on a stick, dipped in mouth wash to do oral care. LPN B stated he had a hard thing in the roof of his mouth, and she finally got it out. During this same observation, LPN B was touching and moving his gastrostomy tube and clamp without PPE for enhanced barrier precaution. The sign on this resident's door stated he was on enhanced barriers precautions and required gown and gloves for staff providing any care. LPN B covered him back up and told him she had to go get supplies. During an interview and observation on 01/07/25 at 12:50 PM, LPN B hung his tube feeding, did not start the infusion pump, wearing gloves but no gown. LPN B removed gloves and exited the room, no hand hygiene observed after removal of her gloves. LPN B came back into R31's room, put new gloves on and checked the gastric residual (amount of enteral feeding left in the stomach from the last feeding) again with gloves but no gown. LPN B stated R31 did not have any gastric residual left in his stomach. However, this writer was unable to see over the side of his bed due to LPN B being so close to the resident's side performing that task. LPN B took her gloves off and put new gloves on to clean off the over the bed table. LPN B removed the gloves and exited the room without washing her hands.

Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) accurately reflected the estimated cost of items and services for which the resident may be charged for two (Resident #13 and #14) of three reviewed for Beneficiary Notification. Findings include: Resident #13 (R13): Review of the medical record reflected R13 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure, chronic kidney disease and diabetes. Facility documentation reflected R13 exhausted their Medicare Part A benefit days, with a last covered day of 8/26/24, and remained in the facility. The ABN form included the cost per 15 minutes of Occupational Therapy (OT) and Physical Therapy (PT) services. The ABN did not include other potential financial liability or services that may no longer be covered by Medicare, such as room and board. Resident #14 (R14):Review of the medical record reflected R14 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included diabetes and dementia. Facility documentation reflected R14 exhausted their Medicare Part A benefit days, and beginning 10/7/24, they may have had to pay out of pocket for OT, PT and daily skilled nursing care. The ABN form reflected the cost per 15 minutes of services. The ABN did not include other potential financial liability or services that may no longer be covered by Medicare, such as room and board. In an interview on 01/08/25 at 4:18 PM, Business Office Manager (BOM) J indicated it made sense that room and board charges would be included on an ABN, however, that was not how they had been taught.

Based on observation, interview, and record review the facility failed to provide necessary care to two of five residents (R22 and R31) reviewed for activities of daily living (ADLs), resulting in these residents not receiving the care needed to maintain their highest practicable well-being. Findings include: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. During an interview on 01/06/25 at 12:45 PM, R31's family R stated R31 had built up around his teeth and what appears to be hanging substance from his back teeth and his tongue covered with a white buildup. R31's family member R also stated she did not feel the staff were brushing his teeth like they should be. R31's family R also stated staff are supposed to be putting a rolled washcloth rolled up in his right hand to keep the fingers from digging into his palm. Record review revealed R31' s care plan included wash and dry right hand every shift and place palm protector or rolled wash cloth between the palm and his fingers. During an observation on 01/06/25 at12:50 PM, R31 had a buildup that appeared to be plaque around teeth and what appears to be stringy substance hanging from his back teeth. R31's tongue was covered with a white, dry buildup. R31's gums were swollen and inflamed. Observation of R31 laying in his bed with the head of his bed elevated approximately 45 degrees to accommodate tube feeding. R31's feet were not floating on a pillow and his feet were rubbing against the foot board. R31's right hand was contracted, and his fingers were bend tightly against his palm. No observation of a rolled washcloth or device to keep his fingers from digging into his palm or to absorb moisture. During an observation on 01/06/25 at 4:30PM, R31 was laying in the same position as 12:45 PM today, in his bed with the head of his bed elevated approximately 45 degrees to accommodate tube feeding. R31's feet were not floating up off the mattress and his feet rubbing up against the foot board. R31's right hand was contracted, and his fingers were bend tightly against his palm. No observation of a rolled washcloth or device to keep his fingers from digging into his palm or to absorb moisture. During an observation on 01/07/25 at 9:00 AM, R31 was laying in his bed with the head of his bed elevated approximately 45 degrees. R31's feet were not floating off the mattress and his feet were pushed up against the foot board. R31's right hand was contracted, and his fingers were bend tightly against his palm. No observation of a rolled washcloth or device to keep his fingers from digging into his palm or to absorb moisture. During an observation on 01/07/25 at 1:00PM, R31 was laying in his bed with the head of bed elevated approximately 45 degrees to accommodate tube feeding. R31's feet were not floating on a pillow or up off the mattress. R31's feet were pressed up against the foot board. R31 had been in the same position for the last four hours with no changes in his position in the bed. During an observation on 01/07/25 at 4:00PM, R31 was laying in the same position in his bed, feet were not floating, feet firm against the foot board. During an interview and observation on 01/07/25 at 12:33 PM, Licensed Practical Nurse (LPN) B, stated she came in do oral care for R31, looked around for supplies, didn't have any in the room, she had to go out of the room to gather supplies. This writer could observed build up on his teeth, gum line puffy, same condition as yesterday, with stringy stuff hanging off his back teeth. LPN B returned to his room with oral care supplies. LPN B used a sponge on a stick, dipped in mouth wash to do oral care. LPN B stated he had a hard thing in the roof of his mouth, and she finally got it out. During this same observation, LPN B was touching and moving his gastrostomy tube and clamp without PPE for enhanced barrier precaution. The sign on this resident's door stated he was on enhanced barriers precautions and required gown and gloves for staff providing any care. LPN B covered him back up and told him she had to go get supplies. During an interview and observation on 01/07/25 at 12:50 PM, LPN B hung his tube feeding, did not start the infusion pump, wearing gloves but no gown. LPN B removed gloves and exited the room, no hand hygiene observed after removal of her gloves. LPN B came back into R31's room, put new gloves on and checked the gastric residual (amount of enteral feeding left in the stomach from the last feeding) again with gloves but no gown. LPN B stated R31 did not have any gastric residual left in his stomach. However, this writer was unable to see over the side of his bed due to LPN B being so close to the resident's side performing that task. LPN B took her gloves off and put new gloves on to clean off the over the bed table. During an interview on 01/07/25 at 3:27 PM, Social Worker (SW) D stated she does follow up after appts such as dental, if more appointments are needed. Writer asked her if there were any follow up appointments made on R31's teeth as the dentist documented he had heavy plaque and cavities. SW D stated she would have to investigate it and wound let writer know. Record review revealed R31 got a shower on Tues and Fri nights. Does not reflect that he had a shower last night (Tuesday night, 01/07/25). R31 does have hospice services so the hospice CNA would be providing care through the week as well. Record review of care plan revealed R31 is care planned for Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily. Turn/reposition every 2 hours and prn. Observe/document/report to physician PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. During an interview on 01/07/25 at 4:27 PM, writer asked LPN B what the medication left at the bedside of R31 was used for, as there was no name on it, no date on it, nor an order for it in the electronic medical record (EMR). LPN B stated there had to be an order for it since they have been using it. LPN B stated she would direct this concern to the RN/Unit Manager M. During an interview on 01/07/25 at 4:35 PM, RN/Unit Manager M was observed looking in her computer for an order for Bio-[NAME] medication. RN/Unit Manager M stated there was not an order, it must have dropped off. RN/Unit Manager asked writer if she should put an order in for the Bio-[NAME] medication? Writer stated I cannot tell you what to do, but it would make sense to have an order for any medications that were given or being used. Record review of physician orders on 01/08/25 at 8:04 AM, revealed a new order put in on 01/07/25 at 6:00 PM for (Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. Give 1 application by mouth every 4 hours for xerostomia may have at bedside) During an observation on 01/08/25 at 8:24 AM, the bottle of the medication Bio-[NAME] was still setting on R31's dresser without any name, date opened or instructions for this medication on it. During an interview on 01/08/25 at 8:26 AM, SW D stated R31 saw the dentist in 03/24 and 10/24. SW D stated the dentist recommendation was for staff to assist with oral care and use a toothbrush. Writer asked if R31 had any additional follow up appointments with the dentist, and SW D stated she didn't know, but she would check. Record review of the dental visit notes dated 10/09/24 recommendation was for staff to brush his teeth and do oral care due to the buildup of plaque. During an observation on 01/08/25 at 8:34 AM, R31's wash basin with hygiene products, did not have a toothbrush in it, only a small tube of toothpaste was present. During an interview on 01/08/25 at 8:50 AM, Certified Nursing Assistant (CNA) N stated she uses a sponge on a stick to do oral care on R31. During an interview on 01/08/25 at 8:52 AM, CNA O stated she cleans R31's teeth with a sponge on a stick, dipped in mouthwash. During an interview on 01/08/25 at 8:51 AM, CNA P, stated she usually cleans R31's mouth with a sponge on a stick and tries to clean his teeth off with that. During an interview on 01/08/25 at 8:58 AM, Registered Nurse (RN) C stated she used a sponge on a stick to get the plaque buildup off, and sometimes she uses a toothbrush. RN C added R31 is a tough one due to the plaque buildup on his teeth. RN C also stated she uses the Bio-[NAME] to keep his mouth moist. Record review revealed R31' s care plan included wash and dry right hand every shift and place palm protector or rolled wash cloth between the palm and his fingers. 49272 Resident #22 (R22) Review of the medical record reflected that R22 was initially admitted to the facility on [DATE] with diagnoses that included: major depressive disorder, anxiety disorder, intermittent explosive disorder, muscle weakness and difficulty in walking. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/24, revealed R22 had a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicated intact cognition. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R22 required substantial/maximal assistance for showering, partial/moderate assistance with upper body dressing and substantial/maximal assistance with lower body dressing. During an observation on 1/6/25 at 1:01 PM, R22 was observed to have greasy, uncombed hair and reported that he had only received 3 showers since he had been here. R22 reported that the staff does not offer him a shower twice weekly. It should be noted that resident was in isolation requiring an N-95 mask to be worn, unable to determine if odor was present. During an observation on 1/8/25 at approximately 2pm, R22 was observed in the hallway, hair remained greasy and uncombed. A review of R22's shower task revealed only one shower documented in a 30-day time span (12/16/24 through 1/6/25), one refusal documented and Not Applicable documented 5 times. Record review revealed R22's shower days should be Monday and Thursday each week. During an interview with Unit Manager (UM) M on 1/8/25 at 2:21PM, she reviewed R22's shower task log for the past 30 days and stated it looked bad. UM M was asked when it would be appropriate to document Not Applicable on the shower task, she reported it would never be appropriate, and that staff should be offering and documenting showers or refusals twice weekly. When asked if the unit managers audit shower and shower related tasks she reported she is new to the role (2 months) and they are working hard on getting everything to match (paper shower sheets that indicate which residents are due for showers each day and task information in the electronic medical record). She further stated that they have not gotten to audits yet but they have done education on charting and 1:1's. Review of the facilities policy titled Activities of Daily Living (ADL) Program updated 4/24, documented in part A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. ADL may include, but are not limited to, bathing, grooming, and dressing. Restorative ADL program may be provided by nursing assistants and other staff trained in provision of ADL care under the supervision of the licensed nurse.

Based on observation, interview, and record review the facility failed to provide pressure ulcer treatments as ordered for one (Resident 54) of three reviewed, resulting in the potential of a worsened pressure ulcer. Findings include: Review of the medical record reflected that R54 was initially admitted to the facility on [DATE] with diagnoses that included: Periprosthetic (relating to an artificial joint) fracture around internal prosthetic (artificial) right knee joint, morbid obesity, Parkinson's disease, heart failure and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24, revealed R54 had a Brief Interview of Mental Status (BIMS) of 12 out of 15, which indicated moderate cognitive impairment. On 1/6/25 at 10:37 AM R54 was observed sitting up at the edge of her bed. A soiled pillow/pillowcase was observed at the foot of R54's bed with brown/yellow colored stain. When asked what the substance was on the pillowcase she reported that she believed it was drainage from the dressing on her right heel and added that the staff isn't good about changing her dressing every day and she was told it was supposed to be changed each day. On 1/6/25 at 10:46 AM, CNA A applied gloves and removed R54's sock to reveal 2 dressings to R54's lateral foot and heel on her right foot. Dressings were dated 1/4/25. CNA A confirmed the date on the dressing was 1/4/25. A review of R54's physician orders revealed the following wound care orders: Wound care to right lateral outer ankle: cleanse with wound wash, pat dry, apply skin prep to reddened skin, cover with a gently border foam gauze daily and as needed, with a start date of 12/27/2224. Wound care to right posterior ankle: Cleanse wound with wound wash, pat dry, apply Medihoney to wound, apply skin prep peri wound, cover with gentle border foam gauze daily and as needed with a start date of 12/20/24. A review of R54's Treatment administration record revealed wound care was documented as completed by LPN B. An attempt was made to contact LPN B on 1/8/25 via phone at 12:22 PM. No return call was received prior to survey exit. On 1/8/25 at 12:38 PM an interview was conducted with Director of Nursing (DON) and Nursing Home Administrator (NHA). When notified of dressing change not completed for R54 on 1/5/25 but documented as completed on the TAR, they reported that they were aware and had spoken with LPN B and provided 1:1 education. LPN B was educated on not documenting a task that hasn't been completed. DON stated that LPN B stated that she passed on to the oncoming nurse that the dressing change had not been done. DON stated that the expectation for documenting is that it should be completed immediately after the task had been completed. Review of the facilities policy titled Documentation Expectations updated 6/23, documented in part Chart events as they occur and maintain chronological order .If a medication or treatment is not administered as ordered, the nurse circles the appropriate box and enters the reason for omission per facility policy .Entries in the medical record should be completed in a timely manner. Entries should be made at the time of the occurrence .

Based on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration. Findings include: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. Concern r/t no physician order for medication for R31, and potential to affect all residents (1 of 60) During an interview on 01/07/25 at 4:27 PM, writer asked LPN B what the medication left at the bedside of R31 was used for, as there was no name on it, no date on it, nor an order for it in the electronic medical record (EMR). LPN B stated there had to be an order for it since they have been using it. LPN B stated she would direct this concern to the RN/Unit Manager M. During an interview on 01/07/25 at 4:35 PM, RN/Unit Manager M was observed looking in her computer for an order for Bio-[NAME] medication. RN/Unit Manager M stated there was not an order, it must have dropped off. RN/Unit Manager asked writer if she should put an order in for the Bio-[NAME] medication? Writer stated I cannot tell you what to do, but it would make sense to have an order for any medications that were given or being used. Record review of physician orders on 01/08/25 at 8:04 AM, revealed a new order put in on 01/07/25 at 6:00 PM for (Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. Give 1 application by mouth every 4 hours for xerostomia may have at bedside) During an observation on 01/08/25 at 8:24 AM, the bottle of the medication Bio-[NAME] was still setting on R31's dresser without any name, date opened or instructions for this medication on it.

Based on observation, interview, and record review the facility failed to ensure for one out of 15 residents (Resident #31) medications were properly and safely stored, labeled with resident's name, date opened, and physician's order for administration. Findings: Resident #31 (R31) Review of the medical record reflected R31 was an initial admission to the facility on [DATE]. Diagnoses of Anoxic Brain Damage (brain injury happens when your brain loses oxygen supply), Dry Mouth, Major depression, Contracture of right hand (when one or more fingers bend toward the palm of the hand), Neuromuscular Dysfunctionof Bladder (when neurological (nervous system) conditions affect the way your bladder works), Dysphagia (difficulty in swallowing), Gastrostomy Tube (surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) and Post-Traumatic Hydrocephalus (is a frequent and serious complication that follows a traumatic brain injury (TBI). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2024, revealed R31 had a Brief Interview of Mental Status (BIMS) of 11 (moderately intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 was dependent on all care. During an interview on 01/07/25 at 4:27 PM, writer asked LPN B what the medication left at the bedside of R31 was used for, as there was no name on it, no date on it, nor an order for it in the electronic medical record (EMR). LPN B stated there had to be an order for it since they have been using it. LPN B stated she would direct this concern to the RN/Unit Manager M. During an interview on 01/07/25 at 4:35 PM, RN/Unit Manager M was observed looking in her computer for an order for Bio-[NAME] medication. RN/Unit Manager M stated there was not an order, it must have dropped off. RN/Unit Manager asked writer if she should put an order in for the Bio-[NAME] medication? Writer stated I cannot tell you what to do, but it would make sense to have an order for any medications that were given or being used. Record review of physician orders on 01/08/25 at 8:04 AM, revealed a new order put in on 01/07/25 at 6:00 PM for (Bio-[NAME] Dry Mouth Moisturizing Mouth/Throat Solution. Give 1 application by mouth every 4 hours for xerostomia may have at bedside) During an observation on 01/08/25 at 8:24 AM, the bottle of the medication Bio-[NAME] was still setting on R31's dresser without any name, date opened or instructions for this medication on it.

This citation pertains to intake MI00145732. Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from mental abuse/verbal abuse (Resident #5), sexual abuse (Resident #1 and Resident #2) and deprivation of goods and services (Resident #6 and Resident #7) by staff and protect Resident #6, Resident #3, and Resident #4. Findings Include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. R2's Behavior Monitoring and interventions task, in the electronic medical record, included history of yelling, cursing, making rude comments, throwing things, and verbal threats. Interventions included reapproach at later time or alternate staff, redirect with conversation, snacks, or activity and to guide R2 away from others. The same report revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. Interventions included to guide R6 away from the area while redirecting to other activity of interest such as watching game shows. The same Behavior Monitoring task indicated to redirect R6 away from R2, do not seat the two next to each other or allow them to be in areas by themselves. The same report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. The same Incident and Investigation Report dated 6/27/24 at 2:39 PM instructed to describe any action taken by the facility to protect the resident during the investigation and in response to the question was education provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. There were not any yes answers documented on the form. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6's doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Abuse Prohibition Policy revised 9/09/22 defined Involuntary Seclusion as separation of a resident from other residents or from his/her room or confinement to her/his room against the resident's will or the will of the resident's legal representative. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. The same report instructed to redirect R4 from the area or triggering event, make R4 aware his comments feel uncomfortable, guide R4 way from others if he starts making sexual or other inappropriate comments, provide one to one staff supervision as necessary. The same report ran on 7/19/24 did not indicate R4 had any behaviors, including sexually inappropriate or grabbing, noted during the last 30 days. Progress Note dated 4/21/24 at 10:00 PM revealed R4 had to be redirected with his sexually charged language, and had been approaching residents being sexually inappropriate. Progress Note dated 4/21/24 at 10:55 PM revealed R4, over the last month, had become increasingly sexually inappropriate to staff and female residents. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Action taken included staff to redirect R4 away from others, redirect him with activities, and conversation. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . Registered Nurse H was interviewed on 7/23/24 at 9:25 AM regarding R4's progress note dated 6/30/24 at 9:01 PM and stated fondling was a poor choice of words. R4 was holding another residents hand and rubbing her wrist and forearm. RN H stated R4 was not re-directable at times and there was two weeks where he was really ramped up. RN H stated the female resident R4 was touching on 6/30/24 was not R5, it was with another female resident. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't reported to State Agency and that she asked R5 questions and took care of it right away, the day the grievance was filed, on 7/02/24. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) On 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room.MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to the documentation of R3's sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of allegations of abuse involving R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility was looking into getting cameras, as cameras could be useful due to the layout of the building. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24, during the survey. A reasonable person (one expect a reasonable person in a similar situation to suffer as a result of the noncompliance), in R1's position would likely suffer recurrent debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of specific residents) Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation, that persisted regardless of whether the precipitating event(s) had ceased. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. R7 was observed lying in bed 7/24/24 at 1:25 PM and stated staff were still denying her food. R7 stated she had requested a second serving at lunch and she did not receive any more food. R7 began crying during the interview and stated when denied food it made her feel less than a human. R7 stated the facility staff thinks she should be on a diet. Certified Nurse Assistant (CNA) K was interviewed on 7/24/24 at 1:30 PM and stated she had requested R7 receive more food and a kitchen staff member stated R7 already received double portions with her lunch meal. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated she did not investigate allegations of abuse regarding R7. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. NHA A stated staff should not deny R7's requests for food. Dietary Manager (DM) N was interviewed on 7/24/24 at 1:45 PM and stated the kitchen had run out of bratwurst during lunch, and stated she did not know if R7 was offered a different item; but would go ask her if she would like something else to eat. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours).

This citation pertains to intake MI00145732. Based on interview and record review, the facility failed to ensure adequate staff were scheduled to supervise and report residents with sexual behaviors and protect vulnerable residents in a census of 61 residents, resulting in the likelihood of allegations of abuse not identified, reported or documented. Findings include: Facility assessment dated [DATE] indicated the facility was approximately 3200 square feet and the average daily census over the past 12 months was 62 residents. 26 residents had a diagnosis of dementia. 54 out of 62 residents were dependent or required staff assistance for dressing. 59 out of 62 residents were dependent or required staff assist for bathing. 49 out of 62 residents were dependent or required staff assist for transfers. 36 residents were dependent or required staff assist for eating. 52 out of 62 residents were dependent or required staff assist in toileting. Staff Schedule dated 6/27/24 indicated a census of 59 residents. 5 Certified Nurse Assistants (CNA's) were scheduled during the 6:00 AM to 6:00 PM shift. One CNA was scheduled to work from 6:00 AM to 10:00 AM and then go home. The same schedule indicated one restorative CNA was scheduled from 7:00 AM to 3:30 PM. There were multiple resident to resident sexual occurrences documented on 6/27/24, that indicated additional staff to supervise resident behavior may have prevented abuse. Staff Schedule dated 7/04/24 revealed a census of 59 residents. There were 5 Certified Nurse Assistants (CNA's) and 2 Nurses on the schedule to work day shift (6:00 AM to 6:00 PM). One CNA was assigned to be one to one with a resident that resided on 100 hall for the entire shift. There was one other CNA assigned to 100 hall. One CNA was noted as no call no show; and was scheduled to work from 8:00 AM through 6:00 PM on 200 hall. There were no CNA's assigned to 200 hall residents from 8:00 AM to 4:00 PM. 2 CNA's were on 300 hall. One CNA was scheduled on 400 hall from 6:00 AM to 3:30 PM. There were no CNA's scheduled on 400 hall from 3:30 PM to 6:00 PM. From 8:00 AM to 4:00 PM, there were 4 CNA's to care for 58 residents, 14 to 15 residents each. There was no restorative CNA scheduled on 7/04/24. During the survey from 7/19/24 through 7/23/24, Staff IP was interviewed and stated they recalled they had a call off on 7/04/24 and they had complained to management about the lack of enough staff. Staff D was interviewed during the survey from 7/19/24 through 7/23/24 and stated staffing on 7/04/24 was not adequate. During the survey from 7/19/24 through 7/23/24, Staff Q stated they was not enough staff on 7/04/24 and the Director of Nursing was notified. Staff Q stated they did not witness any abuse on 7/04/24, and stated they were too busy taking care of their residents to notice anything. During the survey from 7/19/24 through 7/23/24 staff E stated staffing was really difficult on 7/04/24. One resident followed the ladies around with his hand down his pants and was hard to re-direct. During the survey from 7/19/24 through 7/23/24, staff F stated on 7/04/24, there was not enough staff to meet residents needs and they did not get a break or take a lunch. During the survey from 7/19/24 through 7/23/24, staff G stated staffing on 7/04/24 was rough. One CNA was pulled to work on another hall; but the nurse kept pulling them back to work on the hall they were pulled from. There was a fall, on 7/04/24; staff G stated they had just finished assisting another resident, when he heard another resident scream. The resident bumped his head when he fell , and was attempting to use the bathroom. Staff G stated they ended their employment at the facility due to low staffing and poor resident care. Scheduler/CNA R was interviewed on 7/23/24 at 3:36 PM and stated they have budgeted hours and divide by census to determine staffing. Scheduler/CNA stated when the census drops they send staff home. Scheduler/CNA R stated 6 CNA's run a lot smoother during the day. Scheduler/CNA R stated on 7/04/24, had a craziness going on, and did not like to see that. On 6/27/24 they had 5 CNA's that day due to the census. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation.

This citation pertains to intake MI00145732. Based on interview and record review, the facility administration failed to operationalize its policy and procedures to manintain effective use its resources and ensure identification, investigation, and protection of residents from mental abuse, verbal abuse, sexual abuse and deprivation of goods and services in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), and failed to ensure sufficient nursing staff to meet residents needs and the likelihood for continued abuse and unmet resident needs in a current facility census of 61 residents. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident. R2's Behavior Monitoring and interventions task, in the electronic medical record, revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. There were no resident at risk notes or other notes indicating the circumstances of R2's behavior on 6/22/24 at 4:44 PM was investigated or that no other residents were affected. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. The same report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. There were no investigations of documented behaviors on 7/04/24 or 7/21/24. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. The same Incident and Investigation Report dated 6/27/24 at 2:39 PM instructed to describe any action taken by the facility to protect the resident during the investigation and in response to the question was education provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. There were not any yes answers documented from the facility. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room, not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. Progress Note dated 4/21/24 at 10:00 PM revealed R4 had to be redirected with his sexually charged language, and had been approaching residents being sexually inappropriate. Progress Note dated 4/21/24 at 10:55 PM revealed R4, over the last month, had become increasingly sexually inappropriate to staff and female residents. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. There were no incident reports generated. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse [sic] taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't reported to State Agency; and stated that she took care of the grievance right away, the day the grievance was filed. It was not clear how many times R5 felt she was harassed or received unwanted touching by R4 or if there was a pattern regarding the time of day. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put it under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of an abuse allegation that involved R1 and other residents. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility did not have cameras, but cameras could be useful because of the layout of the building, and had recently received a quote. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message on 7/04/24. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24, during the survey. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. DON B was interviewed on 7/24/24 at 11:21 AM and stated she did not investigate allegations of abuse regarding R7. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours). Facility assessment dated [DATE] indicated the facility was approximately 3200 square feet and the average daily census over the past 12 months was 62 residents. 26 residents had a diagnosis of dementia. 54 out of 62 residents were dependent or required staff assistance for dressing. 59 out of 62 residents were dependent or required staff assist for bathing. 49 out of 62 residents were dependent or required staff assist for transfers. 36 residents were dependent or required staff assist for eating. 52 out of 62 residents were dependent or required staff assist in toileting. Staff Schedule dated 6/27/24 indicated a census of 59 residents. 5 Certified Nurse Assistants (CNA's) were scheduled during the 6:00 AM to 6:00 PM shift. One CNA was scheduled to work from 6:00 AM to 10:00 AM and then go home. The same schedule indicated one restorative CNA was scheduled from 7:00 AM to 3:30 PM. There were multiple resident to resident sexual occurrences documented on 6/27/24, that indicated additional staff to supervise resident behavior may have prevented abuse. Staff Schedule dated 7/04/24 revealed a census of 59 residents. There were 5 Certified Nurse Assistants (CNA's) and 2 Nurses on the schedule to work day shift (6:00 AM to 6:00 PM). One CNA was assigned to be one to one with a resident that resided on 100 hall for the entire shift. There was one other CNA assigned to 100 hall. One CNA was noted as no call no show; and was scheduled to work from 8:00 AM through 6:00 PM on 200 hall. There were no CNA's assigned to 200 hall residents from 8:00 AM to 4:00 PM. 2 CNA's were on 300 hall. One CNA was scheduled on 400 hall from 6:00 AM to 3:30 PM. There were no CNA's scheduled on 400 hall from 3:30 PM to 6:00 PM. From 8:00 AM to 4:00 PM, there were 4 CNA's to care for 58 residents, 14 to 15 residents each. There was no restorative CNA scheduled on 7/04/24. During the survey from 7/19/24 through 7/23/24, Staff IP was interviewed and stated they recalled they had a call off on 7/04/24 and they had complained to management about the lack of enough staff. Staff D was interviewed during the survey from 7/19/24 through 7/23/24 and stated staffing on 7/04/24 was not adequate. During the survey from 7/19/24 through 7/23/24, Staff Q stated they was not enough staff on 7/04/24 and the Director of Nursing was notified. Staff Q stated they did not witness any abuse on 7/04/24, and stated they were too busy taking care of their residents to notice anything. During the survey from 7/19/24 through 7/23/24 staff E stated staffing was really difficult on 7/04/24. One resident followed the ladies around with his hand down his pants and was hard to re-direct. During the survey from 7/19/24 through 7/23/24, staff F stated on 7/04/24, there was not enough staff to meet residents needs and they did not get a break or take a lunch. During the survey from 7/19/24 through 7/23/24, staff G stated staffing on 7/04/24 was rough. One CNA was pulled to work on another hall; but the nurse kept pulling them back to work on the hall they were pulled from. There was a fall, on 7/04/24; staff G stated they had just finished assisting another resident, when he heard another resident scream. The resident bumped his head when he fell , and was attempting to use the bathroom. Staff G stated they ended their employment at the facility due to low staffing and poor resident care. Scheduler/CNA R was interviewed on 7/23/24 at 3:36 PM and stated they have budgeted hours and divide by census to determine staffing. Scheduler/CNA stated when the census drops they send staff home. Scheduler/CNA R stated 6 CNA's run a lot smoother during the day. Scheduler/CNA R stated on 7/04/24, had a craziness going on, and did not like to see that. On 6/27/24 they had 5 CNA's that day due to the census. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation.

This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to implement their abuse policy and procedures in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in continued allegations of abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. The same note indicated the progress note would be included in the shift report, 24 hour report and a communications report. R2's Behavior Monitoring and interventions task, in the electronic medical record, included history of yelling, cursing, making rude comments, throwing things, and verbal threats. Interventions included reapproach at later time or alternate staff, redirect with conversation, snacks, or activity and to guide R2 away from others. The same report revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke.R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. Interventions included to guide R6 away from the area while redirecting to other activity of interest such as watching game shows. The same task indicated to redirect R6 away from R2, do not seat the two next to each other or allow them to be in areas by themselves. The same task report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. Under conclusion it was documented guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same Incident and Investigation Report dated 6/27/24 at 2:39 PM instructed to describe any action taken by the facility to protect the resident during the investigation and in response to the question was education provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with a sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. The same report instructed to redirect R4 from the area or triggering event, make R4 aware his comments feel uncomfortable, guide R4 way from others if he starts making sexual or other inappropriate comments, provide one to one staff supervision as necessary. The same report ran on 7/19/24 did not indicate R4 had any behaviors, including sexually inappropriate or grabbing, noted during the last 30 days. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Action taken included staff to redirect R4 away from others, redirect him with activities, and conversation. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't documented on an incident report or reported to State Agency. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) On 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room. MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of allegations of abuse that involved R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility did not have cameras, but cameras could be useful because of the layout of the building. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. LPN J was not removed from the schedule pending investigation. There was no incident report and no other residents or other staff, with the exception of LPN J that were interviewed. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24 during the survey. Abuse Prohibition Policy revised 9/09/22, revealed each resident would be free from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms. The same policy defined sexual abuse as non-consensual sexual contact of any type with a resident and included but not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or batter, such as rape, sodomy, fondling and/or intercourse or coerced nudity; forced observation of masturbation and/or pornography. If at anytime the facility had reason to suspect the resident did not have the capacity to consent to sexual activity the facility should evaluate whether the resident had the capacity to consent. Verbal abuse was use of verbal or nonverbal conduct, gestured communication or sounds to residents within hearing distance, regardless of age, ability to comprehend, or disability; which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. The same policy defined Involuntary Seclusion as separation of a resident from other residents or from his/her room or confinement to her/his room against the resident's will or the will of the resident's legal representative. The Director of Nursing or designee would complete an assessment of the resident(s) and document findings in the medical record. The same policy indicated if the accused was an employee of the facility, he/she would be suspended until the investigation was completed. The facility Quality Assurance Performance Improvement Committee would investigate occurrences, patterns, and trends that may indicate presence of abuse, neglect or misappropriation of resident property to determine the direction of the investigation/intervention, through analysis of systems, audits, and reports. Identification through the safety program begins with the Incident Report. The Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all other not later than 24 hours). Substantiated complaints against nurses would be reported to the State Board of Nursing.

This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to immediately report allegations of abuse in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and Resident #7), resulting in likelihood of continued abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. The same note indicated the progress note would be included in the shift report, 24 hour report and a communications report. R2's Behavior Monitoring and interventions task revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with a sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . Registered Nurse H was interviewed on 7/23/24 at 9:25 AM regarding R4's progress note dated 6/30/24 at 9:01 PM and stated fondling was a poor choice of words. R4 was holding another resident's hand and rubbing her wrist and forearm. RN H stated R4 was not re-directable at times and there was two weeks where he was really ramped up. RN H stated the female resident R4 was touching on 6/30/24 was not R5, it was with another female resident. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't documented on an incident report or reported to State Agency. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room. MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of any abuse allegations that involved R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. LPN J was not removed from the schedule pending investigation. There was no incident report and no other residents or other staff, with the exception of LPN J that were interviewed. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24 during the survey. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours) and substantiated complaints against nurses would be reported to the State Board of Nursing.

This citation pertains to intake MI00145732. Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse, in 7 of 10 residents reviewed for abuse (Resident #1, #2, #3, #4, #5, #6, and #7), resulting in the likelihood of continued abuse. Findings include: Resident #6 (R6) and Resident #2 (R2) Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6 were found in the dining room participating in sexual behaviors; both residents were touching each other in their perineal areas. R6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a cognitive screener) score of 05 (00-07 Severe Cognitive Impairment). R2's MDS dated [DATE] revealed he had a BIMS score of 11 (08-12 Moderate Impairment). Progress Note dated 6/27/24 at 5:02 PM indicated R2 had been sexually inappropriate 3 times during the shift with another resident. The last occurrence was at 4:15 PM, R2 was seen behind the warming station in the dining room, with another male resident, being inappropriate below the waist, same as 2 times prior. R2 was told behavior was not to happen and R2 began yelling and wouldn't leave the dining room. R2's Behavior Monitoring and interventions task, in the electronic medical record, included history of yelling, cursing, making rude comments, throwing things, and verbal threats. The same report revealed on 6/22/24 at 4:44 PM R2 displayed public sexual acts. Activities note dated 6/22/24 at 4:24 PM revealed R2 was asked 3 times to get away from another resident and asked to leave Bingo for being rude to other residents. R2's care plan dated 7/02/24 indicated he had episodes of hypersexuality (sexual addiction, excessive sexual thoughts, desires, urges or behaviors) and R2's guardian did not consent to sexual contact with R6. R6's care plan dated 3/21/23 revealed he had neurodevelopmental disorder and history of temporary stroke. R6's Behavior Monitoring task indicated he had behaviors of entering others personal space, sexually touching other consenting resident, reaching out toward others, masturbating with the door open and curtain not pulled. The same Behavior Monitoring task indicated to redirect R6 away from R2, do not seat the two next to each other or allow them to be in areas by themselves. The same report revealed R6 was sexually inappropriate on 6/27/24 at 8:55 PM, 7/04/24 at 12:10 PM and 7/21/24 at 5:36 AM. Progress Note dated 6/27/24 at 4:39 PM revealed R6 was sexually inappropriate 3 times during the shift with another resident. The last occurrence was noted at 4:15 PM. The same note indicated when R6 was told touching other residents below the waist in the dining room was not to continue, R6 yelled and refused to leave the dining room. R6 attempted to stop staff from backing him up in his wheelchair to take him to his room. R6 was informed by the nurse that he was to stay in his room for his meal because of his inability to follow directions and for the inappropriate sexual behavior that had taken place 2 times prior. R6 started to get loud and stated he was coming out. R6 was informed that he was to stay in his room to eat because he was unable to keep his hands to himself and follow instructions. There was only one incident report generated on 6/27/24 regarding R2 and R6. Incident and Investigation Report dated 6/27/24 at 2:39 PM indicated R2 and R6's chart documentation and progress notes were reviewed. The same report indicated additional interviews were not performed and was not necessary or feasible. The same report under conclusion indicated guardians of both residents did not consent for residents to participate in sexual behavior. The report instructed to provide a brief description of the plan to avoid this situation in the future; the response was education provided to residents and staff on redirection when sexual behaviors were exhibited. The same report instructed to describe any action taken by the facility to protect the resident during the investigation, and in response to the question, education was provided to Licensed Practical Nurse (LPN) J on abuse and safety policies. The same form questioned if the incident was reported to State Agency, and the facility staff checked no, it was not reported. The same investigation included an audit, a list of 21 residents, identified by room number only, dated 6/28/24. The list included 20 residents that were located on the 100 wing, and 1 resident on the 200 wing; there were no residents from the 300 or 400 units. Residents were asked two yes or no questions: had they ever been sexually abused (touched or verbal) and have they seen another resident be sexually abused. The same report was signed by Interim Director of Nursing (DON) B and Nursing Home Administrator (NHA) A. Psychiatric Note dated 7/09/24 and signed by physician's assistant on 7/19/24, revealed R2 was seen due to increased inappropriate sexual behavior. Since last visit changes to R2's medications included Paxil (antidepressant) was discontinued on 7/05/24, Lexapro (antidepressant) was started on 7/12/24 by the primary care physician; and Estradiol (estrogen, female sex hormone) was started by the primary care physician on 7/06/24. The same note indicated R2 was recently noted by staff with his hands down another residents' pants. It was recommended to monitor R2, as several medication changes had been implemented by his primary care physician. Certified Nurse Assistant (CNA) M was interviewed on 7/23/24 at 2:30 PM and stated on 6/27/24, she observed R2 and R6, sitting side by side next to each other at a table in the middle of the main dining room; and was not behind the warming station. CNA M stated R2 was slouched in his wheelchair and R6 had his hand on R2's pants, over his perineal area. CNA M stated R2 and R6 were separated around 7 times on 6/27/24. LPN J was interviewed on 7/23/24 at 12:29 PM and stated the incident on 6/27/24 with R2 and R6 occurred more than once. LPN J stated she wrote occurrences in residents progress notes and other nurses did not because it occurred frequently. LPN J stated she was directed to chart using the term sexual behavior versus sexually inappropriate. LPN J stated on 6/27/24 following the incident with R2, an activity aide took R6 to his room. LPN J stated she went to R6 doorway and told him he needed to keep his hands to himself and that he should eat his dinner in his room. R6 wanted to go back to the dining room, and LPN J stated she told R6 to go back to his room. LPN J stated R6 was drawn to R2, and it was absolutely ridiculous. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated had been interim DON since May of 2024. DON B did not know why incident with R2 and R6 were not reported to State Agency. DON B stated LPN J attempted to barricade R6 in his room on 6/27/24. DON B stated R6 was forced to eat dinner in his room on 6/27/24 and stay in his room for approximately 2 hours. DON B stated LPN J was terminated on 7/18/24, LPN J was not removed from the schedule pending investigation. DON B confirmed she did not interview other staff regarding the incidents that occurred on 6/27/24. DON B stated she did not know why incident with R6 and LPN J was not reported to State Agency. Resident #5 (R5) and Resident #4 (R4) R5 filed a grievance on 7/02/24 alleging R4 kept harassing her and kissing her hand. The same grievance indicated R5 did not like it, it was an ongoing problem and she wanted it to stop. R5's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment indicated she had not had any physical, verbal or other behaviors during the look-back period. R5's progress note dated 6/19/24 indicated she had increased anxiety. Progress note dated 7/02/24 at 1:32 PM indicated they had spoke with R5 regarding the grievance filed about an altercation with a male resident. The male resident was provided with a sitter to ensure resident was safe. R5 was agreeable to the plan. R4's MDS dated [DATE] revealed he had a BIMS score of 03 (00-07 Severe Cognitive Impairment). R4's Behavior Monitoring and interventions task report included history of making verbal threats of physical violence, sexual comments and sexual gestures. The same report instructed to redirect R4 from the area or triggering event, make R4 aware his comments feel uncomfortable, guide R4 way from others if he starts making sexual or other inappropriate comments, provide one to one staff supervision as necessary. Progress Note dated 4/21/24 at 10:00 PM revealed R4 had to be redirected with his sexually charged language, and had been approaching residents being sexually inappropriate. Progress Note dated 4/21/24 at 10:55 PM revealed R4, over the last month, had become increasingly sexually inappropriate to staff and female residents. Progress Note dated 6/19/24 at 12:10 PM indicated R4 was being followed by resident at risk and his physician had increased his estrogen medication. The same note revealed R4 had an increase in sexually inappropriate comments, entering others personal space and attention seeking. Action taken included staff to redirect R4 away from others, redirect him with activities, and conversation. Progress Note dated 6/30/24 at 5:21 AM revealed R4 had inappropriate behavior the first 5 hours of the shift. R4 had followed and made inappropriate comments to another female resident who told him no multiple times, when redirected resident would laugh and then hit on the nurse. R4 was continually redirected and removed twice from common areas for harassing female residents. Progress Note dated 6/30/24 at 9:01 PM revealed R4 .just came out of room in wheelchair and was witnessed fondeling [sic] the same female resident he has been harassing tonight and last night while this nurse taking care of him. Resident was rubbing up her arm and placing hand on her lower back, while holding her hand with his other hand. Resident reminded that hands are to be kept to himself and that it is not ok to touch other residents, especially females. Resident started laughing and said well, what can I do then, touch you? and winked and laughed and started propelling himself towards this nurse. Resident politely asked to return to his room or another area of facility away from this female resident if he could not follow rules and keep his hands to himself. Resident then returned to his room and is now resting in bed . Registered Nurse H was interviewed on 7/23/24 at 9:25 AM regarding R4's progress note dated 6/30/24 at 9:01 PM and stated fondling was a poor choice of words. R4 was holding another resident's hand and rubbing her wrist and forearm. RN H stated R4 was not re-directable at times and there was two weeks where he was really ramped up. RN H stated the female resident R4 was touching on 6/30/24 was not R5, it was with another female resident. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the incident between R4 and R5 wasn't reported to State Agency and that she asked R5 questions and took care of it right away, the day the grievance was filed. Resident #1 (R1), Resident #3 (R3), Resident #6 (R6) 7/19/24 at 10:04 AM R1 was observed sitting in her wheelchair in the hallway near the small dining room. MDS dated [DATE] revealed R1 was admitted to the facility on [DATE], had severely impaired cognition, and had diagnoses including depression and Dementia. Receptionist I was interviewed on 7/24/24 at 12:43 PM, and confirmed she was working on 7/04/24, and witnessed R3 standing in the hall by the front dining room, with his penis exposed. Receptionist I stated R1 was in her wheelchair next to him. R3 was reaching for R1's arm, like he wanted her to touch him. Receptionist I stated she separated R3 and R1 and asked activities staff to keep a close eye on R1. Receptionist I stated she reported the incident to NHA A via phone. Activities Aide (AA) O was interviewed on 7/23/24 at 3:40 PM and stated on 7/04/24, around 3:30 PM, she was in the dining room for Bingo with a group of residents, and saw R2 looking down R1 shirt and R6 hand was on top of R2's pants, over his perineal area. AA O stated she wrote a statement and put in under NHA A's door. AA O stated she had witnessed R6 chase after R2. AA O stated she had also witnessed R2 and R6 with their hands down each others pants, behind the steam table, but did not remember the date. Social Services (SS) C was interviewed on 7/19/24 at 2:00 PM and stated she was not aware of any additional details related to documentation of R3 checked for sexually inappropriateness, in behavior tracking task on 7/04/24 at 12:11 PM, 7/06/24 at 10:22 AM and 3:09 PM; and on 7/07/24 at 12:27 PM. SS C stated R3 had the potential to masturbate in the hallway. SS C stated when behaviors were documented in behavior tracking, she reviewed the care plan, discussed the behavior in the morning meetings and revised the care plan. SS C was unable to provide details of R2's behaviors of public sexual acts documented on 6/22/24 at 4:44 PM or on 7/04/24 at 11:32 AM; in which included cursing. SS C stated R2 and R3 had medication adjustments due to increase masturbation in inappropriate places. SS C stated she had no knowledge of any abuse allegations regarding R1. NHA A was interviewed on 7/19/24 at 2:45 PM and stated the facility had an increase in resident sexual behaviors recently. NHA A stated she did not have any knowledge of any incidents that occurred with R1, R3 or R6 on 7/04/24. NHA A stated the facility did not have cameras and recently received a quote, but cameras could be useful due to the layout of the building. During an interview on 7/23/24 at 12:29 PM, LPN J stated on 7/04/24 at 11:09 AM, a CNA reported to her R2 was following R1 around and touched R1 breasts with his hands. LPN J stated she did not see R2 touch R1's breasts, but did observe R2 following R1 around that morning. LPN J stated R2 stalked people and acted like he was crazy, but R2 knew what he was doing. LPN J stated she reported the incident to DON B via text message. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated behaviors were reviewed in the morning meetings by reviewing the dashboard and notes. DON B stated she was not aware behaviors were documented in the tasks section of the medical record and had never run that report. DON B stated there was no morning meeting on 7/05/24, because most of the management team was off on vacation. DON B stated the first time she heard about the incidents that occurred on 7/04/24 with R1, R3, and R6 was on 7/23/24, during the survey. A reasonable person (one expect a reasonable person in a similar situation to suffer as a result of the noncompliance), in R1's position would likely suffer recurrent debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of specific residents) Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation, that persisted regardless of whether the precipitating event(s) had ceased. Resident #7 (R7) R7's significant change MDS assessment dated [DATE] revealed R7 had a BIMS score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R7 had the diagnoses of endometrial cancer, schizoaffective-bipolar type disorder, and obesity. An electronic mail (email) from hospice staff was sent to facility staff on 7/15/24 at 12:17 PM and indicated a concern regarding LPN J. The hospice staff stated they had spoken to LPN J many times; LPN J refused to give R7 additional food as requested or has removed food from R7's room. The email indicated LPN J had stated that she forced the nurse assistants to clean R7 up after R7 had refused. Hospice staff stated in the same email they had observed LPN J being very gruff and even rude toward residents, including residents that were not under hospice care. The same email indicated if R7 wished to eat chocolate pudding for every meal, then so be it. Interim DON B was interviewed on 7/19/24 at 1:30 PM and stated it was reported LPN J was rude and gruff to R7. DON B stated LPN J told R7 she did not need any more pudding because she weighed 500 pounds. DON B stated the incident with LPN J and R7 was first verbally reported on 7/12/24, and LPN J was terminated on 7/18/24. R7 was observed lying in bed 7/24/24 at 1:25 PM and stated staff were still denying her food. R7 stated she had requested a second serving at lunch and she did not receive any more food. R7 began crying during the interview and stated when denied food it made her feel less than a human. R7 stated the facility staff thinks she should be on a diet. Certified Nurse Assistant (CNA) K was interviewed on 7/24/24 at 1:30 PM and stated she had requested R7 receive more food and a kitchen staff member stated R7 already received double portions with her lunch meal. Interim Director of Nursing (DON) B was interviewed on 7/24/24 at 11:21 AM and stated she did not investigate allegations of abuse regarding R7. NHA A was interviewed on 7/24/24 at 12:09 PM and stated she did not investigate the allegation of abuse reported by hospice staff because she did not receive the email. NHA A stated she has had 6 DON's since December 2023, and the DON B did not know everything she was supposed to be doing. NHA A stated staff should not deny R7's requests for food. Dietary Manager (DM) N was interviewed on 7/24/24 at 1:45 PM and stated the kitchen had run out of bratwurst's during lunch, and stated she did not know if R7 was offered a different item; but would go ask her if she would like something else to eat. Abuse Prohibition Policy revised 9/09/22, revealed the Administrator or designee would notify any State or Federal agencies of allegations per state guideline (2 hours if abuse allegation or serious injury; all others not later than 24 hours).

Based on observation, interview and record review, the facility failed to implement interventions to promote pressure ulcer healing and prevent worsening of pressure ulcers and prevent and identify a pressure ulcer for one (Resident #14) of one reviewed for pressure ulcers, resulting in stage three facility-acquired pressure ulcer, delay in pressure ulcer identification and the increased likelihood for delayed wound healing and/or worsening of wounds. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R14 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R14 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, toileting, hygiene, bathing and one person physical assist with dressing. Further review of the MDS reflected R14 did not have any behaviors including refusal of care. During an observation and interview on on 9/14/22 at 10:10 AM, R14 was observed sitting in a wheelchair with both legs positioned towards the right side of chair with right lateral knee and upper leg resting directly on unpadded frame of wheelchair. R14 appeared well groomed and able to answer questions appropriately. R14 reported worsening of right upper leg facility acquired pressure ulcer and reported concern that physicians will want to amputate leg if would does not improve. R14 reported facility had not provided functional offloading options with current wheelchair or discussed options for more appropriate sized wheelchair for improved positioning. R14 reported seen by wound nurse weekly on Tuesdays and reported constant pain controlled by routine pain medications. During an observation and interview on 9/14/22 at 2:29 PM, Licensed Practical Nurse (LPN) P reported plans to perform R14 wound treatments after R14 returned from shower room and observed several items obtained for treatments form treatment cart. R14 entered room at 2:32 PM with assist from Certified Nurse Assistant (CNA) U. At 2:42 PM, LPN P and this surveyor donned full Personal Protective Equipment including gown, mask, eye protection, and gloves related to R14 enhance precautions related to wounds. -R14 had a wound located on the right medial thigh, just above knee, that appeared to be stage 3 pressure wound with about 10% to 20% slough(non viable tissue) that was about the size of a fifty cent coin. LPN P performed wound care to R14 right medial thigh including, Dakins wound wash, pad dry, Asasep gel, non stick gauze and cover with border gauze. -R14 had open small deep wound to Right hip area with treatment that included Dakins quarter strength(QS), pat dry, Z-guard to peri wound, -R14 had wound located on right lateral thigh, just above knee, that appeared to be about 5cm by 4cm in size with slough and escar(non viable tissue) covering 80% of wound bed. LPN P applied Dakins solution, pat dry, santyl(debridement gel), covered with non stick gauze and bordered gauze. -R14 had open wound noted to coccyx about size of nickel that was cleaned with Dakins solution and left uncovered. -R14 had open wound to right upper ischium that appeared about 8cm by 2cm in size with slough present in about 50% of wound bed. LPN P applied Dakins solution, pat dry, santyl gel, cover with non stick gauze and border gauze. -R14 had triangle dime size open area below anus. LPN P applied dakins solution and pat dry and left uncovered. R14 reported increased pain related to muscle spasms and refused wound treatment to left ischium. -R14 had open wound to right lateral lower leg, just below knee, that was about 3 to 4 inches in length and 1/2 inch wide that appeared to have slough and escar present over 50% of area that was red overall. LPN P did not mention that area or perform treatment to area. LPN P reported did not routinely perform R14 wound care. Total of eight observed open wounds Review of the facility, Skin & Wound Evaluations, dated 9/13/22, reflected R14 had five completed assessments for the following wounds: 1) Stage 4, facility acquired(4/24/22) pressure ulcer to Left Ischial Tuberosity that measured 1.9cm by 1.4cm with no depth and 80% slough. 2) Stage 3, pressure ulcer located on coccyx that measured 0.8cm by 1cm with no depth and 30% slough. 3) Stage 4, facility acquired(8/30/22) pressure ulcer to Right Ischial Tuberosity that measured 8.5cm by 2.4cm with no depth and 60% slough. 4) Stage 3, faciltiy acquired(4/26/22) medical device related pressure ulcer to Right Lateral thigh that measured 5cm by 4.1cm with no depth and 50% slough and 30% escar. 5) Stage 3, facility acquired(8/8/22) pressure ulcer to Right medial thigh that measured 1.6cm by 1.2cm with no depth and 10% slough to wound bed. No mention of open wound to right lateral knee. Review of the physician orders, dated 8/10/22, reflected R14 had treatment orders that included: -Coccyx: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply [MEDICATION(S)] (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 3 pressure ulcer-start date-8/10/22. -Left ischium: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply [MEDICATION(S)] (cut to size), cover with bordered gauze dressing. Change daily. every day shift for Stage 4 pressure ulcer-Start Date-9/14/2022. -Right ischium: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply [MEDICATION(S)] (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 4 pressure ulcer -Start Date-8/31/2022. -Right lateral thigh: cleanse with 1/4 strength Dakins solution, pat dry, apply santyl to wound bed, apply [MEDICATION(S)] (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 3 pressure ulcer-Start Date-7/27/2022. -Right medial thigh: cleanse with 1/4 strength Dakins solution, pat dry, apply [MEDICATION(S)] gel to wound bed, apply [MEDICATION(S)] (cut to size), cover with border gauze dressing. Change daily. every day shift for Stage 3 pressure ulcer -Start Date-8/31/2022. -Right trochanter: Cleanse with 1/4 strength Dakins solution, pat dry, apply zguard to wound bed and leave open to air daily. every day shift for Stage 4 pressure ulcer -Start Date-9/07/2022. -Sacrum: apply chamosyn and leave open to air daily. every day shift for Protection -Start Date-4/06/2022. -Santyl Ointment 250 UNIT/GM ([MEDICATION(S)]) Apply to affected areas topically every day shift for wound care right lateral thigh, coccyx, right ischium, and left ischium wounds -Start Date-9/14/2022. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's Skin Care Plans, revised 8/31/22 , reflected, [named R14] is at risk for skin breakdown/pressure ulcers or further breakdown r/t stage 4 pressure ulcer to right ischium, stage 3 pressure ulcer to right medial thigh, stage 4 pressure ulcer to left ischium, stage 3 pressure ulcer to right lateral thigh, stage 4 pressure ulcer to right trochanter, stage 3 pressure ulcer to coccyx, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] & depression. He has impaired mobility AEB: requires a wheelchair for mobility r/t his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He has a [CONDITION(S)] & a s/p catheter. Urine voids from penis and fistula site from bladder to outside of ischial/scrotal pressure site at times. He often chooses not to lay down/chooses to stay up in his WC for long periods of time. He chooses not to get wound dressings changed at times [named R14] to have wedged cushion on right side of WC vertically to provide support and decrease pressure of RLE when in WC Date Initiated: 05/18/2022 .Knee adductor attached to wheelchair, check for proper placement, pad right wheel chair arm to assist in pressure reduction r/t resident non compliance/moving of knee adducter on wheelchair Date Initiated: Revision on: 06/09/2022 .Knee pressure pillow on as tolerated Date Initiated: 05/18/2022 .Observe skin with showers/care. Notify nurse of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Revision on: 5/18/2022 .Turn/reposition [NAME] at least every 2 hours, more often as needed or requested. Date Initiated: 05/18/2022 . Review of R14's Provider Progress Notes, dated 9/13/22, reflected, Visit Type: Wound Care .Wound care following up on multiple wounds .General: Pt is a 41 yo male w/ past medicalhx of Obstructive sleep apnea, history of spinal cord injury with resulting in [CONDITION(S)], [CONDITION(S)] status post [MEDICAL RECORD OR PHYSICIAN ORDER] .He is being seen today by the wound care team .Right lateral thigh stage III wound (previously unstageable) wound had a small amount of serosanguinous drainage. There is 50% slough and 30% necrosis after debridement, no maceration, and no depth due to slough. The remaining wound is red and granular. Right medial thigh stage III wound (previously unstageable wound) a scant amount of sanguinous drainage. The site has 10% slough, no necrosis, no maceration, and a depth of 0.1 cm. The remaining wound is pink and granular. Right trochanter stage IV (previously an unstageable wound) has a scant amount of serosanguinous drainage. The site is pink and granular has no slough, no necrosis, moderate maceration, a depth of 0.8 cm, and no undermining. There are 2 skin bridges within wound bed. Right ischium stage IV wound has a small amount of serosanguinous dressage. The sites have 60% slough, no necrosis, no maceration, and no depth. The remaining wound is red and granular. Coccyx stage III wound was present upon re-admission had a small amount of sanguinous drainage. There is 30% slough, no necrosis, no maceration, and no depth due to slough. The remaining wound is pink and granular. Left ischium stage IV wound has scant amount of sanguinous drainage. The site has 80% slough, no necrosis, no maceration, and no depth. Periwound presents as hypopigmented scar tissue .ASSESSMENTS AND PLANS L89.219 - Pressure ulcer of right hip, unspecified stage: Cleanse with Dakins, Z-guard daily and open to air. L89.893 - Pressure ulcer of other site, stage 3: Right lateral thigh: Cleanse with Dakins, apply Santyl and [MEDICATION(S)] daily and cover with boarder gauze daily. Right medial thigh: Cleanse with Dakins, apply [MEDICATION(S)] and [MEDICATION(S)] daily and cover with boarder gauze daily. L89.324 - Pressure ulcer of left buttock, stage 4: Left ishium: Cleanse with Dakins, then apply Santyl and [MEDICATION(S)] daily and cover with boarder gauze. L89.153 -Pressure ulcer of sacral region, stage 3: Coccyx: Santyl and [MEDICATION(S)] daily and cover with boarder gauze. L89.314 - Pressure ulcer of right buttock, stage 4: Right ischium: Santyl and [MEDICATION(S)] daily and cover with boarder gauze. R54 - Age-related physical debility: Continue its supportive care. NOTES Wounds are unavoidable due to multiple comorbidities including [CONDITION(S)] and debility. I would expect to see further skin breakdown. Pt is on a pressure relieving bed. Continue frequent repositioning. Dietary is following; patient is getting assistance eating meals as needed. Continue preventative measures and pressure relief. Frequent repositioning, elevate bilateral lower extremities, float heels, apply soft heel lift boots. Encourage proper nutrition and hydration to support wound healing .Nonviable tissue of right lateral thigh was debrided aggressively with #5 curette down to the epithelium epithelial subcutaneous tissue. Patient did not require anesthesia. Healthy amount of bleeding was achieved with some good granulation tissue in wound bed after the debridement. No complaints of pain. Area was 14.8 cm^2. Resident tolerated well and wound care discussed with team afterdebridement. Review of R14 Nursing Progress Notes, dated 8/8/2022 at 11:20 a.m, reflected, Note Text: Skin assessment completed r/t posted alert of a new open area. New open wound found to right inner thigh approximately 1.8cm L x 2.1cm W x 0 D. Wound covered with 100% necrotic tissue, scant serosanguineous drainage present, no signs of infection, and denies pain at wound site. New wound site added to list for evaluation by wound NP. [named provider] notified of new wound site. New orders received for Dakins solution, santyl, and border gauze dressing daily. Sister notified of new wound site. Will continue to monitor. During an interview and observation on 9/15/22 at 5:10 PM, Assistant Director of Nursing(ADON) wound nurse(WN) W reported R14 had 6 pressure ulcer wounds. WN W reported just noticed that R14 only had 5 documented wounds on most recent wound rounds on 9/13/22(one day prior) and reported should be 6 total that were facility acquired with exception of one. WN W reported missed R14 Right trochanter assessment and verified prior wound assessments had been completed for same area weekly prior. WN W reported R14 wounds develop and heal and if during rounds between Nurse Practitioner and herself address at the time. WN W reported was not aware R14 had open wound below right knee that was 3-4 inches long with escar and slough observed by this surveyor on 9/14/22(one day after wound rounds on 9/13/22). WN W reported R14 right latateral thigh wound had intervention of pad on wheelchair that R14 refuses to use because of complaints of pressure on wound. WN W reported history of request for therapy evaluation for proper equipment size/positioning. WN W and this surveyor observed R14 sitting in wheelchair in hall with cushion device attachment noted on right side of frame in a non functioning position. WC W attempted to demonstrate how cushion should be positioned and was unable to properly position cushion.(unable to rotate to position of right knee/leg). WC W verified R14 leg was resting direction on wheelchair frame at area of right lateral thigh stage 3 facility acquired pressure ulcer and also right below knee area was also resting on wheelchair frame. R14 repeated concern fear right leg amputation related to worsening pressure ulcers. WN W reported R14 had been evaluated by therapy for proper equipment size and positioning. During an interview on 9/16/22 at 2:58 PM, Director of Nursing (DON) B and WN W reported R14 had several documented refusals and therapy notes to reflect equipment review and they would provided to this surveyor prior to survey exit. WN W verified had not provided requested documents of R14 refusals or therapy notes as requested 9/15/22 at 5:10 p.m. WN W reported did observe R14 wound to right lateral leg below the knee that day and reported had 100% necrotic(escar) over wound bed that appeared to be consistent with wheelchair frame related to positioning. Review with the facility provided documents, most recently dated 4/27/22, to support R14 refusal of care planned interventions and therapy evaluation, revealed facility Skin & Wound Evaluation with notes that included, Seen by NP in house. Verbal education completed with resident. Will meet with therapy r/t res. request removal of knee adductor & alternate options for positioning/pressure reduction. Continues to choose not to follow POC in relation to offloading pressure, turning/repositioning, supplements for wound healing. Frequently gets up during night and stays in wheelchair for hours at a time Knee adductor to wheelchair noted pushed out from w/c. Res. states he did it because it was messing with the brake for the wc . The facility provided documents reflected no evidence that R14 was evaluated by therapy, including for proper fit of equipment and positioning, or evidence of resident refusals of care after 4/27/22.

Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for two (Resident #16 and #29) of five reviewed for falls, resulting in falls with major injury (fractures). Findings include: Resident #29 (R29): Review of the medical record reflected R29 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included [CONDITION(S)], post-traumatic stress disorder, hallucinations, muscle weakness, unsteadiness on feet, unspecified lack of coordination and difficulty walking. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/28/22, reflected R29 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R29 required total assistance for eating via use of a feeding tube and required limited to extensive assistance for most activities of daily living. On 09/16/22 at 11:01 AM, R29 was observed in bed, with the head of the bed elevated. A standard mattress was observed on the bed. An Incident and Accident Report reflected R29 slid out of his wheelchair, without injury, on 4/27/22. Therapy was in R29's room, turned to shut the door, and R29 was self-transferring to bed. R29's upper body landed on the bed, and his knees touched the floor. The section for interventions implemented reflected there were no new interventions and that it was reviewed by the Physician. A Progress Note for 4/27/22 reflected R29 attempted to self-transfer when therapy was exiting the room and turning to shut the door. Therapy attempted to assist. R29's upper body landed on the bed, and his knees touched the floor. R29 was assisted back to his wheelchair. According to the note, R29 was educated to utilize his call light and wait for staff assistance with ambulation due to weakness and to maintain safety/avoid injury. R29's Care Plan reflected an intervention that was initiated on 4/21/22 and revised on 6/15/22 for, Put the [R29's] call light within reach and encourage him/her to use it for assistance as needed. R29's Care Plan was not updated with a new intervention after his fall on 4/27/22. An Incident and Accident Report reflected R29 was observed on the floor on 5/31/22. He had a scratch to the left forehead and redness to the left shoulder and left knee. The section for interventions implemented reflected first aid was administered. The Incident/Accident Form for the same date reflected corrective actions of Care Plan reviewed and first aid. A Resident at Risk Progress Note for 6/1/22 reflected that on 5/31/22, R29 was observed on the floor, by the bed and stated he was transferring to his chair. The note reflected a wing mattress was present on the bed. Upon observation on 09/16/22 at 11:01 AM, a wing mattress was not observed on R29's bed. Review of R29's Care Plan did not reflect an intervention for a wing mattress had been initiated. An Incident and Accident Report reflected R29 was observed on the floor on 7/10/22. R29 stated he was self-transferring and thought he broke his knuckle. He was observed to have an abrasion to the the top of his head and swelling to the first knuckle, of the first finger, on the left hand. The section for interventions implemented reflected an x-ray (was ordered), educate to use call light and toilet as needed. The Post-Fall Evaluation reflected R29 was self-transferring to his wheelchair for the bathroom and was last toileted at 12:30 PM. An Incident and Accident Investigation Form for an alleged incident date of 7/10/22 at 2:48 PM reflected the section for, Provide a brief description of the plan to avoid this situation in the future if applicable revealed R29 was educated to use his call light and to ask him more frequently if he needed to use the bathroom. A STAT x-ray of the left hand was ordered on 7/10/22 and reflected acute third and fourth metacarpal fractures. A Resident at Risk Progress Note for 7/13/22 reflected R29's Care Plan was reviewed and revised. R29's Care Plan reflected an intervention dated 7/12/22 to ask him frequently if he needed to use the restroom. A Progress Note for 7/29/22 at 4:53 AM reflected that around 2:00 AM, R29 self-transferred from bed to use a walker. He was observed standing in the hallway, stating he had to go to work. Staff assisted R29 back to his room and into bed. The note reflected R29 was educated on using the call light for assistance related to safety. A Progress Note for 7/30/22 at 12:32 AM reflected R29 self-transferred and was observed standing at the end of his bed. A Progress Note for 8/9/22 reflected R29 had a fall while self-transferring, with complaints of pain in the left knee. An Incident and Accident Report for 8/9/22 reflected R29 was observed on the floor, without injury. The section for interventions implemented reflected re-education on using the call light. The Post Fall Evaluation for the same date reflected R29 was self-transferring to the bathroom and was re-educated on the importance of using the call light for safety. An Incident and Accident Report for 8/12/22 reflected R29 was observed on the floor and had abrasions to three toes on the right foot. R29 tried to get up to answer his phone, lost his balance and fell . The section for interventions implemented reflected first aid administered as needed, R29 was reminded to use the call light, and his phone was to be kept in reach. R29's Care Plan reflected an intervention dated 4/21/22 and revised 6/15/22 to, Keep the [R29's] environment as safe as possible with: .call light within reach, commonly used items within reach . An intervention dated 8/17/22 reflected, Please assist resident with putting his phone within reach. During an interview on 09/16/22 at 11:13 AM, R29's falls were reviewed with Director of Nursing (DON) B. Regarding the fall on 4/27/22, DON B reported R29 was referred to Physical Therapy and Occupational Therapy, and he was educated to use his call light and not self-transfer. Regarding the fall on 5/31/22, DON B reported they provided first aid to the scratch on the left forehead and initiated a wing mattress. When queried on the rationale for implementation of a wing mattress, DON B stated she was not sure and would have to do more investigating and looking through notes. DON B reported the wing mattress was not on the Care Plan but should have been. Regarding the fall on 7/10/22, the intervention was to ask R29 if needed assistance to the bathroom more frequently and to continue reeducation on using the call light. DON B reported R29 knew to use his call light and was very capable. Regarding the fall on for 8/9/22, DON B reported that the intervention added to the Care Plan was reeducation to use the call light. Regarding the fall on 8/12/22, the intervention was to keep phone his phone in reach so he did not have to get up to get it. When asked if that should that have already been in place, DON B stated, no, and R29 could keep his phone wherever he wanted. Resident #16(R16) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R16 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), [CONDITION(S)] with dementia, and anxiety. The MDS reflected R16 had a BIM (assessment tool) which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, walking in room and corridor, locomotion on unit and off unit, dressing, hygiene, bathing and two person physical assist with transfers and toileting. The MDS reflected R16 had no hallucinations or delusions and had not rejected care. The MDS also reflected R16 was not on a toileting program and had occasional urinary incontinence. During an observation on 9/14/22 at 9:11 AM R16 was noted laying in bed with eyes closed. R16 had significant bruising noted to left arm and call light was not in reach and was clipped to the top left corner side of the bed. Review of the Nursing Progress Notes, dated 8/31/2022 at 11:17 a.m., for R16, reflected, Resident was readmitted on [DATE] after having a fall on 8/25/22 that resulted in a fracture of the left hip and dislocation of the left shoulder. Res had a successful ORIF and a close reduction on the left shoulder. Resident will be readmitting to hospice. She continues to attempt to self transfer and can be combative at times . Review of the Nursing Progress Notes, dated 8/30/2022 at 4:21 p.m., for R16 reflected, Resident arrived around 1615 from [named] Main Hospital via ambulance with two EMT's. Resident returned to facility post ORIF of left IT fracture and S/P reduction of left shoulder .Patient is painful, verbalized and observed grimacing and clenching .Resident is incontinent of Bowel and Bladder. NWB LUE, WBAT LLE. Review of the facility provided final copy of the Matrix, dated 9/14/22, indicated R16 was marked with , F, which indicated fall. (R16 should have been marked with FMI [fall with major injury]). Review of the Physician History and Physical, dated 9/6/2022, for R16, reflected, She had a fall resulting in L hip fracture and L shoulder dislocation. She required ORIF of L hip and L shoulder was reduced and placed in sling. I am seeing her today for readmission. Today she complains of pain in L hip. She is upright in bed and staff helping her eat .NWB LUE .Vascular dementia without behavioral disturbance . Review of the Acute Provider Note, dated 8/25/2022, for R16, reflected, Patient is an [AGE] year old female with past medical history of [CONDITION(S)], Vitamin D deficiency, [CONDITION(S)], Uterovaginal prolapse, TIA/[CONDITION(S)], Alzheimer?s dementia enrolled in hospice with who is a long [named hospice] term resident in our facility and I am seeing her today for fall. Patient was noted with a fall last night were she was up against the wall and slid down with pain noted to her left elbow and xray was ordered but had not been completed as of 1400. Provider arrived to facility around 2pm and patient was noted on the floor in the dining room and per hospice aide was laying on her left side. Patient was noted with complaints of pain to her left hip/buttock pain and at first would not straighten out her leg, she did slowly attempt to straighten out left leg but noted to be shorten than right and externally rotated with visible pain on patient?s face and verbal complaints of pain. Patient states pain is in her hip and buttocks and guardian did give permission to send to ED for more prompt Evaluation and treatment. Provider stayed with patient until EMS arrived and patient went to [NAME] .Musculoskeletal: Digits/nails: No clubbing, cyanosis, inflammation or ischemia. Left leg shorter than right and pain with palpation to left hip/coccyx/ischium, noted to be externally rotated, some pain with palpation to left elbow .Unspecified fall, initial encounter: Noted on floor in dining room with visible pain and suspected injury to left lower extremity/hip and sent to [NAME] ED with guardian and hospice aware Nurse to have ED perform images of left elbow due to prior fall . Review of the Nurse Progress Note, dated 8/25/2022 at 2:30 p.m., for R16, reflected, Transferred to [named] Main ER. Resident found on the floor of the dinning room laying on her left side in the recovery position .Resident grimacing with pain related to the fall . Review of the Nursing Progress Note, dated 8/24/22 at 8:51 p.m., for R16, reflected, resident had an observed fall in the hallway. No injuries noted, but resident c/o of left elbow painful. On -call [three named providers] notified of fall. X-ray ordered for left elbow. Staff and this writer made multiple attempts to have resident sit in wheelchair as her gait was unsteady. Resident response was beligerent and aggressive behavior. Resident was resistant to care. Review of the facility, Resident At Risk Progress Note, dated 8/24/2022 at 11:28 a.m., for R16, reflected, Reviewed Clinical Indicator: Res had an additional fall on 8/21/22 She was sitting on her bed linen on the floor next to her bed, she appeared to have slid off the edge of the bed. Resident was seen by [mental health provider group] and there was a recommendation to start [MEDICATION(S)] related to afternoon agitation. Action Taken: No injury noted. However did complain about left foot pain when CNA was assisting with her sock, no additional complaints of pain since that day. Resident needs assistance but has very poor safety awareness related to cognition and gets upset with redirection. Physician and guardian agreed to the medication change, order was placed. Will continue to monitor in RAR for fall and medication change . Review of the Fall Care Plans, initiated 8/21/21, reflected R16 was at risk for falls related to history of falls, cognitive status and medication use. The Care Plans goals, revised on 12/4/21, reflected R16 will be free from injury related to falls through review date. The interventions included, Dycem to wheelchair .created 8/18/22 .Encourage Resident to lay down between lunch and dinner .created 8/18/22 .Encourage the [named R16] to use toilet when completing room rounds as resident allows .created 3/23/22 .Encourage the [named R16] to wear appropriate footwear as needed. 10/19/21 education given to not sit on edge of chair and to reposition as resident allows .created 8/21/21 .make frequent checks on resident when she is up in w/c to ensure she is sitting properly. Encourage and readjust as she tolerates/allows .created 4/7/22 .Put the [named R16] call light within reach and encourage her to use it for assistance as needed .created 8/21/21 . Continued review of the Fall Care Plans reflected no evidence of review or changes after R16 falls on 8/21/22, 8/24/22 or 8/25/22(fall with fracture). During an interview on 9/15/22 at 5:00 p.m., Director of Nursing (DON) B reported she was responsible for resident Incident and accident(I/A) reports. This surveyor requested past three months of all I/A reports including complete investigations. DON B provided file folder for R16 fall on 8/25/22 and reported would work on the additional requested documents. Review of R16 Fall Incident and Accident Reported, dated 8/25/22 at 1:51 p.m., reflected under incident description, Hospice Shower assistant approached the nurses desk to notify nurse that resident was on the ground in the dining room. Resident was observed laying in the recovery position with her wheelchair more than 5 feet away. Resident grimacing in pain. Continued review of the fall report reflected R16's fall was unwitnessed and R16 had a history of frequent falls related to her dementia status. The report reflected R16 was sent to the hospital after 911 was called and wad determined to have left hip fracture as well as left shoulder injury. Continued review of the provided complete investigation reflected no evidence of through investigation including when R16 was last seen by staff, last toileted, staff interviews, interventions that were in place or not in place at time of fall. During an interview on 9/16/22 at 1:47 PM, Registered Nurse Unit Manager (RNUM) K reported nurses were expected to completes fall incident and accident report and management team meets every Wednesday to review falls at Resident at Risk Meetings. RNUM K reported nurses are expected to assess resident to determine cause of fall and immediately implement interventions. RNUM K reported team reviews all interventions at weekly Resident at Risk Meetings. RNUM K reported R16 has declined significantly after recent re-admission from the hospital after fall with fractures on 8/25/22 in facility. RNUM K reported prior to fall R16 was at increased risk for fall related to unsteady on feet and need for assistance with several attempts to self transfer. RNUM K reported since R16 return to the facility, post left hip fracture and shoulder dislocation, R16 has not even tried to get up on own and reported R16 has had increased pain with frequent changes in pain management . During an interview on 9/16/22 at 2:02 PM, Certified Nurse Aide (CNA) E reported not present for R16 fall on 8/25/22 but reported was not a witnessed fall. CNA E reported R16 often self transferred prior to fall and was usually wet or had to go to the bathroom at the time of falls. CNA E reported did not complete witness statement because he did not witness fall. During an interview on 9/16/22 at 2:07 PM, DON B reported had forgot to provided this surveyor with requested falls for R16 for past three months that had been requested 9/15/22. DON B reported R16 had started to decline with increased falls and often self transferred and ambulated unassisted looking for kids or looking for husband. DON B reported R16 had fall from bed on 8/21/22 with note to encourage R16 to use call light. This surveyor reported if that intervention was effective or appropriate. DON B reported reminding a resident to use a call light was a baseline care plan standard and was already in place and was not effective to because of R16 advanced dementia. DON B reported did not see evidence of new interventions added after 8/21/22 fall. DON B reported R16 had fall on 8/24/22 in hall outside room 407 after being observed self ambulating unassisted and slipped and fell resulting in left elbow pain. DON B reported fall occurred at 8:37 p.m. according to the Incident/Accident report. DON B reported an the provider was notified at 8:37 p.m. and an X-Ray was ordered at 10:56 p.m. according to the Electronic Medical Record and reported was not completed prior to R16 fall on 8/25/22 at 1:51 p.m. DON B reported interventions were in place at time of R16 fall on 8/24/22 with new interventions to continue to redirect R16. DON B reported that is all they could do with resident like R16 was continue to redirect because she had no purpose to actions and reported R16 had increased need for redirection as day went on and did not like people in her space. DON B reported only so many interventions they could do for R16 because R16 did not like to sit down. DON B reported no evidence to support all interventions had been in place at time of the falls and reported this surveyor had been provided complete investigations for falls. DON B reported recent change in Incident reports from paper to electronic with challenges including details of incidents that DON B was aware of and working on plan. DON B reported R16 fall on 8/25/22 occurred in the main Dining Room at 1:51 p.m. according to the report and reported was unsure if anyone was in the Dining Room at the time of the R16 fall, when resident was last observed prior to fall, that resulted in left hip fracture. DON B confirmed no evidence that care planned intervention were in place at time of R16 8/25/22 fall. Review of R16 provided Fall Incident and Accident Reports reflected R16 had an additional unwitnessed fall on 8/12/22 in hall from the wheelchair, unwitnessed fall 8/2/22 in hall from wheelchair with root cause mood and mental status with interventions to lay down between lunch and dinner(added to care plan 8/18/22), and unwitnessed fall 8/1/22 in hall out of wheelchair with intervention documented as dycem added to wheelchair(added to care plan until 8/18/22).

Based on observation, interview and record review, the facility failed to: (1) prevent a facility acquired stage 2 (partial-thickness skin loss with exposed dermis) left heel pressure injury from worsening to an unstageable (obscured full-thickness skin and tissue loss) pressure injury and prevent the development of an infection; (2) prevent a facility acquired stage 2 left lateral foot pressure injury from worsening to an unstageable pressure injury; and, (3) implement preventative measures to prevent the development of pressure injuries for one (R27) of four residents reviewed for pressure injury in the sample of 33. This caused actual harm to R27 who developed unavoidable pressure injuries resulting in continued deterioration, pain and infection requiring antibiotic therapy. Findings include: Review of R27's most recently available Braden Scale for Predicting Pressure Sore Risk dated 5/26/20 revealed a score of 15 which indicated that R27 had a low/mild risk of developing a pressure injury at that time. Further record review revealed that there was no Braden Scale completed after 5/26/20 for R27. Review of the facility's Skin Management policy and procedure with the last revision on 10/2019 revealed under Practice Guidelines, .2. The Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status by a licensed nurse to determine the risk of pressure injury development . Review of R27's care plan initiated on 7/20/20 with the last revision on 1/06/21 revealed under Focus, (R27) has Actual impairment to skin integrity r/t (related to) stage 2 pressure ulcer of left heel and left lateral foot, DTI (deep tissue injury - intact or non-intact skin with [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister) of left foot 3rd digit, left foot 4th digit, and right trochanter, abrasion to top of left foot, and MASD (moisture associated skin damage) - skin split between buttocks . R27's care plan incorrectly identified the pressure injuries on her left heel and lateral foot as stage 2 instead of unstageable pressure injury. Further review of R27's care plan revealed under Goal, Will have no complications r/t (related to) stage 2 pressure ulcer of the left heel through the review date . According to National Pressure Injury Advisory Panel's (NPIAP) Prevention and treatment of [REDACTED]. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . 1. Review of R27's Progress Notes revealed on 8/31/20 at 12:01pm under Total Body Skin Assessment as a late entry that R27 did not have new skin conditions. However, R27's Progress Notes on that same day at 1:31pm revealed under Resident At Risk, .She is noted with a stage 2 pressure ulcer to the left heel . No further description of the left heel pressure injury was documented. Review of R27's Skin & Wound Evaluation dated 9/2/20 revealed that R27 had an in-house acquired pressure injury to her left heel which was incorrectly coded as a Stage 2. Further review revealed under Wound Measurements, 1. Area 15.2 cm2 (square centimeters); 2. Length 4.3 cm (centimeters); 3. Width 4.6 cm; 4. Depth Not Applicable . The same Skin & Wound Evaluation indicated under Wound Bed, that 100% of the wound was filled with eschar. In an interview with the Assistant Director of Nursing (ADON), who was in-charge of monitoring the wounds of the residents in the facility, on 2/1/21 at 4:24pm, the ADON stated, (I) should have changed the coding and (the left heel pressure injury) should have been labeled as unstageable. When asked when R27's left heel pressure injury changed from stage 2 to unstageable pressure injury, the ADON stated, I took the first picture on 9/2/20. It was unstageable (100% of the wound was filled with eschar) at that point. R27's left heel pressure injury worsened from stage 2 to unstageable pressure injury in two days. According to the website, https://www.healthline.com/health/eschar#prevention medically reviewed by Owen Kramer, MD; written by Rachel Nall, MSN; and, updated on 12/12/19, stated under What are the effects of eschar? .Wounds that advance to the stages where eschar covers them can be very serious. For example, the broken skin on the wound allows bacteria to enter the body, which can lead to [MEDICAL CONDITION] (a skin infection), bacteremia (bacteria in the blood), and [MEDICAL CONDITION] (dangerous body-wide inflammation) than can be life threatening. Your bones and joints can also become infected as a result of the wound . The website further indicated under How is eschar prevented? .For those who use a wheelchair or who have been prescribed bed care, it's important to regularly reposition them to relieve stress and pressure to areas prone to skin breakdown. This may involve switching positions every 15 minutes to 1 hour . Further review of R27's Skin & Wound Evaluations for the months of October, November, December and January revealed that the pressure injury on R27's left heel was continuously coded as stage 2. Wound Measurements were as follows: 10/7/20: Area 13.7cm2; Length 4.2cm; Width 6.3cm; Depth Not Applicable 11/4/20: Area 19.9cm2; Length 4.9cm; Width 5.1cm; Depth Not Applicable 12/2/20: Area 22.9cm2; Length 5.6cm; Width 5.6cm; Depth Not Applicable 1/6/21: Area 23.9cm2; Length 5.7cm; Width 5.4cm; Depth Not Applicable 1/27/21: Area 26.9cm2; Length 5.4cm; Width 5.9cm; Depth Not Applicable In an interview with the ADON on 2/1/21 at 5:24pm when asked of what possibly caused the worsening of R27's pressure injury on the left heel, the ADON stated, She underwent COVID ([MEDICAL CONDITION] disease) infection, severe decline that's why we initiated hospice. She further stated, She was also in the COVID unit and I could not observe her always, did not physically lay eyes on her all the time. During the same interview, the ADON stated, On 1/16/21, the (assigned unit) nurse removed the bandage and skin came off with the bandage (which) detached part of the eschar (then) signs of infection started after that. Review of R27's Progress Notes revealed no documentation on 1/16/21, however, Nurses Notes dated 1/17/21 at 4:17am indicated, c/o (complained of) left heel pain. Administered Tylenol ([MEDICATION NAME]). Further review of R27's Progress Notes revealed under Resident At Risk dated 1/19/21 at 11:27am, .Resident continues to be followed for multiple pressure ulcers. All ulcer sites noted to be stable with no s/sx (signs and symptoms) of infection .Resident noted to request removal of heels up device as she doesn't like it. She has been noted to remove pressure relieving boots herself by kicking them off as she does not like them . There was no documentation that indicated that other options to offload pressure from her heels were offered or tried in place of the pressure relieving device which she did not like. R27's Progress Notes dated 1/23/21 indicated under Telemed Encounter: Notified by nursing staff that resident's left heel is worse. Increased [DIAGNOSES REDACTED] (superficial reddening of the skin as a result of injury or irritation causing dilatation of the blood capillaries) and pain .Left heel eschar noted with increased [DIAGNOSES REDACTED] noted underneath and spreading up foot. Assessment: [MEDICAL CONDITION], left heel; Plan: .Keflex (antibiotic) 500mg (milligram) QID (four times daily) (for) 7 days . Review of R27's most recent Skin & Wound Evaluation dated 1/27/21 revealed under Wound Bed that 10% of the wound was filled with slough and 90% of the wound was filled with eschar. Further review of the same evaluation revealed under Evidence of Infection that there were increased drainage, increased pain, redness/inflammation and bleeding. The evaluation also stated that there was light amount of purulent (consisting of, containing, or discharging pus) exudate with moderate odor and redness of the skin in the surrounding tissue. This same evaluation indicated under Notes on Pain: Resident with complaints of discomfort at wound site with touch. Displayed discomfort with limb/body positioning . It was also stated under Education: Continues on po (oral) ATB (sic - antibiotic) therapy for wound infection. Wound has less [DIAGNOSES REDACTED] (skin redness) to periwound with some improvement but continues with bloody purulent drainage . In an interview with the ADON on 2/2/21 at 10:20am when asked about the possible reasons that infection developed on R27's left heel pressure injury, the ADON stated, I think the development (of infection) could have started when the wound opened up. When asked if all open wound develop infection, she stated, Not all open wound develop infection. The ADON further stated, I think she (had) undergone decline, recovered from other infection and wound began to open. (It's) a combination of factors (like) daily dressing change, physical decline, (I) have to do more research on it. When the ADON was asked about what could have been done to prevent the infection on R27's left heel pressure injury, the ADON stated, Good hand hygiene, keeping areas clean and dry, putting appropriate interventions in place, changing treatment methods if not having results that you wanted to have. We did have changes to the treatment when the wound began to change. When asked if what she had mentioned were all done to prevent infection from developing on R27's left heel pressure injury, the ADON stated, I don't know how to answer that. When asked what could have been done to prevent R27's pressure injuries from developing or worsening, the ADON stated, Maybe some more stringent repositioning, additional interventions in place and frequent repositioning. The ADON further stated, Finding ways to offload (her heels), frequent discussion with her, speaking more frequently with her to keep interventions in place, more frequent speaking (with her, for her) to understand the importance (of those interventions), make sure interventions (are) in place. When asked about possible additional interventions, the ADON stated, (There are) tons of devices, I don't know them all. Therapy to evaluate if there are more devices we could use for positioning. (We could) follow up with (the) guardian and hospice regarding additional interventions they want to pursue or how they want to proceed with things. The ADON also added, Discuss wound clinic (consult) with guardian and hospice if that would affect their services. When asked if R27's pressure injuries were avoidable, the ADON stated, I don't know how to answer your question. (The) sliding to the footboard was avoidable. When asked how she thought R27 developed the left heel pressure injury, the ADON stated, My guess would be not using her boots all the time. The ADON also mentioned that R27 had a history of [REDACTED]. She further stated, Back then (R27 was) in a different condition I suppose. (Now) she physically removes the boots. When asked what interventions could be done to address this concern with a resident who refuses care typically, the ADON stated, Re-approach and rea-apply the interventions (and) at least there should be documentation that they did not wish to do that (interventions in place), re-educate, change (the device) to whatever they would be willing to use if we could find something appropriate. In an interview with the Nurse Practitioner (NP) on 2/2/21 at 1:28pm when asked what could have caused R27's left heel pressure injury infection, the NP stated, I don't think it's the lack of care, it's the resident status, overall decline in patient's status, hospice status. When asked if all hospice residents end up with infected unstageable pressure injury, the NP stated, No. The NP further stated, We do not expect the wound to heal, (but try) not (to) let it worsen. When asked why R27's left heel pressure injury worsen from stage 2 to unstageable pressure injury, the NP stated, Hard to tell. The body (is) not circulating vital cells, [MEDICAL CONDITION], not getting enough nerve functions, damaged from diabetes. When asked about the status of R27's blood sugar, the NP stated, Not overly concerning. She's hospice, we let them have comfort diet or liberal diet. The NP further stated, Blood sugar (is) not being monitored right now. The NP also stated, (There is) not a very good likelihood that we could stop it from getting worse. (R27) doesn't like anything on her feet and one wound that would get infected, it would be the heel because she doesn't like anything on her feet. When the surveyor shared with the NP what the ADON stated about the skin coming off and detaching part of the eschar when a nurse removed the bandage on R27's left heel pressure injury, the NP stated, It's not unreasonable that when one of the nurses was changing the dressing, she could have irritated part of the perimeter of the eschar and they created a portal of entry for the bacteria, at any given time, anybody has staph (staphylococcus - kind of bacteria) and strep (streptococcus - kind of bacteria) on their skin and knowing this patient, (she) may have kicked off her boot and rubbed it on the sheet of the bed if the dressing comes off. She has taken things off before. 2. Review of R27's Skin & Wound Evaluation dated 1/27/21 revealed that R27 had an in-house acquired pressure injury to her left lateral foot which was coded as a Stage 2 that was first assessed on 11/24/20. Further review revealed under Wound Measurements, 1. Area 5.4 cm2; 2. Length 2.1 cm; 3. Width 3.1 cm; 4. Depth Not Applicable . The same Skin & Wound Evaluation did not indicate any description under Wound Bed. Further review of R27's Skin & Wound Evaluations for the months of November, December and January revealed that the pressure injury on R27's left lateral foot was continuously coded as stage 2. In an interview with the ADON on 2/1/21 at 5:24pm, the ADON stated, (The left lateral foot pressure injury) should be coded as unstageable. It is 100% covered with eschar. It started as a stage 2. Review of R27's Progress Notes dated 11/24/20 at 4:58pm revealed, pressure spot on lt (left) foot and tip of toes. Further review of R27's Progress Notes dated 12/1/20 at 9:26am revealed, .On 11/24/20 when floor nurse went to complete resident's heel dressing, resident was noted to have slid down in bed. Pressure reducing boot was in place but top part of foot and toes were sticking out and pressed in to (sic) the footboard of the bed. Upon assessment resident noted to have a DTI (deep tissue injuries) to the left foot 3rd digit and 4th digit as well as a stage 2 pressure ulcer to the left lateral foot below the 5th digit . There was no further documentation in R27's Progress Notes to indicate when the left lateral foot pressure injury worsened from state 2 to unstageable. Further review of R27's Progress Notes from 11/24/20 until 1/26/21 revealed this repetitive documentation, .Resident noted to request removal of heels up device as she doesn't like it. She has been noted to remove pressure relieving boots herself by kicking them off as she does not like them . However, there was no documentation that indicated that other options were offered or tried in place of the pressure relieving device which she did not like. Review of the facility's Skin Management policy and procedure with the last revision on 10/2019 revealed under Practice Guidelines, .3. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan .9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record . In an interview with the ADON on 2/2/21 at 10:20am when asked what could have been done to prevent R27's pressure injuries from developing or worsening, the ADON stated, Maybe some more stringent repositioning, additional interventions in place and frequent repositioning. The ADON further stated, Finding ways to offload (her heels), frequent discussion with her, speaking more frequently with her to keep interventions in place, more frequent speaking (with her for her) to understand the importance (of those interventions), make sure interventions (are) in place. When asked about possible additional interventions, the ADON stated, (There are) tons of devices, I don't know them all. Therapy to evaluate if there are more devices we could use for positioning. (We could) follow up with (the) guardian and hospice regarding additional interventions they want to pursue or how they want to proceed with things. The ADON also added, Discuss wound clinic (consult) with guardian and hospice if that would affect their services. In an interview with the ADON on 2/2/21 at 10:20am when asked if the development of R27's pressure injuries were avoidable, the ADON stated, I don't know how to answer your question. (The) sliding to the footboard was avoidable. 3. Review of R27's care plan initiated on 7/20/20 with the last revision on 1/06/21 revealed under Focus, (R27) has Actual impairment to skin integrity r/t (related to) MASD (moisture associated skin damage) - skin split between buttocks . Further review of R27's care plan revealed under Interventions, .Turn and Reposition every 2 hours as tolerated. Use wedge cushion to assist in repositioning as resident is not able to maintain position on left side without assistance . The following observations were made on R27 on 1/28/21: 8:53am - R27 was lying on her back in bed with the head of bed elevated at approximately 45 degrees angle as the nurse gave her a supplement to drink. 9:39am - R27 was still lying on her back with the head of bed elevated at approximately 45 degrees angle. 10:36am - R27 was in the same position. 11:35am - R27's position in bed did not change 11:40am - R27 was in the same position as the ADON prepared the wound care supplies for R27. R27 was not repositioned in bed until the ADON started changing R27's wound dressings at 11:57am. After the wound care, nursing aide (NA)2 changed R27's incontinence briefs then placed the wedge cushion under R27's back on the right side before leaving the room. Further observations of R27 on 1/28/21 revealed the following: 1:31pm - R27 was flat on her back in bed. The wedge cushion was beside her on the right side of the bed but not placed under her back. 2:30pm - R27 remained in the same position. 3:15pm - R27 was still flat on her back in bed. 4pm - R27's position in bed did not change. 4:54pm - R27 was in the same position in bed. Further observations of R27 on 1/29/21 revealed the following: 8:10am - R27 was sleeping on her back, head of bed elevated at approximately 45 degrees and the wedge cushion was in her wheelchair. 8:42am - R27 was on the same position with the wedge cushion still sitting in her wheelchair and not used to assist with her positioning in bed. 9:32am - R27 remained in the same position and the wedge cushion was not in use for positioning. 9:43am - There was no change with R27's position in bed. 10:27am - R27's position in bed did not change. 11:16am - R27 was still lying on her back in bed with the head of bed elevated at approximately 45 degrees and the wedge cushion was still sitting in her wheelchair. In an interview with the ADON on 2/1/21 at 5:24pm, the ADON stated, She should be turned and repositioned as she tolerates or at least every two hours or more frequent. When asked about what might happen with R27's sacral MASD if she was not being repositioned in bed, the ADON stated, (There is a) high risk (for the sacral moisture associated skin damage) to turn to pressure (injury). During the same interview, the surveyor asked the ADON what was the possible effect of the head of bed being elevated at about 45 degrees for an extended period of time on R27's sacral skin damage. The ADON stated, (There is) increased pressure on the lower back when the head of bed is elevated. When the surveyor reported the observations of the wedge cushion being in R27's wheelchair and being in bed beside R27 but was not placed under her back, the ADON stated, It should be in use and they (nursing staff) could alternate side to side, use the wedge cushion to keep her off her back. When asked about her expectations of nursing staff when a resident has sacral MASD, the ADON stated, My expectation would be to reposition in any manner every two hours even if (it is) just slight offloading from her back. Review of the facility's Skin Management policy and procedure with the last revision on 10/2019 revealed under Policy, It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable (sic) pressure injuries. Further review of the same policy revealed under Overview, Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing . The facility's Skin Management policy and procedure further stated under Practice Guidelines, .3. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan . According to the National Pressure Ulcer Advisory Panel (NPUAP's) Pressure Ulcer Prevention and Treatment Clinical Practice Guidelines, published in 2019, page 27: .Once individuals are identified as being at risk of pressure ulcer development, a prevention program should be developed that aims to minimize the impact of those variables. Failing to provide appropriate prevention strategies when an individual has been identified to be at risk of pressure ulcer development is a failure in the duty of care owed by the health professional and can be deemed as negligence . Also, on page 34 under Repositioning Technique subsection 3.2. Avoid subjecting the skin to pressure .This statement is based on expert opinion. Pressure ulcers occur because of sustained mechanical loading .Therefore, in order to prevent pressure ulcers, the skin should not be exposed to pressure .

This citation is related to intake # MI 630 and MI 415. Based on observation, interview, and record review, the facility 1) failed to prevent, assess, monitor, measure, treat, and document for one Resident (#201) for a facility acquired pressure heel ulcer and the deterioration of 3 venous stasis ulcers (VSU) (2 on the lateral leg and 1 on the ankle) resulting in Resident #201 having a leg amputated, development of hypoxemia, respiratory distress, bradyarrhythmia and worsening shock and subsequent death on [DATE] and 2) failed to prevent, assess, monitor, measure, treat and document wounds for 5 Residents (#204, 205, 207, 210 and 211) of 11 residents reviewed for wounds, resulting in Resident #204 with a back wound, and a left heel unstageable ulcer; Resident #205 with a right foot and back wounds; Resident #207 with (4) wounds that included a right clavicle, a Stage IV sacrum, a left leg thigh and a right heel un-stageable ulcer; Resident #210 with (11 wounds) a left lateral foot, a left lateral malleolus, a left medial malleolus, a left medial calf, a left outer thigh (1), a left outer thigh (2), a left lateral malleolus, a right trochanter, a left ischial, a right ischial and a sacrum wound; and Resident #211 with (3 wounds) a right heel, a facility-acquired top of right foot and a top of right great toe, resulting in the Residents' wounds not being monitored, measured or assessed for over a month, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to facility policy, the deterioration of wounds, and over decline of health and wellbeing of residents with wounds. Findings include: The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE]. The facility was notified of the Immediate Jeopardy verbally on [DATE] at approximately 5:00 PM and in writing [DATE] at 1:48 PM. The Immediate Jeopardy was removed on [DATE]. During an interview on [DATE] in the AM, the Administrator and the DON were requested by the surveyor to observe dressings and wounds on Residents with wounds/dressing changes. During an interview, on [DATE] at 12:40 PM, Medical Director K stated, What can you say. The plan is every week there should be an evaluation, documentation. I do not think the expectation is any different. Once a week is the minimum for the wounds. The standard is for one time a week, no one is excluded from that. There are staffing issues. If they (Residents) don't cooperate, there has to be documentation, and the physician needs to know. It helps to know what to do next for the resident's care, as well as being notified. Medical Director K agreed, when a resident has a change of condition, he (as the attending physician) expected to be notified and if the resident had a guardian, the guardian needed to be contacted with any change of condition or any refusals. Medical Director K stated, That has to happen. Treatment orders were discussed, and Medical Director K stated, Nursing cannot write an order without calling the physician and the consulting physician needs to contact the (attending) physician and receive an approval. A review, of the facility policy Documentation Expectations, dated ,[DATE] revealed Aspects of resident care such as observations and assessments, administration of mediations, and services or treatments performed must be documented in the resident medical record according to company policy. During an interview on [DATE] at 7:20 AM, the Administrator and the DON were requested by the surveyor to observe dressing changes and wounds on residents #202, 203, 204 and 205. At 8:00 AM, all 4 residents were observed out of their rooms and in the dining room. Dressing changes had not been observed. During an interview on [DATE] at 9:15 AM, Assistant Director of Nursing (ADON) H who was responsible for wound care stated, the floor nurses are responsible for the dressing changes today. At 11:00 AM, there were no dressing changes observed. There were no dressing changes for wounds observed at the time the surveyor left the facility for the day at 6:00 PM on [DATE] as requested. During an interview on [DATE] at 5:42 PM, Attending Physician L reported that Resident #201 was seen by podiatry as the specialist in (MONTH) (2019), again on [DATE] and was notified on [DATE] of a decline when it was recommended Resident #201 was to be sent to the wound clinic and was on an antibiotic. Attending physician L stated, Maybe I am part to blame. It is harder with the computer to find information. I don't go look at the wounds. I count on the specialist as they are the experts in that field. I receive the information in my office and review the information at that time. Attending Physician L stated, I if I know they are going to the wound clinic, I feel they are being followed. I trust the wound clinic and defer to the wound professional. Attending Physician L agreed his documentation (for the residents) did not have documentation on the wounds. Attending Physician reported he was not aware of the federal regulations for documentation. During an interview on [DATE] at 7:30 AM, the Administrator and the DON were both requested to see wound care on Residents #204 and #205. At 8:50 AM, ADON H and the DON assisted with observations of Resident wounds and dressing changes on Resident #204. Resident #205 refused. A review, of facility policy Skin Management, dated ,[DATE], revealed 1. Resident, responsible party and attending physician are notified of the development of any diabetic, vascular or arterial ulcer. 2. Etiology of the ulcer is determined as well as the treatment plan. This is achieved via the attending and/or consulting physician . 3. A care plan is developed or updated to reflect the new problem and interventions with evaluation and revisions documented on an ongoing basis. 4. The resident Kardex will also be updated to reflect any changes. 5. The licensed nurse will evaluate the wound weekly and document the status/progress on the Wound/Skin Healing Record, until it is healed. 6. The resident is added to the 24-hour report/dashboard for continued follow-up 8. Consult with certified wound care nurse (CWS or CW[NAME]N) or physician may be appropriate. If a wound care consultation is appropriate, a physician's order should be obtained for the consultation. 9. Quarterly, a system audit of the Skin Management Guideline is conducted to ensure ongoing compliance in all areas. Results will be reported to the QAPI committee for trending, analyzing and recommendations. A review, of the facility policy Lippincott Procedures - Change in status, identifying and communicating, long-term care, dated [DATE], revealed Identify a suspected acute change in the resident . Perform a complete physical assessment, focusing on the identified change in status . Communicate the change in the resident's condition to the appropriate practitioner. Notify the resident's family about the change in the resident's condition and the subsequent treatment plan. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure . Document the acute change in status, behavioral changes, vital signs, and other assessment findings in the appropriate areas in the medical record. Record nursing interventions and the resident's response. Be sure to document all communication with other health care providers as well as the practitioner's orders and any diagnostic tests you performed. Record communication with the resident's family. Note any teaching you provided to the resident and family members as well as areas of learning that required additional teaching. A review, of the facility policy Documentation Expectations, dated ,[DATE], revealed Aspects of resident care such as observations and assessments, administration of mediations, and services or treatments performed must be documented in the resident medical record according to company policy. Resident #201 A review, of Resident # 201's electronic medical record physician orders, physician progress notes [REDACTED]. A review, of Resident #201's Hospital record History & Physical (H & P) dated [DATE] revealed the following information: Subjective: Gangrenous wound to left foot, Physical Exam: .Left heel with extensive gangrenous tissue with areas of purulent drainage associated [MEDICAL CONDITION] vs. Ischemic changes of left calf. Lateral malleolus with 2 small circular 1 cm ulcerations. Foul smelling Laboratory Results: WBC >14.3 (H) (normal 4XXX,[DATE].0 10*3/ uL -microliter), Hemoglobin 11.2 (L) (normal- 12.0 - 15.0 g/dl (Grams per deciliter), Hematocrit 34.1 (L) (Normal 36.0 45.0 %) Lymphocytes 10.1 (L) (Normal 14.0 - 41.0 %) Absolute [DIAGNOSES REDACTED]s 11.50 (H) (Normal 1.96 - 9.72 10*3/uL). Assessment & Plan: Gangrene of left heel with [MEDICAL CONDITION] and [MEDICAL CONDITION], Begin [MEDICATION NAME] and [MEDICATION NAME] (Antibiotics) (Absolute. Lymphocytes- These are one of the first immune cells to arrive at an inflamed or injured area and high [DIAGNOSES REDACTED]s may be due to medical conditions like infection or stress. [DIAGNOSES REDACTED]s-low count may indicate the body's ability to repel infection has weakened.)Had arterial study done on ,[DATE] . Possible stenosis at distal common femoral or proximal superficial femoral artery level. - Repeat arterial study ordered. -SR left ankle showed: Soft tissue ulceration along the medial malleolus. There is question of periosteal reaction along the medial aspect of the distal tibia. No lytic lesion is seen to suggest osteo[DIAGNOSES REDACTED] . - XR (X-ray) left foot showed: Heterogenous soft tissue density along the plantar aspect of the calcaneus in the posterior aspect of the calcaneus consistent with [MEDICAL CONDITION]. There is possible ulcer along the plantar aspect of the calcaneus. There is no evidence to suggest osteo[DIAGNOSES REDACTED] of the bones of the foot. - Vascular surgery consulted, appreciate their input. Believe this to be infectious in nature with chronic vascular disease. -Tylenol prn and [MEDICATION NAME] for pan control . A review, of Resident #201's Hospital record Podiatry Consult dated [DATE] revealed, Assessment/Plan: Left heel ulcer, necrosis, stage IV ulcer, Left medial malleolus ulcer, arterial, full thickness, LLE (Left Lower extremity) [MEDICAL CONDITION], PAD. Dysvascular limb with [MEDICAL CONDITION], possible underlying osteo (osteo[DIAGNOSES REDACTED]). Consult performed, no emergent or urgent foot procedure from my standpoint. Please consult previous PDM on the patient's case from last admission, (physician name). Consult Vascular team for severe PAD, if any chance of limb preservation re vascularization needed prior to foot procedure. High risk of leg amputation. IV abx (antibiotic) per ID or primary team . A review, of Resident #201's Discharge hospital Summary dated [DATE] revealed Resident was discharged on [DATE] with [DIAGNOSES REDACTED]. According to https://www.ahajournals.org/doi/10.1161/CIRXXX 4 However, the term cardiorenal syndrome (CRS) encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in 1 organ may induce acute or chronic dysfunction in the other organ. This scientific statement focuses primarily on the definition of, pathophysiology of, and diagnostic and therapeutic strategies in CRS. A review, of Resident #201's Hospital record Surgical Consult post op dated [DATE] revealed [DIAGNOSES REDACTED]. H & P dated [DATE] revealed, The patient is a [AGE] year-old female with [MEDICAL CONDITION], systolic [MEDICAL CONDITION] (EF 25%), HTN, DM, [MEDICAL CONDITION], and [MEDICAL CONDITION] POD #1 L AKA (left above knee amputation) for L foot gangrene and PAD. Post-operatively the patient developed worsening hypoxemia and respiratory distress and was transferred to the ICU and intubated -0645 this morning. Following this, she developed bradyarrhythythmia and worsening shock .Empiric [MEDICATION NAME] and [MEDICATION NAME], await culture data . A review, of Resident #201's Wound Clinic note dated [DATE], revealed, Wound at 3 Left Heel is an Eschar covered Arterial Ulcer and has received a status of not healed. Initial wound encounter measurements are 9 cm length x 8.5 cm width, with an area of 76.5 sq cm. (square centimeter) No tunneling has been noted. There is a small amount of drainage noted which has a strong odor. Wound bed has 76 - 100% eschar . Patient also has small open ulcers on the medial and lateral ankle Pt (patient) found to have extensive gangrene of left heel with foul odor present. Pt has absented pedal pulses on left LE and is at very high risk [MEDICAL CONDITION] and limb loss. I called (facility) and explained to the severity of the situation. As we do not have vascular surgery in this town, pt was taken to (hospital#1) ER for admission via (Ambulance) transport services. A review, of Resident #201's Facility Podiatry note dated [DATE] revealed, left foot and leg ulcer, infection, approx. 1 month duration, pt having regular wound care, po antibiotics, nursing has concerns about progression of problem, pt has dm, kidney failure, [MEDICAL CONDITION] .symptoms: numbness, redness, swelling .aggravating factors: pressure, Impact on daily life: this infection may compromise diabetic control and her leg High risk-[MEDICAL CONDITION], monofilament 6.8 or less, and [MEDICAL CONDITION] and /or foot disease . the superficial blisters were opened and drained, the black eschar felt soft and fluctuant under and purulence was noted from margins with pressure . Skin Left Abnormal - black eschar approx. 15 cm left plantar During an interview on [DATE] at 3:49 PM, facility Podiatrist T reported that he had he met with the DON and charge nurse by the nurses station and informed both the DON and charge nurse that Resident #201 condition was imminent and had discussed sending resident to the hospital or the wound clinic as soon as possible felt Resident #201 had a significant infection as she had been on antibiotics for 6 weeks. Podiatrist was informed Resident had been sent to the wound clinic on [DATE] and reported he had not been aware that the facility had waited a week and that was not what he had recommended at the time of the meeting with the DON and Charge Nurse on [DATE]. Podiatrist T again stated, I informed them both the DON and Charge nurse Resident's condition was imminent and had recommended they send her to the hospital if they could not get her in to the wound clinic ASAP. During an interview, on [DATE] at 12:40 PM, Medical Director K stated, What can you say. The plan is every week there should be an evaluation, documentation. I do not think the expectation is any different once a week is the minimum for the wounds. The Standard is for one time a week, no one is excluded from that. There are staffing issues. If they (Resident) doesn't cooperate, there must be documentation, and the physician needs to know, it helps to know what to do next for the resident's care, as well as being notified. MD K also agreed with a change of resident condition and has a guardian, the guardian needs to be contacted with any change of condition or any refusals and stated, That has to happen. Treatment orders were discussed, and MD K stated, nursing cannot write an order without calling the physician and the consultant needs to contact the physician and receive an approval. During an interview on [DATE] AT 5:42 PM, attending Physician L reported that resident #201 was seen by podiatry as the specialist on in September, again on [DATE] and was notified on [DATE] of a decline when it was recommended Resident #201 was to be sent to the wound clinic and was on an antibiotic. Attending physician L stated, Maybe I am part to blame. It is harder with the computer to find information. I don't go look at the wounds. I count on the specialist as they are the experts in that field. I receive the information in my office and review the information at that time. Attending Physician L stated, I if I know they are going to the wound clinic, I feel they are being followed. I trust the wound clinic and defer to the wound professional. Attending Physician L agreed his documentation did not have documentation on the wounds. Attending Physician reported he was not aware of the federal regulations for documentation. During an interview on [DATE] at 8:30 AM, Registered Nurse C reported she was responsible for Resident #201 on [DATE], had requested the podiatrist to see Resident as she had not been on the monthly list to be seen by the podiatrist due to concerns related to the wounds on her feet. RN C stated, Podiatrist's nurse came out of resident's room to get me to come into her room, Podiatrist T stated, 'You are spot on this is imminent. She needs to go to the Wound Clinic ASAP.' RN C reported Podiatrist T, ADON H reported she discussed sending Resident #201 to the hospital or the wound clinic and the Podiatrist T said it was imminent and needed to be done ASAP. RN C reported she had voiced she felt Resident #201 needed to go to the hospital when the appointment was not scheduled until [DATE] but was out voted by ADON H. RN C reported she had requested Attending physician L to look at the wound on his last visit to see Resident #201 (unsure of the date) she thought on [DATE]. RN C reported she had started to unwrap Resident #201's wound and Attending Physician L refused to look at the wounds. RN C voice she had been very frustrated with Attending Physician L and ADON H due to Resident #201 having an odor that was very strong on her wound no one listening to her assessed concern, was very pleased Podiatrist T had agreed with the assessed concern but again felt like Podiatrist T was out voted by management once he left the facility. A review, of Resident #201's Nurse Progress note dated [DATE], revealed, Resident has diabetic ulcer on left heel and left lateral ankle. Doctor assessed left heel continues to deteriorate despite courses of antibiotics and changes to dressing regimen. Resident chooses not follow plan of care at times. Doctor notified of changes to left heel, and new orders received to have consult with wound clinic as soon as possible and follow their recommendations. A review, of Resident #201's Attending Physician L physician progress notes [REDACTED]. A review, of Resident #201's Physician orders revealed, Resident was prescribed antibiotics (Bactrim) for wound infections on [DATE] -[DATE], [DATE] -[DATE], and was on [MEDICATION NAME] [DATE] - [DATE] for pneumonia. There was no physician order for [REDACTED].#201 was on antibiotic treatment. A review, of Resident #201's re-admission assessment revealed, Resident was admitted on [DATE], with the following open wounds left lower leg rear, left lower leg front and left outer ankle 6 x 3 (inches). The following 3 wounds were identified as concerns and were last assessed on [DATE] according to the weekly skin assessments and wound measurements. A review, of Resident #201's Skin & Wound Evaluation V5.0 revealed the following assessments and measurements: A review, of Resident #201's skin assessment dated [DATE], revealed, a facility acquired left heel was open and was a Stage 2 pressure ulcer and measured 6.0 cm2 (area) x 2.3 cm x 3.7 blister. A copy of the assessment was not provided as requested on [DATE], [DATE] and [DATE] during the survey. Skin assessment dated [DATE], measured 20.2 cm2 x 4.2 x 6.4; Eschar Stage II Pressure Partial-thickness skin low with exposed dermis, D. Exudate- 1. None 3. Odor 1. None. 3. E. Periwound- Surrounding tissue: 7. Dry/flaky, 4. [MEDICAL CONDITION] 3. Non - [MEDICAL CONDITION] > 4 cm around wound. Skin assessment dated [DATE], measured 23.7 cm 2 x 6.0 x 4.9, Pressure Stage II, Partial-thickness skin low with exposed dermis, D. Exudate- 3. Odor 2. Faint, E. Periwound- Surrounding tissue: 7. Dry/flaky 9 . 2. [DIAGNOSES REDACTED]: Redness of the skin - may be intense bright red to dark red or purple .4. [MEDICAL CONDITION] 3. Non - [MEDICAL CONDITION] > 4 cm around wound, F. Wound Pain .8. Pain (3) 9. Pain Frequency- 3. At Dressing, [NAME] Orders -1. Goal of Care 1. Healable: 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. 3. Monitor/Manage: Wound healing not achievable due to untreatable underlying condition. Skin assessment dated [DATE], measured 21 cm2 x 4.6 x 6.1 C. Wound Bed. 4a. %100 eschar 5. Evidence of Infection- increased drainage, increased pain, E. Periwound- Surrounding tissue: 7. Dry/flaky 9 . 2. [DIAGNOSES REDACTED]: Redness of the skin - may be intense bright red to dark red or purple .6. Periwound- Temperature: 3. Warm . F. Wound Pain .8. Pain (4) 9. Pain Frequency- 3. At Dressing [NAME] Orders -1. Goal of Care: 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration, H. Treatment- Dressing 1. Intact .4. Saturated. Progress- Deteriorating. Notes: Continues PO (oral) atb (antibiotic) for wound infection, treatment order changed to dc (discontinue) skin prep, added iodine. Referral placed to wound clinic for management. Resident frequently chooses not to follow P[NAME] (Plan of Care), chooses not to take nutritional supplements meant to aid in healing. No further assessments were noted in the electronic medical record following [DATE]. There was no documentation that the physician was notified of a change of condition on [DATE] of the increased drainage, increased pain and wound observation. There was no documentation that a referral was placed to the wound clinic, or that the guardian was notified of the deteriorating condition of the heel wound. A review, of Resident #201's Interdisciplinary Care Conference V1.1-V3 form, dated [DATE], revealed, Nursing Summary- a. Summary: Res is medically stable. Continues with [MEDICAL TREATMENT] 3 x a week. Res following up with the wound clinic for [MEDICAL CONDITION] that was present upon admission and has worsened. Res is able to verbalize her own needs. (Resident) takes her medications as ordered. Res is an extensive assist for most ADL's. Res has an upcoming wound appointment related to her heel on (MONTH) 9th. Labs were obtained this am for upcoming wound appointment. The foot ulcer was not present upon admission according to facility records and was acquired on [DATE]. Resident #201's Physician ordered treatments for the left heel included: Dated [DATE], Aqual cell ag (silver) with non-adhesive dressing. Dated [DATE]-[DATE], wound cleanser, pat dry, apply dry dressing, wrap with kerlix and change daily. Dated [DATE]-[DATE], wound cleanser, pat dry, apply [MEDICATION NAME], apply dry dressing, wrap with kerlix and change daily. A review, of Resident #201's Treatment Administration Record (TAR) revealed the following treatment refusals that had not been documented on the left heel: from [DATE]-[DATE] (4 not documented as completed) [DATE]-[DATE] (1 refusal) [DATE] -[DATE] (5 refusals, 1 not documented as completed) and [DATE] -[DATE] (1 refusal). A review, of Resident #201's clinical record revealed there were no ongoing measurements or assessments of one (1) left outer ankle wound from [DATE] until the mention of the wound in the nurse progress note on [DATE]. Wound clinic notes, dated [DATE], revealed Resident #201 had 2 open ulcers on the left ankle, Patient also has small open ulcers on the medial and lateral ankle. This indicated (1) new open area on the left ankle at some point since Resident #201's admission on [DATE]. Physician order, dated [DATE], revealed, Left lateral Ankle: cleanse open areas with wound cleanser, pat dry, apply Aqua cell ag to wound bed, cover with dry dressing, change daily everyday shift for venous stasis ulcer. A review, of Resident #201's Physician orders and Treatment Administration Records (TAR), revealed, there were no physician orders or treatments documented on the treatment records for Resident #201's (2) lateral calf wound areas since admission on [DATE] through discharge on [DATE]. There were 2 lateral calf wounds, but there was no differentiation between the 2 wounds to identify one wound from the other wound in the documentation. For identification purposes in the citation, the wounds are labeled #1 and #2. A review, of Resident #201's Skin & Wound Evaluations (V5.0 forms), revealed, deterioration of the following assessments to the #1 left lateral calf venous stasis ulcers, (no exact date on forms of origination of wound): Dated on [DATE], measured 0.9 cm2 x 0.1 x 1.0 x 0.2, copy of assessment was not provided as requested on [DATE], [DATE] and [DATE] during the survey. Dated on [DATE], measured 1.0 cm2 x 1.2 x 1.2 x 0.3, 90% slough D. Exudate 1. Amount- 3. Moderate Type- Serosanguineous, Odor-2. Faint, E. Periwound - 1. Edges 1. Attached, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing Notes Resident frequently chooses not to follow P[NAME] regarding nutritional supplements, boot/heels up repositioning. Education: (Blank). Dated on [DATE], measured 0.8 cm2 x 1.0 x 1.0 x 0.3 80% slough D. Exudate 1. Amount- 2. Light Type- Serosanguineous, Odor-2. Faint, E. Periwound - 1. Edges 1. Attached, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing. Dated [DATE], measured 0.9 cm2 x 1.0 x 1.2 x 0.2 cm 80% slough, D. Exudate 1. Amount- 3. Moderate Type- Serosanguineous, Odor-1. None, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. No further assessments were noted in the electronic medical record documented after [DATE] for the lateral calf venous stasis ulcer. A review, of Resident #201's Skin & Wound Evaluations (V5.0 form), revealed, deterioration of the following assessments to the #2 left lateral calf venous stasis ulcer (no exact date on forms of origination of wound): Dated on [DATE], measured 2.4 cm2 x 2.2 x 1.4 x 0.2 cm, 100% slough. A copy of the assessment was not provided as requested on [DATE], [DATE] and [DATE] during the survey. Dated on [DATE], measured 3.7 cm2 x 2.8 x 1.7 x 0.3, 80% slough D. Exudate 1. Amount- 3. Moderate Type- Serosanguineous, Odor-2. Faint, Periwound - 1. Edges 1. Attached, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing, 1. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration On [DATE] measured 1.6 cm2 x 2.1 x 1.0 x 0.3, 90% slough, D. Exudate 1. Amount- 3. Moderate Type- 4. Serosanguineous, 3. Odor 1. None, 2. Surrounding Tissue: 1. Dry/Flaky, F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing, 1. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration Dated on [DATE], measured 2.4 cm 2 x 2. 3 x 1.4 x 0.4, 70% slough, D. Exudate 1. Amount- 3. Moderate Type- 4. Serosanguineous, 3. Odor 1. None, 2. Surrounding Tissue: 1. Dry/Flaky, F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing, 1. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration (increase in size of wound noted). No further assessments were noted in the electronic medical record after [DATE]. A review, of Resident #201's Physician orders and Treatment Administration Records (TAR's)for the Left Great toe revealed, from [DATE] -[DATE], cleanse with wound cleanser, pat dry, apply skin prep, cover with dry dressing, change daily everyday shift for necrotic area. A review, of Resident #201's Physician orders and Treatment Administration Record (TAR's)for the Left Great toe revealed treatments discontinued on [DATE], leave open to air. Review of Resident #201's Treatment record and physician order for [REDACTED]. Left great toe (1st digit) was identified as a concern on the (TAR's) dated [DATE] (7 days after admission), with eschar (first documentation noted in EMR) and last assessed on [DATE] on the Wound Skin Evaluation V5.0 assessment. Resident #201's Wound Skin Evaluation (V5.0 form), assessments for the left great toe (1st digit) were as follows and indicated deterioration: Dated on [DATE], measured 0.3 cm2 x 0.6 cm x 0.3 cm, no odor, no Exudate, 2. Surrounding Tissue: 6. Discoloration - black /blue. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration Dated on [DATE], measured 0.4 cm2 x 0.8 cm x 0.7 cm no odor, no Exudate, 2. Surrounding Tissue: 6. Discoloration - black /blue, Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. Dated on [DATE], measured 0.4 cm2 x 0.8 cm x 0.7 cm,2. no Odor, no Exudate, Surrounding Tissue: 6. Discoloration - black /blue, Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. No further assessments were noted in Resident #201's electronic medical record after [DATE]. A review, of Resident #201's Treatment record (TAR) revealed the following treatment refusals and not documented on the lateral calf and great toe: from [DATE]-[DATE] (4 Treatment record was documented as not completed) [DATE]-[DATE] (1 refusal) [DATE] -[DATE] (5 refusals, 1 documented as not completed) and [DATE] -[DATE] (1 refusal). A review, of Resident 201's nurse progress notes dated [DATE] through [DATE], revealed multiple entries of resident refusals of medication. There was no documentation the guardian or the physician was notified of Resident 201's refusals of treatments or medications. A review, of Resident #201's Care plan, date revised [DATE], revealed, Resident has actual impairment to skin integrity r/t falls and several open areas on arms and legs, with interventions of encourage good nutrition and hydration in order to promote healthier skin. Provide dietary supplements as ordered. Observe location, size and treatment of [REDACTED]. to physician, date initiated [DATE]. A review, of Resident #201's Skin integrity Care plan revealed the care plan was not updated since [DATE] to i

This citation pertains to Intake # MI 630. This citation has multiple Deficient Practice Statements DPS). Based on interview and record review, the facility failed to 1) complete a review of resident's total program of care, complete a medical evaluation of resident's condition and review the appropriateness of the resident's medical regimen in regard to the acquiring, treatment, documentation, and rapid deterioration of 6 venous stasis ulcers for 1 Resident (#201) resulting in Immediate Jeopardy due to the Resident's development of 3 venous stasis ulcers to her left leg including a left ankle, left foot and big toe. The left heel was unstageable and covered with eschar. The Immediate Jeopardy started on 09/21/19. The Immediate Jeopardy was identified on 11/22/19 at 9:47 AM. The facility was notified of the Immediate Jeopardy on 11/22/19. The Immediate Jeopardy was removed on 11/22/19. 2) the facility failed to complete a residents' total program of care, complete a medical evaluation of residents' condition and review the appropriateness of the residents' medical regimen in regard to the acquiring, treatment, documentation and/or rapid deterioration of wounds for 4 Residents (#203, 205, 208 and 211) of 11 residents reviewed with wounds resulting in a lack of physician documentation of condition of wounds for Resident #203's open back wound, Resident #205's deterioration of an unstageable heel ulcer, Resident #208's left outer thigh open wound, and Resident #211's (3 wounds) right heel, facility acquired top of right foot and top of right great toe. 3) the facility failed to provide residents' physician progress notes [REDACTED]. review of the appropriateness of residents' medical regimen for 30 Residents (#202, 204, 206, 209, .245, 246, 247, 248, 251, 252, 253, 254, 255, 258, 259, 261, 262, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, and 277), resulting in lack of continued quality care and communication for staff providing care for Residents. Residents #202-209 were used as examples of the deficient practice. Residents #245-277's information was not included in the body of the citation but are available upon request. 4) the facility the facility failed to ensure the attending physician documented and reviewed the hospital discharge summary or hospital progress notes during required visits, for 15 (#212, 215, 216, 218, 221, 222, 226, 227, 233, 234, 235, 236, 237, 238, and 240) of 68 residents reviewed and failed to document a review of the resident's total program of care, for 28 residents (#212, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236, 238, 239, 240, 278) of 68 reviewed. (Total program of care includes: medical services (high risk diagnosis) and medication management, physical, occupational, and speech/language therapy, nursing care (such as: treatments, care plan, blood sugar monitoring, falls .), nutritional interventions (weight monitoring, feeding tubes, supplements) social work and activity services that maintain or improve psychosocial functioning)., including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being (behavioral management) and decisions about the continued appropriateness of the resident's current medical regimen.) This lack of review of the resident's total program of care resulted in 15 residents' return from the hospital, with a lack of documented assessment by the physician, lack of communication, and questionable continuity of care due to the very brief, repetitive, uninformative physician progress notes [REDACTED]. Residents #212 and 214 were used as samples of the deficient practice. Residents #215-278's information was not included in the body of the citation but are available upon request. Findings include: A review, of the facility policy Documentation Expectations, dated 11/2017 revealed, Aspects of resident care such as observations and assessments, administration of mediations, and services or treatments performed must be documented in the resident medical record according to company policy. During an interview, on 11/22/19 at 12:40 PM, Medical Director K stated, What can you say. The plan is every week there should be an evaluation, documentation. I do not think the expectation is any different, once a week is the minimum for the wounds. The Standard is for one time a week, no one is excluded from that. There are staffing issues. If they (Resident) doesn't cooperate, there must be documentation, and the physician needs to know, it helps to know what to do next for the resident's care, as well as being notified. Medical Director K also agreed with a change of resident condition and has a guardian, the guardian needs to be contacted with any change of condition or any refusals and stated, That has to happen. Treatment orders were discussed, and Medical Director K stated, Nursing cannot write an order without calling the physician and the consultant needs to contact the physician and receive an approval. During an interview on 11/25/19 at 5:42 PM, Attending Physician L reported that Resident #201 was seen by podiatry, as the specialist in (MONTH) 2019, again on 10/2/19 and was notified on 10/2/19, of the decline of the wound, when it was recommended Resident #201 be sent to the wound clinic and was reported the Resident was on an antibiotic. Attending Physician L stated, Maybe I am part to blame. It is harder with the computer to find information. I don't go look at the wounds. I count on the specialist as they are the experts in that field. I receive the information in my office and review the information at that time. Attending Physician L stated, I if I know they are going to the wound clinic, I feel they are being followed. I trust the wound clinic and defer to the wound professional. Attending Physician L agreed his documentation (for the residents) did not have documentation on the wounds. Attending Physician L reported he was not aware of the federal regulations for documentation. During an interview on 11/26/19 at 4:48 PM, the Administrator reported she had reviewed a physician note for Attending Physician L and identified a concern approximately a month ago and stated, The physician note needed more extensive documentation, had a talk with Attending Physician L and informed him 'you need more documentation.' The Administrator reported the conversation was not documented at that time. The Administrator reported Attending Physician L does not attend QA meetings. The Administrator agreed there was no plan put in place at that time related to physician documentation. The Administrator agreed she was not aware of the number of missing progress notes for Attending Physician K. The Administrator agreed there was no PIP in place for the lack of documentation for physician progress notes [REDACTED]. DPS STATEMENT #1: Based on interview and record review, the facility failed to 1) complete a review of resident's total program of care, complete a medical evaluation of resident's condition and review the appropriateness of the resident's medical regimen in regard to the acquiring, treatment, documentation, and rapid deterioration of 6 venous stasis ulcers for 1 Resident (#201) resulting in Immediate Jeopardy due to the Resident's development of 3 venous stasis ulcers to her left leg that included a left ankle, left foot and big toe. The left heel was unstageable and covered with eschar. The Immediate Jeopardy started on 09/21/19. The Immediate Jeopardy was identified on 11/22/19 at 9:47 AM. The facility was notified of the Immediate Jeopardy on 11/22/19. The Immediate Jeopardy was removed on 11/22/19. Resident #201: A review, of Resident # 201's electronic medical record Physician orders, physician progress notes [REDACTED]. A review, of Resident #201's Attending Physician L physician progress notes [REDACTED].#201's wounds that included a facility acquired the heel pressure wound (acquisition of 1 VSU (lateral ankle) and the deterioration of 4 VSU (2 lateral leg, great toe and ankle). During an interview on 12/4/19 at 8:30 AM, Registered Nurse C reported she was responsible for Resident #201 on 10/2/19, had requested the podiatrist to see Resident as she had not been on the monthly list to be seen by the podiatrist due to concerns related to the wounds on her feet. RN C stated, Podiatrist's nurse came out of resident's room to get me to come into her room, Podiatrist T stated, 'You are spot on this is imminent. She needs to go to the Wound Clinic ASAP.' RN C reported Podiatrist T, ADON H reported she discussed sending Resident #201 to the hospital or the wound clinic and the Podiatrist T said it was imminent and needed to be done ASAP. RN C reported she had voiced she felt Resident #201 needed to go to the hospital when the appointment was not scheduled until 10/10/19 but was out voted by ADON H. RN C reported she had requested Attending physician L to look at the wound on his last visit to see Resident #201 (unsure of the date) she thought on 9/21/19. RN C reported she had started to unwrap Resident #201's wound and Attending Physician L refused to look at the wounds. RN C voice she had been very frustrated with Attending Physician L and ADON H due to Resident #201 having an odor that was very strong on her wound no one listening to her assessed concern, was very pleased Podiatrist T had agreed with the assessed concern but again felt like Podiatrist T was out voted by management once he left the facility. Abatement plan was accepted on 11/22/19 at 5:00 PM. (Facility name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F-711 regarding the facility's alleged failure of physician to complete a review of resident 201's total plan of care, completion of a medical evaluation of the residents condition and review of the appropriateness of the residents medical regimen in regard to the acquisition, treatment, documentation, and rapid deterioration of VS ulcer. 1. Resident identified to be affected by the alleged deficient practice. Resident #201 no longer resides at the facility. Resident was admitted to the facility on [DATE]. Resident developed a vascular ulcer on the left heel which showed signs of deterioration over time. The physician failed to complete a review of resident 201's total plan of care, complete a medical evaluation of the residents' condition and review the appropriateness of the residents' medical regimen in regard to acquisition, treatment, documentation, and rapid deterioration of the venous stasis ulcers. 2. Residents with the potential to be affected by the alleged deficient practice. The facility currently has 8 residents who require medical evaluations and treatment recommendations of wounds. On 11/22/19 the facility contracted a wound nurse practitioner who will be assessing residents with wounds at the facility and providing documentation and treatment recommendations as needed. The NP will make initial rounds on 11/22/19 and weekly thereafter. The attending Physician will be required to observe the wounds weekly and document on their status. The Medical Director will be responsible for overseeing the care provided by the NP on the residents with wounds. 3. Systemic Measures The facility policies on Skin Management, as well as Medical Director and Physician Services was reviewed and deemed appropriate on 11/20/2019. The Medical Director, Physician's Assistant and other attending physician were educated on the named policies. On 11/22/19 the facility contracted a wound nurse practitioner who will be assessing residents with wounds at the facility and providing documentation and treatment recommendations as needed. The NP will make initial rounds on 11/22/19 and weekly thereafter. The attending Physician will be required to observe the wounds weekly and document on their status. The Medical Director will be responsible for overseeing the care provided by the NP on the residents with wounds. 4. Quality Assurance An Ad Hoc QA was held on 11/20/19 with the Medical Director, Physician's Assistant and other attending physician to discuss their involvement of residents with wounds with regard to review of residents total plan of care, completion of a medical evaluation of the residents condition and review of the appropriateness of the residents medical regimen in regard to the acquisition, treatment and documentation of wounds. The administrative nurses will review the residents with pressure/vascular ulcers to that a physician's progress note regarding the wound has been made. Audits to be completed weekly for 4 weeks, monthly times 3 months. Any areas of non-compliance will be addressed immediately and will be reported to QA Committee for further recommendations. 5. The Administrator is responsible for sustained compliance. DPS STATEMENT #2: 2) failed to complete a resident's total program of care, complete a medical evaluation of residents' condition and review the appropriateness of the residents' medical regimen in regard to the acquiring, treatment, documentation and rapid deterioration of wounds for 4 Residents (#203, 205, 208 and 211) of 11 residents reviewed with wounds, resulting in a lack of physician documentation of condition of wounds for Resident #203's open back wound, Resident #205's deterioration of an unstageable heel ulcer, Resident #208's left outer thigh open wound, and Resident #211's (3 wounds) right heel, facility acquired top of right foot and top of right great toe. Resident # 203: A review, of Resident #203's electronic medical records that included physician progress notes [REDACTED]. A review, of Resident #203's Attending physician K's Physician History and Physical, dated 10/9/19, physician progress notes [REDACTED].#203's open wound area on the back. Resident #205: A review, of Resident #205's electronic medical records that included Physician orders, physician progress notes [REDACTED]. A review, of Resident #205's Attending Physician L's physician progress notes [REDACTED]. There was noted documentation that included Ca (cancer) vertebral column . 9/18/19 no sores and Malignant neoplasm of spine . in multiple notes. There was no documented information related to Resident #205's right heel unstageable ulcer or condition of the back wound in any of the documentation. DPS STATEMENT #3: 3) failed to provide residents' physician progress notes [REDACTED]. review of the appropriateness of residents' medical regimen for 30 Residents (#202, 204, 206, 209, .245, 246, 247, 248, 251, 252, 253, 254, 255, 258, 259, 261, 262, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, and 277), resulting in lack of continued quality care and communication for staff providing care for Residents. Residents #202-209 were used as examples of the deficient practice. Residents #245-277's information was not included in the body of the citation but are available upon request. Resident #202: A review, of Resident #202's electronic medical record revealed resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Further review of the electronic medical record revealed the Resident had a left heel unstageable venous ulcer. A review, of Resident #202's physician progress notes [REDACTED]. A review, of Resident #202's physician progress notes [REDACTED]. A review, of Resident #202's physician progress notes [REDACTED]. We are unable to see base of wound because of covered with eschar without any slough formation . Resident #202's last available documented physician progress notes [REDACTED].left lower extremity [MEDICAL CONDITION] with [MEDICAL CONDITION], Left heel nonhealing/ cervical ulcer. We cleansed the wound with wound cleanser and pat a dry and apply the skin prep at the surrounding area and cover with dry dressing and wrap with Kerlix and secured with tape and change daily. We are keeping the offloading boots and We will monitor the wound and wound dressing every shift. Other physician progress notes [REDACTED]. A review, of Resident #202's care plan, revealed, (Resident) has an unstageable pressure ulcer to his L (left) heel, with an intervention, Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD as needed. Initiated 8/28/18. Resident #204: A review, of Resident #204's electronic medical record including physician progress notes [REDACTED]. A review, of Resident #204's electronic medical record revealed, physician progress notes [REDACTED]. Further review revealed, there was no documentation related to Resident #204's facility acquired left heel pressure ulcer noted at the time of the clinical review on 11/20/19 and 11/21/19 in the physician progress notes [REDACTED]. On 11/22/19, the Administrator provided copies of Resident #204's Physician K's physician documentation dated 10/31/19, 11/4/19, 11/7/19 and 11/14/19. physician progress notes [REDACTED]. Margins are clear. Central area is with darkly pigmented and mildly thick ischemic type of lesion without any increased localized temperature of tenderness or abscess formation. Wound seems to be recently developed and it may get a little bit bigger as day goes on . A review, of physician progress notes [REDACTED]. Margins are clear. Central area is with darkly pigmented and mildly thick ischemic type of lesion without any increased localized temperature of tenderness or abscess formation. Wound seems to be recently developed and it may get a little bit bigger as day goes on .Left heel unstageable/multifactorial associated wound. We consider offloading the area and requested PT (Physical Therapy) OT (Occupational Therapy) to evaluate and treat for positioning and lso offloading the area and consider for multivitamin with mineral one tablet a day. We consider for protein supplements twice a day. We consider for Santyl ointment, cover with non-observable Telva dressing, cover with dry dressing with ABD (padded dressing) and secure with Kerlix change once a day and p.r.n. (as needed) and monitor wound and wound dressing every shift. I also requested for therapy to positioning in the wheelchair A review, of physician progress notes [REDACTED]. A review, of physician progress notes [REDACTED]. A review, of Resident #204's physician progress notes [REDACTED]. The 'note to follow' were missing from Resident #204's electronic medical record during the investigation on 11/20/19 and were still not available at the time of exit of the survey. The physician progress notes [REDACTED]. Resident #206: A review, of Resident #206's face sheet revealed the Resident was admitted on ,[DATE]. A review, of Resident #206's physician progress notes [REDACTED]. The 'note to follow' were missing from Resident #206's electronic medical record during the investigation on 11/20/19. Resident #209: A review, of Resident #209's face sheet revealed the Resident was admitted on [DATE]. A review, of Resident #209's physician progress notes [REDACTED]. The 'note to follow' were missing from Resident #209's electronic medical record during the investigation on 11/20/19. DPS STATEMENT #4: 4) the facility failed to ensure the attending physician documented and reviewed the hospital discharge summary or hospital progress notes during required visits, for 15 (#212, 215, .216, 218, 221, 222, 226, 227, 233, 234, 235, 236, 237, 238, and 240) of 68 residents reviewed and document a review of the resident's total program of care, for 28 residents (#212, 214, . 215, 216, 217, 219, 218, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236, 238, 239, 240, 278) of 68 reviewed. (Total program of care includes: medical services (high risk diagnosis) and medication management, physical, occupational, and speech/language therapy, nursing care (such as: treatments, care plan, blood sugar monitoring, falls .), nutritional interventions, social work and activity services that maintain or improve psychosocial functioning)., including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being (behavioral management) and decisions about the continued appropriateness of the resident's current medical regimen.) This lack of review of the resident's total program of care resulted in lack of follow-up care/documentation post discharge from the hospital for all 15 residents that were hospitalized and very brief, repetitive, and uninformative physician progress notes [REDACTED]. Residents #212 and 214 were used as samples of the deficient practice. Residents #215-278's information was not included in the body of the citation but are available upon request. Resident #212: A review, of Resident #212's H & P (History & Physical) dated 10/2/19, included the following information: S: PT is a new PT to me and his daughter is here and gave us some HX on her dad, he comes to us from Nebraska where he had a stroke and it has affected his RT side, and his speaking ability. The PT is a poor hx and we don't have a lot of records, the daughter is going to try to get them for us. O: VSS Heart: RRR Lung: Decrease BS, No LRLES (sp) (rales), mile wheezing ABD: Soft and no pain Legs: no [MEDICAL CONDITION], right leg doesn't move well EXT: RT side arm and leg not moving well and weak. A: Dementia, [MEDICAL CONDITION], HTN P: Cont Meds that we reviewed and stop some and will watch and see if we need them back. Start P.T and OT. any questions call. Review of Resident #212's baseline physician progress notes [REDACTED]. S: PT is a doing ok, has no coughing and no N/V/D and the PT meds and labs reviewed, PT is poor HX and no CP or SOB at this time. O: VSS Heart: RRR ABD: Soft and no pain Legs: mild [MEDICAL CONDITION] A: Dementia, [MEDICAL CONDITION], RT side weakness P: Cont Meds and care increase activity, call any questions, cont care. Resident #212's physician progress notes [REDACTED]. Resident #214: A review, of Resident #214's electronic medical record that included the face sheet revealed resident was admitted on [DATE], with [DIAGNOSES REDACTED]. A review, of Resident #214's physician progress notes [REDACTED]. The physician progress notes [REDACTED].#214's [DIAGNOSES REDACTED]. A review, of Resident #214's baseline progress notes revealed the following note for Resident #214's physician progress notes [REDACTED]. S: PT is a doing ok, has no coughing and no N/V/D and the PT meds and labs reviewed, PT is poor HX and no CP or SOB at this time. O: VSS Heart: RRR Lung: Decrease BS, no rales or wheezing ABD: Soft and no pain Legs: mild [MEDICAL CONDITION], has contractures of EXT. A: Dementia, [MEDICAL CONDITION] P: Cont Meds and care increase activity, call any questions, cont care. Resident #214's physician progress notes [REDACTED]. The abatement plan was accepted on 11/22/19 at 5:00 PM. (Facility Name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F-711 regarding the facility's alleged failure of physician to complete a review of resident 201's total plan of care, completion of a medical evaluation of the residents condition and review of the appropriateness of the residents medical regimen in regard to the acquisition, treatment, documentation, and rapid deterioration of VS ulcer. 1. Resident identified to be affected by the alleged deficient practice. Resident #201 no longer resides at the facility. Resident was admitted to the facility on [DATE]. Resident developed a vascular ulcer on the left heel which showed signs of deterioration over time. The physician failed to complete a review of resident 201's total plan of care, complete a medical evaluation of the residents' condition and review the appropriateness of the residents' medical regimen in regard to acquisition, treatment, documentation, and rapid deterioration of the venous stasis ulcers. 2. Residents with the potential to be affected by the alleged deficient practice. The facility currently has 8 residents who require medical evaluations and treatment recommendations of wounds. On 11/22/19 the facility contracted a wound nurse practitioner who will be assessing residents with wounds at the facility and providing documentation and treatment recommendations as needed. The NP will make initial rounds on 11/22/19 and weekly thereafter. The attending Physician will be required to observe the wounds weekly and document on their status. The Medical Director will be responsible for overseeing the care provided by the NP on the residents with wounds. 3. Systemic Measures The facility policies on Skin Management, as well as Medical Director and Physician Services was reviewed and deemed appropriate on 11/20/2019. The Medical Director, Physician's Assistant and other attending physician were educated on the named policies. On 11/22/19 the facility contracted a wound nurse practitioner who will be assessing residents with wounds at the facility and providing documentation and treatment recommendations as needed. The NP will make initial rounds on 11/22/19 and weekly thereafter. The attending Physician will be required to observe the wounds weekly and document on their status. The Medical Director will be responsible for overseeing the care provided by the NP on the residents with wounds. 4. Quality Assurance An Ad Hoc QA was held on 11/20/19 with the Medical Director, Physician's Assistant and other attending physician to discuss their involvement of residents with wounds with regard to review of residents total plan of care, completion of a medical evaluation of the residents condition and review of the appropriateness of the residents medical regimen in regard to the acquisition, treatment and documentat

This citation pertains to Intake #MI 630. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for 68 of 68 Residents, who reside in the facility, resulting in unmet care needs, as identified by the issues ascertained during the survey that included the prevention, assessment, monitoring, measuring, treatments and documentation of pressure ulcers and wounds, medication administration, the lack of educated, competent nursing staff, the initiation and revision of the Residents' plan of care, nursing staff feeling frustrated, overworked, exhausted, incompetent, and management staff not available to assist direct care staff with Residents' care and needs, affecting the physical, mental, and psychosocial well-being of all 68 residents residing in the facility. Findings include: The facility was determined to be noncompliant with regulatory requirements F-580, F-600, F-636, F-638, F-640, F-656, F-657, F-684, F-686, F-726, F-727, and F-943. F-580 Based on interview and record review the facility failed to notify the resident's physician and/or the resident's guardian of the rapid deterioration of a change of condition, refusal of care, and transfer of the resident to hospital for one resident (Resident #201), resulting in a lack of communication and a delay in treatment for [REDACTED]. F-600 Based on interview and record review the facility failed to provide the necessary services to have one resident (Resident #201) sent to the hospital or wound clinic without delay for treatment of [REDACTED].#201's left leg. F-636 Based on interview and record review the facility failed to complete Admission Minimum Data Set (MDS) assessments for twelve residents (#203, 207, 211, 212, 216, 224, 237, 240, 241, 242, 243 &, 247) and Annual MDS assessments for three residents (#209, 245 & 246) in a timely manner, resulting in facility not identifying each resident's preferences, goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems were identified for all 15 residents. F-638 Based on interview and record review the facility failed to complete 5 Resident (#217, 233, 248, 249 & 250) Minimum Data Set (MDS) assessments timely of 8 quarterly assessments reviewed resulting in the facility not updating and re-assessing each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified for all 5 residents. F-640 Based on interview and record review the facility failed to complete 1 Resident (#251) discharge Minimum Data Set (MDS) assessment of 1 reviewed, resulting in the lack of potential continuity of care, payment and monitoring of services. F-656 Based on interview and record review the facility failed to develop and implement care planned interventions for 4 residents (#203, 207, 208, 209) of 13 residents reviewed for care plan interventions, resulting in Residents' (#203, 207, 208 and 209) care plans not implemented regarding wounds being monitored, measured or assessed, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to the facility policy, no interventions for refusal of care, and the deterioration of wounds. F-657 Based on interview and record review the facility failed to revise care plans for 7 Residents (#201, 202, 204, 205, 206, 210, and 211) of 13 residents reviewed for care plan interventions, resulting in Residents' (#201, 202, 204, 205, 206, 210 and 211) care plan interventions not updated/revised regarding not having their wounds monitored, measured or assessed, the development of facility acquired wounds, wound infections, treatments and documentation according to the facility policy, no interventions for refusal of care, and the deterioration of wounds. F-684 Based on observation, interview, and record review, the facility failed to provide care and treatment to prevent, assess, monitor, measure, treat, and document for venous stasis ulcers (VSU) and wounds for 6 Residents (#201, 202, 203, 206, 208 and 209) of 11 Residents reviewed for wound care resulting in Resident #201's acquisition of 1 VSU (lateral ankle) and the deterioration of 4 VSU (two lateral leg, one great toe and one ankle) which deteriorated during the resident's stay; Resident #202's left heel unstageable venous ulcer; Resident #203's deterioration of a left heel ulcer; Resident #206's lower extremity surgical wounds; Resident #208's left outer thigh open wound; and Resident #209's facility acquired left great toe wound, in addition the Residents' wounds were not monitored, measured or assessed for over a month, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to the facility policy, the deterioration of wounds, and over decline of health and wellbeing of residents with wounds. F-686 Based on observation, interview, and record review, the facility 1) failed to prevent, assess, monitor, measure, treat, and document for one Resident (#201) for a facility acquired pressure heel ulcer and the deterioration of 3 venous stasis ulcers (VSU) (2 on the lateral leg and 1 on the ankle) resulting in Resident #201 having a leg amputated, development of hypoxemia, respiratory distress, bradyarrhythmia and worsening shock and subsequent death on [DATE] and 2) failed to prevent, assess, monitor, measure, treat and document wounds for 5 Residents (#204, 205, 207, 210 and 211) of 11 residents reviewed for wounds, resulting in Resident #204 with a back wound, and a left heel unstageable ulcer; Resident #205 with a right foot and back wounds; Resident #207 with (4) wounds that included a right clavicle, a Stage IV sacrum, a left leg thigh and a right heel un-stageable ulcer; Resident #210 with (11 wounds) a left lateral foot, a left lateral malleolus, a left medial malleolus, a left medial calf, a left outer thigh (1), a left outer thigh (2), a left lateral malleolus, a right trochanter, a left ischial, a right ischial and a sacrum wound; and Resident #211 with (3 wounds) a right heel, a facility-acquired top of right foot and a top of right great toe, resulting in the Residents' wounds not being monitored, measured or assessed for over a month, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to facility policy, the deterioration of wounds, and over decline of health and wellbeing of residents with wounds. F-726 Based on interview and record review, the facility failed to ensure licensed nurses (RN's-Registered Nurses, and LPN's-Licensed Practical Nurses) and certified nursing assistance (CNA's) received yearly training/competencies to assure resident care and safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of Residents in accordance with the facility assessment and Residents' plan of care, for 10 of 17 licensed nurses reviewed for computer based training and competencies and 23 of 37 CNA's reviewed for computer based training, affecting all 68 Residents residing in the facility, resulting in unmet resident needs that included skin assessment and wound care as ascertained during the survey, and nursing staff lacking necessary training and competencies to adequately care for the needs of the Residents residing in the facility. F-727 Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) served on a full-time basis of 35 hours or more a week in the capacity to coordinate, oversee and evaluate nursing care and services provided to Residents, resulting in the inadequate coordination of resident care with negative clinical outcomes as ascertained during the survey that included the prevention, assessment, monitoring, measuring, treatments and documentation of pressure ulcers and wounds, medication administration, the lack of educated, competent nursing staff, the initiation and revision of the Residents' plan of care, nursing staff feeling frustrated, overworked, exhausted, incompetent, and management staff not available to assist direct care staff with Residents' care and needs, affecting the physical, mental, and psychosocial well-being of all 68 residents residing in the facility. F-943 Based on interview and record review, the facility failed to ensure abuse/neglect and resident rights training was completed for 20 of 93 facility staff members reviewed for issues related to abuse/neglect training. This deficient practice had the potential to affect all 68 residents residing in the facility resulting in the potential for unrecognized, unreported, ongoing abuse, and delayed investigations of alleged violations regarding abuse and neglect. A review, of the facility policy entitled, Nursing Staffing, revised ,[DATE], revealed, Policy: The nursing services department provides 24-hour nursing services. The facility ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Information: Nursing service is provided by number and type of personnel to ensure that each resident: Receives treatments, medications, and diets as prescribed; . Receives proper care to maintain their highest level of functioning (prevent decline in function or poor clinical outcomes); Is kept clean, comfortable, and well-groomed; Is protected from accidents, injury, and infection . A review, of the document entitled, Facility Assessment, signed on [DATE], revealed, . 40. Any other pertinent facts or descriptions of the resident population in the facility that is taken into account when determining staffing and resource needs: We consider overall acuity, census, residents needs, care choices, and isolation as well as the physical, cognitive, and individual acuity of each resident; including preferences . E. Staffing Plan: 60. Average number of licensed nurses providing direct care in a 24 hour period: 5. 61. Average number of nurse aides in a 24 hour period: 15. 62. Average number of other nursing personnel (e.g. those with administrative duties) in a 24 hour period: 3. F. Individual Staff Assignment 67. Describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments: facility staffing is determined by the facility assessment which is completed yearly, or if changes occur that have a significant impact on the type and acuity of the resident population of the facility. We utilize resident satisfaction surveys and facility assessments. Consistent assignments are utilized in care coordination to provide continuity of care across the resident population to improve resident health, controlling cost and improving resident outcomes. A review, of the facility document titled, . Daily Nursing Schedule, for dates on [DATE] through [DATE], revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Unit Managers (UM) had worked the floor with assigned direct resident care for the following dates: -On [DATE], day shift, the DON worked the floor 9 am to 6 pm, ADON H did not work, UM V worked the nightshift, UM I worked the floor from 12 pm to 6 pm. -On [DATE] Saturday, UM V worked the floor, nightshift. -On [DATE] Sunday, UM V worked the floor, nightshift. -On [DATE] Monday, ADON H and UM V work the nightshift. -On [DATE], ADON H worked the nightshift. -On [DATE], ADON H worked the nightshift from 6 pm-6:30 am, the DON worked the floor 6 am-6:30 pm, Unit Manager I worked the floor 6 am-6:30 pm. -On [DATE], the DON worked the floor on day shift, UM V worked the nightshift, ADON H did not work, UM I was the only management available. -On [DATE], the DON was scheduled to work the floor but called in sick, UM I worked the floor on day shift, ADON H worked the night before, UM V worked the nightshift. -On [DATE], the DON worked the floor from 6 am-6:30 pm, UM I worked the floor around 11 am, MDS Nurse M worked the night before and staying until 11:22 am then returning at 9:17 pm for the nightshift, ADON H worked the nightshift and UM V was off. -On [DATE], the DON worked the floor on day shift, ADON H worked the nightshift, UM V was off. UM I was the only one of the management team available. -On [DATE], the DON worked the floor day shift, ADON H was off, UM V worked the nightshift, UM I worked the floor. There was no management team available. The NHA (Nursing Home Administrator) worked 12 am - 4 am on the nightshift to cover the shift with Nurse U working at 4 am and then worked until 6:30 pm. -On [DATE], ADON H was scheduled on the nightshift, UM V was scheduled on 8p -2a. -On [DATE], the DON worked 6 pm to 6 am nightshift, ADON H worked the night before, UM I worked the floor 7:30 am -6:30 pm, UM V was not working. There was no management team available. -On [DATE], the DON worked 10P-6A nightshift, ADON H called in sick, UM V was not working, UM I was the only management team on that day. -On [DATE], the DON was off, ADON H worked 7:01 am to 7:03 pm, UM V worked the nightshift, UM I was the only management team member on this day. -On [DATE], ADON H worked 7:05 am - 7:28 pm, UM I worked the floor day shift, UM V worked the nightshift. -On [DATE], the DON worked the nightshift 2:30 am to 6 am, UM I worked the nightshift from 6 pm-2:30 am, ADON H worked the full nightshift. A summary, of the above data from the Daily Nursing Schedule from [DATE] through [DATE], revealed the following: -The DON had worked as direct care nurse on eleven of the days/nights of the 23 days reviewed in (MONTH) and not able to maintain the duties/hours of a full time DON. -ADON H had covered the nightshift as direct care nurse instead of their scheduled shift as an ADON and was not available to maintain the duties/hours of a full time ADON. -Unit Manager V was scheduled as direct care nurse on the nightshift for (MONTH) and was not available to maintain the duties/hours of a full time Unit Manager on the day shift. -Unit Manager I was scheduled as direct care nurse for nine days/nights and was not available to maintain the duties/hours of a full time Unit Manager on the day shift. A review, of the Daily Nursing Schedules for (MONTH) 1st through 23rd, revealed six days when there was no management team members that did not have assigned direct care of Residents and were not available to maintain the duties/responsibilities of their roles in their management position. An interview was conducted with Confidential Staff 15 regarding staffing concerns. When queried if the Unit Managers had done direct resident care, the Staff stated, Yes, and the ADON and the DON too. We can go to them if we need help, but everyone is busy and it's hard. They can't help us out, they have their own Residents to take care of too. When queried if there were enough CNA's to meet the needs of the Residents, the Staff stated, Some days its good and some days it's not. Depends on what is going on. I am always out there, never sit down and try to help as much as I can. You run constantly. When queried if the Residents' needs were met, the Staff stated, When short staffed it takes more time to meet their needs, they have to wait. We try to get to them as we can, but it is not timely. How often is the facility short staffed? It's almost an everyday occurrence. When queried if core staffing of three nurses on dayshift and two nurses on nightshift was adequate to meet the Residents' needs, the Staff stated, It is not adequate. We have a lot of Acute Residents right now. They take more time. They don't adjust the schedule. If we have three nurses on it's still too busy, and now the Unit Managers, the DON, ADON are all working the floor or doing nightshift, they are not available to help you out. The Staff was asked if the management team and the DON were able to maintain management duties when working as direct care staff and stated, No. When they're on a cart (assigned to care for the residents on the floor), they have their own residence to take care of. We are busy all the time. Confidential Staff 15 indicated the DON working the floor and having assigned direct resident care was not functioning as a Director of Nursing. An interview was conducted with Confidential Staff 10 regarding staffing concerns. The Staff reported that management was asking for staff to pick up extra shifts or double shifts and indicated the staff was overworked, tired and that it was hard to work so many hours in a row and stated, At this point something has to be done or we are done. There is not enough staff and we can't keep going like this. I hate it. I go home feeling guilty. The Confidential Staff was queried regarding management staff (DON, ADON and Unit Managers), available to Residents and staff when worked the floor with assigned direct Resident care. The Staff indicated when the management team, including the Director of Nursing, worked a cart (assigned direct Resident care) they were not available to maintain the duties of their roll and were not available to staff and for other Resident care. The Confidential Staff stated care that was not provided to Residents included, Clinical meetings, delay in treatments, missed appointments, care plan meetings, Resident at Risk meetings and follow through with concerns and education is not being done. When queried regarding the follow through with the Resident at Risk meetings, the Staff stated, They just meet to get it done. They don't get anything done. We have a meeting, but things are not followed through. It's a huge part when management is not available and having to do direct care. An interview was conducted with Confidential Staff 19 regarding the DON coverage. The Confidential Staff indicated the DON had been working the floor as direct care staff and that the rest of the management team was pulled to work the floor, with a Unit Manager and the Assistant Director of Nursing assigned to work the nightshift. The Staff stated, There is no management team. They are all pulled to work the floor, even the DON. There is no one to help out. She (DON) can't do it all. Administration is not helping . I feel terrible for the Residents that live there and for the staff that work there. The leadership and the company are not really doing anything to help with the situation. I lost faith in the management. When queried regarding adequate core staffing of three nurses on days and two nurses on nights, assigned direct resident care, the Confidential Staff stated, Depends on the Residents (acuity). It's not always adequate. Can't do Resident care plus management duties. There is no-way, full assignment and follow all the things as Unit Manager or DON. It's just way too much. There is no management team, they are all working the floor. An interview was conducted with Confidential Staff 2 regarding staffing concerns. The Confidential Staff was queried regarding adequate staff to meet resident needs in a timely manner and stated, No, care is not timely. I feel we are understaffed a lot. It's the worst on weekends. There is not enough staff to meet the needs, no. The Staff indicated that CNA's were put on the Daily Schedule but had other jobs to do also and stated, They will put on there staff that are certified, so the count looks good but they are not doing resident care. When queried if these CNA's were assigned certain residents, the Staff stated, No, but they would still count them so the numbers look good, and indicated the CNA would be counted as a float or to help out but had not worked as direct care staff for the hours that were indicated on the Daily Schedule. An interview was conducted with Confidential Staff 23 regarding adequate staffing. The Staff reported they work double shifts. When queried how often they worked double shifts, the Staff stated, Three out of four times that I work. I usually pick it up. When queried if other staff pick up extra shifts the Staff reported that other CNA's pick up extra shifts also. When queried if they have been mandated to work, the Staff stated, Not any more. I pick up so much they don't mandate me. When queried regarding adequate staff on the weekends, the Staff stated, It's horrible. When queried why staffing was horrible on the weekends, the Staff indicated that many CNA's call in, especially on the weekends, and stated, Last weekend they were short, two weekends ago someone called in, they didn't mandate anyone. One day we ran with 4 CNA's until the nurse got someone to come in and then we had 5. When queried regarding resident's needs met timely, the Staff stated, Yes and no. When queried what needs were not being met timely, the Staff stated, Being laid down, wound care, showers, food. The food comes out and they have to wait a half hour to get it. What we do is the residents (that need assist with eating) go to the large dining room and where there is an extra CNA available to assist, the hall carts have to wait to be passed, and indicated there was not enough staff to assist with feeding and pass the meal trays from the hall carts. When queried regarding the wait for a Resident to be laid down, the Staff stated, They wait 20 or 25 minutes, half an hour. When questioned about resident's showers, the Staff stated, A lot of residents miss a shower. When queried if showers were documented as done but were not completed, the Staff stated, Yes, that happens. On [DATE] at 1:00 PM, an observation was made with Nurse C, of Resident #211's wounds and dressing change. The Nurse removed the [MEDICATION NAME] that was wrapped over the Resident's foot and ankle. There was no gauze padding to the heel, top of foot or toe as ordered. The heel was noted to be blackened that encompassed the entire heel, the right great toe had a blackened area and the area on the top of the foot between the toes was moist, open, with necrotic tissue covering the area. After the new dressing was applied, Nurse C was queried regarding the old dressing that was removed, that lacked the gauze padding to cover the wounds. The Nurse stated, I was working a 16-hour shift yesterday. When I did it, I didn't put on the gauze. They had to do measurements, so it had to be done twice yesterday. I did it last night at 9 or 10 (o'clock). It was at the end of my shift, I missed it. The Nurse was queried regarding working the double shift and stated, We are short (of staff) right now. We have lost some nightshift nurses. I told them I could not come in at 6 this morning (after working sixteen hours the day before), so I came in at 9:30 (am). The Nurse expressed feeling tired and overworked and stated, They are always short staffed. On [DATE] at 5:45 PM, ADON H was queried regarding short staffing and the management team providing direct care for Resident's. The ADON stated, I am working nights on the floor (assigned direct patent care). I had to take that shift. We can't always be there (for staff). The ADON reported that they were unable to monitor/assess/measure Residents' wounds due to a lack of staffing and having to work the night shift as direct care staff. On [DATE] at 11:50 AM, an interview was conducted with the Director of Nursing (DON) regarding the Resident at Risk meetings. The DON explained the Resident at Risk meetings were to be done weekly with the management team, where they discussed any issues the Residents had, that included wound care and stated, We discuss what's been done and what's been changed. The DON indicated the meetings had not taken place on a weekly basis or if a meeting had been held, Nursing management had not attended and stated, I have not been involved in the Resident at Risk meetings (in the month of November). I have been on the floor, (ADON) is working the floor, MDS (MDS Nurse Coordinator) has also been helping on the floor. We have not been able to conduct the Resident at Risk meetings like they should be done. On [DATE] at 11:42 AM, an interview was conducted with the DON regarding Resident #210's wound assessments, measurements, treatments, the development of facility acquired pressure ulcers and the Resident at Risk meetings. The Resident at Risk meetings, for Resident #210, was reviewed and the DON indicated the Resident had not been included in a meeting due to the meeting not occurring after the Resident's return to the facility from a hospitalization for wound infection on [DATE]. The DON stated, The meeting was not done due to staffing. There were too many holes (that needed to be filled), I had to work a med cart. The DON indicated the Resident at Risk meetings were a function the DON would facilitate and voiced frustration with the staffing concerns after the loss of multiple nurses, not being able to use agency staffing, taking direct resident care assignments and not able to perform the duties of the Director of Nursing. When queried regarding the lack of using agency nursing, the DON said the issue had been brought up to the Administrator and had not been facilitated to assist with the short staffing crisis and stated, I asked for agency (agency nurses). They won't let me use agency. We tried. That is not something they will allow, and indicated the cost was one factor that prevented the facility use of agency staffing. The DON stated, When I am on the med cart, floor care, my number one priority is taking care of the Residents. Things get missed. You can't do it all when working the floor. When queried what 'all' meant, the DON stated, All the DON duties and take a med cart (direct resident care). On [DATE] at 2:10 PM, an interview was conducted, with the Minimum Data Set (MDS) Nurse M, regarding Resident care plans. The MDS Nurse indicated the care plans have not been initiated or revised like they should be and stated, There are duplicates in the care plans too, I have to go back and cancel those out and revise the ones that are in there. When queried why the care plans have not been updated, the MDS Nurse stated, They want me to pick up as direct care staff then work my regular schedule for MDS Nurse. There is not enough staff and we can't keep going like this. When queried if other Nurses can complete care plans, the Nurse indicated they can but they are picking up extra hours also and the priority of care of the Residents comes first. MDS Nurse stated, When (Nurse H) had put in the care plans on (Resident #210), she did the admission assessment and they just generated, she probably didn't realize or have time to go back and revise them. I stayed after working a night shift and got a lot of that cleaned up. The MDS Nurse indicated the care plans should include the wound sites, have more specific information of the Resident in the focus, goals and interventions, and be revised as needed. On [DATE] at 11:22 AM, an email was received by the Administrator that stated, We don't have policies on the following: Nurse Competency Agency Staffing The policies were not received prior to the exit of the survey. During an interview, on [DATE] at 11:20 AM, Assistant Director of Nursing (ADON) H reported Resident 201 was refusing treatments, not compliant with measurements and treatments, not wearing boot, wearing shoes with hard soles (tennis shoes), and not using heel up pillow. ADON H reported Resident 201 would, especially on [MEDICAL TREATMENT] days, not want to be messed with and would not allow treatments to be completed or take her medications. ADON H stated, The [MEDICAL TREATMENT] days were worse than other days. ADON H reviewed Resident #201's treatment records, Skin & Wound assessments in the electronic medical record, and stated, The last documented note was [DATE]. ADON H was queried if there were any other documentation available and responded, not to my knowledge. ADON H stated, I have been doing what I can, there have been a lot of staffing issues, I have been covering the floor a lot, (on the midnight shift) and have not been able to do other assigned duties. During an interview, on [DATE] at 9:45 AM, the Director of Nursing (DON) reviewed documentation of Resident #201's electronic medical record, treatment records, Skin & wound assessments, nurse progress notes, physician progress notes [REDACTED]. Agreed there was no documentation of the notification to the physician on [DATE], when resident was not able to get in to the wound clinic ASAP (until 7 days later on [DATE]). Agreed there was no documentation of conversation / recommendations with Podiatrist T, ADON H and RN C and in the clinical record no documentation of Resident #201's transfer from the wound clinic to the hospital on [DATE]. Agreed there was no documentation of the accurate location (hospital) at the time of the transfer, and no documentation in the physician progress notes [REDACTED].#201's wounds. During a review of Resident #201's Skin & Wound evaluations / assessments the DON stated, I could not find any assessments for ankle wounds and there is nothing after [DATE] that is loading (the computer) for any of the other wounds (for resident #201). The DON reported Assistant Director of Nursing (ADON) was responsible for providing care for assessing the wounds weekly but due to staffing had been working the floor and had not completed assigned task. The DON reported ADON H was not certified on wound care. During an interview, on [DATE] at 12:40 PM, Medical Director K stated, What can you say. The plan is every week there should be an evaluation, documentation. I do not think the expectation is any different, once a week is the minimum for the wounds. The standard is for one time a week, no one is excluded from that. There are staffing issues. If they (Resident) doesn't cooperate, there has to be documentation, and the physician needs to know. It helps to know what to do next for the resident's care, as well as being notified. Medical Director K agreed, when a resident has a change of condition, he (as the attending physician) expected to be notified and if the resident had a guardian, the guardian needed to be contacted with any change of condition or any refusals. Medical Director K stated, That has to happen. Treatment orders were discussed, and MD stated, Nursing cannot write an order without calling the physician and the consultant needs to contact the physician and receive an approval. During an interview, on [DATE] at 8:16 AM, MDS Registered Nurse (RN) M reviewed Resident #201 through 213's care plans related to wounds and other care issues. MDS RN M agreed the care plan was not updated and she was responsible for updating the care plans. MDS RN M stated, the morning meetings may be called for the IDT (interdisciplinary team) but, the clinical team has not been intact lately. It is hard to get a full picture of what is going on due to staffing, and reported the care plans were not updated during the morning meetings. During an interview and record review, on [DATE] at 3:10 PM, Minimum Data Set (MDS) (Registered Nurse) M reviewed a list of resident Mi

This citation pertains to intake # MI 630. Based on interview and record review, the facility failed to ensure licensed nurses (RN's-Registered Nurses, and LPN's-Licensed Practical Nurses) and certified nursing assistance (CNA's) received yearly training/competencies to assure resident care and safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of Residents in accordance with the facility assessment and Residents' plan of care, for 10 of 17 licensed nurses reviewed for computer based training and competencies and 23 of 37 CNA's reviewed for computer based training, affecting all 68 Residents residing in the facility, resulting in unmet resident needs that included skin assessment and wound care as ascertained during the survey, and nursing staff lacking necessary training and competencies to adequately care for the needs of the Residents residing in the facility. Findings include: A review, of the facility policy entitled, Nursing Staffing, revised 11/2017, revealed, Policy: The nursing services department provides 24-hour nursing services. The facility ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Information Nursing service is provided by number and type of personnel to ensure that each resident: Receives treatments, medications, and diets as prescribed; . Receives proper care to maintain their highest level of functioning (prevent decline in function or poor clinical outcomes); Is kept clean, comfortable, and well-groomed; Is protected from accidents, injury, and infection . Procedure 1. A RN (registered nurse) Director of Nursing is employed full time . A review, of the document entitled, Facility Assessment, with a signed date on 11/19/2019, revealed, . [NAME] Staff Training/Education: 68. Training topics needed by staff: 1. Communication, 2. Resident Rights, 3. Abuse, Neglect, Exploitation/Elder Justice Act, 4. Infection control, 5. Dementia/Alzheimer, 7. Cognitive Impairments, 8. ADL's (activities of daily living) (ROM (range of motion), Transfers, etc), 9. Change in Condition, 10. Cultural, Ethnic, or Religious Needs, 11. Elopement, 12. Skin/Wound Management, 13. Person Centered/Culture Change, 14. Caring for person with mental and psychosocial disorders. 69. Competencies needed by staff: 1. Activities of Daily Living . 2. Disaster Planning and Procedures, 3. Infection Control . 4. Medication Administration, 5. Resident assessment/examination, 6. Vital Signs. 69 a. Specialized Care Competencies: 1. Respiratory Care . 2. Catheterizations, 4. Wound Care, 5. Dressings, 6. IV (intravenous) Access, 8. Enteral Feeding 9. [MEDICATION NAME] Feeding, 10. Glucometer, 12. Trach, 14. Drains, 15. Caring for [MEDICAL CONDITIONS] and Trauma. 69b. Other Competencies/Training: Staff competencies provide the skills needed for employees to perform their job effectively. Employee competencies are performed annually or whenever necessary to assure that the employees have the knowledge and the ability to perform and provide appropriate care in the work environment while meeting or exceeding the standards of practice in each department . A list of training for staff in the last year was requested from the facility. The document received from the facility, for the mandatory computer based training, entitled, Training Hours, dated 11/21/19, with a date range from 1/1/2019 to 11/21/2019, was reviewed for direct care staff (licensed nurses and CNA's) completing training for aggressive behaviors/behavior management, wound care/pressure injury/ulcer prevention, resident rights and dementia training. The following revealed staff that had not completed the mandatory computer based training, as listed in the Training Hours document: -Aggressive behaviors/behavior management, 16 CNA's and 10 Licensed Nurses did not have this training listed. -Wound management (pressure injury/ulcer prevention and wound care), 23 CNA's and 7 Licensed Nurses did not have this training listed -Resident rights, 13 CNA's and 3 Licensed Nurses did not have this training listed. -Dementia care, 9 CNA's and 4 Licensed Nurses did not have this training listed. On 11/26/19 at 3:57 PM, an interview was conducted with the Director of Nursing (DON) regarding education in-services and the computer based training. The DON stated, It's mandatory (computer based training). The goal is to do it by the 15th of every month. (Assistant Director of Nursing (ADON)) can track it and get people in to do it. When queried if the ADON had been tracking the employees completion of the computer based training, the DON stated, No, not the last few months because she has been on a cart (medication cart/floor care). She had to take a night shift position. When queried what the computer based training consisted of, the DON stated, It's a monthly in-service. It opens each month with the education. I know you can add education into it that needs to be done. It's a regulation, mandatory, it has to be done. A review of the document titled Training Hours, was reviewed, with the DON, of some of the staff not having abuse/neglect, aggressive behaviors, wound management, resident rights and dementia training not completed. When queried why staff have not been completing the mandatory training, the DON stated, It's hard to take someone off the schedule to get it done when you don't have enough staff to cover. Staffing got worse and it fell off the grid. The DON was queried regarding in-services and the computer based training. She responded, The in-service is separate (from the computer based training). That is why (name of computer based training) is mandatory. No matter if an in-service is attended or not, if it's done in (name of computer based training) then it's covered. In a perfect world, it would be done by the 15th, monitor who hasn't done it, call, hound them to get it done until its completed, then start disciplinary action if needed. The DON was queried regarding nursing competencies and stated, I have not done the competencies in the last year. I don't have anything to show you. I have set up like a job fair before and set up stations with the different skills. The DON was queried that since the facility had a Resident with a wound vac, had training of the direct care staff been completed on [DEVICE], the DON stated, I have not done it. We have the one resident now with one, the one before that I think it was maybe back in March. When he came in, we had to put the wound vac on. I was working at cart that day. With everything that was going on, we just went in there and put it on. Normally I wound have the staff come in and observe and teach them at the bedside. When queried how she knows staff is competent to apply, assess and monitor a wound vac, the DON responded, They can ask some of the Nurses that are more familiar with them. I know we need to educate on that. There are no competencies of the Nurses taking care of the Resident with the wound vac? No, I have not done any competencies. Confidential Staff Interviews An interview was conducted with Confidential Staff 10 regarding staff education. The Staff stated, They put a list out last week to get (name of computer training program) done. I don't think many have done any since March. A nurse was not even aware of how to get into the system. There is no time to do it. Not when you are working extra time. You could come in on your day off but when you work so many extra days, who wants to come in and do that. There is no time to do it when you are working. An interview was conducted with Confidential Staff 15 regarding wound care education. When queried if the Staff had received education on wound care, measurements and treatments, the Staff stated, Very little, not a lot, we need more. It's very lacking. The Staff explained, I learned what I know over the years, but I need more education. When you don't use some of these skills all the time, you need practice or reminders. I don't feel confident in some of the skills in wound care and other skills too. When queried regarding [DEVICE], the Staff stated, Need education on that. When queried if they had participated in demonstration of skills or a check off for competencies in nursing skills, the Staff stated, No, we have never done that. My knowledge is acquired by working and learning as I go and what little bit I actually get from here. An interview was conducted with Confidential Staff 2 regarding education provided by the facility on [DEVICE]. The Staff stated, I have some background in [DEVICE]. I assisted some of the nurses, helped them out at shift change. When queried if there were many Residents with [DEVICE], the Staff stated, We have just this one right now. The Staff was queried if the facility provided education and competencies on the use of [DEVICE], the Staff stated, No formal education and no competencies. It's very unofficial. When queried regarding education and competencies done with Nursing staff on wound assessment and measurements for new admissions, the Staff stated, No, there has not been any competencies or wound assessment education with staff that I know of. An interview was conducted with Nurse V regarding education received at the facility. The Nurse stated, I never got a lot of training. People were pulled in all directions. They weren't available to train me. I took the role of Unit Manager but I really wasn't trained in it, then I had to take a night position and I never got to do the role of the Unit Manager. Another Unit Manager was hired but they weren't trained either. The role of the Unit Manager was not really followed because we were pulled to do floor care and take a cart (medication cart). I was put in management but never got the training and then didn't get to do the role. On 12/4/19 at 11:22 AM, an email was received by the Administrator that stated, We don't have policies on the following: Nurse Competency Agency Staffing The policies were not received prior to the exit of the survey. An interview was conducted on 11/22/19 at 9:45 AM, with the Director of Nursing (DON) regarding wound care and competency for ADON H who was responsible for the oversight of wound care, assessments, and treatments. The DON reported ADON H was not certified on wound care. During an interview on 11/26/19 at 4:58 PM, the Administrator was queried regarding training of nurse competencies and responded, No QA monitoring for competencies, and not aware staff had not completed the training for competencies, staff had a mannequin set up and did competencies (date unknown), (computer based training discussed. The administrator agreed the training was not completed. The Administrator stated, Can get staff in to have completed, it is not completed and not tracked for being completed. Have discussed several times in QA as an ongoing thing that needs attention. (ADON H) was looking at it and had a list of staff that needed training. Obviously, it wasn't followed up if it is not in there, hindsight I will have to look at the binders. Review of the facility binders revealed the nurse competencies had not been completed in over a year.

This citation pertains to intake #MI 630. Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of all 68 residents residing in the facility, resulting in insufficient staff to cover nursing requirements, Director of Nursing unable to perform job duties of her job description, Assistant Director of Nursing unable to perform her job description/wound management, Unit Managers unable to perform their job description, Minimum Data Set Nurse unable to perform her job description and the IDT (Interdisciplinary team) had not meet weekly to discuss resident concerns identified. Findings Include: The facility was determined to be noncompliant with regulatory requirements F-580, F-600, F-636, F-638, F-640, F-656, F-657, F-684, F-686, F-711, F-725, F-726, F-727, F-760 F-865 and F-943. F-580: Based on interview and record review the facility failed to notify the resident's physician and/or the resident's guardian of the rapid deterioration of a change of condition, refusal of care, and transfer of the resident to hospital for one resident (Resident #201), resulting in a lack of communication and a delay in treatment for [REDACTED]. F-600: Based on interview and record review the facility failed to provide the necessary services to have one resident (Resident #201) sent to the hospital or wound clinic without delay for treatment of [REDACTED].#201's left leg. F-636: Based on interview and record review the facility failed to complete Admission Minimum Data Set (MDS) assessments for twelve residents (#203, 207, 211, 212, 216, 224, 237, 240, 241, 242, 243 &, 247) and Annual MDS assessments for three residents (#209, 245 & 246) in a timely manner, resulting in facility not identifying each resident's preferences, goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems were identified for all 15 residents. F-638: Based on interview and record review the facility failed to complete 5 Resident (#217, 233, 248, 249 & 250) Minimum Data Set (MDS) assessments timely of 8 quarterly assessments reviewed resulting in the facility not updating and re-assessing each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified for all 5 residents. F-640: Based on interview and record review the facility failed to complete 1 Resident (#251) discharge Minimum Data Set (MDS) assessment of 1 reviewed, resulting in the lack of potential continuity of care, payment and monitoring of services. F-656: Based on interview and record review the facility failed to develop and implement care planned interventions for 4 residents (#203, 207, 208, 209) of 13 residents reviewed for care plan interventions, resulting in Residents' (#203, 207, 208 and 209) care plans not implemented regarding wounds being monitored, measured or assessed, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to the facility policy, no interventions for refusal of care, and the deterioration of wounds. F-657: Based on interview and record review the facility failed to revise care plans for 7 Residents (#201, 202, 204, 205, 206, 210, and 211) of 13 residents reviewed for care plan interventions, resulting in Residents' (#201, 202, 204, 205, 206, 210 and 211) care plan interventions not updated/revised regarding not having their wounds monitored, measured or assessed, the development of facility acquired wounds, wound infections, treatments and documentation according to the facility policy, no interventions for refusal of care, and the deterioration of wounds. F-684: Based on observation, interview, and record review, the facility failed to provide care and treatment to prevent, assess, monitor, measure, treat, and document for venous stasis ulcers (VSU) and wounds for 6 Residents (#201, 202, 203, 206, 208 and 209) of 11 Residents reviewed for wound care resulting in Resident #201's acquisition of 1 VSU (lateral ankle) and the deterioration of 4 VSU (two lateral leg, one great toe and one ankle) which deteriorated during the resident's stay; Resident #202's left heel unstageable venous ulcer; Resident #203's deterioration of a left heel ulcer; Resident #206's lower extremity surgical wounds; Resident #208's left outer thigh open wound; and Resident #209's facility acquired left great toe wound, in addition the Residents' wounds were not monitored, measured or assessed for over a month, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to the facility policy, the deterioration of wounds, and over decline of health and wellbeing of residents with wounds. F-686: Based on observation, interview, and record review, the facility 1) failed to prevent, assess, monitor, measure, treat, and document for one Resident (#201) for a facility acquired pressure heel ulcer and the deterioration of 3 venous stasis ulcers (VSU) (2 on the lateral leg and 1 on the ankle) resulting in Resident #201 having a leg amputated, development of hypoxemia, respiratory distress, bradyarrhythmia and worsening shock and subsequent death on [DATE] and 2) failed to prevent, assess, monitor, measure, treat and document wounds for 5 Residents (#204, 205, 207, 210 and 211) of 11 residents reviewed for wounds, resulting in Resident #204 with a back wound, and a left heel unstageable ulcer; Resident #205 with a right foot and back wounds; Resident #207 with (4) wounds that included a right clavicle, a Stage IV sacrum, a left leg thigh and a right heel un-stageable ulcer; Resident #210 with (11 wounds) a left lateral foot, a left lateral malleolus, a left medial malleolus, a left medial calf, a left outer thigh (1), a left outer thigh (2), a left lateral malleolus, a right trochanter, a left ischial, a right ischial and a sacrum wound; and Resident #211 with (3 wounds) a right heel, a facility-acquired top of right foot and a top of right great toe, resulting in the Residents' wounds not being monitored, measured or assessed for over a month, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to facility policy, the deterioration of wounds, and over decline of health and wellbeing of residents with wounds. F-711: Based on interview and record review, the facility failed to 1) complete a review of resident's total program of care, complete a medical evaluation of resident's condition and review the appropriateness of the resident's medical regimen in regard to the acquiring, treatment, documentation, and rapid deterioration of 6 venous stasis ulcers for 1 Resident (#201) resulting in the Resident's development of 3 venous stasis ulcers to her left leg including a left ankle, left foot and big toe. The left heel was unstageable and covered with eschar. 2) failed to complete a residents' total program of care, complete a medical evaluation of residents' condition and review the appropriateness of the residents' medical regimen in regard to the acquiring, treatment, documentation and/or rapid deterioration of wounds for 4 Residents (#203, 205, 208 and 211) of 11 residents reviewed with wounds resulting in a lack of physician documentation of condition of wounds for Resident #203's open back wound, Resident #205's deterioration of an unstageable heel ulcer, Resident #208's left outer thigh open wound, and Resident #211's (3 wounds) right heel, facility acquired top of right foot and top of right great toe. 3) failed to provide residents' physician progress notes [REDACTED]. review of the appropriateness of residents' medical regimen for 30 Residents (#202, 204, 206, 209, .245, 246, 247, 248, 251, 252, 253, 254, 255, 258, 259, 261, 262, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, and 277), resulting in lack of continued quality care and communication for staff providing care for Residents. Residents #,[DATE] were used as examples of the deficient practice. Residents #,[DATE]'s information was not included in the body of the citation but are available upon request. 4) the facility failed to ensure the attending physician documented and reviewed the hospital discharge summary or hospital progress notes during required visits, for 15 (#212, 215, 216, 218, 221, 222, 226, 227, 233, 234, 235, 236, 237, 238, and 240) of 68 residents reviewed and failed to document a review of the resident's total program of care, for 28 residents (#212, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236, 238, 239, 240, 278) of 68 reviewed. (Total program of care includes: medical services (high risk diagnosis) and medication management, physical, occupational, and speech/language therapy, nursing care (such as: treatments, care plan, blood sugar monitoring, falls .), nutritional interventions (weight monitoring, feeding tubes, supplements) social work and activity services that maintain or improve psychosocial functioning)., including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being (behavioral management) and decisions about the continued appropriateness of the resident's current medical regimen.) This lack of review of the resident's total program of care resulted in 15 residents' return from the hospital, with a lack of documented assessment by the physician, lack of communication, and questionable continuity of care due to the very brief, repetitive, uninformative physician progress notes [REDACTED]. Residents #212 and 214 were used as samples of the deficient practice. Residents #,[DATE]'s information was not included in the body of the citation but are available upon request. F-725: Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for 68 of 68 Residents, who reside in the facility, resulting in unmet care needs, as identified by the issues ascertained during the survey that included the prevention, assessment, monitoring, measuring, treatments and documentation of pressure ulcers and wounds, medication administration, the lack of educated, competent nursing staff, the initiation and revision of the Residents' plan of care, nursing staff feeling frustrated, overworked, exhausted, incompetent, and management staff not available to assist direct care staff with Residents' care and needs, affecting the physical, mental, and psychosocial well-being of all 68 residents residing in the facility. F-726: Based on interview and record review, the facility failed to ensure licensed nurses (RN's-Registered Nurses, and LPN's-Licensed Practical Nurses) and certified nursing assistance (CNA's) received yearly training/competencies to assure resident care and safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of Residents in accordance with the facility assessment and Residents' plan of care, for 10 of 17 licensed nurses reviewed for computer based training and competencies and 23 of 37 CNA's reviewed for computer based training, affecting all 68 Residents residing in the facility, resulting in unmet resident needs that included skin assessment and wound care as ascertained during the survey, and nursing staff lacking necessary training and competencies to adequately care for the needs of the Residents residing in the facility. F-727: Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) served on a full-time basis of 35 hours or more a week in the capacity to coordinate, oversee and evaluate nursing care and services provided to Residents, resulting in the inadequate coordination of resident care with negative clinical outcomes as ascertained during the survey that included the prevention, assessment, monitoring, measuring, treatments and documentation of pressure ulcers and wounds, medication administration, the lack of educated, competent nursing staff, the initiation and revision of the Residents' plan of care, nursing staff feeling frustrated, overworked, exhausted, incompetent, and management staff not available to assist direct care staff with Residents' care and needs, affecting the physical, mental, and psychosocial well-being of all 68 residents residing in the facility. F-760: Based on observation, interview and record review, the facility failed to receive and administer IV (intravenous) medication in a timely manner for one Resident (#210) of eleven Residents reviewed for wound care, resulting in Resident #210 not receiving medication as prescribed for wound infection with the potential for worsening of infection,[MEDICAL CONDITION] and exacerbation of signs and symptoms of wound infection. F-865: Based on observation, interview, and record review the facility failed to identify and monitor concerns and perform quality assurance measures related to staffing, resident wounds, physician progress notes [REDACTED]. team was working the floor. F-943: Based on interview and record review, the facility failed to ensure abuse/neglect and resident rights training was completed for 20 of 93 facility staff members reviewed for issues related to abuse/neglect training. This deficient practice had the potential to affect all 68 residents residing in the facility resulting in the potential for unrecognized, unreported, ongoing abuse, and delayed investigations of alleged violations regarding abuse and neglect. During an interview and record review, on [DATE] at 3:10 PM, Minimum Data Set (MDS) (Registered Nurse) M reviewed a list of resident Minimum Data Set assessments (MDS's) that included admission (5 day, 14 day & 30 day), quarterly, annual and discharge assessments. RN M reported there were multiple assessments that had been late or not completed due to working the floor as a charge nurse. RN M reported management was aware the assessments were late due to doing more than one job and unable to complete the task. During an interview, on [DATE] at 4:58 PM, the Administrator reported during monthly QA meetings, the following staff attended the meetings: Administrator, Director of Nursing (DON), Assistant DON, the leadership team, that included Social Worker Director and Assistant Social Worker, MDS Nurse, Unit Managers, Dietary Manager, Activity Director, and also attending were the following: Restorative CNA, Environmental Supervisor, Central Supply staff, Medical Records, Pharmacist, Medical Director, Corporate staff, Accounts Receivable/Payable and Human Resources and reported the last meeting was held on [DATE]. The Administrator reported wounds were discussed in QA but there was not a PIP (Performance Improvement Project) for wounds and they were not discussed individually in Q[NAME] The Administrator reported the DON pulled a report on wounds for the QA meeting as part of the performance improvement, infection control piece, but the wounds were not discussed for each individual resident. The Administrator was queried why the wounds had not been discussed for the individual residents and responded, I did not know they (the residents' wounds) were not measured and monitored and reported, that the team went over notes, went over the computer dash board and could not explain why the the wounds were in such bad shape, and did not realize the doctors were not seeing the wounds. The Administrator reported corporate had completed a Mock survey and identified multiple residents' wounds as a concern during the week prior to survey. The Mock survey had been conducted on [DATE], [DATE] and [DATE]. The Administrator reported she had reviewed a physician note for Attending Physician L and identified a concern approximately a month ago and stated, The physician note needed more extensive documentation, had a talk with Attending Physician L and informed him 'you need more documentation.' The Administrator reported the conversation was not documented at that time. The Administrator reported Attending Physician L does not attend QA meetings. The Administrator agreed there was no plan put in place at that time related to physician documentation. The Administrator agreed she was not aware of the number of missing progress notes for Attending Physician K. The Administrator agreed there was no PIP in place for the lack of documentation for physician progress notes [REDACTED]. the physician to observe wounds during his rounds. The Administrator reported the unit managers have been working as floor nurses and have been unable to do their roles. The Administrator stated, (Unit Manager I) has not had to work the floor. The Administrator was queried if Unit Manager I was able to fill the roles of the other management staff while the other nurses are working the floor? And responded, It has not been that long. The Administrator stated, Usually staff have gone to the (Administrator) office for nurse questions. The staff were overwhelmed on the floor, instead of reaching out to (Nursing) management as they were not available as they are so stretched. They could not complete tasks. The Administrator reported that staffing had been addressed through the QA committee by staff satisfaction surveys, employee engagement PIP, through employee interviews. The Administrator reported that she had used her interviews and surveys to identify that staff did not feel appreciated. These were completed a couple months ago. The Administrator reported she had started an employee engagement PIP performance and reported third shift feels like they are left out. The Administrator reported she had gone into the facility on the third shift, took in soup/pizza and listened to their concerns. The Administrator reported there was a staffing concern through the month of (MONTH) (2019). The Administrator was queried if staffing was brought up in QA and responded, discussed staffing in morning stand up in AM, stand down in afternoon. The Administrator reported she had discussed with staff what other departments could do to assist staff with staffing concerns. The Administrator reported sometimes she would hold Resident at Risk meetings. The Administrator was queried about providing agency staff for nursing and avoided answering the question, then stated, Nurses had agency before and there were problems with Agency staff with drug diversion and staff sleeping at the nurses' station. The Administrator reported to have resolved nursing staffing concerns with the facility by initiating a sign on bonus for new hires. The Administrator was queried as that takes time, what was she doing for the staffing situation now? and responded, Have someone from (sister facility) that is going to cover shifts. (At time of exit of the survey this had not been initiated). Pick up bonus $,[DATE] hours, $80 for 8 hours, $40 for 4 hours. Midnight a dollar hour shift differential. The Administrator was queried regarding training of nurse competencies and responded, No QA monitoring for competencies, and not aware staff had not completed the training for competencies, staff had a mannequin set up and did competencies (date unknown), (computer based training) discussed. The administrator agreed the training was not completed. The Administrator stated, Can get staff in to have completed, it is not completed and not tracked for being completed. Have discussed several times in QA as an ongoing thing that needs attention. ADON was looking at it and had a list of staff that needed training. Obviously, it wasn't followed up if it is not in there, hindsight I will have to look at the binders. Review of the facility binders revealed the nurse competencies had not been completed in over a year. The Administrator stated, during morning meeting, we go around the room with each staff and I was not informed of the late (Minimum Data Set) assessments. That concerns me as there were that many that were incomplete. The Administrator was queried of the management staff working the floor, including the MDS nurse, how did she expect the task to be completed? The Administrator had no answer. An interview was conducted with Confidential Staff 19 regarding the DON coverage. The Confidential Staff indicated the DON had been working the floor as direct care staff and that the rest of the management team was pulled to work the floor, with a Unit Manager and the Assistant Director of Nursing assigned to work the nightshift. The Staff stated, There is no management team. They are all pulled to work the floor, even the DON. There is no one to help out. She (DON) can't do it all. Administration is not helping . I feel terrible for the Residents that live there and for the staff that work there. The leadership and the company are not really doing anything to help with the situation. I lost faith in the management. When queried regarding adequate core staffing of three nurses on days and two nurses on nights, assigned direct resident care, the Confidential Staff stated, Depends on the Residents (acuity). It's not always adequate. Can't do Resident care plus management duties. There is no-way, full assignment and follow all the things as Unit Manager or DON. It's just way too much. There is no management team, they are all working the floor. On [DATE] during confidential staff interviews, it was reported that several staff had picked up multiple shifts and were informed they were not receiving the pickup bonus as they had been previously informed. A review, of the facility policy Skin Management, dated ,[DATE], revealed, 1. Resident, responsible party and attending physician are notified of the development of any diabetic, vascular or arterial ulcer. 2. Etiology of the ulcer is determined as well as the treatment plan. This is achieved via the attending and/or consulting physician . 3. A care plan is developed or updated to reflect the new problem and interventions with evaluation and revisions documented on an ongoing basis. 4. The resident Kardex will also be updated to reflect any changes. 5. The licensed nurse will evaluate the wound weekly and document the status/progress on the Wound/Skin Healing Record, until it is healed. 6. The resident is added to the 24-hour report/dashboard for continued follow-up 8. Consult with certified wound care nurse (CWS or CW[NAME]N) or physician may be appropriate. If a wound care consultation is appropriate, a physician's orders [REDACTED]. 9. Quarterly, a system audit of the Skin Management Guideline is conducted to ensure ongoing compliance in all areas. Results will be reported to the QAPI committee for trending, analyzing and recommendations.

This citation pertains to intake #MI 630. Based on observation, interview, and record review, the facility failed to identify and monitor concerns and perform quality assurance measures related to staffing, resident wounds, physician progress notes [REDACTED]. as management team was working the floor. Findings include: During an interview, on 11/20/19 at 12:45 PM, the Administrator reported she was already aware of concern for documentation of notifications for transfers and residents change of conditions and had discussed the identified concern in Q[NAME] During an interview, on 11/26/19 at 4:58 PM, the Administrator reported during monthly QA meetings, the following staff attended the meetings: Administrator, Director of Nursing (DON), Assistant DON, the leadership team, that included Social Worker Director and Assistant Social Worker, MDS Nurse, Unit Managers, Dietary Manager, Activity Director, and also attending were the following: Restorative CNA, Environmental Supervisor, Central Supply staff, Medical Records, Pharmacist, Medical Director, Corporate staff, Accounts Receivable/Payable and Human Resources and reported the last meeting was held on 11/13/19. The Administrator reported wounds were discussed in QA but there was not a PIP (Performance Improvement Project) for wounds and they were not discussed individually in Q[NAME] The Administrator reported the DON pulled a report on wounds for the QA meeting as part of the performance improvement, infection control piece, but the wounds were not discussed for each individual resident. The Administrator was queried why the wounds had not been discussed for the individual residents and responded, I did not know they (the residents' wounds) were not measured and monitored and reported, that the team went over notes, went over the computer dash board and could not explain why the the wounds were in such bad shape, and did not realize the doctors were not seeing the wounds. The Administrator reported corporate had completed a Mock survey and identified multiple residents' wounds as a concern during the week prior to survey. The Mock survey had been conducted on 11/13/19, 11/14/19 and 11/15/19. The Administrator reported she had reviewed a physician note for Attending Physician L and identified a concern approximately a month ago and stated, The physician note needed more extensive documentation, had a talk with Attending Physician L and informed him 'you need more documentation.' The Administrator reported the conversation was not documented at that time. The Administrator reported Attending Physician L does not attend QA meetings. The Administrator agreed there was no plan put in place at that time related to physician documentation. The Administrator agreed she was not aware of the number of missing progress notes for Attending Physician K. The Administrator agreed there was no PIP in place for the lack of documentation for physician progress notes [REDACTED]. the physician to observe wounds during his rounds. The Administrator reported the unit managers have been working as floor nurses and have been unable to do their roles. The Administrator stated, (Unit Manager I) has not had to work the floor. The Administrator was queried if Unit Manager I was able to fill the roles of the other management staff while the other nurses are working the floor? And responded, It has not been that long. The Administrator stated, Usually staff have gone to the (Administrator) office for nurse questions. The staff were overwhelmed on the floor, instead of reaching out to (Nursing) management as they were not available as they are so stretched. They could not complete tasks. The Administrator reported that staffing had been addressed through the QA committee by staff satisfaction surveys, employee engagement PIP, through employee interviews. The Administrator reported that she had used her interviews and surveys to identify that staff did not feel appreciated. These were completed a couple months ago. The Administrator reported she had started an employee engagement PIP performance and reported third shift feels like they are left out. The Administrator reported she had gone into the facility on the third shift, took in soup/pizza and listened to their concerns. The Administrator reported there was a staffing concern through the month of (MONTH) (2019). The Administrator was queried if staffing was brought up in QA and responded, discussed staffing in morning stand up in AM, stand down in afternoon. The Administrator reported she had discussed with staff what other departments could do to assist staff with staffing concerns. The Administrator reported sometimes she would hold resident at risk meetings. The Administrator was queried about providing agency staff for nursing and avoided answering the question, then stated, Nurses had agency before and there were problems with Agency staff with drug diversion and staff sleeping at the nurses' station. The Administrator reported to have resolve nursing staffing concerns with the facility by initiating a sign on bonus for new hires. The Administrator was queried as that takes time, what was she doing for the staffing situation now? and responded, Have someone from (sister facility) that is going to cover shifts. (At time of exit of the survey this had not been initiated). Pick up bonus $120/12 hours, $80 for 8 hours, $40 for 4 hours. Midnight a dollar hour shift differential. The Administrator was queried regarding training of nurse competencies and responded, No QA monitoring for competencies, and not aware staff had not completed the training for competencies, staff had a mannequin set up and did competencies (date unknown), (computer based training) discussed. The administrator agreed the training was not completed. The Administrator stated, Can get staff in to have completed, it is not completed and not tracked for being completed. Have discussed several times in QA as an ongoing thing that needs attention. ADON was looking at it and had a list of staff that needed training. Obviously, it wasn't followed up if it is not in there, hindsight I will have to look at the binders. Review of the facility binders revealed the nurse competencies had not been completed in over a year. The Administrator stated, during morning meeting, we go around the room with each staff and I was not informed of the late (Minimum Data Set) assessments. That concerns me as there were that many that were incomplete. The Administrator was queried of the management staff working the floor including the MDS nurse, how did you expect the task to be completed? The Administrator had no answer. On 12/10/19 during confidential staff interviews, it was reported that several staff had picked up multiple shifts and were informed they were not receiving the pickup bonus as they had been previously informed. A review, of the facility policy Skin Management, dated 7/2016, revealed, 1. Resident, responsible party and attending physician are notified of the development of any diabetic, vascular or arterial ulcer. 2. Etiology of the ulcer is determined as well as the treatment plan. This is achieved via the attending and/or consulting physician . 3. A care plan is developed or updated to reflect the new problem and interventions with evaluation and revisions documented on an ongoing basis. 4. The resident Kardex will also be updated to reflect any changes. 5. The licensed nurse will evaluate the wound weekly and document the status/progress on the Wound/Skin Healing Record, until it is healed. 6. The resident is added to the 24-hour report/dashboard for continued follow-up 8. Consult with certified wound care nurse (CWS or CW[NAME]N) or physician may be appropriate. If a wound care consultation is appropriate, a physician's orders [REDACTED]. 9. Quarterly, a system audit of the Skin Management Guideline is conducted to ensure ongoing compliance in all areas. Results will be reported to the QAPI committee for trending, analyzing and recommendations.

This citation pertains to intake #MI 630. Based on interview and record review, the facility failed to provide the necessary services to have one resident (Resident #201) sent to the hospital or wound clinic without delay for treatment of [REDACTED].#201's left leg. Findings include: Resident #201: A review, of Resident #201's Electronic Medical Record (EMR), Physician's orders, Physician's Progress notes, care plans, Minimum Data Set (MDS) assessments, Medication Administration Records (MAR), Treatment Administration Records (TAR), revealed that the resident was admitted on [DATE] - 5/24/19 and readmitted on [DATE] -10/9/19 with [DIAGNOSES REDACTED]. A review, of Resident #201's Wound Clinic note, dated 10/9/19, revealed, Wound at 3 Left Heel is an Eschar covered Arterial Ulcer and has received a status of not healed. Initial wound encounter measurements are 9 cm length x 8.5 cm width, with an area of 76.5 sq cm. No tunneling has been noted. There is a small amount of drainage noted which has a strong odor. Wound bed has 76 - 100% eschar . Patient also has small open ulcers on the medial and lateral ankle Pt (patient) found to have extensive gangrene of left heel with foul odor present. Pt has absented pedal pulses on left LE (lower extremity) and is at very high risk [MEDICAL CONDITION] and limb loss. I called (facility) and explained to the severity of the situation. As we do not have vascular surgery in this town, pt was taken to (hospital) ER for admission via (Ambulance) transport services. A review, of Resident #201's Hospital record of the Surgical Consult, post op dated 11/14/19, revealed, [DIAGNOSES REDACTED]. H & P (history and physical) dated 11/15/19 revealed The patient is a [AGE] year-old female with [MEDICAL CONDITION], systolic [MEDICAL CONDITION] (EF 25%), HTN, DM, [MEDICAL CONDITION], and [MEDICAL CONDITION]. POD (post-op day) #1 L AKA (left above knee amputation) for L (left) foot gangrene and PAD. Post-operatively the patient developed worsening hypoxemia and respiratory distress and was transferred to the ICU (intensive care unit) and intubated -0645 this morning. Following this, she developed bradyarrhythythmia and worsening shock .Empiric [MEDICATION NAME] and [MEDICATION NAME], await culture data . A review, of Resident #201's Facility Podiatry note, dated 10/2/19, revealed, left foot and leg ulcer, infection, approx. 1 month duration, pt having regular wound care, po (oral) antibiotics, nursing has concerns about progression of problem, pt has dm, kidney failure, [MEDICAL CONDITIONS] .symptoms: numbness, redness, swelling .aggravating factors: pressure, Impact on daily life: this infection may compromise diabetic control and her leg High risk-[MEDICAL CONDITION], monofilament 6.8 or less, and [MEDICAL CONDITION] and /or foot disease . the superficial blisters were opened and drained, the black eschar felt soft and fluctuant under and purulence was noted from margins with pressure . Skin Left; Abnormal - black eschar approx. 15 cm left plantar. During an interview on 11/26/19 at 3:49 PM, Facility Podiatrist T reported that he had met with the Director of Nursing (DON) and charge nurse by the nurses' station and informed both the DON and the charge nurse that Resident #201's condition was imminent and had discussed sending resident to the hospital or the wound clinic as soon as possible and felt Resident #201 had a significant infection as she had been on antibiotics for 6 weeks. Podiatrist T reported he was informed Resident had been sent to the wound clinic on 10/9/19 and reported he had not been aware that the facility had waited a week and that was not what he had recommended at the time of the meeting, with the DON and Charge Nurse, on 10/2/19. Podiatrist T again stated, I informed them both the DON and the Charge nurse Resident's condition was imminent and had recommended they send her to the hospital if they could not get her in to the wound clinic ASAP (As Soon As Possible). During an interview, on 11/22/19 at 9:45 AM, the Director of Nursing reviewed documentation of Resident #201 electronic medical record, treatment records, Skin & wound assessments, nurse progress notes, physician progress notes [REDACTED]. Agreed there was no documentation of the notification to the physician on 10/2/19 when resident was not able to get in to the wound clinic ASAP (until 7 days later on 10/9/19). The DON agreed there was no documentation of the conversation / recommendations that Podiatrist T, had with Assistant Director of Nursing (ADON H) and Registered Nurse (RN) C. The DON agreed that in the clinical record there was no documentation of Resident #201's transfer from the wound clinic to the hospital on [DATE]. The DON agreed there was no documentation of the accurate location (hospital) at the time of the transfer, and agreed there was no documentation in the physician's progress notes related to Resident #201's wounds. During a review of Resident #201's Skin & Wound evaluations / assessments the DON stated, I could not find any assessments for ankle wounds and there is nothing after 9/12/19 that is loading (in the computer) for any of the other wounds (for Resident #201). The DON reported that the Assistant Director of Nursing was responsible for providing care for assessing the wounds weekly but, due to staffing issues, had been working the floor and had not completed her assigned tasks. The DON reported ADON H was not certified for wound care. During an interview on 12/4/19 at 8:30 AM, Registered Nurse C reported she was assigned care for Resident #201 on 10/2/19 and had requested Podiatrist T to evaluate Resident #201, due to wounds and odor of wounds on her feet. Resident #201 had not been on the monthly list to be seen by Podiatrist T. RN C stated, The Podiatrist's nurse came out of the Resident #201's room to get me (RN C) to come into her room. RN C further stated, The Podiatrist (T) stated, 'You are spot on. This is imminent. She needs to go to the Wound Clinic ASAP.' RN C reported that she, Podiatrist T, and ADON H had discussed sending Resident #201 to the hospital or the wound clinic and Podiatrist T said it was imminent and needed to be done ASAP. RN C reported she felt Resident #201 needed to go to the hospital immediately because the appointment at the wound clinic was not scheduled until 10/9/19. RN C stated that the ADON overruled her and Resident was not sent to the hospital immediately. RN C reported she had requested that Attending Physician L look at the wound on the heel on his last visit to see Resident #201 (unsure of the date), but thought the date was on 9/21/19. RN C reported she had started to unwrap Resident #201's dressing on the heel and Attending Physician L refused to look at Resident #201's wounds. RN C voiced she had been very frustrated with Attending Physician L and ADON H due to Resident #201 having an odor that was very strong on her wounds, especially on the heel and no one was listening to her assessment concerns. RN C reported she was very pleased Podiatrist T had agreed with the assessed concerns, but again felt like Podiatrist T was out voted by Attending Physician L and ADON H once he left the facility. A review, of Resident #201's Nurse Progress note, dated 10/2/19, revealed, Resident has diabetic ulcer on left heel and left lateral ankle. Doctor assessed left heel continues to deteriorate despite courses of antibiotics and changes to dressing regimen. Resident chooses not follow plan of care at times. Doctor notified of changes to left heel, and new orders received to have consult with wound clinic as soon as possible and follow their recommendations. A review, of Resident #201's Attending Physician L's physician progress notes [REDACTED]. A review, of Resident #201's Physician orders, revealed Resident was prescribed antibiotics (Bactrim) for wound infections on 8/16/19 -8/26/19, 9/8/19 -9/23/19 and was on [MEDICATION NAME] 9/26/19 - 10/9/19 for pneumonia. There was no physician order for [REDACTED]. A review, of the facility policy entitled, Abuse Prohibition Policy, revised 7/2018, revealed, .All facility staff and volunteers shall be in-serviced upon first employment and at least annually thereafter regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, and misappropriation of property . B. Training: 1. The facility will train each employee regarding these policies . 4. The facility will provide ancillary training regarding related policies and procedures. 5. All employees are in-serviced on the complete Abuse Prohibition Policy, at minimum annually. 6. Resident Rights is a subsection and integral part of all job descriptions/evaluations . 8. An integral part of all training and education endeavors for reporting allegations of abuse is an assurance that there will be no administrative retribution or reprisal, appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of burnout, frustration and stress that may lead to abuse; and what constitutes abuse, neglect, exploitation and misappropriation of resident property .

This citation pertains to intake # MI 630 and MI 415. Based on observation, interview, and record review, the facility failed to provide care and treatment to prevent, assess, monitor, measure, treat, and document for venous stasis ulcers (VSU) and wounds for 6 Residents (#201, 202, 203, 206, 208 and 209) of 11 Residents reviewed for wound care resulting in Resident #201's acquisition of 1 VSU (lateral ankle) and the deterioration of 4 VSU (two lateral leg, one great toe and one ankle) which deteriorated during the resident's stay; Resident #202's left heel unstageable venous ulcer; Resident #203's deterioration of a left heel ulcer; Resident #206's lower extremity surgical wounds; Resident #208's left outer thigh open wound; and Resident #209's facility acquired left great toe wound, in addition the Residents' wounds were not monitored, measured or assessed for over a month, the development of facility acquired wounds, wound infections, treatments not completed timely or documented according to the facility policy, the deterioration of wounds, and over decline of health and wellbeing of residents with wounds. Findings included: A review, of the facility policy Skin Management, dated 7/2016, revealed 1. Resident, responsible party and attending physician are notified of the development of any diabetic, vascular or arterial ulcer. 2. Etiology of the ulcer is determined as well as the treatment plan. This is achieved via the attending and/or consulting physician . 3. A care plan is developed or updated to reflect the new problem and interventions with evaluation and revisions documented on an ongoing basis. 4. The resident Kardex will also be updated to reflect any changes. 5. The licensed nurse will evaluate the wound weekly and document the status/progress on the Wound/Skin Healing Record, until it is healed. 6. The resident is added to the 24-hour report/dashboard for continued follow-up 8. Consult with certified wound care nurse (CWS or CW[NAME]N) or physician may be appropriate. If a wound care consultation is appropriate, a physician's order should be obtained for the consultation. 9. Quarterly, a system audit of the Skin Management Guideline is conducted to ensure ongoing compliance in all areas. Results will be reported to the QAPI committee for trending, analyzing and recommendations. A review, of the facility policy Lippincott Procedures - Change in status, identifying and communicating, long-term care dated 12/4/19 revealed Identify a suspected acute change in the resident . Perform a complete physical assessment, focusing on the identified change in status .Communicate the change in the resident's condition to the appropriate practitioner. Notify the resident's family about the change in the resident's condition and the subsequent treatment plan. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure Document the acute change in status, behavioral changes, vital signs, and other assessment findings in the appropriate areas in the medical record. Record nursing interventions and the resident's response. Be sure to document all communication with other health care providers as well as the practitioner's orders and any diagnostic tests you performed. Record communication with the resident's family. Not any teaching you provided to the resident and family members as well as areas of learning that required additional teaching. A review, of the facility policy Documentation Expectations, dated 11/2017 revealed Aspects of resident care such as observations and assessments, administration of mediations, and services or treatments performed must be documented in the resident medical record according to company policy. During an interview on 11/22/19, in the AM, the Administrator and the Director of Nursing (DON) were requested by the surveyor to observe dressings and wounds on Residents with wounds/dressing changes. During an interview on 11/25/19 at 7:20 AM, the Administrator and the DON were requested by the surveyor to observe dressing changes and wounds on residents #202, 203, 204 and 205. At 8:00 AM, all 4 residents were observed out of their rooms and in the dining room. Dressing changes had not been observed. During an interview on 11/25/19 at 9:15 AM, Assistant Director of Nursing (ADON) H, who was responsible for wound care, stated, the floor nurses are responsible for the dressing changes today. On 11/25/19 at 11:00 AM, there were no dressing changes observed. There were no dressing changes for wounds observed at the time the surveyor left the facility for the day at 6:00 PM on 11/25/19 as requested. During an interview, on 11/26/19 at 7:30 AM, the Administrator and the DON were both requested for observation of wound care on Residents #203, #204, and #205. At 8:50 AM, ADON H and the DON assisted with observations of Resident wounds and dressing changes on Resident #202 and #204. Resident #205 refused. Resident #201 A review, of Resident # 201's electronic medical record Physician orders, physician progress notes [REDACTED]. A review, of Resident #201's Wound Clinic note, dated 10/9/19, revealed, Wound at 3 Left Heel is an Eschar covered Arterial Ulcer and has received a status of not healed. Initial wound encounter measurements are 9 cm length x 8.5 cm width, with an area of 76.5 sq. cm. No tunneling has been noted. There is a small amount of drainage noted which has a strong odor. Wound bed has 76 - 100% eschar . Patient also has small open ulcers on the medial and lateral ankle . Pt found to have extensive gangrene of left heel with foul odor present. Pt has absented pedal pulses on left LE and is at very high risk [MEDICAL CONDITION] and limb loss. I called (facility) and explained to the severity of the situation. As we do not have vascular surgery in this town, pt was taken to (hospital) ER for admission via (Ambulance) transport services. During an interview, on 11/26/19 at 3:49 PM, facility Podiatrist T reported that he had met with the DON and the charge nurse by the nurses station and informed both, the DON and the charge nurse, that Resident #201's condition was imminent, had discussed sending resident to the hospital or the wound clinic as soon as possible, felt Resident #201 had a significant infection as she had been on antibiotics for 6 weeks and the infection was ongoing. Podiatrist T reported he was not aware Resident #201 had not been sent to the wound clinic until 10/9/19, not aware that the facility had waited a week. Podiatrist T said, that was not what he had recommended at the time of the meeting with the DON and the charge nurse on 10/2/19. Podiatrist T again stated, I informed them both, the DON and the charge nurse, Resident (#201's) condition was imminent, and I had recommended they send her to the hospital if they could not get her in to the wound clinic ASAP (as soon as possible). During an interview on 11/25/19 at 5:42 PM, Attending Physician L reported that Resident #201 was seen by podiatry as the specialist in September, again on 10/2/19 and was notified on 10/2/19 of a decline when it was recommended Resident #201 was to be sent to the wound clinic and was on an antibiotic. Attending physician L stated, Maybe I am part to blame. It is harder with the computer to find information. I don't go look at the wounds. I count on the specialist as they are the experts in that field. I receive the information in my office and review the information at that time. Attending Physician L stated, I if I know they are going to the wound clinic, I feel they are being followed. I trust the wound clinic and defer to the wound professional. Attending Physician L agreed his documentation (for the residents) did not have documentation on the wounds. Attending Physician reported he was not aware of the federal regulations for documentation. During an interview on 12/4/19 at 8:30 AM, Registered Nurse C reported she was assigned care for Resident #201 on 10/2/19 and had requested Podiatrist T to evaluate Resident #201, due to wounds and odor of wounds on her feet. Resident #201 had not been on the monthly list to be seen by Podiatrist T. RN C stated, The Podiatrist's nurse came out of the Resident 201's room to get me (RN C) to come into her room. RN C further stated, The Podiatrist (T) stated, 'You are spot on. This is imminent. She needs to go to the Wound Clinic ASAP.' RN C reported that she, Podiatrist T, and ADON H had discussed sending Resident #201 to the hospital or the wound clinic and Podiatrist T said it was imminent and needed to be done ASAP. RN C reported she felt Resident #201 needed to go to the hospital because the appointment was not scheduled until 10/9/19 but was out voted by ADON H. RN C reported she had requested Attending Physician L look at the wound on the heel on his last visit to see Resident #201 (unsure of the date) and she thought the date was on 9/21/19. RN C reported she had started to unwrap Resident #201's dressing on the heel and Attending Physician L refused to look at Resident #201's wounds. RN C voiced she had been very frustrated with Attending Physician L and ADON H due to Resident #201 having an odor that was very strong on her wounds, especially on the heel and no one was listening to her assessment concerns. RN C reported she was very pleased Podiatrist T had agreed with the assessed concerns, but again felt like Podiatrist T was out voted by Attending Physician L and ADON H once he left the facility. A review, of Resident #201's Nurse Progress Note, dated 10/2/19, revealed, Resident has diabetic ulcer on left heel and left lateral ankle. Doctor assessed left heel continues to deteriorate despite courses of antibiotics and changes to dressing regimen. Resident chooses not follow plan of care at times. Doctor notified of changes to left heel, and new orders received to have consult with wound clinic as soon as possible and follow their recommendations. A review, of Resident #201's Attending Physician L's physician progress notes [REDACTED].#201's wounds that included a facility-acquired heel pressure wound, acquisition of 1 VSU (lateral ankle) and the deterioration of 4 VSU (2 lateral leg, one great toe and one ankle). A review, of Resident #201's Physician orders revealed Resident was prescribed antibiotics (Bactrim) for wound infections on 8/16/19 -8/26/19, 9/8/19 -9/23/19 and was on [MEDICATION NAME] 9/26/19 - 10/10/19 for pneumonia. There was no physician order for [REDACTED].#201 was on antibiotic treatment. A review, of Resident #201's re-admission assessment revealed, resident was admitted on [DATE] with the following open wounds, left lower leg rear, left lower leg front and left outer ankle 6 x 3 (inches). (Inappropriate documentation of measurements and assessment of wounds) A review, of Resident #201's Treatment Administration Record (TAR) revealed the following treatment refusals that had not been documented on the left heel: from 7/2/19-7/31/19 (4 not documented as completed), 8/1/19-8/30/19 (1 refusal), 9/1/19 -9/30/19 (5 refusals, 1 not documented as completed), and 10/1/19 -10/9/19 (1 refusal). A review, of Resident #201's clinical record reveled there were no ongoing measurements or assessments of one left outer ankle wound from 6/26/19 until the mention of the wound in the nurse progress note on 10/2/19. Wound clinic notes, dated 10/9/19, revealed Resident #201 had 2 open ulcers on the left ankle, Patient also has small open ulcers on the medial and lateral ankle. This indicated (1) new open area on the left ankle at some point since Resident #201's admission on 6/26/19. Physician's order dated 7/1/19, revealed, Left lateral Ankle: cleanse open areas with wound cleanser, pat dry, apply optical ag (silver) to wound bed, cover with dry dressing, change daily everyday shift for venous stasis ulcer. A review, of Resident #201's Physician's orders and treatment records, revealed there were no physician orders or treatments documented on the treatment records for Resident #201's (2) lateral calf wound areas since admission on 6/26/19 through discharge on 10/9/19. A review, of Resident #201's Skin & Wound Evaluations (V5.0 forms), revealed deterioration of the following assessments to the #1 (for this citation this wound is identified as #1 as there were 2 wounds in the area and not identified in the documentation with identifiers) left lateral calf venous stasis ulcer (no exact date of the origination of the wound on the forms): Dated on 7/16/19, measured 0.9 cm 2 x 0.1 x 1.0 x 0.2, copy of assessment was not provided as requested on 11/20/19, 12/4/19 and 12/6/19 during the survey. Dated on 8/27/19, measured 1.0 cm 2 x 1.2 x 1.2 x 0.3, 90% slough D. Exudate 1. Amount- 3. Moderate, Type- Serosanguineous, Odor-2. Faint, E. Periwound - 1. Edges 1. Attached, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3), 9. Pain Frequency- 3. At Dressing; Notes Resident frequently chooses not to follow P[NAME] (plan of care) regarding nutritional supplements, boot/heels up repositioning. Education: (Blank). Dated on 9/4/19, measured 0.8 cm 2 x 1.0 x 1.0 x 0.3 80% slough D. Exudate 1. Amount- 2. Light, Type- Serosanguineous, Odor-2. Faint, E. Periwound - 1. Edges 1. Attached, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3), 9. Pain Frequency- 3. At Dressing. Dated 9/12/19, measured 0.9 cm 2 x 1.0 x 1.2 x 0.2 cm 80% slough, D. Exudate 1. Amount- 3. Moderate, Type- Serosanguineous, Odor-1. None, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3), 9. Pain Frequency- 3. At Dressing. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. No further assessments were noted in the electronic medical record documented after 9/12/19 for the #1 lateral calf venous stasis ulcer. A review, of Resident #201's Skin & Wound Evaluations (V5.0 form), revealed deterioration of the following assessments to the #2 left lateral calf venous stasis ulcer (no exact date on forms of origination of wound): Dated on 7/16/19, measured 2.4 cm 2 x 2.2 x 1.4 x 0.2 cm, 100% slough. A copy of the assessment was not provided as requested on 11/20/19, 12/4/19 and 12/6/19 during the survey. Dated on 8/27/19, measured 3.7 cm 2 x 2.8 x 1.7 x 0.3 cm, 80% slough D. Exudate 1. Amount- 3. Moderate, Type- Serosanguineous, Odor-2. Faint, Peri wound - 1. Edges 1. Attached, 2. Surrounding Tissue: 1. Blanching 7. Dry/Flaky, 4. [MEDICAL CONDITION]- 3. Non-pitting .F. Wound Pain- 8. Pain (3), 9. Pain Frequency- 3. At Dressing, 1. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration On 9/4/19 measured 1.6 cm 2 x 2.1 x 1.0 x 0.3 cm, 90% slough, D. Exudate 1. Amount- 3. Moderate, Type- 4. Serosanguineous, 3. Odor 1. None, 2. Surrounding Tissue: 1. Dry/Flaky, F. Wound Pain- 8. Pain (3), 9. Pain Frequency- 3. At Dressing, 1. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration Dated on 9/12/19, measured 2.4 cm 2 x 2. 3 x 1.4 x 0.4, 70% slough, D. Exudate 1. Amount- 3. Moderate Type- 4. Serosanguineous, 3. Odor 1. None, 2. Surrounding Tissue: 1. Dry/Flaky, F. Wound Pain- 8. Pain (3) 9. Pain Frequency- 3. At Dressing, 1. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. Increase in size of wound noted since 9/4/19. No further assessments were noted in the electronic medical record after 9/12/19 of wound #2 lateral calf venous stasis ulcer. A review, of Resident #201's Physician orders and treatment records for the Left Great toe revealed from 7/2/19 -9/4/19 cleanse with wound cleanser, pat dry, apply skin prep, cover with dry dressing, change daily everyday shift for necrotic area. A review, of Resident #201's Physician orders and treatment record for the Left Great toe revealed treatments discontinued on 9/4/19 leave open to air. A review, of Resident #201's Treatment record and physician order for [REDACTED]. Left great toe (1st digit) was identified as a concern on the Treatment record dated (MONTH) 7/2/19 (7 days after re-admission) with eschar (first documentation noted in EMR) There were no skin assessments prior to 8/28/19 and last documented as assessed on 9/12/19 by nursing Wound Skin Evaluation (V5.0 form) assessments. Resident #201's Wound Skin Evaluation (V5.0 form) assessments of the left great toe revealed the following: On 8/28/19 measured 0.3 cm 2 x 0.6 cm x 0.3 cm, no odor, no Exudate, 2. Surrounding Tissue: 6. Discoloration - black /blue. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration On 9/4/19 measured 0.4 cm 2 x 0.8 cm x 0.7 cm no odor, no Exudate, 2. Surrounding Tissue: 6. Discoloration - black /blue, Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. Wound had increased in size. On 9/12/19 measured 0.4 cm 2 x 0.8 cm x 0.7 cm, 2. no Odor, no Exudate, Surrounding Tissue: 6. Discoloration - black /blue, Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. No further assessments were noted in the electronic medical record after 9/12/19. A review, of Resident 201's Nurse Progress Notes, dated 6/26/19 through 10/9/19, revealed multiple entries of resident refusals of medication. There was no documentation the guardian or the physician was notified of Resident 201's refusals of treatments or medications. A review, of Resident #201's Care plan, dated 7/11/19, revealed Resident has actual impairment to skin integrity r/t (related to) falls and several open areas on arms and legs with interventions of encourage good nutrition and hydration in order to promote healthier skin. Provide dietary supplements as ordered. Observe location, size and treatment of [REDACTED]. Resident #201's Skin integrity Care plan was not updated since 6/26/19, to include the new facility acquired left heel pressure/venous stasis ulcer, the outer ankle, the left great toe, specifics to any of the stasis ulcers, or included interventions for Resident #201's refusals of care and treatments. During an interview, on 11/25/19 at 8:20 AM, MDS Registered Nurse (RN) M reviewed Resident's care plan for skin integrity, wound care and revisions and stated, The care plan was not updated with new open areas. MDS Nurse M reported she was responsible for updating Resident #201's care plan but, due to staffing had not been able to keep up with the task. MDS RN M stated, the facility morning meetings may be called to meet but, the clinical team has not been intact lately. It is hard to get a full picture of what is going on due to staffing, and reported the care plans were not updated during the morning meetings. During an interview, on 11/20/19 at 8:50 AM, Social Worker (SW) A reported resident went to the wound clinic, was transported by (ambulance) and was not sure why guardian was not notified at the time of transfer from the wound clinic to the hospital on [DATE]. SW A reported resident had been deemed incompetent prior to admission to the facility due to poor choices and lack of selfcare. SW A reported resident went to the appointment by herself as she was able to voice her own wants and needs and scored a 15 on her BIMS (indicated was alert and oriented). SW A reported Guardian had come to the facility to see Resident #201 and Resident was not in the facility and Guardian was upset. SW A reported she had explained the situation and she had apologized to the guardian and stated, it was a slip through the crack. During an interview, on 11/20/19 at 10:15 AM, Registered Nurse (RN) C, was assigned care on the unit and was responsible for resident at the time resident was sent to the wound clinic appointment. RN C reported she was informed by the wound clinic nurse shortly after resident had left the wound clinic and was transferred to the hospital (unable to provide specific time). RN C reported guardian should have been called, and stated, I should have made sure the guardian was called or made sure the wound clinic did it, and stated, The wound clinic stated the wound looked bad and were going to send resident to the hospital. RN C reported she had received education for notification of transfer /change of condition from the administrator today (11/20/19). Review of Resident #201's documentation of the MAR's, TAR's, and progress notes revealed frequent refusals of medications and treatments. RN C was queried if resident had refused any medications or treatments and responded, At first had refused treatments, and occasionally refused medications. RN C was queried if the guardian had been notified of refusals and responded, No. During an interview, on 11/20/19 at 11:20 AM, Assistant Director of Nursing (ADON) H reported Resident 201 was refusing treatments, not compliant with measurements and treatments, not wearing boot, wearing shoes with hard soles (tennis shoes), and not using heel up pillow. ADON H reported Resident 201 would, especially on [MEDICAL TREATMENT] days, not want to be messed with and would not allow treatments to be completed or take her medications. ADON H stated, The [MEDICAL TREATMENT] days were worse than other days. ADON H reviewed Resident #201's treatment records, Skin & Wound assessments in the electronic medical record, and stated, The last documented note was 9/12/19. ADON H was queried if there were any other documentation available and responded, not to my knowledge. ADON H stated, I have been doing what I can, there have been a lot of staffing issues, I have been covering the floor a lot, (on the midnight shift) and have not been able to do other assigned duties. ADON H stated, I cannot honestly say the guardian was aware of the behaviors (refusals) and had conversations with guardian but not specific with wound concerns. ADON H stated, Resident #201 was offered protein supplements but, she was not drinking the supplements, offered a shake, not our standard, more for kidney issues and (Resident #201) did not like it. ADON H reported prior to going to the wound clinic, Resident #201 had refused to go to the wound clinic but was unsure if this was discussed with the guardian and ADON H reported she was unable to locate any documentation related to the conversation of Resident 201's refusal to go to the wound clinic. ADON H reported she had not informed the guardian of the Resident's refusal and reported Resident #201 had not been to the wound clinic until 10/9/19 as previously reported. During an interview, on 11/20/19 at 12:45 PM, the Administrator reported she was already aware of concerns for documentation of notifications and had discussed the concern in QA (quality assurance), but had not been aware of the concern for wound assessments not being completed. During an interview, on 11/22/19 at 9:45 AM, the Director of Nursing (DON) reviewed documentation of Resident #201's electronic medical record, treatment records, Skin & wound assessments, nurse progress notes, physician progress notes [REDACTED]. Agreed there was no documentation of the notification to the physician on 10/2/19, when resident was not able to get in to the wound clinic ASAP (until 7 days later on 10/9/19). Agreed there was no documentation of conversation / recommendations with Podiatrist T, ADON H and RN C and in the clinical record no documentation of Resident #201's transfer from the wound clinic to the hospital on [DATE]. Agreed there was no documentation of the accurate location (hospital) at the time of the transfer, and no documentation in the physician progress notes [REDACTED].#201's wounds. During a review of Resident #201's Skin & Wound evaluations / assessments the DON stated, I could not find any assessments for ankle wounds and there is nothing after 9/12/19 that is loading (the computer) for any of the other wounds (for resident #201). The DON reported Assistant Director of Nursing (ADON) was responsible for providing care for assessing the wounds weekly but due to staffing had been working the floor and had not completed assigned task. The DON reported ADON H was not certified on wound care. An interview was conducted on 11/22/19 at 11:50 AM, with the DON and Regional Clinical Coordinator (RCC) U. RCC U reported the corporate staff had been at the facility the previous week and identified skin issues as a concern but had not assisted the staff with getting the assessments up to date. The DON reported according to facility policy, any changes with Resident wounds the physician should be notified, agreed the facility was doing treatments but no changes documented, no physicians notified, and the wounds were to be monitored for at least 4 weeks after they were healed. The DON reported Residents should be provided education with any refusals of treatments, guardian or physician has to be notified and care planned, even if they are their own responsible party. The DON stated, The responsible party should be notified with the first contact of refusal. The DON reported Resident #201's guardian came into the facility but, I cannot speak that there was any conversation with the guardian, about her wounds. During an interview, on 11/22/19 at 12:40 PM, Medical Director K stated, What can you say. The plan is every week there should be an evaluation, documentation. I do not think the expectation is any different. Once a week is the minimum for the wounds. The standard is for one time a week, no one is excluded from that. There are staffing issues. If they (Residents) don't cooperate, there has to be documentation, and the physician needs to know. It helps to know what to do next for the resident's care, as well as being notified. Medical Director K agreed, when a resident has a change of condition, he (as the attending physician) expected to be notified and if the resident had a guardian, the guardian needed to be contacted with any change of condition or any refusals. Medical Director K stated, That has to happen. Treatment orders were discussed, and Medical Director K stated, Nursing cannot write an order without calling the physician and the consulting physician needs to contact the (attending) physician and receive an approval. Resident #202 A review, of Resident #202's electronic medical record revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the electronic medical record revealed the resident had a left heel unstageable venous ulcer. A review, of Resident #202's physician progress notes [REDACTED]. A review, of Resident #202's physician progress notes [REDACTED]. A review, of Resident #202's physician progress notes [REDACTED]. We are unable to see base of wound because of covered with eschar without any slough formation . Resident #202's last documented available physician progress notes [REDACTED].left lower extremity [MEDICAL CONDITION] with [MEDICAL CONDITION], Left heel nonhealing/ cervical (sp) ulcer. We cleansed the wound with wound cleanser and pat a dry and apply the skin prep at the surrounding area and cover with dry dressing and wrap with Kerlix and secured with tape and change daily. We are keeping the offloading boots and We will monitor the wound and wound dressing every shift. A review, of Resident #202's Nursing Admission assessment, dated 8/17/18, revealed, 3. Pressure injury - Heels very soft and red. Circled Mushy. A review, of Resident #202's Physician order dated 7/17/19, for left heel treatment of [REDACTED]. Review of the Skin and Wound Evaluation (V5.0 form), dated 11/20/19, revealed, Left Heel, Pressure, unstageable, slough and or/ eschar, 1.2 cm 2, x 1.2 cm x 1.6 cm, E. Periwound- 4. [MEDICAL CONDITION]. non pitting > 4 cm around wound. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. A review, of the Skin and Wound Evaluation (V5.0 form), dated 10/24/19, revealed, Left Heel, Pressure, unstageable, 100% slough, 0.8 cm 2 x 0.8 x 1.2 cm, Exudate, 2. Light. 4. Serosanguineous. Goal of Care- 2. Slow to heal: wound healing is slow or stalled but stable, little/no deterioration. A review, of Resident #202's Skin and Wound Evaluation (V5.0 form), dated 9/12/19, revealed, Left Heel, Pressure, unstageable, slough and or/ eschar, Area 0.5 cm 2, 0.7 cm x 1.0 x 0.2 cm. A review, of Resident #202's Skin and Wound Evaluation (V5.0 form), dated 9/4/19, revealed, Left Heel, Pressure, unstageable, slough and or/ eschar, Area 1 x 2.0 x 1.1 cm with Periwound/surrounding tissue earthman: Redness of the skin. A review, of Resident #202's Care plan, revealed, (Resident) has an unstageable pressure ulcer to his L (left) heel. He also has a history of additional pressure ulcers that have resolved since admission. He is also at risk for further breakdown r/t his bowel and bladder incontinence and impaired mobility. He has a peg tube in place. He chooses to wear tennis shoes instead of his heel protectors at times. Res also has a cyst on his back, dated 8/28/18, with an intervention that included Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD as needed. Initiated 8/28/18. During an interview, on 11/25/19 at 8:16 AM, MDS Registered Nurse (RN) M reviewed Resident #202's care plan for unstageable p

Based on observation, interview and record review, the facility failed to 1) provide supervision to prevent the elopement and ensure the safety of 1 (Resident #101) of 5 sampled residents, 2) ensure resident wander guard placement checks were completed and documented per facility policy and 3) ensure all exit doors had properly functioning alarms, resulting in Immediate Jeopardy for Resident #101, who was put at risk for physical harm, injury and/or death and placing 2 other residents assessed at risk for elopement, at high risk for serious harm. Findings Include: Review of the Face Sheet, facility Minimum Data Set ((MDS) dated [DATE], nurses, social service note's dated 7/20/17 to 8/12/17, and hospital History and Physical and Behavioral Health Services note's dated 7/18/17 and 6/30/17, revealed Resident #101 was an [AGE] year old male, admitted to the facility from a geriatric psychiatric unit on 7/20/17, alert to self, cognitively impaired with intermittent confusion, oriented to person only with short and long term memory loss, aggression, agitation with combative behaviors, wandered oblivious to safety needs and who had a wander guard placed by the facility to his left ankle due to being assessed an elopement risk. The resident's [DIAGNOSES REDACTED]. Review of the facility Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 had a BIMS (cognitive assessment tool) of 8 and review of his BIMS dated 9/14/17, revealed he had a score of 7, cognitively impaired. Review of the Social Service Admission Evaluation dated 7/27/17, stated responses are delayed. Review of the facility Activities Evaluation dated 7/24/17, stated Resident stated he enjoys going for walks but would like someone to walk with him because he gets lost. Review of the Inpatient Behavioral Health Services Progress Note's (hospital records) dated 7/18/17, stated Continued hospitalization Necessary due to: risk of harm to others recent aggression. Dementia with behavioral disturbances, anxiety, arsenic poisoning, CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease, depression. Review of the facility admission Data Collection dated 7/20/17, revealed Resident #101 was alert, oriented to person only, had short and long term memory loss, was cognitively impaired with intermittent confusion, was independent with his wheelchair, had the ability to exit the building and wandered oblivious to safety needs. Review of the IDT (interdisciplinary team meeting) note dated 7/25/17, stated deficits from long term poisoning (arsenic), res (resident) A & O x 1 (alert to self only); the residents medications included Lexapro (antianxiety and depression medication), Ativan (antianxiety medication) and risperidone (antipsychotic medication). Review of the Physical Therapy (PT) note dated 7/20/17, stated high risk for falls secondary to impulsive ambulation. Review of the facility copy of the hospital letter of cognitive impairment for Resident #101 dated 11/29/16, stated his (the resident) prognosis with the Dementia and his other co-morbidities is poor, and in my medical opinion he requires the assistance and monitoring of another individual 24/7 for safety. Review of the facility Statement of Incompetency dated 8/8/17, revealed Resident #101 was incompetent due to, difficulty processing, cognitively poor incite. Review of the facility Elopement Risk Alert (un-dated), revealed a picture of Resident #101 and stated areas/places to focus search, parking lot. During an interview done on 9/14/17 at 9:10 a.m., staff member U (Director of Social Service) stated, he (Resident #101) fluctuates with his cognition, I can't say he is safe to be outside alone. Review of the physician order [REDACTED]. Observation of Resident #101 was made on 9/12/17 at 2:30 p.m. The resident was sitting in his wheelchair in his room with a wander guard on his left ankle. He was confused and unable to recall his elopement on 8/3/17 at 3:45 p.m. Elopement on 8/3/17: Review of the facility Incident Report and Investigation dated 8/4/17, revealed on 8/3/17 at 3:45 p.m., Resident #101 was observed by staff member E (Occupational Therapist/OT) in his wheelchair outside of the facility, alone, unsupervised along the sidewalk in the East parking lot. (Staff member E) redirected the resident into the facility and notified (staff member M former Director of Nursing) of the resident being outside. The facility concluded the resident was assisted by a family member and this was validated by (staff member D Activity Assistant). Review of IDT note dated 8/8/17, stated 8/3/17 res (Resident #101) noted to be outside, redirected inside. Review of the facility plan to remove the immediate Jeopardy dated 9/14/17, stated On 9/13/17 at 5:40 p.m., management staff met for a debriefing of the elopement procedure and Ad Hoc QAPI. The root cause analysis was determined to be non-functional exit door. Observation was made on 9/12/17 at 3:00 p.m., accompanied by staff member F (Director of Maintenance) and staff member G (Staff Education/Infection Control, RN) of the facility east parking lot where Resident #101 was found. The resident was found in his wheelchair with his wheelchair wheels stuck in the mud/grass on the edge of the sidewalk just off of the staff parking lot (east parking lot). The distance measured by staff member F from the location the resident was found (on 8/3/17), to the facility exit driveway leading to a very busy 2 lane 55 mile an hour road was 150 feet and approximately 106 feet from the activity exit door. Review of Resident #101's Wander Guard care plan dated 8/7/17, stated nursing to check placement of wander guard every shift, nursing to check function of wander guard every day, facility exit doors are alarmed, re-direct resident when exit seeking, direct supervision while outside, 15 minute checks. During an interview done on 9/12/17 at 1:55 p.m. and per hand written statement dated 9/13/17 at 12:43 p.m., staff member D (Activity Aide) stated I was coming back to the activity room (on 8/3/17), I saw him (Resident #101) through the activity room window, in the parking lot with another residents family members. He was sitting in his wheelchair by the parked cars, I thought he was with his family. I didn't see him leave out the door. During an interview done on 9/13/17 at 9:20 a.m., staff member E (Occupational Therapist/OT) stated I was leaving work at 3:42 p.m. (on 8/3/17), I walked out and I saw him (Resident #101) in the East parking lot in his wheelchair on the side walk. Two wheels of his wheelchair were stuck in the grass/mud, (staff member G Charge Nurse, LPN) was out there, I asked her if she was with him, she said she was not with him, she did not know he was there. He (the resident) was by himself, he was confused. (Staff member G) and I got him to the parking lot and I brought him to the front door. (Staff member N Human Resource/HR) let us in the building. From my understanding, no one was aware he was out of the building. I told (staff member M former Director of Nursing/DON) I found him out in the parking lot. During an interview done on 9/13/17 at 8:06 a.m., staff member N (HR) stated we were in a meeting and the front door alarm sounded. I got up and checked it. (Staff member E OT) was at the front door trying to get in with (Resident #101), because he had a wander guard on the door would not open, I let them in. She (staff member E OT) said she found him (the resident) in the parking lot by himself. I did not hear an alarm (an exit door alarm sounding) prior to the meeting. During an interview done on 9/13/17 at 7:20 a.m., and per record review of hand written note's dated 8/4/17, staff member G (Charge Nurse, LPN) stated I was outside on break (on 8/3/17 at 3:45 p.m.), (staff member E OT) called me over and she pointed the resident out to me. He was in his wheelchair on the sidewalk, his wheel had gotten stuck in the grass so he couldn't go anywhere. He was confused, he wanted to go home, he pointed toward the trees, that's where he said he came from. I didn't hear any alarms (prior to finding the resident outside the facility). I don't know how he got out there, he's always trying to go outside. When this surveyor asked staff member G if this incident could have been prevented, she stated yes. During an interview done on 9/12/17 at 1:00 p.m., staff member M (Former Director of Nursing/DON) stated I was in a meeting, we heard the front door alarm going off, (staff member E OT) was trying to get back in the front door with the resident (Resident #101). He was found outside in the south side of the east parking lot alone in his wheelchair. The (staff member E) said she found him outside alone, I said (to staff member T Administrator at the time of the elopement) we need to investigate this. I left and text' d (staff member T former Administrator), I said are we considering this is an elopement, he called me back and said it's not an elopement. During a phone interview done on 9/13/17 at 1:50 p.m., staff member T (former Administrator) stated a family member pushed him out. During an interview done on 9/12/17 at 2:45 p.m., staff member H (Staff education/Infection Control, RN) stated, I do think this is an elopement, (staff member E OT) told me when she left work (on 8/3/17), she went to the staff east parking lot and she saw (Resident #101) on the side walk, he was by himself. During an interview done on 9/12/17 at 2:15 p.m., staff member I (Nursing Assistant/CNA) stated, he got out and was roaming around the parking lot, it doesn't make sense to me, the alarm (door alarm) would have gone off. During an interview done on 9/12/17 at 2:00 p.m., staff member B (Director of Nursing/DON) revealed all the managers met and went over the residents elopement and thought he got out of the facility by a family member letting him out and stated, it was a group effort. Review of the facility Best Practices-Elopement policy dated 11/23/16, stated Elopement occurs when a resident, who is not alert and oriented, is found off Center premises, unaccompanied, without the knowledge of the staff or when a resident is identified as missing from the Center. Facility Wander Guard Checks: On 9/12/17, review of Resident #101's Treatment Record dated 8/17, revealed no documentation on, 8/1/17 (on all 3 shifts), 8/2/17 (on all 3 shifts), 8/3/17 (on all 3 shifts), 8/10/17 (11:00 p.m. to 7:00 a.m. shift) and on 8/30/17 (7:00 a.m. to 3:00 p.m. shift), confirming nursing staff had checked his wander guard on his left ankle for placement and functionality. On 9/14/17, review of Resident #101's Treatment Record dated 8/17, revealed filled in documentation of nursing staff checking his wander guard for placement and functionality on 8/1/17, 8/2/17, and 8/3/17. During an interview done on 9/14/17 at 11:40 a.m., accompanied by staff member A (Administrator) and staff member B (current Director of Nursing/DON), staff members Q and V (Unit Managers, RN's) said the newly added initials (filled in on the treatment sheet dated 8/17) had been done after 9/12/17 (the survey enter date) and admitted to them being their initials. Review of the facility Elopement/Wandering Risk policy dated 9/1/16, stated Document patient centered interventions in the patient/resident Care Plan and Kardex. If utilizing a wander guard monitoring system device check placement of the device every shift and functionality every day. During an interview done on 9/14/17 at 11:20 a.m., staff members A (Administrator) and B (Director of Nursing/DON) said staff members Q and V (Unit Managers, RN's) should have properly documented the residents wander guard checks daily and should not have filled in the blank day shift (7:00 a.m. to 3:00 p.m.) holes on the Treatment Sheet for the dates of 8//17, 8/2/17 and 8/3/17. Review of the facility Best Practices-Elopement policy dated 11/23/16, stated Monitoring devices are dated upon placement and activation, monitoring devices are checked every shift for placement and daily for function. Facility Exit Door Alarms: Observation of all facility exit doors was done on 9/13/17 from 11:00 a.m. through 11:30 a.m. Observation of the 200 Hall exit door done at 11:10 a.m., revealed it had a battery operated alarm on it and it was turned to chime (the lowest sounding alarm setting). When this surveyor opened the door, it chimed 2 times in a very low pitch. The 200 Hall exit door did not activate at either of the two nursing stations, nor did the blue light at the nursing stations activate indicating an exit door had been open, it was not properly functioning. During an interview done on 9/13/17 at 11:10 a.m., staff member F (Director of Maintenance) said the 200 Hall exit door alarm should have been set on instant (the loudest sounding alarm setting), not chime. He said chime was not loud enough to be herd by staff and he immediately set the door alarm to the instant setting. Observation of the facility's Large Dining Room exit door was done on 9/13/17 at 11:14 a.m., accompanied by staff member F. When the door was opened by staff member F, the door alarm was not functioning properly, it failed to sound at the nurse's stations, nor did it activate the blue light at the nurse's stations indicating the exit door had been opened. Observation of the facility's 300 Hall exit door was done on 9/13/17 at 11:18 a.m., accompanied by staff member F. When the door was opened by staff member F, the door alarm was not functioning properly, it failed to sound at the nurse's stations, nor did it activate the blue light at the nurse's stations indicating the exit door had been opened. During an interview done on 9/13/17 at 11:10 a.m., staff member F (Director of Maintenance) said he had been aware facility exit doors (the 200 Hall exit door, the Large Dining Room exit door and the 300 Hall exit door) were not properly functioning and stated the door alarms don't activate at any nurses stations or any other location in the building, they just sound at the door itself. In May I had the alarm company come out and we got a quote to fix the door alarms, I told them (previous Administrator), I gave it to the Administrator, I did not hear back, I got the quote in May, no one is scheduled to come out and fix them. During an interview done on 9/14/17 at 8:53 a.m., staff member N (Human Resource) stated, the doors (exit doors) have been like that for 6 years. Review of the alarm company work quote #17-2011 dated 5/31/17, revealed the alarm company had been to the facility and educated staff on exit doors including the alarm system. Review of the alarm company work quote #RRGMQ2582 dated 6/7/17, revealed an amount totaling $13,358.80, to secure all facility exit doors and to install properly working alarms. During an interview done on 9/14/17 at 2:00 p.m., facility contractor (W) informed this surveyor that he had been contacted on 9/13/17 by the facility to fix the exit door alarm system (ensure all exit doors had properly functioning door alarm systems). Contractor W stated, all that was on the doors (200 Hall exit door, Main Dining room exit door and 300 Hall exit door) was a local sounder alarm, it was not connected to the nursing stations, it was a battery system. We are installing an alarm care system today (9/14/17) with a manual key pad for alarm reset and mag lock. There was no locks on the 3 doors at all. Review of the alarm company work quote #RRGM2648 dated 9/13/17, with staff member A's (Administrator) signature, revealed a total amount of $28,211.20 to repair the exit door alarm system. Review of the facility door monitoring sheets dated 7/3/17 through 8/27/17, revealed the exit door alarms had not been checked for proper function on the following dates: -5/6/17 & 5/7/17 -5/13/17 & 5/14/17 -6/10/17 & 6/11/17 -6/17/17 & 6/18/17 -6/24/17 & 6/25/17 -7/2/17 -7/8/17 & 7/9/17 -7/15/17 & 7/16/17 -7/22/17 & 7/23/17 -7/29/17 & 7/30/17 -8/5/17 & 8/6/17 -8/12/17 & 8/13/17 -8/19/17 & 8/20/17 -8/26/17 & 8/27/17 During an interview done on 9/13/17 at 8:40 a.m., staff member F (Director of Maintenance) stated I am responsible for Monday through Friday door checks, I don't know who's responsible for the weekends. I don't check the door alarms on weekends unless I am in the building. During an interview done on 9/13/17 at 9:02 a.m., staff member A (Administrator) revealed the weekend managers are to fill out a cooperate compliance rounds sheet (Customer Care Liaison sheet) on the weekends and they are to be put in the Administrators box on Mondays and stated, it needs to be done. Review of the facility Customer Care Liaison sheets dated 4/10/17 through 9/10/17, (sheets dated 5/2/17 to 7/31/17 were not able to found by the facility), revealed 100% had no documentation under the door alarms checked area. No staff had been checking the facility exit door alarms for functionality. Review of the Policies and Procedures, Fire Doors Leading to Stairwells and Exits dated 11/30/14, given to this surveyor by staff member S (Administrator) on 9/14/17 at 11:15 a.m., (the only policy facility had regarding exit door alarm monitoring) stated all staff shall be aware of the status of all fire doors regarding whether they are secured or not. In the event that any staff member finds a fire door inappropriately locked (alarm not functioning properly), the following step must be taken: Immediately notify the Executive Director or designee. Review of the facility Resident Abuse policy dated 11/30/14, stated Neglect: the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Failure to take precautionary measures to protect the health and safety of the resident. Resident #101 was assessed by the facility upon admission (on 7/20/17) to be an elopement risk and was given a wander guard. The resident had a known history of confusion, anxiety, combative behaviors and saying he wanting to go outside. He eloped from the facility, unbeknownst to staff on 8/3/17 and was found by staff member E (OT) in his wheelchair, with his wheelchair wheels stuck in the muddy grass on the sidewalk off of the East parking lot approximately 150 feet from a very busy 55 MPH road. Staff were unaware he had eloped, no exit door alarm was activated indicating the door had been opened and there were no witnesses' who saw him leave the facility on 8/3/17. On 9/13/17, 3 facility exit doors were found no function properly (exit doors on the 200 Hall, Main Dining room and on the 300 Hall). On 9/13/17, the exit door alarm checks were found to be incomplete for a total of 14 days, no documentation was found of them being checked for proper functioning. On 9/12/17, no documentation was found on the residents Treatment Sheet (dated 8/1/17) that his wander guard had been checked for placement and functionality on 8/1/17, 8/2/17 and 8/3/17. On 9/14/17, documentation was found to be added on the same treatment sheet (dated 8/1/17), for the dates of 8/1/17, 8/2/17 and 8/3/17, indicating that the residents wander guard had been checked for placement and functionality. Resident #101 left the faciity on [DATE] without authorization or supervision, putting him in danger of serious injury or death. On 9/13/17 at 2:03 p.m., notification of Immediate Jeopardy was given to the Administrator that began on 8/3/17 at 3:45 p.m., as a result of the facilities failure to prevent the elopement and ensure the safety of Resident #101, who was an elopement risk, the facilities failure to ensure 3 exit doors alarms systems were properly functioning and the facilities failure to properly check and document the residents wander guard on a daily basis. On 9/14/17, the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1. On 9/13/17 at 11:30 a.m., facility managers were educated by staff member A (Administrator) on checking the functionality of all exit doors, 20 of 20 managers were educated. 2. On 9/13/17 at 12:48 p.m., all exit doors were checked by staff member F (Director of Maintenance) to ensure all doors were secure and set on the instant (loudest setting) mode. 7 of 7 doors were checked. 3. On 9/13/17 at 12:50 p.m., staff member A (Administrator) received an email from the alarm company with a quote for placement of new alarms (Mag Locks) for the 200 Hall, 300 Hall, Main Dining and Rehab exit doors. 4. On 9/13/17 at 2:15 p.m., staff education was started by staff members H (Assistant Director of Nursing/ADON, RN) and O (Regional Nurse Consultant, RN) regarding the facility Elopement Policy. 83 of 85 staff members have been educated. The remaining 2 staff will be educated by staff member H (ADON) prior to the start of their next scheduled shift. 5. On 9/13/17 at 2:20 p.m., a head count of all in-house residents was completed by staff members Q and V (Unit Managers, RN's). 56 of a census of 56 residents were accounted for. 6. On 9/13/17 at 3:20 p.m., 3 facility residents were identified as having wander guards. Sampled Residents #101, and #102 were in the facility and Resident #103 was discharged to the hospital. All alarms were located on the residents' left ankles and all expiration dates were current. 7. On 9/13/17 at 3:50 p.m., a door watch schedule was instituted for the four exit doors (200 Hall, 300 Hall, Rehab Hall and Large Dining room) 8. On 9/13/17 at 4:00 p.m., education was completed by staff member F (Director of Maintenance) for 3 of 3 staff door monitors regarding door alarm watch to include the instant mode setting for the non-secure doors. 9. On 9/13/17 at 4:18 p.m., Elopement Risk Evaluation Assessments were completed for 56 of 56 (100%) residents in-house by 2 RN's. 2 of the 3 residents (Resident #103 had been discharged to the hospital), who were formerly identified as being at risk for elopement, continued to remain at risk at this time. This was confirmed by the Regional Nurse Consultant (staff member O). 10. On 9/13/17 at 5:00 p.m., Facility Elopement books identifying residents at risk for elopement were reviewed by staff member A (Administrator) and found to be current. 11. On 9/13/17 at 5:24 p.m., an elopement drill was conducted by staff member O (Regional Nurse Consultant, RN). 25 of 25 staff responded appropriately per facility Elopement policy. Elopement drills will be conducted 1 time per shift per month, according to the facility policy. 12. On 9/13/17 at 5:40 p.m., management staff met for a debriefing of the Elopement Procedure and Ad Hoc QAPI. The root cause analysis was determined to be non-functional exit door alarms. 13. On 9/13/17 at 6:24 p.m., 2 RN's continued to complete the education regarding the elopement process. 14. On 9/13/17 at 6:30 p.m., 2 RN's validated that Resident Safety Checks for residents at risk for elopement were still in place. 15. On 9/14/17, the alarm company installed the Wandering System and Lock Alarms to the 4 doors (200 Hall, 300 Hall, Main Dining exit door and the Rehab exit door). 16. New employee orientation will include the elopement process education. 17. The alarm company will continue to maintain the exit door alarm system, per facility preventive maintenance program. 18. Staff member A (Administrator) is responsible for the implementation of the above enumerated abatement plan. Although the immediate jeopardy was removed on 9/13/17. The facility remained out of compliance at an isolated scope and severity of no actual harm but potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not been verified by the state agency.

Based on interview and record review the facility failed to prevent sexual abuse in 2 residents (#101 and #106) out of a sample of 5 residents and 1 supplemental resident having observed sexually inappropriate touching and contact resulting in residents (#101 and #106) being subjected to sexual abuse and placing all female residents at risk for sexual abuse and serious harm. The facility was placed in Immediate Jeopardy as a result of the facilities failure to protect residents #101 and #106 from sexual abuse having observed sexually inappropriate touching and contact related by Resident #102 who was observed sexually inappropriately touching Resident #101 on both 7/26/15 and 9/27/15; and kissing Resident #106 on 8/19/15. The immediate jeopardy was identified on 11/19/15 at 1:30 PM. Resident #102's care plan was reviewed and determined that on 7/9/15 it was updated to reflect a new behavior of sexually inappropriately touching a resident. Administrator A was notified of the immediate jeopardy on 11/20/15 at 9:30 AM. On 11/20/15 at 12:14 PM, the immediate jeopardy was removed when the following corrective action plan was initiated: 1) The facility planned to ask family members of non interviewable residents did they have any concerns for the residents residing there. 2) Licensed nurses were re-educated on 11/20/15 on proper documentation, notification of Administrator A, completing SBAR communication form and progress notes with an emphasis on implementing an immediate intervention to ensure resident safety. 3) That Administrator A will question interviewable residents and responsible parties of non interviewable residents and facility staff if they witnessed any residents being touched in an inappropriate way and if they feel residents are safe in the facility 3 to 5 times weekly for 4 weeks, then once monthly for 4 weeks. Any areas of concern will be addressed immediately and findings will be reported to Quality Assurance/Performance Improvement Committee monthly. The surveyor confirmed removal by record review of the licensed nurses that received training on 11/20/15 and observation that the facility was acting on their immediate plan of 1:1 supervision during the lunch meal at about 12:00 PM. Although the immediate jeopardy was removed on 11-20-15, the facility remained out of compliance with a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all licensed nurses had not received their training yet, interviews of family members and responsible parties of non interviewable residents had not taken place yet and sustained compliance had not been verified by the state agency. Findings include: Resident #101's care plan indicated she had dementia, anxiety, [MEDICAL CONDITION], mild [MEDICAL CONDITIONS], difficulty communicating and making her needs known. On 11/19/15 at about 10:45 AM, in the Administrator's office, Administrator A, Director of Nursing B and Unit Manager E agreed Resident #101 was unable to speak or communicate with them, they had to check on her to ensure her needs were met and they were only able to tell if she was in pain. On 11/19/15 at 11:25 AM Resident #101 was observed in her room in a Geri chair. Resident #102's Preadmission Screening, dated 9/18/14, reflected he had been diagnosed with [REDACTED]. He requires 24/7 supervision. Resident #102's behavior care plan, dated 7/9/15, reflected Resident #102 had a new behavior of attempting inappropriate touch of others. Nurses' notes dated 7/26/15 at 9:30 AM, reflected Was notified by Housekeeper (G) that she seen (Resident #102) with his hand down (Resident #101's) shirt .At 0933 (Administrator A) was notified . Also IDT Interdisciplinary Team reviewed this on 11/12/15. The facility approaches were to observe for behavioral symptoms, psychiatric services as needed, 15 minute resident safety checks when out of room from 7/20/15 through 8/3/15. There is a side notation for the same care plan dated 7/26/15 reflecting Resident #102 will be 1:1. Resident #102 was observed between 8:00 AM and 8:30 AM on 11/20/15 in his room without 1:1 supervision. On 11/19/15 at about 12:15 PM, on the 100 hall, Housekeeper G stated that on 7/26/15 Resident #102 had his hand on the top of Resident #101's clothing, that he put his hand on her side and Housekeeper G stated he touched Resident #101 on her side from underneath her arm to the lower half of her stomach, then reached his hand across her stomach. There was no documentation that the residents guardian was notified of the inappropriate touching. In an interview with resident #101's guardian on 11/20/15 at 10:57 am, he confirmed that he was not notified by the facility regarding the residents inappropriate touching. On 11/19/15 at 1:20 PM on the 100 hall Resident #102 was observed propelling himself down the hall, Unit Manager F stated she was watching Resident #102. Unit Manager F was asked what her name was and was she a nurse aide? Unit Manager F stated she was a unit manager and Resident #102 had no assigned nurse aide today and she and the other managers and nursing staff were taking turns watching him. On 11/19/15 at 5:30 PM, Resident #102 was observed with an assigned nurse aide sitting outside of his room providing 1:1 supervision. On 11/20/15 between 8:00 AM and 8:30 AM, Resident #102 was observed in his room with his door partially open, staff were in the hallway, but Resident #102 had no direct 1:1 supervision. Nurses' notes dated 8/19/15 reflected .cna (certified nurse aide) reported at 1900 she saw Resident (#102) kissing a female Resident in the hallway. Reported to (Name) of DON and (Name) of Administrator by the cna. On 11/20/15 at 8:40 AM, Licensed Practical Nurse (LPN) H confirmed she wrote the documentation in the nurses' notes on 8/19/15 stating that Resident (#102) was kissing another resident and the incident was reported to DON B and Administrator A. Nurse H said Resident #102 was kissing Resident #106. LPN H stated if either she or the nurse aide that witnessed Resident #102 kissing Resident #106 had not reported it to DON B and Administrator A she wouldn't have written it. The resident roster reflected that Resident #102 resided on the other side of the building facility's from Resident #106. On 11/20/15 at 9:30 AM, on the 400 unit, LPN I verified that Resident #106 and Resident #102 like each other. Both Resident #102 and #106 like to hold hands, and Resident #106 likes to touch Resident #102. Resident #106 becomes angry whenever they are separated. LPN I was asked was she aware of Resident #102 sexually inappropriately touching any other residents. LPN I stated as far as I know the only resident, Resident (#102) goes after is Resident #101. Record review reflected Resident #106 had a statement of incompetency dated 11-22-13, thus resident was unable to give consent to the kissing by resident #102. Nurses' notes dated 9/27/15 at 1500 reflected Resident (#102) was seen placing his hand on the vaginal area of another resident over her clothes. He was immediately removed from the area and instructed to not do that, He is on 15 minute checks. femail (sic) resident was placed by nurses station and watched. On 11/19/15 at 1:25 PM, Nurse D (the nurse that documented the observation on 9/27/15) confirmed Resident #102 placed his hand in Resident #101's vaginal area over her clothing, that he reported this incident to DON B then told all nursing staff to watch Resident #102. Additionally, Nurse D stated Resident #102 had a history of [REDACTED].#101, and all nursing staff was aware of it. On 11/19/15 at about 10:50 AM, the nursing notes for 7/26/15, 8/19/15 and 9/27/15 were reviewed with Administrator A. Administrator A said she was not aware of the incidents that took place on 8/19/15 or 9/27/15; however, she was aware of 7/26/15. Administrator A stated she did not report the incident on 7/26/15 to the State Agency because it was not sexual touch, that according to her investigation, Resident #102 only placed his hand on her side on the outside of the clothing. ( )

This citation pertains to MI 465, MI 468 and the annual survey. Based on observation, interview and record review the facility failed to complete accurate comprehensive assessments for 5 of 5 residents (#10, #11, #14, #18 and #20) reviewed for assessments from a total sample of 15 residents, resulting in pressure ulcers not being assessed as pressure ulcers, not being treated as pressure ulcers, and ultimately becoming worse. Findings Include: Resident #11 Review of the Face Sheet dated 5/7/14 and the most current Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #11 had clear speech, was usually understood by others, understands, was modified independent for decision making, had disorganized thinking, was totally dependent for transfers, toileting, eating, and was incontinent of bowel and bladder. Further review of the MDS revealed Resident #11 had no pressure ulcers upon admission to the facility. Review of the Wound Care Services note dated 5/12/15, which was the only wound care services note in the chart, revealed Resident #11 had a Sacral Unstageable (Full thickness loss of dermis-depth unknown) Pressure Ulcer that measured 3.5 x2.5 centimeters (cm), a Right Buttock Stage 2 (Partial thickness loss of dermis) pressure ulcer that measured 2.5x2x0 cm and a Left Buttock Stage 2 Pressure Ulcer that measured 3x3.7x0 cm. Review of the Admission/Readmission Data Collection Form, undated (resident was admitted on [DATE]), revealed Resident #11 was assessed to be at risk for pressure ulcers. Resident scored 15 on the Braden scale, where 15-18 is at risk. Review of the admission physician orders [REDACTED]. Review of the Treatment Records for April and May revealed initials indicating a Braden scale assessment was completed on 4/18/15 and 4/25/15, however review of the Medical Chart failed to reveal an actual Braden Scale Assessment. Review of the medical chart revealed the next Braden Scale Assessment was not completed until 5/3/15, 2 weeks after admission, and at that time revealed Resident #11 was now at Moderate Risk for Pressure Sores. Review of the medical chart failed to reveal any interventions were put into place at this time to prevent the development or worsening of pressure ulcers. Review of the Weekly Skin Integrity Review Forms, revealed that weekly skin checks were completed on 4/18/15, no skin issues indicated, 4/25/15 skin intact, 5/2/15 skin intact, 5/5/15, there were documented 3 open areas on the back side of Resident #11. Review of the medical chart failed to reveal that any type of wound assessment to include wound staging, measure, description was completed at this time. The Weekly Skin Integrity Review on 5/12/15 again depicted 3 open areas on Resident #11's backside, again a review of the medical chart failed to reveal any type of wound assessment was completed. Review of the medical chart revealed it was not until the Wound Care Services physician, who on 5/12/15 was the first time he had been in the building, documented any type of wound description or measurements, to include being assessed as pressure sores. In an interview on 5/14/15 at 3:00 p.m., the facility's wound care nurse, Licensed Practical Nurse (LPN) E stated that she had not had any formal training in regards to wound care and had only been in that position for 3 weeks. LPN E further stated, When I first seen the wound on the bum (Resident #11's pressure ulcers, on 5/12/15) it looked like he slid down in the wheelchair and that is why I called it an abrasion. My assessment (of Resident #11's ulcers) was done in the morning, the wound doctor came about 2:00 p.m. and assessed (Resident #11's wounds as pressure ulcers), to me it looked like abrasions .(Resident #11's wounds) were originally diagnosed as abrasions, and not pressure ulcers, and that is why there were no interventions put into place. Resident #14 Review of the Face Sheet dated 4/2/15 and the most recent MDS dated [DATE], Resident #14 was a [AGE] year old female that was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #14 had clear speech, was understood, understands, was cognitively intact and required extensive assistance with activities of daily living. In an interview on 5/15/15 at 11:40 a.m., Hospital Nurse Case Manager, Registered Nurse (RN) NN stated that Resident #14, Was transported via facility van to the wound clinic, she was being seen by the wound clinic for a wound on her heel. The PA (Physician Assistant) at the clinic knew something was wrong, (Resident #14) was found to be hypotensive (low blood pressure), somewhat incoherent, and she was sent to the ER. From there (Resident #14) was admitted to the CCU, it was there that it was noted that (Resident #14) had a significant, unstageable wound on the upper buttock area. The hospital had to wait for (Resident #14) to become medically stable, but the wound on the buttock required surgical debridement. Review of the hospital Consultation Note dated 4/27/15 revealed, (Resident #14) is well known to me. (Resident #14) has a known pressure ulceration of the plantar aspect of the right heel. In fact, she was sent to our office the wound center last Friday (4/24/15). She comes from (facility name) and this was just a routine follow up on that right heel ulceration. When (Resident #14) got here (the wound clinic on 4/24/15), she was here alone with just the bus driver. The bus driver stated that (Resident #14) had been yelling and moaning the entire trip here to (the wound clinic). We got the patient in the room, she was definitely not her normal self. Normally (Resident #14) recognizes me, is able to have a conversation with me and on Friday she was just moaning and crying out for help .(Resident #14) was not felt to be stable so we contacted 911 who transported her from our wound center to the hospital. From the ER she was admitted to CCU with a [DIAGNOSES REDACTED]. Upon admission to the hospital, nursing noticed a very large left buttock pressure ulceration, as well as significant skin breakdown on the buttocks/perineal area. There had been no mention of this and I had not even been asked to see this when she came to the wound center. It should be noted (Resident #14) is nonambulatory and always comes in a wheelchair. Again, no staff was with her on Friday when she came except for the bus driver. Under the assessment portion of this notes it reveals, Left buttock pressure ulceration extensive and necrotic, unstageable at this time, present on admission (to the hospital). Review of the facility Admission/Readmission Data Collection form dated 4/2/15, failed to reveal any type skin impairment was documented on Resident #14's coccyx area. Further review of the form revealed Resident #14 had heel ulcers on both right and left heels and was assessed as moderate risk, on the Braden Scale, for developing pressure sores (scored a 13, 13-14 is considered moderate risk). Review of Resident #14's medical record failed to reveal any documentation relating to any type of pressure sores on Resident #14's buttocks until 4/21/15, where it was documented that Resident had a ulcer on the left buttock, and an area reddened on the right buttock. Review of Resident #14's medical record failed to reveal that a wound sheet which would include measurements and staging of the wound was completed. In an interview on 5/15/15 at 1:35, facility wound nurse, LPN E stated, The last time I saw the wound (on her buttock) was on 4/23/15, they looked like abrasions to me, it looked like (Resident #14) slid down in the bed, and caused an abrasion on her bum .no I did not start a wound sheet (for the new ulcer that was identified on 4/21/15). Review of Resident #14's medical chart and hospital records revealed that there was no mention of Resident #14 having a pressure ulcer on her buttock until 4/21/15, on 4/24/15 only three days later, Resident #14 was admitted to the hospital and found to have a left buttock pressure ulceration extensive and necrotic, unstageable, which required surgical debridement. Resident #14 no longer resided at the facility. ( ) Resident #10 According to the Minimum Data Set, dated dated [DATE], Resident #10 scored 12/15 on the BIMS/Brief Interview for Mental Status, revealing she was cognitively intact, needed total assistance with bed mobility and hygiene, and had [DIAGNOSES REDACTED]. Review of Resident #10's Pressure Ulcer Record, revealed she had a Stage II pressure ulcer on 11/13/14 that measured 1.4 cm x 0.6 cm x 0.2 cm with a red wound bed with granulation tissue that healed on 3/09/15. In an interview, on 5/13/15 at 10:43 AM, DON/Director of Nursing B stated, (Resident #10) currently has shearing; they are not pressure ulcers. In an interview, on 5/13/15 at 10:50 AM, Wound Nurse, LPN/Licensed Practical Nurse E reported, The doctor says (Resident #10) has a skin tear. All skin assessments for Resident #10 were requested; there were Weekly Skin Integrity Review forms for Resident #10 for January 2015 - April 2015, but there were none for May, 2015. According to Resident #10's Non-Pressure Skin Condition Record, dated 4/09/15, she had an open area on her Coccyx that measured 0.5 cm x 0.2 cm x superficial that was healed on 4/20/15; there was no further documentation of skin impairment on Non-Pressure Skin Condition Records or Pressure Ulcer Records. Per a Wound Care Services report, dated 5/12/15, Resident #10 had 5 wounds on her coccyx and right buttock of Moderate Severity: Wound #1 - Distal Sacral is a Partial Thickness Skin Tear (1 cm x 0.3 cm x 0 cm) Wound #2 - Sacral Mid is a Partial Thickness Skin Tear (1.1 cm x 0.3 cm x O cm) Wound #3 - Proximal Sacral is a Partial Thickness Skin Tear (1.3 cm 0.3 cm x 0 cm) Wound #4 - Left Distal Buttock is a Partial Thickness Erosion (0.5 cm x 0.2 cm x 0 cm) Wound #5 - Left Proximal Buttock is a Partial Thickness Erosion (0.9 cm x 0.6 cm x 0 cm) On 5/13/15 at 1:35 PM, Resident #10 was observed sitting upright in her wheelchair watching TV in her room. On 5/13/15 at 3:05 PM, Resident #10 was observed laying in bed on her back with her heels resting on the mattress. After Nurse Aide F rolled Resident #10 to her side and exposed her backside for observation, this Surveyor observed 5 wounds on Resident #10's sacrum, the largest of which was just to the left of center on the coccyx; an approximately 1.5 cm x 1.5 cm x 0.25 cm diameter crater-shaped wound, described as a hole by Nurse Aide F. In an interview, on 5/13/15 at 3:30 PM, Resident #10 was observed laying in bed on her back with the head of the bed elevated approximately 10 degrees. Resident #10 reported the facility did not always have the adult brief size she was supposed to wear and so staff often put a brief on that was either too big or too small, and when they put a brief on that is too small, my urine runs out of it. Resident #10 reported she currently had open areas on the bottom by the crack, and said they were caused by sitting and laying in urine for a long time. Resident #10 reported she sometimes got up in the wheelchair but if she sat for too long it hurts. In an interview, on 5/15/15 at 3:50 PM, DON B was asked why Resident #10's current wounds were not assessed and measurements recorded on the Weekly Skin Integrity Review, Non-Pressure Skin Condition Record, or Pressure Ulcer Record or and DON B stated, The nurse looks at it if an aide tells them, she puts it on the Weekly Skin Integrity Review, then the nurse tells the Wound Nurse (LPN E); she's supposed to do the measurements. On 5/15/15, Resident #10 was observed, with her eyes closed, laying on her back in bed, with the head of the bed elevated approximately 40 degrees, at 9:20 AM, 12:50 PM, 2:00 PM, 3:30 PM, and 3:45 PM. Each time Resident #10 was observed on 5/15/15, she had slipped lower in bed, and by 3:45 PM, only her head and shoulders remained elevated. Resident #18 According to Resident #18's Face Sheet, dated 1/12/15, he was a [AGE] year old man who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's skin care records revealed no Pressure Ulcer Records, only Weekly Skin Integrity Reviews and Non-Pressure Skin Condition Records. The Weekly Skin Integrity Review, dated 5/12/15 revealed an, Open area R (right) coccyx area (no measurements); this Right coccyx area was not on the Non-Pressure Skin Condition Record or a Pressure Ulcer Record. The Non-Pressure Skin Condition Record, dated 3/09/15, 3/25/15, 3/30/15, 4/15/15, 4/20/15, 4/28/15, 5/05/15, and 5/12/15, revealed Location: L (left) Left ischium. Type: (check one) Rash, Bruise, Surgical, Skin Tear, Abrasion, Scratch, Tube Site, Arterial Ulcer, Excoriation, [MEDICAL CONDITION] Ulcer, Diabetic Neuropathic Ulcer, Other On the line next to Other, staff wrote Shearing. The size of the wound was initially 1.8 cm x 2.5 cm x depth not recorded on 3/09/15 and almost resolved - 0.3 cm x 0.3 cm x depth not recorded on 5/12/15. Review of verbal Physician Orders, revealed licensed nurses labeled the ischial wound as shearing rather than pressure ulcer on 3/09/15, 3/30/15, 4/15/15, and 4/29/15. Review of Resident #18's Care Plans revealed a Problem .arterial or venous stasis ulcer below knees to feet and on 2/13/15 staff added Left buttock cheek has 3 cm x .5 cm reddened thicken skin; keep off coccyx, turn frequently. There was no individualized Care Plan for the prevention of pressure ulcers. Resident #20 According to Resident #20's Face Sheet, dated 1/12/15, he was a [AGE] year old man who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a Wound Care Services progress report for Resident #20, dated 5/12/15, The patient's (Resident #20's) skin is becoming more fragile. He sustained a blister on the fatty portion of the buttock last week .Weight 227 lbs (pounds) .The nature of the lesion(s) is ulcer .The wound is red. The wound is soft and non-tender .Left Buttocks .0.8 cm length x 1 cm width, with an area of 0.626 sq cm (square centimeters) . According to verbal Physician Orders, Resident #20, an order was written for the treatment of [REDACTED]. According to Resident #20's Interdisciplinary Progress Notes, dated 5/07/15 at 10:00 AM, Noted shearing area on left buttock .(no measurements were documented). According to Resident #20's Weekly Skin Integrity Review, dated 4/06/15, Skin Tear; (circled - left upper buttock) Dark pink (no measurements were recorded). Resident #20 had neither a Non-Pressure Skin Condition Record nor a Pressure Ulcer Record. ( )

This citation pertains to intakes MI 4651, MI 468 and the annual survey. Based on observation, interview and record review, the facility failed to accurately identify, accurately assess, monitor and treat pressure wounds for 3 of 3 sampled residents (#10, #11, #14) and two supplemental residents (#18 and #20) reviewed for pressure ulcers, from a total sample of 15 residents resulting in the development and worsening of pressure wounds. Findings Include: Resident #11 Review of the Face Sheet dated 5/7/14 and the most current Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #11 had clear speech, was usually understood by others, understands, was modified independent for decision making, had disorganized thinking, was totally dependent for transfers, toileting, eating, and was incontinent of bowel and bladder. Further review of the MDS revealed Resident #11 had no pressure ulcers upon admission to the facility. Review of the Wound Care Services note dated 5/12/15, which was the only wound care services note in the chart, revealed Resident #11 had a Sacral Unstageable (Full thickness loss of dermis-depth unknown) Pressure Ulcer that measured 3.5 x2.5 centimeters (cm), a Right Buttock Stage 2 (Partial thickness loss of dermis) pressure ulcer that measured 2.5x2x0 cm and a Left Buttock Stage 2 Pressure Ulcer that measured 3x3.7x0 cm. Review of the medical chart failed to reveal any type of careplan with interventions were in place to prevent the development and/or worsening of pressure sores, before 5/12/15. Review of the Admission/Readmission Data Collection Form, undated (resident was admitted on [DATE]), revealed Resident #11 was assessed to be at risk for pressure ulcers (Scored 15 on the Braden scale, 15-18 is at risk). Review of the admission physician orders [REDACTED]. Review of the Treatment Records for April and May revealed initials indicating a Braden scale assessment was completed on 4/18/15 and 4/25/15, however review of the Medical Chart failed to reveal an actual Braden Scale Assessment. Review of the medical chart revealed the next Braden Scale Assessment was not completed until 5/3/15, 2 weeks after admission, and at that time revealed Resident #11 was now at Moderate Risk for Pressure Sores. Review of the medical chart failed to reveal any interventions were put into place at this time to prevent the development or worsening of pressure ulcers. Review of the Weekly Skin Integrity Review Forms, revealed that weekly skin checks were completed on 4/18/15, no skin issues indicated, 4/25/15 skin intact, 5/2/15 skin intact, 5/5/15, there were documented 3 open areas on the back side of Resident #11. Review of the medical chart failed to reveal that any type of wound assessment to include wound staging, measure, description was completed at this time. The Weekly Skin Integrity Review on 5/12/15 again depicted 3 open areas on Resident #11's backside, again a review of the medical chart failed to reveal any type of wound assessment was completed. Review of the medical chart revealed it was not until the Wound Care Services physician, who on 5/12/15 was the first time he had been in the building, documented any type of wound description or measurements. In an interview on 5/14/15 at 3:00 p.m., the facility's wound care nurse, Licensed Practical Nurse (LPN) E stated that she had not had any formal training in regards to wound care and had only been in that position for 3 weeks. LPN E further stated, When I first seen the wound on the bum (Resident #11's pressure ulcers, on 5/12/15) it looked like he slid down in the wheelchair and that is why I called it an abrasion. My assessment (of Resident #11's ulcers) was done in the morning, the wound doctor came about 2:00 p.m. and assessed (Resident #11's wounds as pressure ulcers), to me it looked like abrasions .(Resident #11's wounds) were originally diagnosed as abrasions, and not pressure ulcers, and that is why there were no interventions put into place. Resident #14 Resident #14 no longer resided at the facility. Review of the Face Sheet dated 4/2/15 and the most recent MDS dated [DATE], Resident #14 was a [AGE] year old female that was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #14 had clear speech, was understood, understands, was cognitively intact and required extensive assistance with activities of daily living. Review of the Daily Skilled Nursing Note dated 4/24/15, revealed, (Resident #14) to Dr. (doctor) appt at 12:15 p.m., did not return was sent to the ER (emergency room ) from doctor's office. Review of the Hospital ER note dated 4/24/15 at 1:57 p.m. revealed, (Resident #14) is a resident of (facility), was at the wound clinic when her (blood pressure) was found to be 50 (mmHg, millimeters of mercury) systolic (below 90 mmHg is considered hypotensive). Review of the Hospital ER note dated 4/24/15 at 5:00 p.m. revealed Resident #14 was being transferred to the CCU (Critical Care Unit) for, Sepsis (an illness that affects every part of the body that is a response from infection), Pneumonia, [MEDICAL CONDITION] (high levels of potassium in the blood) and [MEDICAL CONDITION] (kidney failure). In an interview on 5/15/15 at 11:40 a.m., Hospital Nurse Case Manager, Registered Nurse (RN) NN stated that Resident #14, Was transported via facility van to the wound clinic, she was being seen by the wound clinic for a wound on her heel. The PA (Physician Assistant) at the clinic knew something was wrong, (Resident #14) was found to be hypotensive (low blood pressure), somewhat incoherent, and she was sent to the ER. From there (Resident #14) was admitted to the CCU, it was there that it was noted that (Resident #14) had a significant, unstageable wound on the upper buttock area. The hospital had to wait for (Resident #14) to become medically stable, but the wound on the buttock required surgical debridement. Review of the hospital Consultation Note dated 4/27/15 revealed, (Resident #14) is well known to me. (Resident #14) has a known pressure ulceration of the plantar aspect of the right heel. In fact, she was sent to our office the wound center last Friday (4/24/15). She comes from (facility name) and this was just a routine follow up on that right heel ulceration. When (Resident #14) got here (the wound clinic on 4/24/15), she was here alone with just the bus driver. The bus driver stated that (Resident #14) had been yelling and moaning the entire trip here to (the wound clinic). We got the patient in the room, she was definitely not her normal self. Normally (Resident #14) recognizes me, is able to have a conversation with me and on Friday she was just moaning and crying out for help .(Resident #14) was not felt to be stable so we contacted 911 who transported her from our wound center to the hospital. From the ER she was admitted to CCU with a [DIAGNOSES REDACTED]. Upon admission to the hospital, nursing noticed a very large left buttock pressure ulceration, as well as significant skin breakdown on the buttocks/perineal area. There had been no mention of this and I had not even been asked to see this when she came to the wound center. It should be noted (Resident #14) is nonambulatory and always comes in a wheelchair. Again, no staff was with her on Friday when she came except for the bus driver. Under the assessment portion of this note it revealed, Left buttock pressure ulceration extensive and necrotic, unstageable at this time, present on admission (to the hospital). Review of the facility Admission/Readmission Data Collection form dated 4/2/15, failed to reveal any type skin impairment was documented on Resident #14's coccyx area. Further review of the form revealed Resident #14 had heel ulcers on both right and left heels and was assessed as moderate risk, on the Braden Scale, for developing pressure sores (scored a 13, 13-14 is considered moderate risk). Review of the facility care plan revealed there were only interventions in place for the care of Resident #14's heel ulcers. There were no interventions in place to prevent the development of new pressure sores. Review of Resident #14's medical record failed to reveal any documentation relating to any type of pressure sores on Resident #14's buttocks until 4/21/15, where it was documented that Resident had a ulcer on the left buttock, and an area reddened on the right buttock. Review of Resident #14's medical record failed to reveal that a wound sheet which would include measurements and staging of the wound was completed. In an interview on 5/15/15 at 1:35, facility wound nurse, LPN E stated, The last time I saw the wound (on her buttock) was on 4/23/15, they looked like abrasions to me, it looked like (Resident #14) slid down in the bed, and caused an abrasion on her bum .no I did not start a wound sheet (for the new ulcer that was identified on 4/21/15). Review of Resident #14's medical chart and hospital records revealed that there was no mention of Resident #14 having a pressure ulcer on her buttock until 4/21/15, on 4/24/15 only three days later, Resident #14 was admitted to the hospital and found to have a left buttock pressure ulceration extensive and necrotic, unstageable, which required surgical debridement. ( ) According to the facility's Wound Care Prevention & Treatment Objectives, Creation Date: 01-08-2012/Last Review Date: 09-1-2011 (prior to Creation Date), .Objectives . Accurately identify existing pressure ulcers and appropriate stages to optimize healing by utilizing consistent, standardized treatment .Protect against adverse effects of external forces . According to the facility's Introduction to Pressure Sore Protocols Policy, Creation Date: 01-08-2012/Last Review Date: 09-1-2011 (prior to Creation Date), Pressure ulcers are defined as localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface and/or is subjected to shear force for a period of time. Early Intervention is designed for residents at Increased risk for pressure ulcer development. The principle components of early Intervention are Protection from adverse effects of friction, shearing, pressure, and moisture; and Reduction of Incidence though education and training programs . According to the facility's Skin observation - Skin Care Alert, Creation Date: 01-06-12/Last Review Date: 02/06-2014, Procedure: 1. Staff member is to obtain a skin observation sheet; 2. Staff member is to mark on the body form the area that the resident has a skin condition and identify the type of skin condition to the best of their individual ability; 3. Staff members are to turn the form into the nurse in charge of the resident as soon as completed. The facility wound care policies did not specify who was to measure the wounds, or when they were to do so. In an interview, on 5/12/15 at 1:25 PM, LPN/Licensed Practical Nurse E introduced herself as the facility's Wound Nurse, and stated she had just worked at the facility for the past 3 months. LPN E stated she had been an LPN for [AGE] years but had no previous specialized experience as a Wound Nurse other than education given to her, after hire, by the DON/Director of Nursing, who was wound certified. In an interview, on 5/15/15 at 10:15 AM, Administrator A reported, We need a presentation and general education on pressure ulcers and wound care. This is what we need help with . Resident #10 According to the Minimum Data Set, dated dated [DATE], Resident #10 scored 12/15 on the BIMS/Brief Interview for Mental Status, revealing she was cognitively intact, needed total assistance with bed mobility and hygiene, and had [DIAGNOSES REDACTED]. Review of Resident #10's Pressure Ulcer Record, revealed she had a Stage II pressure ulcer on 11/13/14 that measured 1.4 cm x 0.6 cm x 0.2 cm with a red wound bed with granulation tissue that healed on 3/09/15. In an interview, on 5/13/15 at 10:43 AM, DON/Director of Nursing B stated, (Resident #10) currently has shearing; they are not pressure ulcers. In an interview, on 5/13/15 at 10:50 AM, Wound Nurse, LPN/Licensed Practical Nurse E reported The doctor says (Resident #10) has a skin tear. This Surveyor requested all skin assessments for Resident #10; there were Weekly Skin Integrity Review forms for Resident #10 for January 2015 - April 2015, but there were none for May, 2015. According to Resident #10's Non-Pressure Skin Condition Record, dated 4/09/15, she had an open area on her Coccyx that measured 0.5 cm x 0.2 cm x superficial that was healed on 4/20/15; there was no further documentation of skin impairment on Non-Pressure Skin Condition Records or Pressure Ulcer Records. Review of Resident #10's temporary Admission Care Plan, dated 11/12/14, revealed a Problem of Pressure Sores/Skin Care; Goal: Prevent/heal pressure sores; Follow facility skin care protocol, Preventive measures: Immediately report any redness or skin breakdown to charge nurse. However, Resident #10's working Care Plan did not include the Problem (Resident #10) is at risk for pressure ulcers with goals and interventions until after a readmission on 3/01/15. Per a Wound Care Services report, dated 5/12/15, Resident #10 had 5 wounds on her coccyx and right buttock of Moderate Severity: Wound #1 - Distal Sacral is a Partial Thickness Skin Tear (1 cm x 0.3 cm x 0 cm) Wound #2 - Sacral Mid is a Partial Thickness Skin Tear (1.1 cm x 0.3 cm x O cm) Wound #3 - Proximal Sacral is a Partial Thickness Skin Tear (1.3 cm 0.3 cm x 0 cm) Wound #4 - Left Distal Buttock is a Partial Thickness Erosion (0.5 cm x 0.2 cm x 0 cm) Wound #5 - Left Proximal Buttock is a Partial Thickness Erosion (0.9 cm x 0.6 cm x 0 cm) On 5/13/15 at 1:35 PM, Resident #10 was observed sitting upright in her wheelchair watching TV in her room. On 5/13/15 at 3:05 PM, Resident #10 was observed laying in bed on her back with her heels resting on the mattress. After Nurse Aide F rolled Resident #10 to her side and exposed her backside for observation, this Surveyor observed 5 wounds on Resident #10's sacrum, the largest of which was just to the left of center on the coccyx; an approximately 1.5 cm x 1.5 cm x 0.25 cm diameter crater-shaped wound, described as a hole by Nurse Aide F. In an interview, on 5/13/15 at 3:30 PM, Resident #10 was observed laying in bed on her back with the head of the bed elevated approximately 10 degrees. Resident #10 reported the facility did not always have the adult brief size she was supposed to wear and so staff often put a brief on that was either too big or too small, and when they put a brief on that is too small, my urine runs out of it. Resident #10 reported she currently had open areas on the bottom by the crack, and said they were caused by sitting and laying in urine for a long time. Resident #10 reported she sometimes got up in the wheelchair but if she sat for too long it hurts. In an interview, on 5/15/15 at 3:50 PM, DON B was asked why Resident #10's current wounds were not assessed and measurements recorded on the Weekly Skin Integrity Review, Non-Pressure Skin Condition Record, or Pressure Ulcer Record or and she stated, The nurse looks at it if an aide tells them, she puts it on the Weekly Skin Integrity Review, then the nurse tells the Wound Nurse (LPN E); she's supposed to do the measurements. On 5/15/15, Resident #10 was observed, with her eyes closed, laying on her back in bed, with the head of the bed elevated approximately 40 degrees, at 9:20 AM, 12:50 PM, 2:00 PM, 3:30 PM, and 3:45 PM. Each time Resident #10 was observed on 5/15/15, she had slipped lower in bed, and by 3:45 PM, only her head and shoulders remained elevated. Resident #18 According to Resident #18's Face Sheet, dated 1/12/15, he was a [AGE] year old man who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's skin care records revealed no Pressure Ulcer Records, only Weekly Skin Integrity Reviews and Non-Pressure Skin Condition Records. The Weekly Skin Integrity Review, dated 5/12/15 revealed an, Open area R (right) coccyx area (no measurements); this Right coccyx area was not on the Non-Pressure Skin Condition Record or a Pressure Ulcer Record. The Non-Pressure Skin Condition Record, dated 3/09/15, 3/25/15, 3/30/15, 4/15/15, 4/20/15, 4/28/15, 5/05/15, and 5/12/15, revealed Location: L (left) Left ischium. Type: (check one) Rash, Bruise, Surgical, Skin Tear, Abrasion, Scratch, Tube Site, Arterial Ulcer, Excoriation, [MEDICAL CONDITION] Ulcer, Diabetic Neuropathic Ulcer, Other On the line next to Other, staff wrote Shearing. (The size of the wound was initially 1.8 cm x 2.5 cm x depth not recorded on 3/09/15 and almost resolved - 0.3 cm x 0.3 cm x depth not recorded on 5/12/15.) Review of verbal Physician Orders, revealed licensed nurses labeled the ischial wound as shearing rather than pressure ulcer on 3/09/15, 3/30/15, 4/15/15, and 4/29/15. Review of Resident #18's Care Plans revealed a Problem .arterial or venous stasis ulcer below knees to feet and on 2/13/15 staff added Left buttock cheek has 3 cm x .5 cm reddened thicken skin; keep off coccyx, turn frequently. There was no individualized Care Plan for the prevention of pressure ulcers. Resident #20 According to Resident #20's Face Sheet, dated 1/12/15, he was a [AGE] year old man who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a Wound Care Services progress report for Resident #20, dated 5/12/15, The patient's (Resident #20's) skin is becoming more fragile. He sustained a blister on the fatty portion of the buttock last week .Weight 227 lbs (pounds) .The nature of the lesion(s) is ulcer .The wound is red. The wound is soft and non-tender .Left Buttocks .0.8 cm length x 1 cm width, with an area of 0.626 sq cm (square centimeters) . According to verbal Physician Orders, Resident #20, an order was written for the treatment of [REDACTED]. According to Resident #20's Interdisciplinary Progress Notes, dated 5/07/15 at 10:00 AM, Noted shearing area on left buttock . According to Resident #20's Weekly Skin Integrity Review, dated 4/06/15, Skin Tear; (circled - left upper buttock) Dark pink. Resident #20 had neither a Non-Pressure Skin Condition Record nor a Pressure Ulcer Record. ( )

Based on interview and record review the facility failed to apply and supply proper [MEDICAL CONDITION] equipment for 1 of 1 resident reviewed with a [MEDICAL CONDITION] (#23) from a total of 5 sampled residents, resulting in the potential for respiratory distress and respiratory arrest. Findings include: Citation relates to MI 021 According to the most recent Quarterly Minimum Data Set (MDS) completed on 11/11/14, Resident #23 was an [AGE] year old female who was admitted to the facility on [DATE]. She was severely impaired mentally, totally dependent for bed mobility/dressing/eating/hygiene/ and bathing. Her active [DIAGNOSES REDACTED]. Section J-Health Conditions of the MDS reflected Resident #23 was checked for short breath/trouble breathing sitting at rest and lying flat. Likewise, Section O-Special Treatments, Procedures, and Programs of the MDS reflected Resident #23 was checked for oxygen therapy, suctioning, and [MEDICAL CONDITION] care. On 12/25/14 the facility's "NURSING HOME TO HOSPITAL TRANSFER FORM" dated 12/25/14 at 7:30 AM reflected Resident #23 was sent to a local hospital. The reason for transfer read:[MEDICAL CONDITION] changed #6 size unavailable at facility. The physician's orders [REDACTED].#23 to hospital ER for changed trach. The hospital emergency department transfer record reflected reason for visit: "PT TO ER [MEDICAL CONDITION]. PER (name of nursing facility), PT HAS A 4 [MEDICAL CONDITION]& PT NEEDS A SIZE 6. PT ALSO HAS PNEUMONIA WITH THICK PRODUCTIVE SPUTUM. PT PRESENTS WITH INCREASE RESPIRATIONS AND IS DIAPHORETIC (sweaty)...Additional Instructions: MAKE SURE YOU ARE USING THE APPROPRIATE SIZED TUBING [MEDICAL CONDITION] NEBULIZED TREATMENTS..." The Nurse Unit Manager for the 200 Hall ("D") stated that Resident #23 was totally dependent on tube feeding and [MEDICAL CONDITION] humidified air on 1/13/15 at 3:27 PM. Nurse Manager "D" also stated that nurses and the respiratory therapist were responsible [MEDICAL CONDITION], but the respiratory therapist was responsible for changing the [MEDICAL CONDITION] monthly. Registered Nurse ("L") who worked the night shift on 12/24/14 was called writer back on 1/13/14 at 4:32 PM. Nurse "L" was asked to recall caring for Resident #23 on the night of 12/24/14. Nurse "L" revealed the following: If I was on I [MEDICAL CONDITION]. I believe she was a size 6. I believe I had all the equipment. She had recurrent respiratory infections. I can't recall if she was on an antibiotic. Nurse "L" was asked if he could recall Resident #23 being sent to Emergency on 12/25/15. He replied, "I think I recall her going out to ER and having a size 4 inner cannula. I think that's all that was available. I had nothing else to put in there. I wanted to keep her airway open, clear and patent or change the entire assembly, but I did not have one". Nurse "L" was asked who was to restock [MEDICAL CONDITION]. Nurse "L" replied that, they had multiple people who did that. "We are supposed to have the supplies available. I even had another nurse look. The #4 shiley inner cannula was in place when I went to [MEDICAL CONDITION], and the only thing in the room was a size 4. We had a 6 inner cannula, but it was a screw lock not a click lock and could not be used. I was concerned that the #4 cannula was smaller, but I thought they had changed it. She was not working to breath. I think she was sent out because we did not have the size that we needed. I was afraid if the inner cannula was left out, it could have occluded. We did not have what we needed. I checked her frequently. Normally we would have a inner and outer part, the whole apparatus but we did not have that either". On 1/14/15 at 9:59 AM the Admissions Coordinator/Previous Central Supply Coordinator ("R") was asked if she recalled [MEDICAL CONDITION] cannula size for Resident #23. Staff "R" stated that Resident #23 had a size #[MEDICAL CONDITION] DIC (Disposable Inner Cannula). Staff "R" was not aware that Resident #23 was changed to a different size. Staff "R" was informed that they were short on supplies, ordered replacements but could not recall the exact date. Staff "R" believed she was told before Christmas about [MEDICAL CONDITION] shortage. Staff "R" stated, " I don't know how they got a size #4. I only put the #6's in that were ordered for her in her room". Staff "R" denied stocking #4 inner cannulas in Resident #23's room. Registered Nurse ("K") who worked the night shift on 12/23/14 was called on 1/14/15 at 10:15 AM. Nurse "K" revealed that she did inner cannula changes on Resident #23, and thought Resident #23 had a size #6.5 inner cannula. Nurse denied Resident #23 having a inner cannula smaller that a #6.5. Nurse "K" stated that there were times when the facility was on back order for supplies. Later the same day during an interview at 3:27 PM, Nurse "K" revealed that they were out of supplies a couple of days before 12/23/14. On 1/14/15 at 10:48 AM Respiratory Therapist (RT "S") was asked if she could recall Resident #23. RT "S" revealed that Resident #23 had had a stroke, which was the reason for her trach. RT "S" stated she did the [MEDICAL CONDITION]. She revealed there was not [MEDICAL CONDITION](whole apparatus change) in December 2014 because there was not one available. "They were out of [MEDICAL CONDITION]. she had a #6 shiley, no shiley's were available. I couldn't really do anything, all I could change was the dressing. There were some size #4 in the room. PR "S" stated she had informed facility staff administration that they were getting low on supplies several weeks prior, and that a back [MEDICAL CONDITION] be in each room. December 2014 physician's orders [REDACTED]./t cough & phlegm, change inner cannula daily and as needed #6 shiley ([MEDICAL CONDITION]) dated 4/1/13 [MEDICAL CONDITION] every 8 hours ([MEDICAL CONDITION]) dated 4/1/13. An order dated 10/2/14 reflected [MEDICAL CONDITION] supplies q (every) day size 6 DIC inner cannulas, sterile water, 4 x 4 gauze pads 12 per day, T-drain sponges 1 package q three times per day and prn (as needed) 4 pairs of glover per change. The care plan for Resident #23's problem, "Resident #23's name has a [MEDICAL CONDITION] r/t cardiovascular accident and is unable to care care for it herself" with an onset date 1/31/13 and updated 12/29/14 reflected the following goals: *perform "resident's name"[MEDICAL CONDITION] every shift *check "resident's name"[MEDICAL CONDITION] daily for redness or drainage *listen to "resident's name" lung sounds every shift *observe "resident's name" vital signs *observe oxygen sats as needed *observe skin [MEDICAL CONDITION] every shift *respiratory therapy to follow as needed The care plan did not reflect what [MEDICAL CONDITION] #23 was to wear, what to do if secretions occurred/monitor secretions for consistency and/or color to rule out infection, supplies needed for [MEDICAL CONDITION] care, to maintain humidified mask over trach, or positioning to maintain with [MEDICAL CONDITION]. Physician's notes dated 11/17/14 reflected Resident #23 had been sent to the emergency room due to distress over the weekend and was diagnosed with [REDACTED]. Physician's notes dated 12/1/14 reflected Resident #23 lung sounds were with rales, rhonchi, coarse and was being treated for [REDACTED]. Medication Administration Records (MARS) 11/14 reflected "change inner cannula qd & prn #6 shiley", but was circled on 11/12/14 (missing initials and circled initials indicate a medication/treatment are not done). The back of the MAR indicated [REDACTED]. The 12/14 MAR indicated [REDACTED]. On 12/24/14 at 4:00 PM, the box for signature of completed event was empty and no note was available on the back of the MAR indicated [REDACTED]. Also, the 12/14 MARS reflected "change inner cannula qd & prn #6 shiley", but initials were circled on 12/26/14 (missing initials and circled initials are indicators a medication/treatment was not done). The back of the MAR indicated [REDACTED]. On 1/13/15 at 12:40 PM the Director of Nursing (DON "B") was asked what does it mean when nurses circle initials on the MAR. DON "B" stated it means to look for further documentation on the MAR/TAR or in the chart. No documentation related to the MAR/TAR was available documenting why the treatments were not done. The following were noted in the daily therapy progress note used by respiratory therapist ("S"): 10/13/14: Resident had a shiley #6, had thick light yellow secretions, was on a [MEDICAL CONDITION], and Resident #23'[MEDICAL CONDITION] changed with the same size #6 trach. 11/17/14: Resident had a shiley #6, which was changed with the same size trach. 12/24/14: Resident had dark yellow thick secretions, and Resident #23 was suctioned for a small amount. A nebulizer treatment was given to relieve working of breathing, but was still labored. The respiratory therapist recommended another chest X-ray, and noted the resident had a foul odored secretions that indicated infection. The secretions were dark yellow/ brown tinged in color. DAILY SKILLED NURSE'S NOTE dated 12/23/14 reflected Resident #23 had labored breathing at times with wheezing during the night and day shift. The DAILY SKILLED NURSE'S NOTE dated 12/25/14 reflected Resident #23 had rales/rhonchi, wheezes and a productive cough on the night shift. The note written by Licensed Practical Nurse ("U") on 12/25/14 at 8:00 AM reflected the following: "Reported to this nurse that [MEDICAL CONDITION] #4 was causing some problems checked resident and noted more saliva [MEDICAL CONDITION]& resp's more labored HOB (arrow up)-[MEDICAL CONDITION] some relief. On ATB for pneumonia. family in and nurse understood [MEDICAL CONDITION] changed to #4-Res. usually needs #6 [MEDICATION NAME]. Not available-called IPC (Nurse Practitioner "T's" name) to sent to ER to [MEDICAL CONDITION]. New order to send to (name of hospital) for #[MEDICAL CONDITION]" The DAILY SKILLED NURSE'S NOTE for 12/24/14, when Nurse "L" revealed that a #4 shiley inner cannula was in place, when he change the inner cannula with another #4 shiley inner cannula as well could not be located in the closed record. DON "B" was asked to locate the missing document on 1/13/14 at 12:40. At 1:28 PM, DON "B" revealed she had went through the medical records and did not have it for 12/24/14. "If it's not in the chart/closed records that you have then it was not done". The facility's 3 page undated "[MEDICAL CONDITION] Care" policy procedure reflected: "1. Review physician's orders [REDACTED].." The most recent physician's orders [REDACTED].#23 was to have a size #6 DIC, and [MEDICAL CONDITION] supplies every day. The facility failed to apply the correct ordered sized #6 shiley DIC for Resident #23, and failed to stock the correct sized #6 shiley DIC for Resident #23 with a known history of [MEDICAL CONDITION], thick secretions, and recurrent pneumonia. ( )

Based on interview and observation the facility failed to rinse soiled washcloths and maintain a clean commode in a dignified manner for personal bathroom use for 1 supplemental Resident (#21) who shared a bathroom with 3 other residents, resulting in feeling of disgust, anger and dehumanization. Findings include: Resident #21 was admitted to the facility on [DATE]. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (13-15 cognitively intact). On 4/25/14 at around 1:55 PM Resident #21 revealed that on "4/24/14 at around 10:00 a.m., I just finished using the bathroom but had not completely closed the door and a Nursing Assistant (NA) came into the bathroom from the adjourning room [ROOM NUMBER] (rooms #313 and #315 shared a bathroom).The NA had 3 washcloths soiled with stool in the sink and one at the faucet, rinsing it off (for a total of 4). They were all covered with stool. I was just about to wash my hands and brush my teeth. The NA said "excuse me, I just have a couple of rags to rinse out", I told her it was ok because I was finished. I didn't realized they were soiled rags until I saw them. Once she finished, she took the rags, rang them out and took them back into room [ROOM NUMBER]. She came back in the bathroom took her gloves off and used her hands to rinse the sink out with water in a swirling motion. She did not clean the sink with cleanser". Resident #21 said, "I hate using this bathroom. It made me feel sick when she did that, it was just disgusting. That's where I wash my hand, wash my face and brush my teeth. They have a soiled utility room down the hall where she could have did that. Who knows how much stuff goes on in that sink that we don't know about. I didn't tell anyone, it doesn't do any good because when I do, they blow it off or make it worse. I washed the sink out myself with regular soap and a wash cloth, and sent the wash cloth to laundry right away. Yesterday the toilet was soiled and I asked a NA to clean it, I went in later and it was still dirty. I let the NA know again and she said, "I already cleaned it once". Right now the toilet is dirty, go in and look at it. They are supposed to clean it, because the others need help to use the bathroom." Resident #21's toilet seat was viewed at 2:09 p.m. and was observed to have smears of stool all over the toilet seat. Resident #21 stated, "and that's how it looked after an aid cleaned it, after she helped the guy use the bathroom. That's disgusting, it makes me angry and I don't want to use the bathroom like that." While charting in the hall across from the resident's room, the resident was observed using the urinal (the door was not closed). The resident in room [ROOM NUMBER]-2 was wheelchair bound, had to be assisted and could not ambulate independently. The residents in room [ROOM NUMBER]-1 and 313-2, could not ambulate independently and needed assistance to toilet. Resident #21 was the only ambulatory resident out of the 4 residents assigned to the bathroom. At 2:13 PM Registered Nurse ("D") revealed that both residents required assistance to the bathroom. At 2:30 p.m., NA ("T") for Resident #21's hall, stated that both 313-1 and 313-2 required a Hoyer lift and 2 person assist. She revealed that 313-1 was care planned for bed checks every 2 hours and that 313-2 would tell the aides that he had toileted after he had already gone. Staff "T" also revealed that 315-2 was a 2 person assist and he stands and can use the bathroom. The fourteen day MDS (minimum data set) assessment for the resident in 315-2 reflected that he required extensive assistance of 2 people for transfers and toilet use. 313-2 admission/readmission data collection sheet dated 3/31/14 reflected he was a 2 person assist to transfer, and 313-1 admission/readmission data collection dated 4/22/14 reflected he was a 2 person assist for transfers and was frequently incontinent of bowel/bladder. Later, at around 4:30 p.m., the Administrator ("A") was informed of the stool-soiled seat and replied he would get it taken care of. ( )

Based on observation, interview and record review the facility failed to provide the necessary care and services per the professional standards of quality to recognize and implement interventions to prevent the worsening or development of pressure sores in 2 residents (#6 and #14) and notify the physician of a newly developed pressure ulcer in 1 resident (#6) out of 10 sampled for pressure ulcers from a total sample of 17, resulting in the development, worsening and potential for infection of pressure ulcers. Findings include: Review of the "Resident Face Sheet", undated, revealed Resident #6 was a [AGE] year old female that was admitted to the facility 3/6/14, and readmitted on [DATE]. Review of the most current Minimum Data Set ((MDS) dated [DATE], revealed that Resident #6 had clear speech, usually understood, usually understands, and had no cognitive impairments. The MDS revealed that Resident #6 had [DIAGNOSES REDACTED]. Review of the Admission/Readmission Data Collection form dated 3/15/14 revealed Resident #6's only pressure ulcer was found on her right lower leg. The form further revealed that Resident #6 did not have a foot ulcer, and was a High Risk for developing Pressure Ulcers. The form revealed that upon admission, Resident #6's Braden Scale Score (scale used for predicting pressure sore risk) was a 12, with 10-12 being documented as High Risk. Review of the Physician's Admission Order Sheet dated 3/15/14, revealed Resident #6 was to have skin sweeps completed upon admission and every week on shower days. Review of the facility's "Pressure Ulcer Protocol At-a-Glance", a document provided to this surveyor by the Director of Nursing (DON), revealed weekly skin integrity checks and weekly pressure ulcer records are to be completed by nursing staff. Review of the physician order [REDACTED].#6 was to have heels up off the bed at all times, and that both heels were to be cleaned, pat dry, apply skin prep, allow to dry then cover with an ABD pad (dressing) then wrap with Kerlix (gauze bandage wrap) every day Review of the "Weekly Skin Integrity Review" form dated 3/15/14 and updated 3/30/14, 4/6/14, 4/16/14 and 4/22/14 revealed Resident #6 was free from any type of pressure wounds or redness on both heels, however review of the "Pressure Ulcer Record" dated 4/21/14 revealed Resident #6 had a stage II pressure ulcer on both of her heels. The record revealed the pressure ulcer on her right heel measured 1.5 centimeters (cm) x 3.3 cm, and the pressure ulcer on her left heel measured 3 cm x 9 cm. Review of Resident #6's treatment record from 4/7/14 through 4/22/14 revealed treatments to Resident #6's heels were not completed 9 times. The record also revealed that 7 out of 28 shifts, Resident #6's heels were not documented as up off bed. During an observation 4/23/14 at 10:00 Resident #6's heels were resting on the bed. During an observation on 4/25/14 at 2:50 p.m., this surveyor observed an unstageable pressure sore on Resident #6's right heel that measured approximately 3 cm x 5 cm, and an unstageable pressure sore on Resident #6's left heel that measured approximately 4 cm x 10 cm. Both wounds were completely black and the wound on the left heel had some drainage. During an interview on 4/23/14 at 12:30 p.m., DON "B" was asked who is responsible for wound care in the facility, DON "B" stated, "we recently switched back to the floor nurses caring for resident wounds...during skin sweeps, if the nurses were to identify new wounds, they would document these findings on the 24 hour nursing report. DON "B" stated, Assistant DON (ADON) "AA" looks at the 24 hour nursing reports everyday, and when seeing that a new wound was documented, ADON "AA" would then assess, measure and stage the wound. DON "B" stated that ADON "AA" was currently on medical leave. This surveyor asked who was now responsible for assessing, measuring and staging resident wounds, DON "B" stated, "I guess the nurses could tell (ADON "F") about the new wounds and then she would measure and stage the wounds". Review of the "Weekly Skin Integrity Review" form dated 3/15/14 and updated 3/30/14, 4/6/14, 4/16/14 and 4/22/14 revealed that on 4/6/14 resident #6 had an "Open Area" documented to be on the coccyx, this area was also documented on 4/22/14, but not on 4/16/14. During an interview on 4/23/14 at 11:45 a.m. RN "D" stated Resident #6, "has a brand new one (pressure ulcer) on her coccyx". RN "D" was asked if the new pressure ulcer had been reported to the physician, the response was no. On 4/23/14 a review of Resident #6's medical chart failed to reveal that the physician was contacted concerning the new pressure ulcer that was found on resident's coccyx. The review of the chart also failed to reveal that a treatment for [REDACTED]. During an interview on 4/24/14 at 12:00 p.m. When asked if aware of Resident #6's pressure ulcer on the coccyx, Nurse Practitioner (NP) "J" stated, "I am not aware of an issue with her coccyx". This surveyor reviewed the wound binder on 4/22/14, 4/23/14, 4/24/14 and 4/25/14. It was not until 4/25/14 that a "Pressure Ulcer Record" was placed in the wound binder, review of this record failed to reveal a date and failed to reveal the stage of the pressure ulcer. During an observation on 4/25/14 at 2:50 p.m., with the assistance of ADON "F", RN "G" turned Resident #6 on her side and then removed her brief. This surveyor observed a stage II pressure ulcer on Resident #6's coccyx. The pressure ulcer measured approximately 3 centimeters by 5 centimeters. During this observation, there was no dressing in place, and there was stool in the pressure ulcer. This surveyor asked ADON "F" if she had seen Resident #6's wounds, ADON "F" stated, "No, I have not seen the wounds before now". Review of Resident #6's medical chart revealed that on 4/25/14, 19 days after the "open area" on Resident #6's coccyx was first assessed, a physician order [REDACTED]. ( ) On 4/24/14 starting at 11:05 a.m., the dressing change to the right heel and the right gluteal fold of Resident #14 was observed performed by Registered Nurse (" D"). The Nurse Practitioner (NP)("J") was present during the entire dressing change process. RN "D" placed supplies on a barrier on the bed side table. Both RN "D" and NP "J" washed their hands and put on gloves. While attempting to remove the dressing to Resident #14's right heel, RN "D" had to use a gauze doused with wound wash to remove the old dressing. The old dressing was observed to have serous drainage on the dressing, thick gold colored purulent drainage was noted oozing out of the heel, the center was pink in color, surrounded in slough, and a small black colored scab was noted posterior to the wound. No barrier was placed under the right heel. NP "J" was asked what the stage of the pressure ulcer was, and replied a in a low voice, a healing stage 3. RN "D" then proceeded to put skin prep on the right great toe. RN "D" did not wash her hands after removing the soiled dressing to the right heel. RN "D" then proceeded to clean the pressure wound one time only with a pre-moistened 4 x 4 (gauze was sprayed with wound cleanser and placed in a medicine cup), starting at the center and moving to the outer edges of the wound. RN "D" did not spray the wound with the wound cleanser and pat the pressure wound dry. A section of the calcium alginate dressing with antibacterial silver was cut out from the larger intact dressing to fit the wound size, and applied to the pressure wound . RN "D" was asked when was the last time the area was measured, and replied "she did not know". The pressure wound to the right heel was not measured during the dressing change. RN "D" was then asked to stage the opened area and stated, "It looks like a pressure ulcer with drainage". A wet 4 x 4 gauze dressing doused with sterile water was applied on top of the calcium alginate dressing, a ABD dressing, and wrapped with a Kerlix dressing. RN "D" removed her gloves, put on a new pair of gloves but did not wash her hands. According to WOUND CARE ADVISOR 2014 the following are the calcium alginate dressing actions : Transforms into a moist gel consistency when it comes into contact with exudate or moisture, Absorbs up to 20 times its weight, Conforms to the shape of the wound, Fills in dead space: As it absorbs moisture and exudate, the gel fibers swell, making the dressing larger than when applied and the Moist gel consistency will maintain moist healing environment and facilitate autolytic debridement. It also reflected the product should not be moistened before use. A vertical uncovered pressure wound (slit) to Resident #14's coccyx area was observed, and measured at approximately 1-1.5 inches in length. The center of the pressure wound was pink and no drainage was noted. RN "D" was asked to stage the coccyx pressure ulcer, and replied it was a stage 1. RN "D" cleansed the area once with a pre-moistened wound cleanser 4 x 4 . RN "D" removed the old dressing to the right gluteal fold, that had serious fluid and blood noted on it. RN "D" touched the pressure ulcer site with her right gloved hand. The area was approximately 7.5 x 4.5 inches (with a hand used as a reference), the entire area was reddened with sporadic bleeding areas, and two small horizontal slits measuring approximately 1/4 of inch were noted. NP "J" had instructed RN "D" to remove the dressing for observation. NP "J" stated that the opened horizontal slits looked like abscesses, were deep, hard, approximately the size of a quarter, and needed antibiotics and a foam-like dressing. RN "D" then verbalized she wanted to complete the coccyx dressing, and obtained zinc oxide from a medicine cup and placed it on top of the pressure dressing to the coccyx. RN "D" still had not washed her hands from the beginning, nor did she wash them after making contact with pressure ulcer to the right gluteal fold. After applying the zinc oxide, RN "D" removed her gloves, entered the hall, and sanitized her hands (no sanitizer was noted in the resident's room). She entered the room and quickly exited because of the wrong type of dressing and entered a second time. While RN "D" exited the room the second time, NP "J" was asked to stage the heel wound. NP "J" stated the wound was hypergranulated at the center with slough at inferior margins, with some slough stable and hard. NP "J" revealed she did not know about the opened areas at the gluteal fold. NP "J" staged the gluteal fold as a stage 2 with abscesses. RN "D" returned and gloved her hands. RN "D" was asked to stage the gluteal fold and stated "I would stage at 1 blanchable". Twice RN "D" used a 4 x 4 pre-moistened gauze to cleanse the large pressure ulcer. She did not spray the area with wound cleanser and pat dry. A hydrafoam dressing was applied to the area, topped with an ABD dressing and secured with tape. Both staff washed their hands upon the completion of the right gluteal fold dressing change. At 12:00 PM RN "D" was asked what guidance did she use for staging pressure wounds. RN "D" revealed she had never staged any pressure wounds, and that the facility used to have a treatment nurse who did it. She then looked in her treatment book for pressure wound staging references and was only able to find "Treatment Protocols for Wound Care". She was unable to locate any reference to pressure wound staging. RN "D" was asked when she should wash her hands during dressing changes, and replied "before and after". At 12:30 PM NP "J" stated she did not have any information related to the right gluteal pressure wound, but had 2 orders for January 2014, when asked if she was aware of the status of the right gluteal fold pressure ulcer. At 12:35 PM the Director of Nursing (DON) "B" was asked to locate wound skin care sheets for the right gluteal fold pressure ulcer for Resident #14. DON "B" stated it should be on a non-pressure skin condition record. At 12:45 PM NP "J" revealed that staff should be vigilant about treatment and change dressing daily or they can turn into abscesses. Later on 4/24/14 at approximately 1:00 PM DON "B" provided guidance related to pressure ulcer staging for nurses and dressing changes policy. DON "B" stated the information was in the treatment book, yet RN "D" was unable to locate it. Also, some of the references were obtained at that time on-line. The facility's Wound and Skin Protocol Options dated 10/10 for Stage 2 and 3 reflected "...Treat compromised areas, per physician order". Under the alginates sections it reflected "...For high exudating wounds, cover with absorbent gauze dressing and change at least daily..." Apply wet to dry dressing on top of alginate was not reflected on the policy. The "Assessment and Documentation of Wounds" policy dated 1/01/11 reflected accurate assessment and documentation of wound and wound status is vitally important in management of wounds regardless of the etiology. The Skin Assessment-weekly policy dated 2/6/14 reflected a licensed nurse will complete a total body assessment on each resident weekly and document the assessment on the "Weekly Skin Integrity Review" form...If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form for pressure areas and complete the "Pressure Ulcer Record". For all other skin conditions, complete the "Non-Pressure Skin Condition Record". Treatment Administration Records (TAR) for 4/14 reflected that on 3/1/14 Resident #14 had an open area to the right gluteal fold, yet a non-pressure skin condition record or weekly skin integrity review was not done on a regular basis as the policy directed. Resident #14's Braden scale (tool used for predicting pressure sore risk) reflected a score of 14 (13-14 moderate risk) on 1/06/14, and 18 (15-18 at risk) on April 15 & 21, 2014. Weekly skin integrity review sheets viewed from 1/20/14 to 4/21/14 reflected only one entry related to the right gluteal fold dated 4/15/14. The entry dated 4/15/14 reflected 10 x 14 redness. Yet treatment sheets reflected the following for the right gluteal fold: "01/2014- Cleanse right lower gluteal fold pat dry apply [MEDICATION NAME] cream QID (four times a day) and PRN (as needed)." Two treatments were noted not done on January 22, 29, 30 and 31/2014. "03/2014-lower gluteal fold: cleanse, pat dry, apply [MEDICATION NAME] cream QID and PRN" changed 2/28/14 (no entries noted). "04/2014: lower right gluteal fold: cleanse, dry, apply [MEDICATION NAME] cream to skin surround open area, apply thin layer of wound gel to open area, cover with dry dressing daily and PRN until healed". One treatment was noted not done on 4/41/14. Later, on 4/24/14 at approximately 2:00 PM, Resident #14's chart was noted to have an order dated 4/24/14 at 12:05 PM reflecting, "1) Cleanse right posterior thin/lower buttock abscess pat dry apply foam pad and secure q (every) day and prn until healed. 2) [MEDICATION NAME] (antibiotic) 450 mg (milligrams) po (by mouth) q 8 hours x 10 days Dx abscess/(illegible word). On 4/25/14 at 2:50 PM Licensed Practical Nurse "K" was asked what do the blank boxes that are outlined mean on the treatment sheet. Staff "K" stated if the designated days did not have initials, that meant it just wasn't done. "If it is not signed it did not happen". Respectfully, treatment sheets of dressing changes to the right heel ulcer reflected the following: January 26, 29 2014, February 19, 26 and 28 2014, March 14 and 31 2014 and April 4, 7, 11, and 23 2014. The facility's care plan for the right gluteal fold, with no onset date, and a goal date of 6/14, reflected "(1) approach: 1/31/14 new order for gluteal fold". No specific interventions were noted related to the right gluteal fold. The care plan initiated 10/03/13 for a Stage 2 pressure ulcer to right buttock/coccyx. The words Stage 2 buttock/coccyx had lines written through them and "right heel pressure ulcer and right lower gluteal fold" written under it. No new interventions/approaches had been added to the original care plan dated 10/3/113 other than "new orders" and "new treatment". The facility did not consistently monitor, assess and treat the right gluteal pressure ulcer. Also, the facility did not change dressings as ordered for the right gluteal pressure ulcer and right heel pressure ulcer. ( )

Based on interview and record review the facility failed to follow the professional standard of practice in performing dressing changes for 1 (#104) sampled resident, failed to perform multiple measurements of a pressure ulcer for 2 (#35 and #104) sampled resident and failed to perform skin sweeps for 1 (#35) sampled resident of 3 residents reviewed for dressing changes, pressure ulcer measurements and skin assessments from a total of 8 residents resulting in the potential for delayed healing of wounds and a failure to assess new open wounds timely. Findings include: According to Resident #104's Minimum Data Assessment ((MDS) dated [DATE] Resident #104 was a [AGE] year old female with [DIAGNOSES REDACTED]. According to Resident #104's June 2014 Monthly physician orders, a treatment was to be completed to the right buttock with [MEDICATION NAME] and a wet to dry dressing and secured with tape daily. According to Resident #104's June 2014 Treatment Record form the physician prescribed treatment was not completed on 6/5/14, 6/6/14, 6/9/14, and 6/11/14. Resident #104 had not received the physician prescribed treatment 4 days out of 17 at the time of the review of her treatments. According to Resident #104's Pressure Ulcer Record dated 6/1/14, Resident #104's Stage III pressure ulcer measured 1.8 cm (centimeters) x 0.5 cm x 4.2 cm and was not measured according to the Pressure Ulcer Record until 18 days later on 6/19/14 and measured 1.5 cm x .3 cm x 3.5 cm. On 6/19/14 at 11:27 am, Registered Nurse "B" was questioned about Resident #104's measurements and stated, "I was not able to get to resident while she was in the hall, I had attempted to get to her earlier in the week on Monday, Tuesday or Wednesday." On 6/19/14 at 3:40 pm, Administrator "A" reported staff random audits were completed 3-5 times a week to monitor compliance with dressing changes and concerns were then discussed on the following day in morning meeting. According to the Facility "Pressure Ulcer Protocol At-A-Glance," "Assessment were to be completed 1. On admission (WC-120-A) (facility form); Care plan if applicable; (WC-130-A) if applicable, 2. Weekly Skin Integrity Checks (WC-190-A), 3. Weekly Pressure Ulcer Record, (WC-130-A) and 4. Quarterly (WC-120-A) ; Care plan if applicable; (WC-130-A) if applicable, *Anytime a pressure ulcer is identified a (WC 130-A) must be completed." ( ) According to the undated face sheet Resident #35 was a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The pressure ulcer care plan dated 5/15/13 reflected Resident #35 had a healing stage 4 ( full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer and she had a history of [REDACTED]. The approaches/interventions included 1) weekly full skin evaluation/skin sweep and 2) weekly evaluation of wound healing that included wound measurements. The Weekly Skin Integrity Review dated 4/6/14/14 through 6/9/14 reflected Resident #35's skin sweep was done on an irregular intervals or not performed at all as indicated the following; 4/6/14 2 open areas identified 4/13/14 not done 4/20/14 not done 4/21/14 coccyx area (2 weeks from the previous assessment) 4/27/14 not done 5/4/14 scheduled but not done 5/5/14 coccyx area healed, open area on right inner thigh (2 weeks from the previous assessment) 5/7/14 open area as indicated on diagram 5/19/14 open areas as indicated on diagram (2 weeks from the previous assessment) 6/2/14 open area as indicated on diagram (2 weeks from the previous assessment) 6/7/14 open areas as indicated on diagram (5 days from the previous assessment) The Pressure Ulcer Record for the coccyx wound dated 4/2/14 through 6/1/14 reflected Resident #35 wound had measurements recorded only 4 times as follows; 4/2/14 coccyx pressure ulcer, 6 cm x 5.8 cm x 0.8 cm, unstageable 5/7/14 coccyx pressure ulcer, 2.0 x 4.0 stage 4 5/13/14 coccyx 2.0 x 3.5 x 3.0 stage 4 5/20/14 coccyx 2.0 x 3.4 x 2.8 stage 4 5/27/14 refused 6/1/14 refused On 6/20/14 at 10:00 a.m., both the interim Director of Nursing, (staff "B") and the unit manager, (staff "C") could not provide any clear reason why Resident #35 was refusing the treatment or wound assessment. Not evaluating or monitoring stage 4 pressure ulcer wound over 1 month constitutes not only the violation of standard practice but also could seriously jeopardize resident's health risk. ( )

Based on observation, interview and record review, the facility failed to accurately assess, monitor and treat pressure wounds for 2 of 10 sampled residents (#6 and #14) reviewed for pressure ulcers, from a total sample of 17 residents resulting in the development and worsening of pressure wounds. Findings include: Review of the "Resident Face Sheet", undated, revealed Resident #6 was a [AGE] year old female that was admitted to the facility 3/6/14, and readmitted on [DATE]. Review of the most current Minimum Data Set ((MDS) dated [DATE], revealed that Resident #6 had clear speech, usually understood, usually understands, and had no cognitive impairments. The MDS revealed that Resident #6 had [DIAGNOSES REDACTED]. Review of the Admission/Readmission Data Collection form dated 3/15/14 revealed Resident #6's only pressure ulcer was found on her right lower leg. The form further revealed that Resident #6 did no have a foot ulcer, and was a High Risk for developing Pressure Ulcers. The form revealed that upon admission, Resident #6's Braden Scale Score (scale used for predicting pressure sore risk) was a 12, with 10-12 being documented as High Risk. Review of the Physician's Admission Order Sheet dated 3/15/14, revealed Resident #6 was to have skin sweeps completed upon admission and every week on shower days. Review of the facility's "Pressure Ulcer Protocol At-a-Glance", a document provided to this surveyor by the Director of Nursing (DON), revealed weekly skin integrity checks and weekly pressure ulcer records are to be completed by nursing staff. Review of the physician order [REDACTED].#6 was to have heels up off the bed at all times, and that both heels were to be cleaned, pat dry, apply skin prep, allow to dry then cover with an ABD pad (dressing) then wrap with Kerlix (gauze bandage wrap) every day Review of the "Weekly Skin Integrity Review" form dated 3/15/14 and updated 3/30/14, 4/6/14, 4/16/14 and 4/22/14 revealed Resident #6 was free from any type of pressure wounds or redness on both heels, however review of the "Pressure Ulcer Record" dated 4/21/14 revealed Resident #6 had a stage II pressure ulcer on both of her heels. The record revealed the pressure ulcer on her right heel measured 1.5 centimeters (cm) x 3.3 cm, and the pressure ulcer on her left heel measured 3 cm x 9 cm. Review of Resident #6's treatment record from 4/7/14 through 4/22/14 revealed treatments to Resident #6's heels were not completed 9 times. The record also revealed that 7 out of 28 shifts, Resident #6's heels were not documented as up off bed. During an observation 4/23/14 at 10:00 Resident #6's heels were resting on the bed. During an observation on 4/25/14 at 2:50 p.m., this surveyor observed an unstageable pressure sore on Resident #6's right heel that measured approximately 3 cm x 5 cm, and an unstageable pressure sore on Resident #6's left heel that measured approximately 4 cm x 10 cm. Both wounds were completely black and the wound on the left heel had some drainage. During an interview on 4/23/14 at 12:30 p.m., DON "B" was asked who is responsible for wound care in the facility, DON "B" stated, "we recently switched back to the floor nurses caring for resident wounds...during skin sweeps, if the nurses were to identify new wounds, they would document these findings on the 24 hour nursing report. DON "B" stated, Assistant DON (ADON) "AA" looks at the 24 hour nursing reports everyday, and when seeing that a new wound was documented, ADON "AA" would then assess, measure and stage the wound. DON "B" stated that ADON "AA" was currently on medical leave. This surveyor asked who was now responsible for assessing, measuring and staging resident wounds, DON "B" stated, "I guess the nurses could tell (ADON "F") about the new wounds and then she would measure and stage the wounds". Review of the "Weekly Skin Integrity Review" form dated 3/15/14 and updated 3/30/14, 4/6/14, 4/16/14 and 4/22/14 revealed that on 4/6/14 resident #6 had an "Open Area" documented to be on the coccyx, this area was also documented on 4/22/14, but not on 4/16/14. During an interview on 4/23/14 at 11:45 a.m. RN "D" stated Resident #6, "has a brand new one (pressure ulcer) on her coccyx". RN "D" was asked if the new pressure ulcer had been reported to the physician, the response was no. On 4/23/14 a review of Resident #6's medical chart failed to reveal that the physician was contacted concerning the new pressure ulcer that was found on resident's coccyx. The review of the chart also failed to reveal that a treatment for [REDACTED]. During an interview on 4/24/14 at 12:00 p.m. When asked if aware of Resident #6's pressure ulcer on the coccyx, Nurse Practitioner (NP) "J" stated, "I am not aware of an issue with her coccyx". This surveyor reviewed the wound binder on 4/22/14, 4/23/14, 4/24/14 and 4/25/14. It was not until 4/25/14 that a "Pressure Ulcer Record" was placed in the wound binder, review of this record failed to reveal a date and failed to reveal the stage of the pressure ulcer. During an observation on 4/25/14 at 2:50 p.m., with the assistance of ADON "F", RN "G" turned Resident #6 on her side and then removed her brief. This surveyor observed a stage II pressure ulcer on Resident #6's coccyx. The pressure ulcer measured approximately 3 centimeters by 5 centimeters. During this observation, there was no dressing in place, and there was stool in the pressure ulcer. This surveyor asked ADON "F" if she had seen Resident #6's wounds, ADON "F" stated, "No, I have not seen the wounds before now". Review of Resident #6's medical chart revealed that on 4/25/14, 19 days after the "open area" on Resident #6's coccyx was first assessed, a physician order [REDACTED]. ( ) According to the face sheet in his clinical record, Resident #14 was a [AGE] year old male with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] was coded to indicate Resident #10's required maximum assistance with transfers, ambulation, dressing, and bathing. The Brief Interview for Mental Status was coded 01 of a possible 15, indicating severe dementia. A review of the Nurse's Notes for Resident #14 revealed he went to the hospital on [DATE] and returned on 9/10/13. A Nursing Note dated 9/11/13 documented a new treatment order: "New order to treat R(ight) heel stage II pressure ulcer from hospital stay. Cleanse with wound wash, dry. Ca(lcium) Alginate AG (silver) to wound bed and cover with 4 X 4 (gauze bandage), ABD pad, wrap in Kerlix daily and PRN (as needed) until healed. Wound measures 3 x 3 cm 0.1 deep." On 9/13/13, the physician wrote a new order: "D/C previous tx (treatment) to R heel. Cleanse w(ith) wound wash, pat dry. Skin prep to eschar, wound gel to open area, cover dry 4 X 4, wrap in Kerlix daily and PRN until healed". The Treatment Sheet for resident #10, dated 9/01/13 thru (sic) 9/30/13, indicated this wound treatment order was carried out except for 9/19 and 9/22/13. The entries for those dates were circled indicating the treatment did not take place, but there were no notes on the treatment sheet to indicate why not. The Treatment sheet for resident #14 dated 10/01/13 thru (sic) 10/31/13 indicated the treatment order was still being followed except for 10/19/13 and 10/25/13 when the sheet was blank. There were no notes on the back of treatment sheet to indicate why. The physician wrote a new treatment order dated 11/06/13 which stated: "Cleanse R heel, apply thin layer Santyl then cover W-D (wet to dry) every day." A new treatment order was written by the physician dated 11/27/13 which stated: "Cleanse R heel, pat dry, apply skin prep, ABD (abdominal-thick gauze) pad and Kerlix (stretchy gauze) every day." On 1/13/14 a new order was written: "1. D/C (stop) previous Santyl to coccyx. 2. Cleanse coccyx are (with) ww (wound wash), pat dry, apply stock zinc oxide cream 20% QID (4 times per day) and PRN. 3. Cleanse R lower gluteal fold, pat dry, apply [MEDICATION NAME] cream QID (4 times daily)and PRN (as needed)." A review of the Treatment Sheet for Resident #14 for the month of January 2014 reveals the coccyx wound treatment was not administered in the evening on January 22 and not administered in the mornings of January 29, 30, or 31. The treatment for [REDACTED]. In addition, the treatment to the right heel was not completed on January 20 and 29. Resident #1's Treatment Sheet dated 2/01/14 thru (sic) 2/28/14 included directions to cleanse the right big toe and apply skin prep daily. The documentation indicates this was not done on February 4, 6, 7, 12, 16, 19, 27, and 28. The same Treatment Sheet included the treatment orders for the coccyx. Documentation on the sheet indicates the treatments were not done on February 6, the evenings of the 8th and 9th, all day the 19th, and the mornings of the 28th and 29th. The same February Treatment Sheet included the treatment orders for the right gluteal fold. Documentation was missing for this treatment on the 5th, 6th, and 19th. Finally, the orders for the treatment of [REDACTED]. Only 4 treatments were documented with the last one occurring on 2/24/14. A review of the Treatment Sheets for Resident #14 dated 3/01/14 thru (sic) 3/31/14 included the order for treatment to the coccyx. The treatment was to be done 4 times per day. Documentation indicates the treatments were only done 2 times per day on March 2, 3, 7, 11, 14, 15, 17, 25, and 31. The treatment to the right heel was not done on 3/14/14 and 3/31/14. ( ) On 4/24/14 starting at 11:05 a.m., the dressing change to the right heel and the right gluteal fold of Resident #14 was observed performed by Registered Nurse (" D"). The Nurse Practitioner (NP)("J") was present during the entire dressing change process. RN "D" placed supplies on a barrier on the bed side table. Both RN "D" and NP "J" washed their hands and put on gloves. While attempting to remove the dressing to Resident #14's right heel, RN "D" had to use a gauze doused with wound wash to remove the old dressing. The old dressing was observed to have serous drainage on the dressing, thick gold colored purulent drainage was noted oozing out of the heel, the center was pink in color, surrounded in slough, and a small black colored scab was noted posterior to the wound. No barrier was placed under the right heel. NP "J" was asked what the stage of the pressure ulcer was, and replied a in a low voice, a healing stage 3. RN "D" then proceeded to put skin prep on the right great toe. RN "D" did not wash her hands after removing the soiled dressing to the right heel. RN "D" then proceeded to clean the pressure wound one time only with a pre-moistened 4 x 4 (gauze was sprayed with wound cleanser and placed in a medicine cup), starting at the center and moving to the outer edges of the wound. RN "D" did not spray the wound with the wound cleanser and pat the pressure wound dry. A section of the calcium alginate dressing with antibacterial silver was cut out from the larger intact dressing to fit the wound size, and applied to the pressure wound . RN "D" was asked when was the last time the area was measured, and replied "she did not know". The pressure wound to the right heel was not measured during the dressing change. RN "D" was then asked to stage the opened area and stated, "It looks like a pressure ulcer with drainage". A wet 4 x 4 gauze dressing doused with sterile water was applied on top of the calcium alginate dressing, a ABD dressing, and wrapped with a Kerlix dressing. RN "D" removed her gloves, put on a new pair of gloves but did not wash her hands. According to WOUND CARE ADVISOR 2014 the following are the calcium alginate dressing actions : Transforms into a moist gel consistency when it comes into contact with exudate or moisture, Absorbs up to 20 times its weight, Conforms to the shape of the wound, Fills in dead space: As it absorbs moisture and exudate, the gel fibers swell, making the dressing larger than when applied and the Moist gel consistency will maintain moist healing environment and facilitate autolytic debridement. It also reflected the product should not be moistened before use. A vertical uncovered pressure wound (slit) to Resident #14's coccyx area was observed, and measured at approximately 1-1.5 inches in length. The center of the pressure wound was pink and no drainage was noted. RN "D" was asked to stage the coccyx pressure ulcer, and replied it was a stage 1. RN "D" cleansed the area once with a pre-moistened wound cleanser 4 x 4 . RN "D" removed the old dressing to the right gluteal fold, that had serious fluid and blood noted on it. RN "D" touched the pressure ulcer site with her right gloved hand. The area was approximately 7.5 x 4.5 inches (with a hand used as a reference), the entire area was reddened with sporadic bleeding areas, and two small horizontal slits measuring approximately 1/4 of inch were noted. NP "J" had instructed RN "D" to remove the dressing for observation. NP "J" stated that the opened horizontal slits looked like abscesses, were deep, hard, approximately the size of a quarter, and needed antibiotics and a foam-like dressing. RN "D" then verbalized she wanted to complete the coccyx dressing, and obtained zinc oxide from a medicine cup and placed it on top of the pressure dressing to the coccyx. RN "D" still had not washed her hands from the beginning, nor did she wash them after making contact with pressure ulcer to the right gluteal fold. After applying the zinc oxide, RN "D" removed her gloves, entered the hall, and sanitized her hands (no sanitizer was noted in the resident's room). She entered the room and quickly exited because of the wrong type of dressing and entered a second time. While RN "D" exited the room the second time, NP "J" was asked to stage the heel wound. NP "J" stated the wound was hypergranulated at the center with slough at inferior margins, with some slough stable and hard. NP "J" revealed she did not know about the opened areas at the gluteal fold. NP "J" staged the gluteal fold as a stage 2 with abscesses. RN "D" returned and gloved her hands. RN "D" was asked to stage the gluteal fold and stated "I would stage at 1 blanchable". Twice RN "D" used a 4 x 4 pre-moistened gauze to cleanse the large pressure ulcer. She did not spray the area with wound cleanser and pat dry. A hydrafoam dressing was applied to the area, topped with an ABD dressing and secured with tape. Both staff washed their hands upon the completion of the right gluteal fold dressing change. At 12:00 PM RN "D" was asked what guidance did she use for staging pressure wounds. RN "D" revealed she had never staged any pressure wounds, and that the facility used to have a treatment nurse who did it. She then looked in her treatment book for pressure wound staging references and was only able to find "Treatment Protocols for Wound Care". She was unable to locate any reference to pressure wound staging. RN "D" was asked when she should wash her hands during dressing changes, and replied "before and after". At 12:30 PM NP "J" stated she did not have any information related to the right gluteal pressure wound, but had 2 orders for January 2014, when asked if she was aware of the status of the right gluteal fold pressure ulcer. At 12:35 PM the Director of Nursing (DON) "B" was asked to locate wound skin care sheets for the right gluteal fold pressure ulcer for Resident #14. DON "B" stated it should be on a non-pressure skin condition record. At 12:45 PM NP "J" revealed that staff should be vigilant about treatment and change dressing daily or they can turn into abscesses. Later on 4/24/14 at approximately 1:00 PM DON "B" provided guidance related to pressure ulcer staging for nurses and dressing changes policy. DON "B" stated the information was in the treatment book, yet RN "D" was unable to locate it. Also, some of the references were obtained at that time on-line. The facility's Wound and Skin Protocol Options dated 10/10 for Stage 2 and 3 reflected "...Treat compromised areas, per physician order". Under the alginates sections it reflected "...For high exudating wounds, cover with absorbent gauze dressing and change at least daily..." Apply wet to dry dressing on top of alginate was not reflected on the policy. The "Assessment and Documentation of Wounds" policy dated 1/01/11 reflected accurate assessment and documentation of wound and wound status is vitally important in management of wounds regardless of the etiology. The Skin Assessment-weekly policy dated 2/6/14 reflected a licensed nurse will complete a total body assessment on each resident weekly and document the assessment on the "Weekly Skin Integrity Review" form...If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form for pressure areas and complete the "Pressure Ulcer Record". For all other skin conditions, complete the "Non-Pressure Skin Condition Record". Treatment Administration Records (TAR) for 4/14 reflected that on 3/1/14 Resident #14 had an open area to the right gluteal fold, yet a non-pressure skin condition record or weekly skin integrity review was not done on a regular basis as the policy directed. Resident #14's Braden scale (tool used for predicting pressure sore risk) reflected a score of 14 (13-14 moderate risk) on 1/06/14, and 18 (15-18 at risk) on April 15 & 21, 2014. Weekly skin integrity review sheets viewed from 1/20/14 to 4/21/14 reflected only one entry related to the right gluteal fold dated 4/15/14. The entry dated 4/15/14 reflected 10 x 14 redness. Yet treatment sheets reflected the following for the right gluteal fold: "01/2014- Cleanse right lower gluteal fold pat dry apply [MEDICATION NAME] cream QID (four times a day) and PRN (as needed)." Two treatments were noted not done on January 22, 29, 30 and 31/2014. "03/2014-lower gluteal fold: cleanse, pat dry, apply [MEDICATION NAME] cream QID and PRN" changed 2/28/14 (no entries noted). "04/2014: lower right gluteal fold: cleanse, dry, apply [MEDICATION NAME] cream to skin surround open area, apply thin layer of wound gel to open area, cover with dry dressing daily and PRN until healed". One treatment was noted not done on 4/41/14. Later, on 4/24/14 at approximately 2:00 PM, Resident #14's chart was noted to have an order dated 4/24/14 at 12:05 PM reflecting, "1) Cleanse right posterior thin/lower buttock abscess pat dry apply foam pad and secure q (every) day and prn until healed. 2) [MEDICATION NAME] (antibiotic) 450 mg (milligrams) po (by mouth) q 8 hours x 10 days Dx abscess/(illegible word). On 4/25/14 at 2:50 PM Licensed Practical Nurse "K" was asked what do the blank boxes that are outlined mean on the treatment sheet. Staff "K" stated if the designated days did not have initials, that meant it just wasn't done. "If it is not signed it did not happen". Respectfully, treatment sheets of dressing changes to the right heel ulcer reflected the following: January 26, 29 2014, February 19, 26 and 28 2014, March 14 and 31 2014 and April 4, 7, 11, and 23 2014. The facility's care plan for the right gluteal fold, with no onset date, and a goal date of 6/14, reflected "(1) approach: 1/31/14 new order for gluteal fold". No specific interventions were noted related to the right gluteal fold. The care plan initiated 10/03/13 for a Stage 2 pressure ulcer to right buttock/coccyx. The words Stage 2 buttock/coccyx had lines written through them and "right heel pressure ulcer and right lower gluteal fold" written under it. No new interventions/approaches had been added to the original care plan dated 10/3/113 other than "new orders" and "new treatment". The facility did not consistently monitor, assess and treat the right gluteal pressure ulcer. Also, the facility did not change dressings as ordered for the right gluteal pressure ulcer and right heel pressure ulcer. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICE STATEMENTS (DPS): "A" AND "B" DPS A) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO EVALUATE THE EFFECTIVENESS OF FALL INTERVENTIONS FOR 1 OF 8 RESIDENTS (#11) REVIEWED FOR FALLS FROM A TOTAL 17 RESIDENTS AND UNSTEADY TOILET SEAT IN ROOM SHARED BY 107 AND 105 AFFECTING 3 RESIDENTS, RESULTING IN A FOREHEAD LACERATION AND BILATERAL NASAL BONE FRACTURE WITH LEFT SCALP HEMATOMA FOR RESIDENT #11 AND POTENTIAL FOR INJURY FOR RESIDENTS WHO USED UNSTEADY TOILET SEAT. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, UNDATED, RESIDENT #11 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED RESIDENT #11 HAD A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 6 OUT OF 15 POSSIBLE POINTS, MEANING SHE HAD MODERATELY SEVERE COGNITIVE IMPAIRMENT. ON 6/11/13 AT 11:30 A.M., DURING A MEDICATION PASS, RESIDENT #11 WAS OBSERVED SITTING IN HER WHEELCHAIR IN HER ROOM. BOTH OF HER LOWER EYE LIDS WERE BRIGHT RED WITH CONSIDERABLE AMOUNT OF EYE DISCHARGE. SHE ALSO HAD MULTIPLE SORE LIKE LESIONS ON HER FACE INCLUDING HER CHIN AND FOREHEAD. THE ROOM LOOKED CROWDED BECAUSE OF 2 LARGE CHAIRS, OVER-BED TABLE AND FLOOR MAT IN ADDITION TO HER ROOM MATE'S EQUIPMENT. THERE WAS NOT ENOUGH FLOOR SPACE FOR RESIDENT #11 TO WHEEL HERSELF IN THE ROOM. AS THE LICENSED PRACTICAL NURSE, (STAFF "W") APPLIED THE EYE OINTMENT RESIDENT #11 STATED SHE WAS BOTHERED BY THE MUCUS FROM THE EYE. THE PHYSICIAN'S PROGRESS NOTES DATED 1/18/13 THROUGH 6/1/13 REFLECTED RESIDENT #11 AS HAVING ON ON-GOING CHRONIC EYE INFECTION. INCIDENT REPORTS DATED DECEMBER 2012 THROUGH MAY 2013 REFLECTED RESIDENT #11 HAD 5 FALLS (12/11/12, 1/28/13, 2/3/13, 5/7/13, 5/10/13). REVIEW OF ALL OF THESE FALL INCIDENTS REFLECTED THE CAUSE MAY HAVE BEEN RELATED TO RESIDENT #11'S ATTEMPT TO SELF TRANSFER. THE NURSE'S NOTE DATED 1/28/13 REFLECTED RESIDENT #11 WAS OBSERVED SITTING ON BUTTOCKS ON FLOOR NEXT TO HER BED, HITTING THE FOOT BOARD AND SUSTAINED BUMP ON HER BACK OF HER HEAD. THE SBAR(SITUATION/BACKGROUND/ASSESSMENT/RECOMMENDATION ) DATED 2/3/13 REFLECTED RESIDENT #11 WAS FOUND ON FLOOR (LOCATION NOT SPECIFIED) AND SUSTAINED BUMP AND BRUISE ON RIGHT SIDE OF HER HEAD. SHE HAD BEEN ASSESSED TO BE CONFUSED ALL DAY. THE INCIDENT REPORT DATED 5/7/13 AT 8:00 P.M., REFLECTED RESIDENT #11 WAS FOUND LYING ON FLOOR IN HER ROOM. SHE HAD SUSTAINED A LACERATION FROM STRIKING HER RIGHT FOREHEAD. RESIDENT #11 WAS SENT TO emergency room FOR TREATMENT. THE HOSPITAL RECORD DATED 5/7/13 STATED RESIDENT #11 HAD 3 CM LACERATION OVER HER RIGHT HEMI-EYE BROW FROM A FALL WHILE GETTING OUT OF HER WHEELCHAIR. THE WOUND WAS CLOSED WITH SUTURES. THE INVESTIGATIVE REPORT FOR THE ABOVE INCIDENT STATED RESIDENT #11 ATTEMPTED SELF TRANSFER. THE CORRECTIVE MEASURES INCLUDED STAFF TO ANSWER ALARMS AS SOON AS POSSIBLE, MAKE SURE FLOOR MAT IN PLACE, THE BED TO BE IN LOW POSITION AND EDUCATE RESIDENT TO USE CALL LIGHT FOR ASSISTANCE. THERE WAS NO COMPREHENSIVE ROOT CAUSE ANALYSIS AND NEW/MODIFIED INTERVENTIONS. THE INCIDENT REPORT DATED 5/10/13 AT 5:00 P.M., REFLECTED RESIDENT #11 WAS FOUND LYING ON FLOOR IN HER ROOM. SHE HAD SUSTAINED SKIN TEAR ON HER FOREHEAD AND DEVIATED NOSE. RESIDENT #11 WAS SENT TO emergency room FOR TREATMENT. THE HOSPITAL RECORD DATED 5/10/13 STATED RESIDENT #11 SUSTAINED NASAL BONE FRACTURE ON BOTH SIDE, SCALP HEMATOMA WITH 3 CM LACERATION ON HER FOREHEAD FROM A FALL WHILE LEANING FORWARD IN A WHEELCHAIR, HITTING HER FOREHEAD ON THE FLOOR. THE PATIENT HAD A RECENT FALL THE SAME VARIETY WITH STITCHES OVER THE RIGHT EYEBROW. ON 6/13/13 AT 10;40 A.M., THE LICENSED PRACTICAL NURSE, (STAFF "F") STATED HE WAS ON DUTY AT THE TIME OF THE INCIDENT ON 5/10/13. STAFF "F" STATED, "WHEN I SAW THE RESIDENT I KNEW IMMEDIATELY SHE HAD BROKEN HER NOSE, BECAUSE HER NOSE TWISTED TO ONE SIDE, AND I SET IT BACK IN PLACE SO THAT HER NOSE LOOKED STRAIGHTER. I HAD AN EXTENSIVE TRAINING DOING THINGS LIKE THAT AS A NAVY CORPSMAN LONG TIME AGO." THE INVESTIGATIVE REPORT FOR THE ABOVE INCIDENT STATED RESIDENT #11 ATTEMPTED TO PICK SOMETHING OFF THE FLOOR. THE CORRECTIVE MEASURES INCLUDED CLOSE OBSERVATION, EVERY 15 MINUTE CHECKS AND RE-EDUCATE RESIDENT TO USE CALL LIGHT FOR ASSISTANCE. THERE WAS NO COMPREHENSIVE ROOT CAUSE ANALYSIS AND NEW/MODIFIED INTERVENTIONS. THE FALL CARE PLAN DATED 5/7/13 (NO PREVIOUS FALL CARE PLAN WAS ON FILE) REFLECTED RESIDENT #11 had a history of [REDACTED]. THE INTERVENTIONS INCLUDED 1) STAND-BY-ASSIST, 2) TENNIS SHOES FOR AMBULATION, 3) NIGHT LIGHT, 4) REMIND RESIDENT FOR ASSIST, 5) MONITOR CHANGES IN CONDITION THAT MAY WARRANT INCREASED SUPERVISION, 6) QUARTERLY FALL RISK ASSESSMENT, 7) CLEAR PATHWAYS, 8) CALL LIGHT WITHIN REACH, 9) PRESSURE SENSITIVE ALARM IN BED AND WHEELCHAIR, 10) LOW BED, 11) DO NOT KEEP RESIDENT ALONE IN BEDROOM. ON 6/12/13 AT 11:10 A.M., THE "100" AND "200" HALL UNIT MANAGER, (STAFF "B") WAS ASKED WHETHER THE FALL INTERVENTIONS FOR RESIDENT #11 HAD BEEN EFFECTIVE TO PREVENT HER SELF-TRANSFER ATTEMPT OR NOT. STAFF "B" REPLIED "NO." STAFF "B" WAS THEN ASKED WHETHER THE CURRENT INTERVENTIONS HAD BEEN RE-EVALUATED TO MODIFY OR REVISE TO DECREASE OR MINIMIZE THE RESIDENT'S FALL. STAFF "B" CONFIRMED THAT RESIDENT #11'S FALL CARE PLAN HAD NOT BEEN UPDATED TO REFLECT HER RISK FACTORS SUCH AS VISUAL IMPAIRMENT DUE TO CHRONIC EYE INFECTION, ENVIRONMENTAL HAZARD DUE TO CROWDED ROOM, INABILITY TO EDUCATE RESIDENT USE OF CALL LIGHT DUE TO HER SEVERE COGNITIVE IMPAIRMENT, USE OF PSYCHOACTIVE MEDICATIONS (ANTI-DEPRESSANT, MEMORY ENHANCER) AND OCCASIONAL URINE INCONTINENCE, CONTRIBUTING HER FREQUENT FALLS AND APPROPRIATE INTERVENTIONS. ( ) DURING THE ENVIRONMENTAL TOUR ON 6/10/13 STARTING AT 10:20 AM WITH THE ADMINISTRATOR, MAINTENANCE DIRECTOR STAFF "R" AND HOUSEKEEPING DIRECTOR STAFF "FF" THE BATHROOM TO ROOM 107 WAS OBSERVED TO HAVE A LOOSE COMMODE SEAT. WHEN TOUCHED THE COMMODE SEAT EASILY SLID FROM RIGHT TO LEFT BYPASSING THE COMMODE BY APPROXIMATELY 2-3 INCHES, CREATING A POTENTIAL FOR SLIP/FALL OFF THE COMMODE SEAT. THE BATHROOM TO ROOM 107 WAS SHARED BY ROOM 105, AND SERVICED 3 RESIDENTS. ( ) DPS B) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION NECESSARY TO MANAGE THE BEHAVIORS EXHIBITED BY 1 OF 7 RESIDENTS (#12) REVIEWED FOR DEMENTIA WITH BEHAVIORS, FROM A TOTAL SAMPLE OF 17 RESIDENTS, RESULTING IN OTHER RESIDENTS EXPERIENCING ANXIETY AND DISTRESS (SAMPLE RESIDENTS #1 AND #8; SUPPLEMENTAL SAMPLE RESIDENTS #18, #19, #20, #21, #22, #23, #24 AND #27; AND 4 OF 8 RESIDENTS PARTICIPATING IN THE CONFIDENTIAL RESIDENT GROUP INTERVIEW). FINDINGS INCLUDE: ACCORDING TO THE DEMENTIA WITH BEHAVIOR CARE PLAN DATED 12/6/11 AND UPDATED 9/30/12, RESIDENT #12 WAS A [AGE] year OLD FEMALE WHO WEIGHED 195 POUNDS AND WHO HAD DEMONSTRATED VIOLENT BEHAVIOR DIRECTED TOWARD HERSELF OR OTHERS. THE CARE PLAN IDENTIFIED BEHAVIORS THAT INCLUDED REFUSING PRESCRIBED MEDICATIONS AND DIFFICULTY ACCEPTING REDIRECTION WITHOUT VERBAL OR BEHAVIORAL ESCALATION. CARE PLAN APPROACHES INCLUDED ASSESSING FOR CAUSATIVE FACTORS, PRAISING THE RESIDENT FOR APPROPRIATE BEHAVIORS, MONITORING LABORATORY DATA AS AVAILABLE, UPDATING THE MEDICAL DOCTOR REGARDING RESIDENT REFUSALS, AND REAPPROACHING THE RESIDENT LATER, OR HAVING A DIFFERENT STAFF MEMBER APPROACH, WHEN PROBLEM BEHAVIORS WERE EXHIBITED. SOCIAL SERVICE NOTES DATED 10/3/12 REFLECTED THAT RESIDENT #12 HAD POOR SAFETY AWARENESS AND COULD BE IMPULSIVE AND WAS "USUALLY...NON-VERBAL WHEN SPOKEN TO. THE NOTES FURTHER STATED THAT RESIDENT #12 WOULD IMPULSIVELY SING, SWEAR OR MAKE RANDOM STATEMENTS LIKE "GIVE ME COFFEE" AND HAD: "A LONG HISTORY OF BEING RESISTIVE TO CARE... BEHAVIORS ARE DIFFICULT TO ALTER..." SOCIAL SERVICE NOTES 11/2012 THROUGH 5/2013 REFLECTED THAT RESIDENT #12 WAS TRANSFERRED FOR GERIATRIC PSYCHIATRIC hospitalization on [DATE], 4/12/13, 4/17/13 AND 5/28/13. THE "FINAL REPORT" DATED 5/17/13 FROM THE GERIATRIC PSYCHIATRIC HOSPITAL REFLECTED: " (RESIDENT HAS)...ESTABLISHED [DIAGNOSES REDACTED]. THE PATIENT (RESIDENT #12) ATTEMPTED TO STAB (ANOTHER) RESIDENT WITH A BUTTER KNIFE AND (WAS) ALSO REFUSING MEDICATION AND NOT REDIRECTABLE..." FACILITY PROGRESS NOTES DATED 6/11/13 REFLECTED THAT RESIDENT #12 WAS ALERT AND ORIENTED X 1 (TO SELF ONLY), INDICATING SEVERE COGNITIVE IMPAIRMENT. ON 6/11/13 AT 10:00 AM, DURING A CONFIDENTIAL GROUP INTERVIEW WITH FACILITY RESIDENTS, 2 OF 8 RESIDENTS PARTICIPATING STATED THAT THEY WERE AFRAID OF RESIDENT #12. AN ADDITIONAL 2 RESIDENTS STATED, "IF SHE HITS ME I AM GOING TO HIT HER BACK." THE RESIDENTS EXPLAINED, "YOU HAVE TO WALK BY HER GINGERLY...OR ELSE SHE WILL HAUL OFF AND HIT YOU." ONE OF THE RESIDENT'S IN THE GROUP INTERVIEW REPORTED THAT RESIDENT #12 HAD THROWN A KNIFE AT HER ROOMMATE IN THE DINING ROOM. DURING FOLLOW-UP INTERVIEW THE NEXT MORNING, ON 6/11/13 AT ABOUT 11:00 AM, THE FACILITY'S DIRECTOR OF NURSING (DON) STATED THAT SHE WAS NOT AWARE THAT OTHER RESIDENTS WERE AFRAID OF RESIDENT #12. THE DON WAS ASKED IF THERE WAS AN INCIDENT WHEN RESIDENT #12 HAD THROWN A KNIFE IN THE DINING ROOM. THE DON SAID THERE WAS AN INCIDENT WHEN RESIDENT #12 THREW A KNIFE IN THE DINING ROOM AND AND THE KNIFE HAD LANDED ON THE FLOOR, BY ANOTHER RESIDENT'S (#27'S) TABLE. THE DON STATED THAT THERE WAS NO INCIDENT AND ACCIDENT REPORT COMPLETED, BECAUSE THE KNIFE DID NOT HIT RESIDENT #27, IT JUST LANDED ON THE FLOOR. DURING AN INTERVIEW WITH RESIDENT #27 ON 6/12/13 AT ABOUT 2:00 PM, RESIDENT #27 SAID THAT RESIDENT #12 WOULD GET ANGRY WHEN OTHER RESIDENTS TOLD HER TO "SHUT UP" WHEN SHE WAS SINGING. ON 6/12/13 AT APPROXIMATELY 3:00 PM, ALL OF RESIDENT #12'S BEHAVIOR MONITORING LOGS, AND ALL OF THE FACILITY'S INCIDENT AND ACCIDENT REPORTS INVOLVING RESIDENT #12, WERE REQUESTED FOR THE PAST SURVEY YEAR. RESIDENT #12'S "BEHAVIOR SYMPTOM MONITORING" LOG HAD AN ENTRY DATED 3/19/13 WHEN NURSE AIDE STAFF HAD DOCUMENTED: "I WAS COMING OUT OF STORAGE ROOM AND (RESIDENT #12) WAS STANDING AT HER DINING ROOM TABLE OVER RESIDENT (#27) WHO WAS JUST COMING INTO THE DINING ROOM YELLING AND SCREAMING AT HER AND THREW A KNIFE AT HER, IT LANDED ON FLOOR...(RESIDENT #27) STATED I DID NOTHING TO DESERVE THIS BEHAVIOR." AN INCIDENT AND ACCIDENT REPORT DATED 5/15/13 AT 17:15 REFLECTED: "(RESIDENT #12) ATTEMPTED TO STAB ANOTHER RES. (#18) WITH A BUTTER KNIFE. CNA (CERTIFIED NURSE AIDE) IN DINING ROOM WITNESSED THE ACT IN PROGRESS AND YELLED 'STOP', DISTRACTING THE RES. (AND) STOPPING THE ACT FROM OCCURRING BEFORE CONTACT WAS MADE. THIS RN (REGISTERED NURSE), ANOTHER RN AND NP (NURSE PRACTITIONER) ATTEMPTED TO REMOVE RES. FROM THE DINING ROOM W/OUT SUCCESS. RES. ATTEMPTED VIOLENCE TOWARD STAFF AND WAS UNABLE TO BE REDIRECTED." DURING AN INTERVIEW ON 6/13/13 AT ABOUT 2:30 PM, SOCIAL WORKER "Q" STATED SHE HAD NOT BEEN INVOLVED IN ANY PSYCHOSOCIAL ASSESSMENT OF THE IMPACT ON RESIDENT #18 RELATED TO THE INCIDENT ON 5/5/13 INVOLVING RESIDENT #12. SOCIAL SERVICES NOTES DATED 5/28/13 REFLECTED: "(RESIDENT #12 HAD) MULTIPLE INCIDENTS OF MAKING CONTACT WITH STAFF AND RESIDENTS DESPITE JUST BEING readmitted FROM (NAME OF PSYCHIATRIC HOSPITAL) ON 5/22/13..." ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 5/13/13, RESIDENT #1 HAD SEVERE COGNITIVE IMPAIRMENT WITH MEMORY PROBLEMS, WAS INDEPENDENT WITH AMBULATION AND WANDERED DAILY. ACCORDING TO THE FACILITY DOCUMENT TITLED "SBAR-PHYSICIAN/NP/PA COMMUNICATION AND PROGRESS NOTE", DATED 12/22/12, THE FOLLOWING WAS OBSERVED BY A NURSE AT 11:00 AM: RESIDENT #1 WAS SEATED IN A CHAIR ACROSS FROM THE WEST NURSES STATION. RESIDENT #12 SAT DOWN NEXT TO RESIDENT #1, BUT DID NOT SPEAK. ACCORDING TO TO THE DOCUMENT: "SHE (RESIDENT #12) TURNED UNPROVOKED TO (RESIDENT #1) AND PUNCHED HER (WITH) A CLOSED FIST IN THE R (RIGHT) CHEEK...SHE (RESIDENT #1) WAS CRYING AND SAID HER JAW HURT." RESIDENT #12 WAS TAKEN BACK TO THE OTHER SIDE OF THE BUILDING BY 2 CNAS (CERTIFIED NURSE ASSISTANTS), AND "PUT ON 1:1 SUPERVISION FOR SAFETY." ACCORDING THE FACILITY INCIDENT AND ACCIDENT REPORT, DATED 12/24/12 FOR THE INCIDENT THAT HAD OCCURRED ON 12/22/12 (UNDER SECTION 3): "CORRECTIVE/REMEDIAL MEASURES TAKEN TO AVOID REPETITION OF THE ACCIDENT/INCIDENT: ENCOURAGE RESIDENT (#1) TO STAY AWAY FROM RESIDENT (#12) THAT MADE CONTACT WITH HER." UNDER THE SECTION OF THE REPORT THAT ASKED: "COULD THE INCIDENT HAVE BEEN ANTICIPATED OR AVOIDED?" THE WORD "NO" WAS WRITTEN, AND UNDER "COULD SUCH AN INCIDENT BE AVOIDED IN THE FUTURE?" THE WORD "NO" WAS WRITTEN AGAIN. BASED ON REVIEW OF RESIDENT #12'S CLINICAL RECORD, THERE WAS NO DOCUMENTATION TO REFLECT THAT THE FACILITY'S SUPERVISION OF RESIDENT #12 WAS RE-EVALUATED BY THE INTERDISCIPLINARY TEAM OR THAT NEW AND SPECIFIC STRATEGIES FOR SUPERVISION WERE DEVELOPED. DURING AN INTERVIEW ON 6/10/13 AT 10:05 AM, THE DON DESCRIBED RESIDENT #12 AS INDEPENDENTLY AMBULATORY THROUGHOUT THE FACILITY WITH A TENDENCY TO "SWIPE" PEOPLE AND OBJECTS OUT HER WAY WHEN SHE BECAME UPSET. THE DON SAID, ONCE RESIDENT #12 SEATED HERSELF IN THE DINING ROOM, NO ATTEMPTS WERE MADE TO MOVE HER, AND SHE NEEDED TO BE SERVED HER BEVERAGES AND MEALS FIRST, ALL TO AVOID OUTBURSTS. THE DON ASKED ABOUT THE CARE PLAN FOR PROVIDING SUPERVISION TO PROTECT RESIDENT #12 AND OTHER RESIDENTS, AND WAS SPECIFICALLY ASKED IF RESIDENT #12 ALWAYS RECEIVED 1:1 SUPERVISION. THE DON ANSWERED, "NO." WHEN ASKED IF DIFFERENT FACILITY PLACEMENT HAD EVER BEEN CONSIDERED, THE DON RESPONDED THAT RESIDENT #12 HAD FEW CHOICES BECAUSE OF HER HISTORY AND BEHAVIORS. ON 6/13/12 AT APPROXIMATELY 2:00 PM, RESIDENT #12 WAS OBSERVED AS SHE WALKED BY THE WEST NURSES STATION. SEVEN OTHER FACILITY RESIDENTS WHO WERE SEATED IN CHAIRS AND WHEEL CHAIRS BY THE WEST NURSES STATION, CHATTING AMONG THEMSELVES,WERE OBSERVED TO STOP TALKING AND WATCH RESIDENT #12, AS SHE WALKED BY. AS RESIDENT #12 WALKED AWAY DOWN THE HALL, ALL 7 RESIDENTS CONTINUED TO QUIETLY WATCH HER. ON 6/14/13 AT 10:45 AM, TELEPHONE INTERVIEW WITH THE DON VERIFIED THAT THE 1:1 SUPERVISION OF RESIDENT #12 WAS DISCONTINUED ON 12/25/12, 3 DAYS AFTER RESIDENT #12 HAD PUNCHED RESIDENT #1 ACCORDING TO THE JUNE 2013 MONTHLY physician's orders [REDACTED]. ACCORDING TO THE QUARTERLY MDS assessment dated [DATE], RESIDENT #8 HAD A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) INTERVIEW SCORE OF "0" (ZERO) OUT OF A POSSIBLE 15. THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 9/3/12 REFLECTED THAT RESIDENT #12: "MADE CONTACT TO THIS RES (#8) WITH (A) REACHING DEVICE." THE FACILITY'S "DETERMINATION OF UNAVOIDABLE ACCIDENT" FORM, DATED 9/3/12, REFLECTED THE INTERVENTIONS INCLUDING OBSERVING AND MAKING 15 MINUTE CHECKS FOR 24 HOURS. THE ATTACHED NURSES NOTES DATED 9/3/12 REFLECTED: "THIS NURSE OVERHEARD RES SHOUTING. UPON INVESTIGATION, THIS NURSE NOTED RES (#8) TO BE SITTING IN W/C (WHEEL CHAIR) IN ANOTHER RESIDENT ROOM. OTHER RESIDENT (#12) USED REACHING DEVICE AND TAPPED THIS RESIDENTS (#8) SHOULDER. OTHER RESIDENT (#12) SHOUTING 'GET OUT OF MY ROOM!' THIS RES REMOVED FROM ROOM. NO INJURY TO EITHER RESIDENT. DR (NAME) AWARE. MESSAGE LEFT WITH GUARDIAN." THE FACILITY'S "SBAR" COMMUNICATION TOOL DATED 5/24/13 REFLECTED THAT RESIDENT #8 WAS STRUCK BY ANOTHER RESIDENT (#12) IN THE BACK OF THE HEAD WITH BACK OF OPEN HAND. THE "PROGRESS NOTE" PORTION OF THE "SBAR" TOOL REFLECTED RESIDENT #8 HAD COMPLAINED OF DISCOMFORT DURING THE INCIDENT. THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 11/7/12 AT 3:00 AM, REFLECTED RESIDENT #12 MADE CONTACT WITH AN OPEN HAND TO ANOTHER RESIDENT'S (#23'S) SHOULDER. THE CORRECTIVE MEASURE WAS TO "MONITOR (RESIDENT #12) FOR AGGRESSIVE BEHAVIORS. UTILIZE 1:1 IF NECESSARY." THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 11/26/12 AT 10:30 AM REFLECTED RESIDENT #12 HAD MADE CONTACT LIGHTLY WITH ANOTHER RESIDENT'S (#22'S) ARM AND RIGHT SHOULDER. THE CORRECTIVE MEASURE FOR RESIDENT #12 WAS TO: RE-DIRECT HER TO HER ROOM AND OFFER SNACK AND COFFEE ... 1:1 CAN BE PROVIDED IF NEEDED." THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 11/26/12 AT 12:30 PM REFLECTED THAT RESIDENT #12 HAD MADE CONTACT TO BACK OF RESIDENT #21'S HEAD. THE CORRECTIVE MEASURE WAS TO "REMIND ALERT RES (#21) TO STAY CLEAR OF OTHER RESIDENT (#12) WHEN (#12 WAS) AGGITATED (sic). " THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 3/24/13 AT 11:37 AM REFLECTED THAT RESIDENT #12 HAD LEFT A "RED MARK" ON RESIDENT #20. THE INVESTIGATION PORTION OF THE REPORT REFLECTED THE FOLLOWING INFORMATION: "KITCHEN STAFF INTERVENED RESIDENT (#12) FLAILING ARMS AT OTHER RESIDENT (#20) IN W/C (WHEEL CHAIR) THIS RESIDENT (#12) STRUCK OTHER RESIDENT (#20) ON RIGHT CHEEKBONE." THERE WAS A QUESTION ON THE INVESTIGATION PORTION THAT ASKED, "COULD SUCH AN INCIDENT BE AVOIDED IN THE FUTURE? IF SO, HOW?" THE DOCUMENTED RESPONSE WAS: "THIS RESIDENT (#12) IS UNPREDICTABLE." THE NURSES NOTES DATED 3/24/13 REFLECTED THAT RESIDENT #20 HAD BEEN INSTRUCTED TO STAY AWAY FROM RESIDENT #12 AND NOT TO GET WITHIN REACH OF HER. THE FACILITY INCIDENT AND ACCIDENT REPORT DATED 4/2/13 AT 20:30 (8:30 PM) REFLECTED THAT RESIDENT #12 HAD "PUNCHED ANOTHER RESIDENT (#19) IN THE LEFT SHOULDER WITH HER FIST AS THEY PASTED (sic) BY HER." THE INVESTIGATION PORTION OF THE REPORT REFLECTED: "RESIDENT (#12) WAS SITTING IN A CHAIR IN DAY ROOM WHEN ANOTHER RES. (#19) PASSED BY HER. RESIDENT #12 PUNCHED THIS RESIDENT IN UPPER LEFT SHOULDER AND KICKED AT THIS RES (#19'S) W/C (WHEEL CHAIR)." THE CORRECTIVE MEASURE WAS TO: "REDIRECT RESIDENT WHEN AGITATION BEGINS TO ENSURE NO ONE IS IN THIS RESIDENT'S (#12'S) PATH." THE INCIDENT REPORT INVESTIGATION DATED 5/28/13 AT 2:30 PM, REFLECTED: "(RESIDENT #12) HIT ROOMMATE IN SHOULDER. RESIDENT (#12) WAS ENTERING ROOM AND ROOMMATE WAS WITHIN REACH. RESIDENT (#12) SCREAMED AND HIT RESIDENT #24. ROOMMATE (#24) STATES 'SHE PUNCHED ME HARD!' NO BRUISE OR APPARENT INJURY." THIS SAME REPORT REFLECTED THAT RESIDENT #12 WAS PLACED ON 1:1 SUPERVISION. ACCORDING TO THE INCIDENT REPORT, THE ANSWER TO THE QUESTION "COULD SUCH AN INCIDENT BE AVOIDED IN THE FUTURE?" WAS "POSSIBLY. GIVE RESIDENT SPACE AND ENSURE DISTANCE." BASED ON REVIEW OF RESIDENT #12'S CLINICAL RECORD, THERE WAS NO DOCUMENTATION TO REFLECT THAT THE "SPACE AND DISTANCE" NECESSARY TO KEEP OTHER RESIDENTS SAFE FROM RESIDENT #12'S BEHAVIORS HAD BEEN RE-EVALUATED, SPECIFIED OR QUANTIFIED BY THE FACILITY'S INTERDISCIPLINARY TEAM; OR THAT THE TEAM HAD IDENTIFIED THE SPECIFIC SUPERVISION STRATEGIES THAT WOULD BE NECESSARY. DURING AN INTERVIEW ON 6/13/13 AT 3:15 PM, THE FACILITY'S ADMINISTRATOR STATED THAT HE DID NOT BELIEVE RESIDENT #12'S ACTIONS WERE WILLFUL BECAUSE THE BEHAVIORS REFLECTED THE RESIDENT'S EFFORTS TO TRY TO COMMUNICATE. ( )

Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for 1 of 4 (Resident #312) residents reviewed for falls, from a total sample of 10 residents, resulting in Resident #312 sustaining a 2 centimeter laceration to the right eyebrow from an unwitnessed fall/incident, that required suture closure at the local emergency room . Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #312 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #312 had severe cognitive impairment and required limited to extensive staff assistance with activities of daily living. In an observation and interview on 8/16/13 at 8:00 AM, Resident #312 was observed sitting in dining room, seated in a wheel chair. Resident #312 was unable to answer questions related to the bruise to her right eyebrow. Review of the "Occupational Therapy OT Initial Evaluation" dated 7/25/13 revealed, "Summary of Cognitive Impairments: Resident has poor safety awareness and insight towards deficits. She is only oriented to herself. She has a difficult time following directions/processing them. Resident's cognitive impairments inhibit her from being independent with ADLs (activities of daily living)." Review of the "Physician Admission Order Sheet" dated 7/24/13 untimed, revealed Resident #312 would have personal safety alarms while in bed and chair, and mats on the floor beside of the bed for safety. Review of the "Fall Risk Evaluation" dated 7/24/13 revealed a score of 14, "total score of 10 or more deems resident at risk." Review of the "Incident & Accident Report" dated 7/25/13 at 4:15 PM revealed Resident #312 was found on the floor in her room (incident unwitnessed) and documented under "corrective/remedial measures taken to avoid repetition of the accident/incident" revealed "every 15 minute safety checks and physical therapy to evaluate resident." Review of the "Physician Orderers" dated 7/25/13 at 4:30 PM revealed, "Send Resident out for CT Scan...Fall with hematoma (swollen/bruised) forehead." Review of the "Admission Care Plan" dated 7/24/13 revealed the intervention of "every 15 minute safety checks" was added to the care plan but no date was indicated. Review of the policy/procedure for "Resident Safety Checks" dated 1/1/07 last reviewed on 9/1/11 revealed, "Resident safety checks can be initiated by a physician or Clinical Nurse who deems a resident to be at risk to self or others...check resident at required intervals...initial form indicating check was completed...form is filed in Medical Record." In an interview on 8/16/13 at 8:40 AM, Medical Records Staff #10 stated that she was unable to locate any 15 minute safety checks for Resident #312 from 7/25/13 through 8/11/13. Medical Records Staff #10 stated, she (Resident #312) wasn't started on safety checks until 8/12/13." In an interview on 8/16/13 at 10:10 AM, Director of Nursing (DON) #2 stated that the every 15 minute safety checks were added to the care plan but there was no documentation to validate that the 15 minute safety checks were initiated or done. In an interview on 8/16/13 at 10:30 AM, Registered Nurse (RN) #13 stated that on 7/31/13 at 4:20 PM, Resident #312 was found in her room, on the floor mat, between the wheelchair and the bed. RN #13 stated the incident was unwitnessed. When RN #13 was asked if any immediate interventions to prevent reoccurrence were put into place to prevent further falls, RN #13 stated, "No." Review of the "Incident & Accident Report" dated 8/2/13 at 5:45 AM, revealed Resident #312 was found on the floor of her room (unwitnessed incident) and bed bolsters were added to the falls care plan. Review of the "Incident & Accident Report: dated 8/5/13 at 10:40 PM, revealed Resident #312 was found face down on the floor near the nurses station in the hall (unwitnessed incident). Review of the "Physician Orders" dated 8/5/13 at 10:50 PM revealed, "Send to E.R. (emergency room ) to evaluate and treat s/p (status [REDACTED]. Review of the hospital records dated 8/5/13 at 11:48 PM, revealed Resident #312 had a 2 centimeter laceration above the right eyebrow that required one suture and dermabond (glue) to close the laceration. In an interview on 8/16/13 at 10:10 AM, When DON #2 was asked what immediate interventions were put into place to prevent reoccurrence upon Resident #312's return from the hospital on [DATE] at 3:40 AM, DON #2 stated, "nothing more at that point." Review of the "Incident & Accident Report" dated 8/7/13 at 2:10 PM, revealed that Resident #312 entered another resident's room and a visitor attempted to remove Resident #312 from the room, by pushing her (Resident #312) wheelchair, when Resident #312 grabbed the footboard of the bed and held on, resulting in Resident #312 ending up on her knees on the floor. Review of the "Physician Orders" dated 8/9/13 at 8:15 AM, revealed, "Resident to have lap buddy placed while up in w/c (wheelchair) for repositioning. Observe Q (every) 30 minutes and release every 2 hours." Review of "Incident & Accident Report" dated 8/11/13 at 8:05 PM, revealed Resident #312 was found on the floor in her room (unwitnessed incident) with her wheelchair (that she was seated in) tipped over backwards onto the floor, with the lap buddy still on the chair. "Corrective/Remedial measures taken to avoid repetition of the accident/incident: Antitip bars added to resident's w/c (wheelchair). Resident placed on 1 to 1 supervision." Record review of the "Resident Safety Check" revealed "15 Minute Check" for "Safety Concerns: Falls" revealed no safety checks for 8/11/13 but were initiated on 8/12/13 at 6:00 AM. Records dated 8/14/13 revealed no initials (checks) at the following intervals: 4:00 PM, 4:15 PM, 4:45 PM, 5:00 PM, 5:15 PM, 5:30 PM, and 5:45 PM. Record dated 8/15/13 revealed no initials (checks) at the following intervals: 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 1:00 PM, 1:15 PM, 1:30 PM, and 1:45 PM. In a telephone interview on 8/20/13 at 4:45 PM, Registered Nurse (RN) #12 stated that the antitip bars were not added on 8/11/13. RN #12 stated a maintenance request was submitted to the maintenance staff the morning of 8/12/13 and the antitip bars were added to Resident #312's wheelchair on 8/12/13. (# )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN A PERIPHERALLY INSERTED CENTRAL CATHETER (INTRAVENOUS LINE) AND FAILED TO TRANSCRIBE MEDICATION ORDERS IN A TIMELY MANNER FOR ONE RESIDENT (#7) OF TWO RESIDENTS REVIEWED WITH INTRAVENOUS LINES; AND FAILED TO PERFORM ASSESSMENT OF HEART RATE DURING AEROSOLIZED ADMINISTRATION OF RESPIRATORY MEDICATIONS AND FAILED TO SUPERVISE RESIDENTS DURING THE RESPIRATORY TREATMENTS FOR TWO RESIDENTS (#7, AND #14) OF TWO OBSERVED RESPIRATORY TREATMENTS OUT OF A SAMPLE OF 17 RESIDENTS RESULTING IN THE POTENTIAL FOR THE DEVELOPMENT OF [MEDICAL CONDITION] OR INFECTION AND A DELAY IN ANTIBIOTIC treatment for [REDACTED]. FINDINGS INCLUDE: THE FACE SHEET FOR RESIDENT #7, DATED 7/9/2012, REFLECTED THAT THIS [AGE] year OLD MALE HAD ORIGINALLY BEEN admitted to the facility on [DATE]. THE NURSE PRACTITIONER'S (STAFF "A") PROGRESS NOTES DATED 7/6/2012, REFLECTED AN ASSESSMENT THAT INCLUDED [MEDICAL CONDITION] BACTERIAL PNEUMONIA AND BLOOD INFECTION, [MEDICAL CONDITION], CHRONIC [MEDICAL CONDITION] WITH A [MEDICAL CONDITION], A HISTORY OF DEEP VEIN [MEDICAL CONDITION], AND HIGH BLOOD PRESSURE. AN ORDER, DATED 7/21/2012, REFLECTED THAT RESIDENT #7 WAS SENT TO THE HOSPITAL emergency room FOR EVALUATION BECAUSE OF A PULSE OXIMETRY READING OF 62% (NORMAL RANGE IS ABOVE 90%), CONGESTION, THICK GREEN SPUTUM, AND MENTAL STATUS CHANGES. A HOSPITAL physician progress notes [REDACTED]. THE HOSPITAL PHYSICIAN ORDERS [REDACTED]. THE ORDERS INCLUDED INSTRUCTIONS FOR THE PICC LINE DRESSING TO BE CHANGED ON 7/27/2012 AND THEN WEEKLY, TO CHANGE THE PICC LINE CAP WEEKLY, AND TO "FLUSH PER PROTOCOL - POWER PICC". THE FACILITY PHYSICIAN ADMISSION ORDER SHEET, DATED 7/26/2012, REFLECTED THAT RESIDENT #7 WAS TO HAVE A PICC LINE DRESSING CHANGE ON 7/27/2012, THEN THE DRESSING CHANGE WAS TO BE WEEKLY. THE AUGUST 2012 TREATMENT SHEET REFLECTED THAT THE PICC LINE DRESSING WAS TO BE CHANGED ON AUGUST 3, 2012. HOWEVER, THAT DATE WAS BLANK, AND A NOTATION REFLECTED THE DRESSING CHANGE HAD BEEN PERFORMED LATE ON AUGUST 4 TH. THE NEXT DATE INDICATED FOR THE DRESSING CHANGE WAS AUGUST 10 TH. THE NURSE CIRCLED HER/HIS INITIALS, INDICATING THE PROCEDURE WAS NOT PERFORMED AND MADE A NOTATION ON THE BACK OF THE SHEET THAT RESIDENT #7 HAD REFUSED TO HAVE THE PICC DRESSING CHANGED. THERE WAS NO CORRELATING NURSING PROGRESS NOTE FOR 8/3/2012 THAT ADDRESSED THE REFUSAL BY RESIDENT #7 OR IF ANY ADDITIONAL ATTEMPTS WERE MADE TO CHANGE THE DRESSING AS ORDERED OR, FOR EXAMPLE, IF RESIDENT #7 WAS EDUCATED ON THE IMPORTANCE OF THE DRESSING CHANGE. THE NEXT DATE THE PICC DRESSING WAS TO BE CHANGED, ACCORDING TO THE 8/2012 TREATMENT RECORD, WAS 8/10/2012. THE NURSE AGAIN CIRCLED HIS/HER INITIALS ON THAT DATE. THERE WAS NO NOTATION ON THE BACK OF THE TREATMENT RECORD TO INDICATE WHY THE DRESSING CHANGE WAS NOT DONE OR WHAT THE PLAN WAS TO MAINTAIN THE PATENCY PICC SITE TO REDUCE THE RISK OF INFECTION. THE NEXT SCHEDULED DRESSING CHANGE WAS FOR 8/17/2012. AGAIN, THE NURSE CIRCLED HIS/HER INITIALS INDICATING THAT THE DRESSING CHANGE WAS NOT DONE. THERE WAS NO NOTATION ON THE BACK OF THE TREATMENT RECORD THAT EXPLAINED WHY THE DRESSING CHANGE WAS NOT DONE OR WHAT THE PLAN WAS TO MAINTAIN THE SITE TO REDUCE THE RISK OF INFECTION. THE NEXT DATE THE PICC DRESSING WAS SCHEDULED TO BE CHANGED WAS 8/24/2012. THE SPACE FOR THE NURSE'S INITIALS WAS BLANK. ACCORDING TO THE "GUIDELINES FOR THE PREVENTION OF INTRAVASCULAR CATHETER-RELATED INFECTIONS, 2011", WEEKLY DRESSING CHANGES WERE RECOMMENDED TO MINIMIZE THE RISK OF CATHETER INFECTION. ACCORDING TO THE GUIDELINES, THE COST OF THESE INFECTIONS IS SUBSTANTIAL IN TERMS OF RESIDENT OUTCOMES. ACCORDING TO THE FACILITY POLICY FOR CENTRAL LINE DRESSING CHANGE, DATED 3/12, THE DRESSING CHANGE WAS TO OCCUR EVERY SEVEN DAYS. RESIDENT #7'S ORDER SHEET, DATED 7/26/2012, INCLUDED THE ANTIBIOTIC [MEDICATION NAME] 1 GRAM TO BE GIVEN INTRAVENOUSLY (IV) EVERY DAY FOR 12 DAYS. THE PICC WAS TO BE FLUSHED WITH 10 CUBIC CENTIMETERS (CCS) OF NORMAL SALINE BEFORE AND AFTER MEDICATIONS AND TO BE FLUSHED WITH 3 CCS OF [MEDICATION NAME] (A DRUG USED TO PREVENT BLOOD CLOT FORMATION) AFTER THE MEDICATIONS. ACCORDING TO THE IV MEDICATION SHEET, DATED FOR AUGUST 2012, THE LAST DOSE OF THE ANTIBIOTIC AND THE LAST DATE OF THE NORMAL SALINE AND [MEDICATION NAME] FLUSHES WERE ON 8/7/2012. ON 8/28/2012 AT 10:15 AM, STAFF REGISTERED NURSE "C" WAS ASKED TO CONFIRM THE DATE OF THE LAST FLUSH OF THE PICC LINE, HER RESPONSE WAS "IT LOOKS LIKE IT HASN'T BEEN DONE SINCE THE 7 TH". ACCORDING TO THE FACILITY INFUSION MAINTENANCE TABLE, DATED MARCH 2010, PROVIDED BY THE DIRECTOR OF NURSES ON 8/28/2012 WHEN THE POLICY WAS REQUESTED, A DISTINCTION WAS MADE BETWEEN CARE REGIMENS FOR A NON VALVED PICC LINE AND A VALVED PICC LINE. WHEN THE DIRECTOR OF NURSES WAS ASKED ON 8/28/2012 AT 11:30 AM WHICH TYPE OF PICC LINE RESIDENT #7 HAD, SHE WAS NOT SURE. THE ADMISSION NURSING ASSESSMENT, DATED 7/26/2012, REFLECTED THE PRESENCE OF THE PICC LINE IN THE LEFT ARM, BUT NOT THE SIZE OR TYPE OF PICC LINE. ON 8/28/2012 AT 1:45 PM, THIS SURVEYOR OBSERVED THE PICC SITE. A TRANSPARENT DRESSING WAS OBSERVED. THE INTRAVENOUS CATHETER WAS A DOUBLE LUMEN POWER PICC, 18 GAUGE, 5 FRENCH. ACCORDING TO THE NURSING INSTRUCTIONS FOR THE POWER PICC, REVISED MARCH 2012 AND ACCESSED ON 8/28/2012 AT WWW.POWERPICC.COM, THE PICC LINE SHOULD HAVE BEEN FLUSHED AT LEAST WEEKLY WHEN NOT IN USE. ACCORDING TO THE NURSING INSTRUCTIONS FOR THE POWER PICC, REVISED MARCH 2012 AND ACCESSED ON 8/28/2012 AT WWW.POWERPICC.COM, THE EXTERNAL LENGTH OF THE CATHETER SHOULD HAVE BEEN ASSESSED DURING ALL DRESSING CHANGES TO DETERMINE IF THE POSITION OF THE CATHETER HAD CHANGED. THE INTRAVENOUS CATHETER MUST STAY SECURE TO MINIMIZE THE RISK OF AN [MEDICATION NAME] WHICH COULD CLOG A BLOOD VESSEL AND IMPEDE CIRCULATION. THERE WAS NO DOCUMENTATION THAT THE LENGTH OF THE EXTERNAL CATHETER HAD BEEN ASSESSED AT ANY TIME. ACCORDING TO RESIDENT #7'S ADMISSION ORDER SHEET, DATED 7/26/2012, THE MEDICATION [MEDICATION NAME] 2.5 MILLIGRAMS (MG), TO PREVENT BLOOD CLOTS FROM FORMING WAS ORDERED TO BE ADMINISTERED BY INJECTION ONCE A DAY. A REPORT FROM AN INDEPENDENT PROVIDER, DATED 7/30/2012, REFLECTED THAT A VENOUS EXAMINATION OF THE RIGHT ARM WAS PERFORMED THAT GAVE THE IMPRESSION OF A [MEDICAL CONDITION] OF THE RIGHT [MEDICATION NAME] VEIN. THE REPORT INDICATED THAT THE DOSE OF THE [MEDICATION NAME] WAS INCREASED TO 7.5 MG FOR 10 DAYS. ACCORDING TO THE NURSING INSTRUCTIONS FOR THE POWER PICC, REVISED MARCH 2012 AND ACCESSED ON 8/28/2012 AT WWW.POWERPICC.COM, ONE OF THE POSSIBLE COMPLICATIONS OF A POWER PICC INCLUDES BLOOD CLOTS. FLUSHING THE IV CATHETER ON A ROUTINE BASIS AIDES IN THE PREVENTION OF BLOOD CLOT FORMATION. A PHYSICIAN COMMUNICATION PROGRESS NOTE REFLECTED THAT AT 12:35 AM ON 8/27/2012, RESIDENT #7 WAS COUGHING UP A LARGE AMOUNT OF THICK GREEN SPUTUM, HIS TEMPERATURE WAS ELEVATED AT 101.5 DEGREES FARENHEIT, HIS PULSE WAS ELEVATED AT 104, HIS RESPIRATORY RATE WAS 28 (NORMAL 12-20), HIS PULSE OXIMETRY WAS 84 % (NORMAL OF ABOVE 90%) AND HIS LUNG SOUNDS WERE ABNORMALLY CONGESTED. THE NURSE PRACTITIONER WAS NOTIFIED, AND GAVE an order for [REDACTED]. THE PHYSICIAN PRESCRIBED AN ORAL ANTIBIOTIC AND RESIDENT #7 WAS SENT BACK TO THE FACILITY. ON MONDAY 8/27/2012, NURSE PRACTITIONER "A" PRESCRIBED THE INTRAVENOUS ANTIBIOTIC [MEDICATION NAME] 1 GRAM TO BE GIVEN EVERY TWELVE HOURS FOR 10 DAYS AND DISCONTINUED THE ORAL ANTIBIOTIC PRESCRIBED IN THE emergency room DUE TO AN ALLERGY. THE NURSE PRACTITIONER WROTE IN A PROGRESS NOTE THAT HER ASSESSMENT REVEALED PNEUMONIA WITH A HISTORY OF [MEDICAL CONDITION] AND PLACED RESIDENT #7 IN ISOLATION PRECAUTIONS. BY 10:55 AM ON 8/27/2012, THE ISOLATION CART WAS OBSERVED BESIDE THE DOOR OF THE RESIDENT ROOM. DURING THE AFTERNOON OF 8/28/2012, RESIDENT #7'S MEDICAL RECORD WAS RETURNED TO THE NURSING UNIT AND HANDED TO REGISTERED NURSE "C" WITH THE COMMENT THAT THERE WERE NEW ORDERS IN THE CHART THAT NEEDED TO BE NOTED. STAFF NURSE "C" WAS OBSERVED TO PLACE THE CHART ON THE TOP OF THE CHART RACK. THE NURSE WHO TRANSCRIBED THE ORDERS WRITTEN ON 8/27/2012 FOR RESIDENT #7, RECORDED THE TIME AS "2000" OR 8:00 PM. ON TUESDAY 8/28/2012 AT 10:15 AM, STAFF REGISTERED NURSE "C" STATED THAT RESIDENT #7'S PICC LINE WAS PLUGGED AND UNUSABLE. A NURSING PROGRESS NOTE DATED 8/28/2012 REFLECTED THAT THE PHYSICIAN HAD PRESCRIBED A MEDICATION FOR REMOVAL OF A BLOOD CLOT OF THE PICC LINE. AN INTRAVENOUS REGISTERED NURSE WAS CONTACTED AND ARRIVED AT THE FACILITY ON 8/28/2012 AT 5:30 PM AND WAS SUCCESSFUL IN UNCLOGGING THE PICC LINE. A REVIEW OF THE IV MEDICATION SHEET, DATED AUGUST 2012, REFLECTED THAT THE FIRST DOSE OF THE [MEDICATION NAME] 1 GRAM WAS ADMINISTERED AT 6:00 AM ON WEDNESDAY 8/29/2012, AT LEAST 36 HOURS AFTER THE NURSE PRACTITIONER HAD WRITTEN THE ANTIBIOTIC ORDER. DURING AN INTERVIEW WITH NURSE PRACTITIONER, STAFF "A" ON 8/29/2012 AT 10:00 AM, STAFF "A" STATED THAT SHE WAS UNAWARE THAT THE FACILITY HAD NOT BEEN MAINTAINING THE PICC LINE AND AGREED THAT THERE WAS TOO LONG OF A TIME PERIOD BETWEEN HER WRITTEN PRESCRIPTION AND THE ADMINISTRATION OF THE FIRST DOSE OF IV [MEDICATION NAME] FOR RESIDENT #7. DURING AN INTERVIEW WITH STAFF LICENSED PRACTICAL NURSE "D" ON 8/29/2012 AT 10:45 AM, SHE STATED THAT THE CUT OFF TIME TO PLACE ORDERS FOR PHARMACY DELIVERY WAS 4:00 PM. STAFF "D" STATED THAT WHEN SHE RECEIVED NEW ORDERS SHE "ABSOLUTELY" MADE SURE THAT ANY MEDICATION ORDERS WERE FAXED TO THE PHARMACY BEFORE 4:00 PM TO ENSURE MEDICATION DELIVERY. A REVIEW OF THE MEDICAL RECORD FOR RESIDENT #7 DID NOT REVEAL A CARE PLAN THAT ADDRESSED THE MAINTENANCE OR CARE OF THE PICC LINE OR OBSERVATION FOR SIGNS OR SYMPTOMS THAT WOULD BE IDENTIFIED TO ALERT THE NURSING STAFF OF POSSIBLE INFECTION TO THE PICC SITE. ( ) DURING MEDICATION PASS OBSERVATION ON 8/27/12 AT 9:23 AM WITH REGISTERED NURSE "L", RESIDENT #14'S MEDICATION ADMINISTRATION WAS OBSERVED. THE RESIDENT RECEIVED ONE VIAL OF [MEDICATION NAME]/[MEDICATION NAME] 0.5 MILLIGRAMS (MG)/ 2 MILLILITERS (ML) NEBULIZER SUSPENSION AT 9:36 AM. AFTER APPLYING THE MASK WITH THE MEDICATION TO THE RESIDENT'S FACE NURSE "L" LEFT THE RESIDENT'S ROOM. PRIOR TO ADMINISTERING THE MEDICATION TO RESIDENT #14 NURSE "L" DID NOT CHECK THE RESIDENT'S OXYGEN SATURATION, PULSE OR LUNG SOUNDS. AT 9:56 AM THE RESIDENT WAS OBSERVED IN HIS ROOM UNATTENDED WITH THE MASK ON AND RECEIVING THE NEBULIZER TREATMENT, THE NURSE WAS NOT OBSERVED BACK IN THE ROOM TO CHECK ON THE RESIDENT. AT 9:59 AM NURSING ASSISTANT (NA) "N" ENTERED THE RESIDENT'S ROOM AND REMOVED HIS MASK, PLACED IT IN A PLASTIC BAG AND CUT THE NEBULIZING MACHINE OFF. NURSE "L" DID NOT ENTER THE ROOM TO CHECK THE RESIDENT'S OXYGEN LEVEL, HEART RATE, OR LUNG SOUNDS UPON COMPLETION OF THE NEBULIZING TREATMENT. AT 10:22 AM, NA "N" WAS ASKED WHY SHE AND NOT THE NURSE REMOVED THE MASK AND TURNED THE NEBULIZING MACHINE OFF. NA "N" REVEALED THAT THE NURSE INFORMED HER THAT THE TREATMENT WAS DONE AND SHE VOLUNTEERED TO REMOVE IT. FROM 9:36 AM TO 10:22 AM NURSE "L" WAS OBSERVED AND HAD NOT RE-ENTERED THE RESIDENT'S ROOM TO ASSESS HIM DURING OR AFTER TREATMENT. AT 11:20 AM THE SOCIAL WORKER "STAFF O" WAS ASKED ABOUT THE COGNITIVE STATUS OF RESIDENT #14. STAFF "O" REVEALED THAT THE RESIDENT HAD POOR SAFETY AWARENESS, WAS IMPULSIVE, DID NOT MAKE HIS OWN MEDICAL DECISIONS, HAD A LEGAL GUARDIAN AND THAT IF HIS OXYGEN SATURATION WERE LOW HE WAS DIFFICULT TO REDIRECT. UPON REVIEW OF THE RESIDENT #14'S CHART DURING MEDICATION RECONCILIATION ON 8/27/12 AT 11:00 AM A SELF ADMINISTRATION FORM WAS NOT PRESENT TO INDICATE THE RESIDENT WAS COGNITIVE TO ADMINISTER MEDICATIONS INDEPENDENTLY. ON 8/28/12 AT 12:00 PM NURSE "L" WAS ASKED WHAT STEPS SHOULD BE TAKEN WHEN ADMINISTERING A MEDICATED NEBULIZING TREATMENT. NURSE "L" STATED, "GO IN PUT IT ON, START IT, LISTEN TO HEART AND LUNG SOUNDS BEFORE AND AFTER, MASK GOES BACK IN BAG". WHEN ASKED IF THE NURSE SHOULD STAY IN THE ROOM DURING THE TREATMENT, NURSE "L" REPLIED "YES, SHOULD STAY IN ROOM". ( ) DURING MEDICATION PASS OBSERVATION ON 8/27/12 AT 12:12 AM WITH REGISTERED NURSE "C", RESIDENT #7'S MEDICATION ADMINISTRATION WAS OBSERVED. RESIDENT #7 RECEIVED ONE VIAL OF [MEDICATION NAME]/[MEDICATION NAME] 0.5 (MG)/ 2 (ML) NEBULIZER TREATMENT STARTING AT 12:25 PM. PRIOR TO ADMINISTERING THE MEDICATION REGISTERED NURSE "L" DID NOT CHECK THE RESIDENT'S OXYGEN SATURATION, PULSE OR LUNG SOUNDS. AFTER APPLYING THE MASK WITH THE MEDICATION TO THE RESIDENT'S FACE NURSE "C" LEFT THE RESIDENT'S ROOM. WHILE IN THE ROOM RESIDENT #7 WAS OBSERVED TO BE ANXIOUS, TELLING HIS SIGNIFICANT OTHER TO GO GET THE PAINT AND THE PAINT TRAYS MULTIPLE TIMES. AT 12:35 PM NURSE "C" WAS ASKED ABOUT THE RESIDENT'S COGNITION. NURSE "C" REVEALED THAT THE RESIDENT HAD RECENTLY WENT TO THE HOSPITAL, HAD [MEDICAL CONDITION] FROM PNEUMONIA AND URINARY TRACT INFECTION, AND WAS UP MOST OF THE NIGHT. AT 12:40 PM NURSE "C" WAS OBSERVED PEEKING HER HEAD IN THE DOOR OF RESIDENT #7 AND STATED TO THE RESIDENT'S SIGNIFICANT OTHER THAT THE TREATMENT WAS JUST ABOUT DONE. THE RESIDENT'S SIGNIFICANT OTHER REPLIED, "YES, IT JUST FINISHED." NURSE "C" DID NOT ENTER THE ROOM TO CHECK THE RESIDENT'S OXYGEN SATURATION, PULSE OR LUNG SOUNDS FOLLOWING THE TREATMENT. AT 12:50 PM (24 MINUTES AFTER THE TREATMENT WAS STARTED), NURSE "C" ENTERED THE RESIDENT'S ROOM. THE RESIDENT WAS OBSERVED IN THE BED WITH HIS NEBULIZING TREATMENT MASK OFF OF HIS FACE, AND THE MACHINE OFF PRIOR TO THE NURSE ENTERING THE ROOM. THE NURSE WAS NOT OBSERVED STAYING WITH THE RESIDENT AT ANY TIME AFTER ADMINISTERING THE MEDICATION NEBULIZING TREATMENT, AND ONLY ENTERED THE room [ROOM NUMBER] MINUTES AFTER IT'S COMPLETION. UPON REVIEW OF THE RESIDENT'S CHART DURING MEDICATION RECONCILIATION ON 8/28/12 AT 12:00 PM A SELF ADMINISTRATION FORM WAS NOT PRESENT TO INDICATE THE RESIDENT WAS COGNITIVE TO ADMINISTER MEDICATIONS INDEPENDENTLY. ON 8/28/12 AT 11:56 AM LICENSED PRACTICAL NURSE "F", WAS ASKED WHAT STEPS ARE TAKEN FOR A RESIDENT RECEIVING A MEDICATION NEBULIZING TREATMENT. NURSE "F" REPLIED, "CHECK OXYGEN SATURATION BEFORE TREATMENT, RECHECK LUNG SOUNDS AND OXYGEN SATURATION AFTER TREATMENT, MASK GOES BACK IN BAG, MASK IS CHANGED EVERY WEEK, STAY WITH RESIDENT". THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 8/28/12 AT 12:55 PM, AND ASKED WHAT STEPS SHOULD BE TAKEN FOR A RESIDENT RECEIVING A MEDICATION NEBULIZING TREATMENT. THE DON REPLIED THAT, THE NURSES SHOULD STAY WITH THE RESIDENT UNTIL THE TREATMENT IS DONE AND PULSE, OXYGEN SATURATION, AND LUNG SOUNDS SHOULD BE CHECKED BEFORE AND AFTER THE TREATMENT. A FACILITY FLOWSHEET TITLED "NEBULIZER TREATMENT FLOW SHEET" UPDATED 05/10 REFLECTED DOCUMENTATION TO BE COMPLETED RELATED TO NEBULIZER TREATMENTS. THE SHEET REFLECTED PULSE, RESPIRATION, LUNG SOUNDS, OXYGEN SATURATION, COUGH, TOTAL NURSING TIME, AND NURSES INITIALS. THE PREVIOUS ITEMS WERE TO BE CHECKED PRIOR AND AFTER TREATMENT. NO "NEBULIZER TREATMENT FLOW SHEET" DOCUMENTATION WAS FOUND FOR EITHER RESIDENT #7 OR #14. THE FACILITY'S "HAND HELD NEBULIZER (SMALL VOLUME NEBULIZER)" DATED 03/12 REFLECTED THE FOLLOWING: UNDER THE DOCUMENTATION SHALL INCLUDE: "... 7. BREATH SOUNDS BEFORE AND AFTER TREATMENT 8. HEART RATE AND RESPIRATORY RATE BEFORE AND AFTER TREATMENT 9. COUGH AND SPUTUM PRODUCED, IF APPLICABLE. INCLUDE AMOUNT, COLOR, AND CONSISTENCY 10. RESIDENT'S RESPONSE TO TREATMENT INCLUDING ANY ADVERSE REACTION OR SIDE EFFECTS EXPERIENCED BY THE RESIDENT AND ASSOCIATED INTERVENTION 11. EFFECTIVENESS OF TREATMENT..." UNDER PROCEDURE: ... 7. ASSESS THE RESIDENT. ESTABLISH BASELINE RESPIRATORY RATE, HEART RATE, AND BREATH SOUNDS. 12. INSTRUCT THE RESIDENT TO TAKE SLOW DEEP INSPIRATIONS WITH END RESPIRATORY PAUSES (2-3 SECONDS). EXHALE SLOWLY 13. ADMINISTER TREATMENT UNTIL MEDICATION IS DEPLETED, USUALLY TREATMENTS REQUIRE 10-15 MINUTES. THE RESIDENT SHOULD INHALE APPROXIMATELY 6-8 TIMES PER MINUTE. MONITOR HEART RATE AND LEVEL OF CONSCIOUSNESS BEFORE, DURING, AND IMMEDIATELY AFTER THE TREATMENT..." NONE OF THE ABOVE STEPS WERE OBSERVED FOR EITHER RESIDENT #7 OR #14 DURING THEIR NEBULIZING TREATMENTS. ( )

This citation pertains to intake MI 700. Based on observation, interview, and record review, the facility 1) failed to follow up with doctor's orders and with resident's physical well-being in 1 of 5 sampled residents (#101) from a total sample of 5 residents, resulting in a delay in treatment for [REDACTED].#101) of 5 sampled residents, from a total sample of 5 residents, resulting in Resident #101 leaning forward and falling out of his wheelchair, secondary to a high temperature and infection. Findings include: 1. Review of Resident #101's medical record revealed a [AGE] year old male who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he was cognitively intact, and required extensive assistance of one person for transfers, dressing, toileting and personal hygiene. Facility nurse's note dated 6/3/12 at 11:30 PM indicated Resident #101 was observed lying on his left side with his left arm under him, after his alarm was heard sounding. The nurse's note indicated Resident #101 was able to move all extremities (arms and legs), but did complain of pain in his left hip and leg and was then transferred to bed with assist of two staff. The nurse's note indicated once Resident #101 was in bed, he stated his hip pain was worse, so Resident #101's physician was notified, new orders were received for an Xray of Resident #101's left hip, and the Xray company was notified to do an Xray of Resident #101's left hip immediately. The nurse's note indicated Resident #101 was found at the foot of his roommate's bed and nursing will continue to monitor Resident #101. The nurse's note indicated neurological evaluations were started. Review of Resident #101's medical record did not reveal any documentation regarding Resident #101's fall, pain, injury, vital signs, skin, neurological checks or any type of assessment and/or monitoring of Resident #101 from the time of the initial nurse's note at 11:30 pm on 6/3/12 until 6:30 am on 6/4/12, when RN # 11 arrived for the next shift (first shift on 6/4/12). Facility incident report dated 6/3/12 indicated Resident #101 was found on the floor in front of his roommates bed, and that Resident #101 complained of left hip pain. There were no vital signs documented on the incident report. The Medication Administration Record [REDACTED]. Radiology report signed by radiologist on 6/4/12 at 9:15 am indicated Resident #101 had: 1. Cortical irregularity at the subcapital portion of the femur and an incomplete fracture cannot be excluded. Follow up study was recommended. 2. Mild [MEDICAL CONDITION]. 3. Moderate degree of [MEDICAL CONDITION]. Facility Communication and Progress Note form titled "SBAR" dated 6/4/12 indicated the reason for the communication to the physician was that Resident #101 had increased confusion, increased pain to the left hip, pain to the back, [MEDICAL CONDITION](increased heart rate), high blood pressure, temperature of 100 degrees, and an Xray of the left hip which requested follow up, with the problems starting at 10:00 pm and progressively got worse with time. Resident #101's vital signs were a blood pressure of 153/97 (normal range 90/60 to 120/80), heart rate 117 (normal range 60 to 80), respiratory rate 20 per minute, temperature 100 degrees (normal 98.6), and Pulse Oximetry (oxygen in the blood) of 84% (normal 90 to 95 %). Nurse's notes on the back side of the Facility Communication and Progress Note form dated 6/4/12 indicated at 6:30 am Resident #101 was noted to be confused with incoherent babble and had pain with movement, with an Xray of the left hip done at 8:30 am, results in at 9:30 am, which suggested follow up and the physician was notified at 9:45 am. The nurse's notes at 8:45 am indicated Resident #101's blood oxygen level was at 84 % and oxygen at 2 liters by nasal cannula was applied with [MEDICAL CONDITION] (swelling) noted to posterior (back) hip with complaints of back pain. The nurse's notes indicated Resident #101 was transferred to the hospital at 11:03 am by Ambulance. In an interview 8/2/12 at 3:00 pm, LPN #5 stated on 6/3/12 Resident #101 was found on the floor of his room by an aide who responded to his alarm. LPN #5 stated she entered Resident #101's room and observed him on the floor in front of his roommate's bed on his side, and when she assessed him, he complained of pain on the side he fell on to. LPN #5 stated once Resident #101 was moved into his bed, he complained of worsening pain in his left hip, so she (LPN #5) called the physician and obtained an order for [REDACTED].#5 stated she told the Xray company to come immediately when she spoke with them on the phone, but when she left the next morning at 7:00 am they had not come yet to do the Xray of Resident #101's left hip. LPN #5 also stated that Resident #101 complained of pain and was very uncomfortable throughout the night. She (LPN #5) stated Resident #101 did receive his regularly scheduled pain medication, and it probably helped a little, but Resident #101 was still uncomfortable. The surveyor asked LPN #5 if she contacted Resident #101's physician regarding Resident #101's pain or to inform the physician that the Xray had not been done, and LPN #5 stated she did not contact Resident #101's physician again after she obtained the initial order for the Xray of Resident #101's left hip. In a second interview on 8/3/12 at 8:45 am, the surveyor asked LPN #5 when she documented the nurse's note which described the fall of Resident #101 on 6/3/12 at 10:50 PM , and LPN #5 stated she wrote the full page nurse's note the morning of 6/4/12 before she left at the end of her shift. The surveyor asked LPN #5 if she documented any monitoring of Resident #101 throughout the night of 6/3/12 into 6/4/12, and LPN #5 stated, "If it's not there, it didn't happen". The surveyor asked LPN #5 if she documented a pain assessment, where it could be located in the medical record for Resident #101 and LPN #5 stated in the nurse's notes. The surveyor then asked LPN #5 if she did a pain assessment of Resident #101 throughout the night of 6/3/12 into 6/4/12 on Resident #101 and LPN #5 stated, "Of course I did, it just wasn't documented". When the surveyor asked LPN #5 how often she assessed Resident #101 during the night of 6/3/12 and what the results of her assessments were, LPN #5 stated, "I would just be guessing since it was 2 months ago", but she reported that she knew she assessed him and that he did have discomfort through the night and it did hurt him when he was checked for bed check. Review of radiology timeline provided to the surveyor by radiology representative #4, revealed Resident #101's Xray of the left hip was completed on 6/4/12 at 8:55 am. In an interview on 8/3/12 at 12:17 pm, the surveyor asked facility Director of Nursing #2 (DON#2) to review Resident #101's medical record and asked DON #2 if there was any documented monitoring, assessments or interventions for Resident #101 after his fall on 6/3/12 at 10:50 pm until the first shift nurse documented a request for transfer to the hospital from the physician on 6/4/12, following the completed Xray. DON #2 stated there was none. When the surveyor asked DON #2 why the Xray of Resident #101's left hip was not done until the morning of 6/4/12, DON #2 stated the Xray company entered the order wrong, that LPN #5 had called the order in as a "now" order and the Xray company had entered it as a "normal" order, so they did not come until the next morning. When the surveyor asked DON #2 why LPN #5 had not called the Xray company back, to ask why they did not come, DON #2 stated, "good question". DON #2 stated when the first shift nurse arrived and realized the Xray had not been done, she (first shift nurse) called and asked them why they weren't there yet, and the Xray company stated they were on the way. DON #2 stated LPN #5 should have called the Xray company to question why they had not come to do the Xray for Resident #101. Hospital emergency triage notes dated 6/4/12 indicated Resident #101 arrived to the hospital on [DATE] at 11:36 am and was seen by the triage nurse at 11:49 am. The triage notes indicated Resident #101 had fallen on 6/3/12 and "today" his left leg was slightly rotated in and Resident #101 had pain with movement in the left hip. The pain assessment section of the triage notes indicated Resident #101's pain was not adequately controlled, was in his left hip, and was an ache which he rated as an 8 on a scale of 1 to 10. Review of hospital radiology report dated 6/4/12 for Resident #101 indicated findings of: Deformity of the left femoral neck was identified suggesting displaced acute fracture. The left femoral head was in normal location. Hospital Records dated 6/4/12 revealed an emergency room physician report which indicated Resident #101 fell on [DATE] at the facility, injured his left hip and had been unable to get up since, with pain in his left hip at all times, with conclusion of acute left [MEDICAL CONDITION]. 2. Nurse's notes for Resident #101 for 6/11/12 at 3:30 pm indicated new orders were received for an urinalysis to be done with cultures and sensitivity if indicated, potassium to be given to Resident #101 and vitals signs to be done every 4 hours with temperature and pulse oximetry (oxygen level in the blood) for 24 hours then every shift, and labs to be done on 6/13/12. physician's orders [REDACTED].#101 indicated urinalysis to be done with cultures and sensitivity if indicated, potassium to be given to Resident #101 and vitals signs to be done every 4 hours with temperature and pulse oximetry (oxygen level in the blood) for 24 hours then every shift, and labs to be done on 6/13/12. Laboratory results for Resident #101 indicated a white blood cell count (indicates infection) of 12.2 (normal 4.5 to 10.5). Medication Administration Record [REDACTED]. physician's orders [REDACTED].#101 was started on [MEDICATION NAME] (antibiotic) for three days for Pneumonia and [MEDICATION NAME] (antibiotic) for 10 days for Pneumonia. Review of the blood pressure record revealed: 6/11/12 Resident #101's vitals signs were recorded at 5:25 pm, and 11:00 pm, with no pulse oximetry documented. 6/12/12 Resident #101's vitals signs were recorded at 2:00 pm, and 11:00 pm, with no pulse oximetry documented. 6/13/12 Resident #101's vitals signs were recorded at 11:00 pm, with no pulse oximetry documented. 6/14/12 Resident #101's vitals signs were recorded at 10:00 am, and 11:00 pm, with no pulse oximetry documented. 6/15/12, 6/16/12 Resident #101 vitals were taken twice, 6/18/12, 6/19/12, 6/20/12, Resident #101 vitals were taken once, 6/22/12 Resident #101's vitals were taken twice, 6/22/12, 6/23/12, 6/24/12, and 6/25/12, Resident #101's vital signs were taken twice. All times listed above were without a pulse oximetry. On 6/26/12 Resident #101's vital signs were taken once at 3:30 pm with no pulse oximetry and no vitals signs are documented on the blood pressure record on 6/27/12. Facility skilled nursing note form used by the facility for Resident #101 had a day shift column and a night shift column for the 12 hour day shift nurse and the 12 hour night shift nurse to document their assessment for Resident #101. On 6/15/12, 6/17/12, 6/19/12, 6/20/12, and 6/22/12 there was no documented nursing assessments on the night shift for Resident #101 while he was being treated for [REDACTED].#101 on the day shift or on the night shift, while he was being treated for [REDACTED]. Resident #101's falls care plan dated 8/23/11 indicated Resident #101 was at risk for falls due to a history of falling with interventions listed to include monitoring Resident #101 for changes in his condition that may warrant increased supervision/assistance and notify the physician. Facility incident report dated 6/27/12 indicated at 9:45 am, Resident #101 slid out of a wheelchair and had a reddened, raised area on his forehead. The incident report indicated Resident #101 was transferred to the emergency room for evaluation and treatment to determine the underlying cause of the fall. Facility nurse's note dated 6/27/12 indicated resident #101 slid out of wheelchair and was observed by the nurse in a prone position, on his stomach, on the floor, with a bruise on his left forehead, with neurological assessment which showed slight weakness in left grip and movement of left foot and sluggish pupil reaction. Review of transfer record dated 6/27/12 revealed vitals signs documented with the exception of a temperature. In an interview on 8/2/12 at 3:35 pm, Activities Assistant #6 (AA#6) stated that as she was walking in the hall on 6/27/12, she observed Resident #101 in his room, slump forward in his wheelchair, with his shoulders falling forward, until he fell out of his wheelchair, onto the floor. AA#6 stated she he heard Resident #101 make a horrible noise that sounded like an "ugh" as he landed on the floor. AA #6 stated she hollered for help and then went to Resident #101's side to comfort him. AA #6 stated nursing staff came right away, and she let them take over. Review of hospital records dated 6/27/12 revealed that Resident #101 arrived to the hospital with a temperature of 103 degrees (normal 98.6) and was identified to have a urinary tract infection positive [MEDICAL CONDITION] (Infection resistant to many antibiotics) with [MEDICAL CONDITION] (Sepsis is a potentially life-threatening complication of an infection). #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ASSESS AND MONITOR SIGNS AND SYMPTOMS OF AN EYE INFECTION FOR 1 OF 2 RESIDENTS (#104) WITH CHRONIC EYE INFECTIONS FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN A DELAY IN treatment of [REDACTED]. FINDINGS INCLUDE: ACCORDING TO THE MONTHLY physician's orders [REDACTED].#104 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 3/28/12 WITH [DIAGNOSES REDACTED]. THE NURSE PRACTITIONER'S PROGRESS NOTE DATED 9/17/12 REFLECTED RESIDENT #104 WAS VISITED FOR FOLLOW UP OF "RED EYES AND CRUST." THE NOTE DESCRIBED, " PATIENT REPORTED RIGHT EYE PAINFUL AND ITCHING FOR ONE DAY. POSITIVE FOR CRUSTING THIS A.M." THE NURSE PRACTITIONER'S ASSESSMENT INCLUDED 1) [MEDICAL CONDITION]-[MEDICATION NAME] (CONTAINS ANTIBIOTIC) 0.6 % ONE DROP EACH EYE THREE TIMES DAILY FOR 7 DAYS. THE NURSE PRACTITIONER'S PROGRESS NOTE DATED 10/8/12 REFLECTED RESIDENT #104 WAS SEEN FOR DRY EYES AND RESIDENT #104 WAS PRESCRIBED ARTIFICIAL TEARS FOUR TIMES A DAY. NURSE'S NOTES DATED 5/22/12 THROUGH 10/16/12 REFLECTED RESIDENT #104 NOTED AS HAVING ON-GOING EYE PROBLEMS; THE NOTE ON 5/25/12 STATED, "OBSERVED SMALL AMOUNT YELLOW DRAINAGE ON BILAT. EYES DURING NIGHT." THE NOTE ON 6/12/12 STATED, " BILAT. EYES WITH CRUST, DIFFICULTY OPENING...SHORT TIME LATER RESIDENT AGAIN WITH DRAINAGE." THE NOTE ON 6/22/12 STATED, " NEW ORDER RECEIVED JOHNSON AND JOHNSON BABY SHAMPOO EYE LIDS SCRUB TWICE DAILY FOR 10 DAYS, [MEDICATION NAME] (ANTIBIOTIC) EYE OINTMENT APPLY TO BOTH EYES LIDS FOUR TIMES A DAY FOR 10 DAYS." THE NOTE ON 8/7/12 STATED, "SAW EYE DOCTOR IN HOUSE TODAY. NEW ORDERS [MEDICATION NAME] DROPS FOR ONE WEEK." THE NOTE ON 9/10/12 STATED, "BABY SHAMPOO EYE WASH TWICE DAILY FOR 7 DAYS. [MEDICATION NAME] 0.6 % EYE DROPS, ONE DROP IN BILAT EYES THREE TIMES DAILY FOR 7 DAYS FOR [MEDICAL CONDITION]." THE NOTE ON 9/17/12 STATED, "EXTEND [MEDICATION NAME] EYE DROPS BILAT. (BOTH) EYES FOR 7 MORE DAYS." THE NOTE ON 10/8/12 STATED, "NEW ORDER FOR ARTIFICIAL TEARS 2 DROPS BOTH EYES FOUR TIMES A DAY FOR 14 DAYS-DRY EYES." NURSES NOTES DATED 10/16/12 REFLECTED, "RES (RESIDENT) RIGHT EYE BLOOD SHOT. NO DRAINAGE NOTED. RES COMPLAIN OF DISCOMFORT. EYE DROPS GIVEN AS ORDERED AT NOON. RES STATES FEELS A LITTLE BETTER. WILL CONTINUE MONITOR." HOWEVER, NO FURTHER NURSES NOTES DOCUMENTED, ASSESSING AND MONITORING OF THE RESIDENT'S BLOOD SHOT RIGHT EYE OR THE DISCOMFORT. FURTHERMORE, THERE WERE NO CARE PLANS DEVELOPED REGARDING THE RESIDENT'S ONGOING PROBLEM OF AN EYE CONDITION. THE NURSE PRACTITIONER'S PROGRESS NOTE DATED THE WEEK OF SURVEY ON 10/24/12, 8 DAYS LATER, REFLECTED RESIDENT #104 WAS VISITED FOR AN ACUTE [MEDICAL CONDITION] HAVING DISCHARGE AND INFECTION IN THE RIGHT EYE. THE physician's orders [REDACTED]. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE MAR indicated [REDACTED]. THE BACK PAGE OF THE MAR indicated [REDACTED]. THE physician's orders [REDACTED]. ON 10/25/12 AT 10:30 A.M., THE ASSISTANT UNIT MANAGER, (STAFF "A") STATED THE MIDNIGHT NURSE HAD CALLED PHARMACY AND WAS INFORMED THERE WOULD BE A DELAY OF SHIPMENT WITH THE EYE DROP. THE NURSE THEN OBTAINED AN OKAY ORDER FROM THE PHYSICIAN TO START 2 DAYS LATER. THIS FURTHER DELAYED ANTIBIOTIC treatment for [REDACTED]. ON 10/25/12 AT 12 NOON, RESIDENT #104 WAS OBSERVED LYING IN BED WITH HER EYES HALFWAY CLOSED. AS THE RESIDENT AWAKENED SHE HAD SIGNIFICANT EYE DRAINAGE ON BOTH OF HER EYES. THE RESIDENT'S RIGHT EYE WAS RED AND HAD A MODERATE AMOUNT OF LIGHT YELLOW DRAINAGE. THE RESIDENT STATED SHE HAD AN EYE PROBLEM FOR OVER 2 WEEKS. SHE STATED SHE HAD A LOT OF PAIN AT FIRST, BUT THE PAIN WAS NOT AS BAD AS BEFORE, ALTHOUGH IT STILL BOTHERED HER. RESIDENT #104 ALSO STATED IN REGARDS TO HER EYE DISCOMFORT AND DRAINAGE, "THEY HAVE BEEN GIVING ME EYE DROPS, BUT IT IS NOT HELPING. CAN YOU FIND OUT WHAT THEY ARE GIVING ME ?" THE MAR FOR OCTOBER 2012 REFLECTED RESIDENT #104 ONLY RECEIVED ARTIFICIAL TEARS FROM 10/8/12 THROUGH 10/22/12. THE RESIDENT RECEIVED NO MEDICATION EYE DROPS DURING THIS PERIOD AND WAS STILL AWAITING HER ANTIBIOTIC EYE MEDICATION AT THE TIME OF THE SURVEY EXIT ON 10-26-12. ( )

This citation pertains to intake number MI 059. Based on observation, interview, and record review the facility failed to use safety equipment properly in 1 of 3 residents (Resident #104) identified as a fall risk, from a total sample of 6 residents, resulting in Resident #104 sustaining a left hip fracture. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed that the Resident #104 was a [AGE] year old female who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #104 had severe cognitive impairments and required extensive assistance to total dependence on staff for activities of daily living. Review of the Incident and Accident Report dated 7/16/11 revealed Resident #104 "fell in room, un-witnessed," and sustained skin tears to her right finger and left knee. Further review of the report revealed an identified error, and described as "alarm not applied". Review of the "Incident and Accident Report/Michigan" dated 8/27/11 revealed Resident #104 had an unwitnessed fall in the hallway on 8/27/11 at 4:30 AM. Per the Incident and Accident Report the cause of the incident was "up from bed, alarm present, found in floor beside Resident, alarming, alarm type was Tab alarm". In an interview on 8/31/11 at 12:45 PM, Certified Nurse Aide (CNA) #18 stated around 3:40 AM on 8/27/11 she heard an alarm sounding and left her 1:1 assignment to assess the situation and as soon as she turned the corner she saw Resident #104 on the ground in the middle of the hallway. CNA #18 stated she found the magnetic clip to the alarm device attached to Resident #104 and the box portion of the device on the ground beside Resident #104, unattached from the magnetic clip. In a second interview on 9/1/11 at 12:22 PM, CNA #18 stated she found the alarm box on the ground and the magnetic clip was still attached to Resident #104. CNA #18 stated "the alarm was only sounding for a few seconds and for (Resident #104) to get all the way from her bed to the hallway it (the alarm) had to have not gone off until she fell or as she was falling in the hallway." When the Surveyor asked CNA #18 where the alarm box is usually secured when Resident #104 is in bed she stated "I have no idea. I usually don't do it...there is no place to hook it on her bed, they (other CNA's) say they usually put it between the mattress and the headboard." In an interview on 9/1/11 at 8:48 AM, CNA #20 stated the alarm box system for Resident #104 was placed in-between the mattress and headboard that night on 8/27/11. The alarm box was not securely attached to the bed and/or mattress frame as intended by the manufacturer allowing the magnetic tab to not separate from the alarm box when Resident #104 got out of bed, therefore alarm did not sound when Resident #104 got up from the bed. Review of the "Potential For Injury Care Plan-Fall" dated 8/27/10 and re-written on 4/29/11 revealed Resident #104 was to have a personal tab alarm on in bed and when in the wheelchair. Per the care plan, no identified additional interventions were put into place after Resident #104's first fall on 7/16/11. Review of the X-Ray Report dated 8/27/11 revealed Resident #104 sustained a "transverse fracture through the left femoral neck (left hip fracture) without displacement." ( )

THIS CITATION PERTAINS TO MI 067. BASED ON INTERVIEW AND RECORDS REVIEW, THE FACILITY FAILED TO KEEP 1 (#103) OF 4 SAMPLED RESIDENTS FREE FROM ABUSE WHEN RESIDENT #102 HIT RESIDENT #103 IN THE FACE AND UPPER BODY WITH A CLOSED FIST 10 TO 15 TIMES, RESULTING IN BRUISING, PAIN, EMOTIONAL DISTRESS, FEAR, AND THE POTENTIAL FOR FRACTURED FACIAL BONES FOR RESIDENT #103. FINDINGS INCLUDE: RESIDENT #102 NO LONGER RESIDED IN THE FACILITY AT THE TIME OF THE INVESTIGATION. REVIEW OF RESIDENT #103's MEDICAL RECORD REVEALED AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED SHE WAS MODERATELY IMPAIRED WITH HER COGNITIVE DECISION MAKING ABILITIES, REQUIRED 2 PERSON EXTENSIVE ASSISTANCE WITH TRANSFERS, LOCOMOTION AND DRESSING, COULD BE PHYSICALLY ABUSIVE, AND WAS RESISTANT TO CARE. FACILITY NURSE'S NOTES DATED 11/21/10 AT 9:45 AM, DOCUMENTED THAT RESIDENT #103 WAS STRUCK IN THE FACE, SHOULDER AND UPPER ARM, WITH A FIST BY ANOTHER RESIDENT. A NURSE'S NOTES DATED 11/21/10 DOCUMENTED THAT RESIDENT #103 HAD A RAISED RED AREA ON HER FOREHEAD AND COMPLAINED OF DISCOMFORT WHEN HER RIGHT UPPER ARM WAS TOUCHED. NURSE'S NOTES DATED 11/21/10 AT 9:00 PM DOCUMENTED THAT RESIDENT #103 WAS ANXIOUS AND RESTLESS. REVIEW OF RESIDENT #102's MEDICAL RECORD REVEALED A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HIS MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED HE WAS SEVERELY IMPAIRED WITH COGNITIVE DECISION MAKING ABILITIES, REQUIRED LIMITED ASSISTANCE OF ONE PERSON FOR TRANSFERS, AMBULATION, DRESSING AND HYGIENE, AND HAD BEHAVIOR SYMPTOMS TO INCLUDE WANDERING, VERBALLY ABUSIVE BEHAVIOR, PHYSICALLY ABUSIVE BEHAVIOR, SOCIALLY INAPPROPRIATE BEHAVIOR, AND WAS RESISTANT TO CARE. A PSYCHIATRIC EVALUATION DATED 11/8/10 DOCUMENTED THAT RESIDENT #102 had a history of [REDACTED]. NURSE'S NOTES FOR RESIDENT #102 DATED 10/17/10 DOCUMENTED AN ALTERCATION BETWEEN RESIDENT #102 AND ANOTHER FEMALE RESIDENT. NURSE'S NOTES FOR RESIDENT #102 DATED 11/17/10 DOCUMENTED THAT RESIDENT #102 HAD BEEN AGGRESSIVE TOWARD STAFF THE PREVIOUS DAY. NURSE'S NOTES FOR RESIDENT #102 DATED 11/19/10 DOCUMENTED THAT RESIDENT #102 WAS EXTREMELY COMBATIVE THAT MORNING. NURSE'S NOTES DATED 11/21/10 DOCUMENTED THAT RESIDENT #102 WAS OBSERVED BY STAFF STRIKING ANOTHER RESIDENT IN THE FACE AND SHOULDER. A FACILITY INCIDENT REPORT DATED 11/21/10 STATED THAT RESIDENT #102 WAS OBSERVED HITTING RESIDENT #103 SEVERAL TIMES IN THE FACE, SHOULDER AND RIGHT ARM WITH A FIST. IN A WRITTEN STATEMENT DATED 11/21/10 STAFF #14 STATED A FEW WEEKS PRIOR TO 11/21/10, EVERY TIME RESIDENT #102 WAS WALKED BY RESIDENT #103, RESIDENT #102 WOULD REACH OUT AGGRESSIVELY TOWARD RESIDENT #103. STAFF #14 STATED SHE HAD TO PLACE HERSELF BETWEEN RESIDENT #102 AND RESIDENT #103 TO PREVENT ANY PHYSICAL CONTACT. STAFF #14 STATED SHE REPORTED TO THE NURSE THAT RESIDENT #102 WAS SPECIFICALLY GOING AFTER RESIDENT #103 AND WAS NOT ACTING THAT WAY TOWARD ANYONE EXCEPT RESIDENT #103. IN AN INTERVIEW ON 12/15/10 AT 11:15 AM, STAFF #9 STATED ON 11/21/10 SHE WAS CLEANING IN THE ROOM NEXT TO RESIDENT #103's ROOM WHEN SHE HEARD AN ALARM AND STEPPED INTO THE HALL TO SEE RESIDENT #102 AND RESIDENT #103 IN THE HALL, WITH NO OTHER STAFF MEMBERS NEARBY. STAFF #9 STATED THAT RESIDENT #102 WAS STANDING AND SWINGING HIS ARMS AND HITTING RESIDENT #103 IN THE FACE WITH A CLOSED FIST "OVER AND OVER". STAFF #9 STATED THAT RESIDENT #103 HAD TEARS RUNNING DOWN HER FACE AND WAS IN A RECLINING WHEELCHAIR. STAFF #9 STATED SHE TRIED TO GET RESIDENT #102 TO STOP HITTING RESIDENT #103, BUT HE KEPT HITTING HER, SO STAFF #9 STATED SHE HOLLERED FOR HELP AND KEPT TRYING TO GET RESIDENT #102 TO STOP. STAFF #9 STATED STAFF #10 CAME DOWN THE HALL TO HELP. JUST AS STAFF #10 GOT TO RESIDENT #102 AND RESIDENT #103, RESIDENT #102 STOPPED HITTING RESIDENT #103. STAFF #9 STATED THAT RESIDENT #102 WAS CONTINUOUSLY STRIKING RESIDENT #103 "VERY HARD WITH HIS FIST". STAFF #9 STATED SHE OBSERVED RED MARKS ON RESIDENT #103's FACE AT THE TIME OF THE INCIDENT AND THAT RESIDENT #103 HAD BRUISING ON HER FOREHEAD, NEAR HER LIP, AND ON HER CHEEK FOR SEVERAL DAYS AFTER THE INCIDENT. STAFF #9 STATED SHE HAD SEEN RESIDENT #102 BE AGGRESSIVE AND HIT PEOPLE BEFORE. IN AN INTERVIEW ON 12/15/10 AT 11:15 AM, STAFF #10 STATED SHE WAS IN THE HALL ON 11/21/10 AND HEARD STAFF #9 YELL FOR HELP. STAFF #10 STATED AS SHE RAN DOWN THE HALL, SHE OBSERVED RESIDENT #103 HITTING RESIDENT #102 IN THE FACE WITH A CLOSED FIST. STAFF #10 STATED RESIDENT #102 WAS STANDING AND RESIDENT #103 WAS SEATED IN A RECLINING WHEELCHAIR. STAFF #10 STATED SHE OBSERVED RESIDENT #103 HIT RESIDENT #102 10 TO 15 TIMES "HARD, LIKE A FIGHTER". STAFF #10 STATED SHE TRIED TO CALM RESIDENT #103 BY ASKING HIM TO PLEASE STOP AS SHE RAN DOWN THE HALL, AND JUST AS SHE GOT TO RESIDENT #103, HE STOPPED HITTING RESIDENT #102. STAFF #10 STATED THAT RESIDENT #103 HIT RESIDENT #102 VERY HARD AND SHE WAS SURPRISED THAT RESIDENT #103's NOSE WASN'T BLEEDING. STAFF #10 STATED RESIDENT #103 HAD REDNESS ON HER FACE AT THE TIME OF THE INCIDENT AND BRUISING ON HER FACE, LIP, CHEEK AND FOREHEAD FOR A FEW DAYS AFTER THE INCIDENT. STAFF #10 STATED SHE REPORTED THE INCIDENT TO THE NURSE AND SEPARATED THE TWO RESIDENTS. STAFF #10 STATED THAT RESIDENT #102 HAD SWUNG AT HER IN THE PAST. IN AN INTERVIEW ON 12/15/10 AT 11:25 AM IN RESIDENT #103's ROOM, RESIDENT #103 WAS ASKED BY THE SURVEYOR IF ANYONE HAD EVER HURT HER. RESIDENT #103 STATED A MAN HAD HIT HER. WHEN ASKED WHERE THE MAN HIT HER, RESIDENT #103 MADE A FIST WITH HER RIGHT HAND AND STRUCK HERSELF IN THE FOREHEAD THREE TIMES. WHEN ASKED BY THE SURVEYOR IF THAT IS HOW THE MAN HIT HER, RESIDENT #103 STATED, "YEAH". WHEN ASKED IF IT HURT HER, RESIDENT #103 STATED, "OH YEAH". WHEN ASKED BY THE SURVEYOR IF SHE WAS HIT ANYWHERE ELSE, RESIDENT #103 MADE A FIST AGAIN WITH HER RIGHT HAND AND STRUCK HERSELF IN THE FOREHEAD THREE TIMES. WHEN ASKED BY THE SURVEYOR IF SHE KNEW WHO HAD HIT HER, RESIDENT #103 STATED NO. IN AN INTERVIEW ON 12/15/10 AT 1:35 PM, STAFF #15 STATED SHE REGULARLY CARES FOR RESIDENT #103. STAFF #15 STATED THAT RESIDENT #103 DID HAVE SOME BRUISING ON HER FACE FOR A FEW DAYS AFTER RESIDENT #102 HIT HER. IN AN INTERVIEW ON 12/17/10 AT 11:15 AM, STAFF NURSE #5 STATED ON 11/21/10 SHE WAS SITTING AT THE NURSE'S STATION AND HEARD AN ALARM, SO SHE STOOD UP. STAFF NURSE #5 STATED SHE SAW STAFF #10 RUNNING FROM THE TUB ROOM AREA ON THE HALL, AND STAFF #10 STATED TO HER, "COME ON, HE IS HITTING HER". STAFF NURSE #5 STATED SHE WENT DOWN THE HALL AND OBSERVED STAFF #9 TRYING TO GET RESIDENT #102 TO SIT IN HIS WHEELCHAIR. STAFF NURSE #5 STATED SHE DID NOT SEE RESIDENT #102 HIT RESIDENT #103. STAFF NURSE #5 STATED SHE ASKED RESIDENT #103 IF SHE WAS OKAY AND THAT RESIDENT #103 TOLD HER "NO, HE HIT ME". STAFF NURSE #5 STATED RESIDENT #103 LOOKED SCARED AND HAD A "STRICKEN" LOOK ON HER FACE. STAFF NURSE #5 STATED THAT SHE OBSERVED A RED, RAISED AREA ON RESIDENT #103's FOREHEAD AND ICE WAS APPLIED TO THAT AREA. STAFF NURSE #5 STATED THE PHYSICIAN WAS CALLED AND CAME IN TO THE FACILITY TO ASSESS RESIDENT #103. STAFF NURSE #5 STATED THE INCIDENT SCARED AND UPSET RESIDENT #103 FOR A LITTLE BIT. STAFF NURSE #5 STATED THAT RESIDENT #102 HAD BEEN AGGRESSIVE TOWARD OTHER RESIDENTS BEFORE, INCLUDING RESIDENT #103. #

THIS CITATION PERTAINS TO INTAKE MI 237 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION FOR 1 (#103) OF 7 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 WHEN SHE ATTEMPTED TO DRINK A BLEACH/WATER MIXTURE FROM AN UNATTENDED BUCKET ON A HOUSEKEEPING CART ON 7/13/10 AND WHO DRANK ANOTHER RESIDENT'S MEDICATIONS ON 9/6/10, AND WANDERED UNSUPERVISED THROUGHOUT THE FACILITY EATING AND DRINKING EVERYTHING SHE COULD GET, RESULTING IN HIGH RISK FOR POISONING, HYPONATREMIA (LOW SODIUM), MEDICATION OVERDOSE, CHOKING, AND DEATH. FINDINGS INCLUDE: A REVIEW OF RESIDENT 103'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A HOSPITAL DISCHARGE SUMMARY DATED 7/9/10 DOCUMENTED THAT RESIDENT 103 had a history of [REDACTED]. THE DISCHARGE SUMMARY ALSO DOCUMENTED THAT WHILE IN THE HOSPITAL RESIDENT 103 HAD BEEN DRINKING A LOT OF WATER, TAKING FOOD OFF FROM OTHER PATIENT'S TRAYS AND FROM LEFT OVER FOOD TRAYS. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT HER DECISION MAKING ABILITY WAS POOR, SHE REQUIRED CUES AND SUPERVISION, WANDERED THE FACILITY, EXHIBITED VERBAL AND PHYSICALLY ABUSIVE BEHAVIORS, EXHIBITED SOCIALLY INAPPROPRIATE BEHAVIORS AND WAS RESISTANT TO CARE. FACILITY NURSES NOTES DATED 7/12/10 DOCUMENTED THAT RESIDENT 103 WANDERED CONTINUOUSLY, TOOK FOOD AND DRINKS OFF PEERS TRAYS, TOOK THINGS OFF THE TOP OF THE MEDICATION CARTS DURING MEDICATION PASS, DRINKS LARGE AMOUNTS OF FLUIDS AND IS OBSESSED WITH GETTING MORE FOODS AND FLUIDS. FACILITY NURSES NOTES DATED 8/16/10 DOCUMENTED THAT RESIDENT 103 WENT INTO OTHER RESIDENTS' ROOMS AND TOOK FOOD OFF THEIR TRAYS, ATTEMPTED TO TAKE PUDDING AND FLUID OFF THE MEDICATION CARTS, AND DRINKS ENORMOUS QUANTITIES OF FLUID. FACILITY NURSES NOTES DATED 9/6/10 DOCUMENTED THAT RESIDENT 103 WAS SEEN DRINKING ANOTHER RESIDENT'S MEDICATIONS WHICH CONSISTED OF DEPAKENE 250 MG LIQUID (ANTI-SEIZURE MEDICATION) AND DILANTIN 125 MG LIQUID (ANTI-SEIZURE MEDICATION). FACILITY MEDICATION ADMINISTRATION RECORD FOR 9/1/10 THROUGH 9/30/10 LISTED RESIDENT 103's MEDICATIONS AS ACTOS 15 MG (FOR HIGH BLOOD SUGAR), ARICEPT 10 MG (FOR DEMENTIA), DEPAKOTE 500 MG TWICE DAILY (ANTI-SEIZURE), TYLENOL (FOR ARTHRITIS), RISPERDAL 1 MG IN THE MORNING (ANTI-PSYCHOTIC), RISPERDAL 2 MG AT BEDTIME, DULCOLAX (FOR CONSTIPATION) AS NEEDED AND MILK OF MAGNESIA (FOR CONSTIPATION) AS NEEDED. A FACILITY INCIDENT/ACCIDENT REPORT DATED 7/13/10 STATED THAT A HOUSEKEEPER FOUND RESIDENT 103 TIPPING A BUCKET OF BLEACH WATER UP AS IF TO DRINK FROM IT. A FACILITY INCIDENT/ACCIDENT REPORT DATED 9/6/10 STATED THAT ANOTHER RESIDENT'S MEDICATIONS WERE PREPARED AND WHILE THE NURSE HELPED RESIDENT TO SIT UP, RESIDENT 103 CAME UP AND DRANK THE MEDICATIONS. A SIGNED STATEMENT BY THE DIRECTOR OF NURSING DATED 9/6/10 STATED THAT RESIDENT 103 DRANK ANOTHER RESIDENT'S MEDICATION INCLUDING DEPAKOTE AND DILANTIN. DURING OBSERVATIONS ON 9/7/10 AT 9:30 AM, 10:00 AM, AND 11:00 AM, RESIDENT 103 WAS OBSERVED WANDERING IN THE HALLS OF THE FACILITY WITHOUT SUPERVISION OF FACILITY STAFF. DURING OBSERVATIONS ON 9/8/10 AT 9:20 AM, AND 10:25 AM, RESIDENT 103 WAS OBSERVED WALKING IN THE HALL NEAR THE 300/400 NURSE'S STATION WITHOUT SUPERVISION OF FACILITY STAFF. IN AN INTERVIEW ON 9/7/10 AT 9:50 AM, STAFF #5 (HOUSEKEEPER) STATED ON 7/13/10 SHE LEFT A BUCKET OF BLEACH WATER MIXTURE ON TOP OF HER CART AND WENT INTO ROOM 309 TO WASH THE BEDS. STAFF #5 STATED WHEN SHE WAS CLEANING BED 1, SHE SAW RESIDENT 103 STANDING BY HER CART, THEN WENT TO BED 2 TO CLEAN IT. STAFF #5 STATED WHEN SHE TURNED AROUND SHE SAW RESIDENT 103 HAD PICKED UP THE BUCKET OF BLEACH WATER AND WAS TIPPING IT TO HER MOUTH AS IF TO DRINK IT. STAFF #5 STATED SHE TOLD RESIDENT 103 TO "STOP" AND RESIDENT 103 PUT THE BUCKET DOWN. STAFF #5 STATED THAT PRIOR TO RESIDENT 103 ATTEMPTING TO DRINK THE BLEACH WATER, SHE (STAFF #5) WAS AWARE THAT RESIDENT 103 TAKES WHATEVER SHE CAN AND DRINKS IT AND THAT RESIDENT 103 WOULD GO INTO OTHER RESIDENTS' ROOMS AND DRINK THEIR WATER. IN AN INTERVIEW ON 9/7/10 AT 12:25 PM, STAFF NURSE #9 STATED SHE WAS PASSING MEDICATIONS ON THE MORNING ON 9/6/10 AND RESIDENT 103 HAD BEEN FOLLOWING HER (STAFF #9) ALL MORNING WHILE SHE PASSED OUT MEDICATIONS ASKING FOR HER PILLS. STAFF #9 STATED SHE POURED RESIDENT 105's MEDICATIONS, WHICH INCLUDED DILANTIN AND DEPAKENE, 5 MILLILITERS EACH, INTO A LITTLE CUP AND THEN SET THE CUP ON THE HAND RAIL IN THE HALL. STAFF #9 STATED SHE THEN LEANED DOWN TO ADJUST RESIDENT 105's WHEELCHAIR AND AT THAT TIME RESIDENT 103 CAME UP, TOOK THE CUP OF LIQUID MEDICATION OFF FROM THE HAND RAIL AND DRANK THE ENTIRE CONTENTS OF THE CUP. STAFF #9 STATED THAT PRIOR TO THE MORNING OF 9/6/10, SHE (STAFF#9) HAD CAUGHT RESIDENT 103 EATING PUDDING OFF THE TOP OF THE MEDICATION CART, EATING OTHER RESIDENTS' FOOD AND THAT RESIDENT 103 WILL EAT OR DRINK ANYTHING. IN AN INTERVIEW ON 9/7/10 AT 9:30 AM, THE ASSISTANT DIRECTOR OF NURSING STATED THAT RESIDENT 103 DOES GO INTO OTHER RESIDENTS' ROOMS, EATS AND DRINKS THEIR THINGS, TRIES TO GET STUFF OFF THE MEDICATION CARTS AND THAT SHE had a history of [REDACTED]. WHEN ASKED BY THE SURVEYOR WHAT INTERVENTIONS WERE IN PLACE TO KEEP RESIDENT 103 SAFE, THE ASSISTANT DIRECTOR OF NURSING STATED, "WE TRY TO KEEP AN EYE ON HER". IN AN INTERVIEW ON 9/7/10 AT 11:35 AM, STAFF #8 STATED THAT RESIDENT 103 GOES INTO OTHER RESIDENTS' ROOMS AND DRINKS AND EATS THEIR FOOD. STAFF #8 STATED THAT RESIDENT 103 WILL ALSO TAKE LIQUIDS OFF THE MEDICATION CARTS AND ONCE DRANK A VISITORS DRINK. STAFF #8 STATED THAT RESIDENT 103 IS VERY FAST. STAFF #8 STATED THAT RESIDENT 103 IS NOT SUPERVISED AT ALL TIMES. IN AN INTERVIEW ON 9/8/10 AT 9:25 AM, STAFF NURSE #10 STATED THAT RESIDENT 103's GENERAL BEHAVIOR IS THAT SHE IS VERY IMPULSIVE AND COMPULSIVE ABOUT EATING AND DRINKING, AND SHE IS NOT ABLE TO RESIST THINGS. STAFF NURSE #10 STATED THAT RESIDENT 103 WILL WALK INTO OTHER RESIDENTS' ROOMS, TAKE THEIR FOOD AND EAT IT. STAFF NURSE #10 STATED THAT RESIDENT 103 WILL TAKE JUICE AND THINGS OFF THE MEDICATION CARTS AND DRINK IT. STAFF NURSE #10 STATED RESIDENT 103's BEHAVIOR IS A DAILY THING AND LASTS ALL DAY LONG. STAFF #10 STATED THAT RESIDENT 103 IS VERY FAST AND ONCE SHE (RESIDENT 103) HAS SOMETHING IN HER HAND, STAFF AREN'T ABLE TO GET IT BACK. STAFF NURSE #10 STATED THAT RESIDENT 103 IS AT THE DRINKING FOUNTAIN DRINKING WATER AT LEAST 15 TO 20 TIMES PER HOUR AND THAT SHE IS HUNGRY AND THIRSTY ALL OF THE TIME, AND REGULARLY FOLLOWS NURSES WITH THEIR MEDICATION CARTS. STAFF NURSE #10 STATED THAT RESIDENT 103 IS NOT SUPERVISED AT ALL TIMES. IN AN INTERVIEW ON 9/7/10 AT 12:40 PM, THE DIRECTOR OF NURSING STATED THAT RESIDENT 103 DID ATTEMPT TO DRINK BLEACH WATER FROM AN UNATTENDED BUCKET ON TOP OF A HOUSEKEEPING CART IN JULY OF 2010. THE DIRECTOR OF NURSING STATED THAT RESIDENT 103 DID DRINK ANOTHER RESIDENT'S MEDICATION THAT WAS PLACED ON A HAND RAIL IN THE HALL OF THE FACILITY ON 9/6/10. THE DIRECTOR OF NURSING STATED THAT SHE DID SPEAK WITH THE NURSE WHO LEFT THE CUP OF MEDICATIONS ON THE HAND RAIL AND TOLD HER TO KEEP ALL PREPARED MEDICATIONS IN HER HAND UNTIL SHE GIVES THEM TO THE INTENDED RESIDENT. THE DIRECTOR OF NURSING STATED NO OTHER CHANGES HAVE BEEN MADE SINCE RESIDENT 103 DRANK ANOTHER RESIDENT'S MEDICATION. ON 9/9/10 1:30 PM, THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 7/13/10, WHEN RESIDENT 103 ATTEMPTED TO DRINK A BLEACH/WATER MIXTURE FROM AN UNATTENDED BUCKET ON A HOUSEKEEPING CART. ON 9/10/10 AT 12:00 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. RESIDENT #103 WAS PLACED ON 1:1 SUPERVISION AND HER PLAN OF CARE WAS REVIEWED AND UPDATED BY THE INTERDISCIPLINARY TEAM. 2. ON 9/9/10, 14 RESIDENTS WHO DISPLAY WANDERING OR UNUSUAL BEHAVIOR WERE IDENTIFIED BY THE IDT AND WERE RE-ASSESSED BY THE IDT. THEIR CARE PLANS AND RESIDENT INFORMATION SHEETS WERE UPDATED ACCORDINGLY. SUPERVISION WAS ADJUSTED ACCORDINGLY FOR THESE RESIDENTS BASED ON THE RE-ASSESSMENT. 3. AS OF 9/10/10, 7 OF 8 HOUSEKEEPERS, 3 OF 4 LAUNDRY EMPLOYEES, 17 OF 17 DEPARTMENT HEADS/ADMINISTRATIVE/ANCILLARY, 23 OF 27 LICENSED NURSES, 15 OF 42 CERTIFIED NURSE AIDES, 7 OF 9 DIETARY EMPLOYEES, AND 3 OF 7 THERAPY EMPLOYEES WERE INSERVICED ON SAFETY MEASURES WITH CHEMICALS AND MEDICATIONS. 4. MAINTENANCE/HOUSEKEEPING WILL ELIMINATE THE USE OF 10:1 BLEACH WATER IN BUCKETS AND WILL UTILIZE THE PRE-PACKAGED DISPOSABLE WIPES WHEN NEEDED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/10/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF NO ACTUAL HARM, BUT POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAD NOT BEEN IN-SERVICED, THE PRE-PACKAGED DISPOSABLE WIPES WERE NOT YET IN THE FACILITY, AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #

Based on observation, interview and record review, the facility failed to prevent verbal and physical abuse of 1 Resident #101 of 4 sampled Residents, resulting in Resident #101 suffering emotional harm and causing a large painful bruise. Findings include: On 9-1-2010 an unannounced onsite investigation was conducted. Resident #101 was in the facility at the time of the investigation. Resident #101 was an [AGE] year old female. She was admitted readmitted to the facility on [DATE]. According to her medical record she had the following [DIAGNOSES REDACTED]. The medical record listed her as her own person. The short portable mental status questionnaire scored the Resident at 10 out of 10 on her mental function, on 7-12-2010. During an interview with Resident #101 on 9-1-10 at 8:45 AM the Resident showed the surveyor a large bruise on her left breast and left [MEDICATION NAME] area. (bruise was measured later and was 3 1/2" by 1/2" on the left breast and the bruise on the left chest was 3 1/2 by 3" by 6"). The Resident said, the bruised was caused by a caregiver 3-4 weeks ago and her grand daughter reported the incident to the facility administration about a week after it happened. When Resident #101 was asked if the bruise still hurt she said it hurts when you touch it and she rated it at a level 3-4 out of 10 on a pain scale, with 10 being severe pain. She said the pain at first was an 8-9 out of 10. Resident #101 had the name of the caregiver that hurt her written on a paper in her room. Resident #101 went on to say that the caregiver that caused the bruise came into her room that night with an attitude and said, "no crying, screamming or yelling when I am working." Resident #101, said the caregiver started handling her very rough. She said the bruise happened when the caregiver pulled on her very hard to get her off the toilet. When asked if she thought the caregiver intended to hurt her she said, "yes, there was no need to pull on her that hard." Resident #101 went on to demostrate how the caregiver pulled on her. Resident #101 put both hands up in front of her, closed her fingers tight and pulled her hand up toward her chest fast, and said she jurked me right up. She said, there was another caregiver helping her and that person did not pull hard. Resident #101 said, she was crying when the caregiver hurt her. The other caregiver tried to comfort her and said, "It will be all right sweetly", before she left the room. During an telephone interview with CNA #2, at 11:20 AM, on 9-1-2010, CNA #2 was asked if she worked with Resident #101 and CNA #1 on 8-11-2010 and she said, "yes." When asked if CNA #1 told Resident #101 that she would not have any crying, screaming or yelling when she was working, CNA #2, said, "yes, I was just two steps behind her when we walked in the room". CNA #2 was asked if CNA #1 pulled to hard on the gait belt when getting Resident #101 off the toilet, CNA #2 said, "yes". When asked how she knew it was to hard she said, "we were not trained to use the belt like that." When CNA #2 was asked if she did anything about the incident she said she talked with CNA #1 after they left the room and told her she should not have talked to Resident #101 like that or treated her like that."When CNA #2 was asked if she reported CNA #1 she said, "think I told LPN #2 that night, but I am not sure." CNA #2 was asked if the facility asked her questions about Resident #101's bruise she said she got a phone call from the Assistant Director of Nursing (ADON) on 8-19-2010 and she told the ADON at that time that CNA #1 was physically and verbally abusive to Resident #101. The nurses progress note dated 8-12-2010 at 13:35 said, "Noted to have large area of bruising on left lateral breat." During an interview with the Assistant Director of Nursing (ADON) on 9-1-10 at 11:10 AM, the ADON said, CNA #1 and CNA #2 were working with Resident #101 on 3rd shift on 8-11-10. During an interview with the Social Worker on 9-1-20-10, the Social Worker was asked if she had talked to Resident #101 about her bruise on her left breast and left chest and she said, "no." ( )