Every finding on record at Regency at Fremont

Based on observation, interview and record reviews, the facility failed to effectively clean and maintain food service equipment, potentially affecting 94 residents, that receive food and beverages from the kitchen.Findings include:On 6/07/26 between 3:35 AM and 04:00 AM during the initial tour with the NHA the following concerns were observed:Observation of the Arctic 2-Door Cooler revealed a container of food (possible mechanically altered eggs) was found not date marked or labeled as to its contents. NHA removed/discarded the contents during the tour.Review of the FDA 2017 Food Code Section, 3-501.17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Food Safety Food), Date Marking. Reflects the following, (A) . refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME AND TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C(41 F) or less for a maximum of 7 days.Review of FDA 2017 Food Code Section, 3-501.18 Ready-to-Eat Potentially Hazardous Food (Time/Temperature Control for Safety Food) Reflects the following (A) A FOOD specified in 3-501.17 (A) or (B) shall be discarded if it: .(2) Is in a container or PACKAGE that does not bear a date or day; .Observation of the dish machine area revealed hot water was continuously leaking from the hot and cold water handles for the spray arm fixture. The nozzle on the spray arm had a build-up of stuck on grime and food residue build-up.Review of the FDA 2017 Food Code Section, 5-205.15 System Maintained in Good Repair Reflects the following, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. Reflects the following, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.Several soiled utensils were observed being stored on/with clean utensils in the cook line area. NHA removed soiled utensils during the tour. Can opener blade was also observed to have a build-up of food debris/grime on it. The can opener was placed in the dish washing area to be cleaned.Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. Reflects the following, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTESNISLS shall be clean to sight and touch.Observation of three water filters (located on the wall that supplies water to the ice machines) were found undated/labeled.Review of the FDA 2017 Food Code Section, 5-205.13 Scheduling Inspection and Service for a Water System Device. Reflects the following, A device such as a water treatment device or backflow preventer shall be scheduled for inspection and service, in accordance with manufacturer's instructions and as necessary to prevent device failure based on local water conditions, and records demonstrating inspection and service shall be maintained by the PERSON IN CHARGE.The ice machine was observed not to be working properly, producing ice.Review of the FDA 2017 Food Code Section, 4-501.11 Good Repair and Proper Adjustment. Reflects the following, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.Further observation of this area revealed a submerged drain line coming from the ice machine and draining into the floor drain. (Located beneath the 3-compartment sink.) Water was observed continuously streaming from the drain line.Review of the FDA 2017 Food Code Section, 5-202.13 Backflow Prevention, Air Gap. Reflects the following, 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 2.5mm (1 inch).The Walk-In-Freezer door was observed to no longer be functioning properly. Ice and rust buildup were observed causing the door to not close/seal properly.Review of the FDA 2017 Food Code Section, 4-501.11 Good Repair and Proper Adjustment. Reflects the following, . (B) EQUIPMENT Components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturers specifications.A follow-up observation of the kitchen took place on 6/08/26 at 11:43 AM, with Certified Dietary Manager (CDM) A. Observation of the steamtable, prior to tray assembly, revealed that several wells in the steam table were low on water resulting in the food temps not being maintained. Pureed meat was found at 117 degrees as a result of low water levels not reaching the bottom of the pan. (Water was added to steam table wells and the pureed meat was reheated to 167 degrees prior to residents being served.) The plate warmer was also observed not to functioning/maintaining hot plates.Review of the FDA 2017 Food Code Section, 4-501.11 Good Repair and Proper Adjustment. Reflects the following, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on observation and record review, the facility failed to safely transport two of four wheelchair dependent residents (Resident #3, Resident #72), reviewed for accidents and supervision, and provide direct supervision of residents in the dining rooms on the locked dementia unit. Findings: Resident #3 (R3) Review of a Face Sheet revealed R3 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of aphasia ( does not speak) and right sided weakness and paralysis following a stroke, and dementia. R3 is completely dependent on staff to provide activities of daily living. During an observation on 06/08/26 at 6:51 AM, Certified Nurse Aide (CNA) E pushed R3 in his broda chair (a specialty chair that allows for the resident to be better supported and that can change positions) from R3's room to the dining area and R3's legs and feet were unsupported on the footrests and dangled between the footrests. R3 was left unsupervised in the dining room with his back to the doorway. During an observation on 06/08/26 at 7:10 AM, R3 remained in the main dining room alone without staff supervision and his back to the doorway. R3 did not have a way to alert staff if help was needed. During an observation on 06/08/26 at 7:34 AM, R3 and five other residents sat in the main dining room without direct staff supervision. During an observation on 06/09/26 at 7:15 AM, R3 and three other male residents sat in the main dining room of the locked dementia unit without direct staff supervision. During an observation on 06/09/26 at 7:20 AM, R3 and six other residents sat in the main dining room of the locked dementia unit without direct staff supervision. During an observation on 06/09/26 at 7:17 AM, thirteen residents sat around the nurse's station. The area was congested and difficult to navigate for resident's who ambulated independently (walked on their own). During an observation on 06/09/26 at 7:23 AM, three residents sat in the cardinal dining room on the locked dementia unit without direct staff supervision. During an observation on 06/09/2026 at 9:33 AM, 13 residents were unsupervised in the cardinal dining room while waiting for an activity. There was no music playing nor any meaningful activities in front of the residents to occupy them while they sat alone without staff supervision. Resident #72 (R72) Review of a Face Sheet revealed R72 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of muscle wasting and atrophy (shrinkage) following a stroke, aphasia (difficulty speaking) dementia, and heart disease. Review of a BIMS (brief interview for mental status) interview for R72 completed 06/08/26 reflected a score of 0/15 which indicated severe cognitive impairment. During an observation on 06/08/26 at 7:34 AM, R72 and five other residents sat in the main dining room without direct staff supervision. During an observation on 06/09/26 at 7:20 AM, R72 and six other residents sat in the main dining room of the locked dementia unit without direct staff supervision. Review of an Incident Report's (IR) and Post Fall Evaluation's (PFE) reflected between 02/18/26 and 06/08/26 R72 had six unwitnessed falls. Review of the facility policy Fall Management reflected .Each resident is assisted in attaining/maintaining his or her highest level of function by providing the resident adequate supervision and functional programs as appropriate to minimize the risk for falls.

This site pertains to the annual survey and Intake 3017765.Based on observation, interview and record review, the facility failed to maintain appropriate hot food temperatures and failed to serve palatable/quality food items for residents eating food prepared in the kitchen.Findings include:During an interview on 6/08/26 at 3:02 PM, Complainant J revealed a concern about the poor quality and lack of food being served. Complainant J stated, There is often not enough food on the plate. What is being served is horrible and unappetizing. Complainant J further revealed she brought in meals practically daily to ensure her resident, ate at least one decent meal a day. During a kitchen observation on 6/08/26 at 11:43 AM, [NAME] K was observed taking temperatures prior to plating resident food from the steam table. A large hotel pan of what looked like pureed sausage gravy was temped at 155 degrees. [NAME] K revealed thick white gravy substance was beef stroganoff. The noodles in the next large pan looked to overcooked noodles.Further observation of [NAME] K plating resident meals revealed tongs were being used to inconsistently portion noodles onto resident plates. Portion sizes ranged from less than the size of a deck of cards to sometimes twice the size.On 6/8/26 at 12:50 PM, a food tray was obtained from the 200-Hallway. The tray sampled contained a 54-degree side salad, 2 64-degree glasses of chocolate milk and a roll. Beneath the covered lid was a plate that was cool to touch and portion of beef stroganoff that was just bigger than a deck of cards. The noodles were cold, bland/flavorless and overcooked. This surveyor couldn't tell if there were mushrooms in the pasty white looking stroganoff. The stroganoff did not have chunks of meat, rather ground up bits of meat that had no flavor. The not warm, bland, flavorless stroganoff temped at 121 degrees.On 06/09/2026 at 12:41 PM, another lunch tray was pulled to check for food quality/palatability. At 12:43 PM the following temperatures were obtained from a resident tray on the 200-hallway cart (the last resident trays to be served). The following items were noted: the plate was cool to touch. A scoop of al [NAME] carrots temped at 99.9 degrees, six seasoned potato wedges temped at approximately 102 degrees, with 4 chicken nuggets (bigger than a quarter but smaller than a 50-cent piece) temped out at 111 degrees. The chicken nuggets had a wet, gummy, chewy texture that was completely unappetizing. On 6/9/26 at 12:50 PM, two anonymous residents (residents who did not want to be mentioned) were observed eating in a dining area. Both residents stated that the lunch was not great today, and that it was pretty awful most of the time. Resident A had eaten an individual container of ice cream, one bite of chicken and a few fries because they were cold and did not taste good. Resident B revealed, My lunch was not good. The chicken was tough; and my fries were kind of cold. Both residents stated the food here does not taste very good.Review of Resident A and Resident B's Electronic Medical Record (EMR) reflected weight loss but not significant weight loss at this time. During an interview to go over some concerns on 6/09/2026 at 1:00 PM, the Nursing Home Administrator (NHA) stated, I thought there was a problem with food palatability. During an interview on 6/9/26 at 3:05 PM, the NHA reported that the facility was aware there were concerns about food palatability. The NHA said that the facility had just started a Food Council (a group of interested residents who would meet monthly to discuss food and dining) two months ago, but there was still work to be done to increase resident satisfaction.

Based on observation, interview, and record review, the facility failed to implement the use of and utilize personal protective equipment for three of three residents (Resident #102, Resident #69, and Resident #70) reviewed for infection control and failed to clean glucometers according to manufacturer guidelines. Findings:Resident #102 (R102) Review of a Face Sheet revealed R102 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnoses of acute kidney failure. Review of an admission Nursing Comprehensive Evaluation completed 06/06/26 revealed the following observed skin concerns: (a) Groin-open boil with dressing to left groin, (b) Coccyx-unstageable pressure injury, and (c) Abdomen-bilateral open boils to folds. During an observation on 06/07/26 at 3:01 AM, no PPE (personal protective equipment) sat near the room for staff to utilize during close contact care nor was a sign posted near the resident's room alerting staff of the need to utilize enhanced barrier precautions. During an observation on 06/08/26 at 2:50 PM, no PPE (personal protective equipment) sat near the room for staff to utilize during close contact care nor a sign was not posted near the resident's room alerting staff of the need to utilize enhanced barrier precautions (EBP's). During an interview on 06/08/26 at 3:20 PM, the Director of Nursing (DON) indicated that EBP's (enhanced barrier precautions) could be initiated by any nursing staff without a physician order. Resident #69 (R69) Review of a Face Sheet revealed R69 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of a second degree burn to the left thigh and Alzheimer's dementia. Review of an admission Nursing Comprehensive Evaluation completed 05/15/26 revealed the following skin concerns: (a) stage 2 pressure injuries to bilateral buttocks, (b) a burn injury to the left thigh, and (c) a burn injury to the right thigh. During an observation on 06/09/26 at 7:24 AM, certified nurse aide (CNA) H assisted R69 to the bathroom and did not utilized personal protective equipment for enhanced barrier precautions (EBP). Resident #70 (R70) Review of a Face Sheet revealed R70 was a [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses of a stage 3 pressure ulcer to the sacral area, vascular dementia, and a stroke that caused left-sided weakness and paralysis. During an observation on 06/08/26 at 4:12 PM, Certified Nurse Aide (CNA) E and CNA F provided care to R70 and did not utilize PPE for EBP. During an observation on 06/08/26 at 4:15 PM, a sign hung at the entrance to R70's room alerting staff that Enhanced Barrier Precautions were to be used when providing direct and close contact resident care. Review of the facility policy Enhanced Barrier Precautions (EBP), last reviewed 03/05/25, reflected: It is the intent of this facility to use Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for preventing the transmission of CDC targeted multidrug-resistant organisms (MDRO's) .Enhanced Barrier Precautions are indicated for residents with a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO and should remain in place for the duration of the resident's stay or until the resolution or the wound or discontinuation of the indwelling medical device. During an observation on 6/7/26 at 4:45 AM, Licensed Practical Nurse (LPN) T performed a blood glucose check on R54. After she performed the procedure, she cleaned the glucometer machine with an alcohol pad from the top drawer of her medication cart. During an observation on 6/7/26 at 4:50 PM, LPN T performed a blood glucose check on R101. After she performed the procedure, she cleaned the glucometer machine with an alcohol pad from the top drawer of her medication cart. During an interview on 6/8/26 at 12:50 PM, Registered Nurse (RN) B stated she cleans the glucometer machine with [name brand] germicidal wipes after each use. She stated she thought the wait time was 10 minutes. During an interview on 6/9/26 at 9:25 AM, LPN C stated she cleans the glucometer machines with an alcohol pad between each resident use. She stated she makes sure the machine is completely wiped down with the pad and when it dries, it dries. During an interview on 6/9/26 at 10:00 AM, RN D stated he cleans the glucometer machine with purple wipes (color of the lid to the container of the [name brand] germicidal wipes) after each use. He stated he wraps the machine in a cloth and lets it sit for 2 minutes to make sure the machine is disinfected. During an interview on 6/9/26 at 1:00 PM, the Director of Nursing/Infection Control Preventionist (DON/ICP) stated staff are supposed to clean the glucometers with bleach wipes after each use. She stated alcohol pads/wipes are not appropriate. A review of the user's manual for the brand of glucometer that the facility uses, dated 4/24, revealed there are four disinfection/germicidal wipes that are approved for use with the brand of the glucometer that the facility uses (the [name brand] germicidal wipes that the facility had in their medication carts was not one of them). It also states other EPA (Environmental Protection Agency) registered wipes may be used for disinfectiong the [name brand of glucometer], however, these wipes have not been validated and could affect the performance of your meter. A review of the lable for the [name brand] germicidal wipes that the facility had in their medication carts, this brand of germicidal wipe was listed as an EPA registered wipe that can be used to clean and disinfect blood glucose meters (glucometers). The label also revealed that it takes 2 minutes for the wipe to disinfect an object.

Based on interview and record review, the facility failed to allow the resident and/or the resident's responsible party the right to be informed and to make treatment decisions for 1 of 5 residents (R93) reviewed for unnecessary medications. Findings include: A review of R93's admission Record, dated 6/8/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R93's admission Record revealed they had multiple diagnoses that included anxiety, post-traumatic stress disorder, and depression. R93's admission Record also revealed they had a guardian. A review of R93's Order Recap Report, dated 5/1/25 to 6/9/26, revealed that R93 had physician orders for diazepam (a psychotropic medication- a medication that alters perception, mood, cognition, consciousness, or behaviors by changing brain function) for anxiety on and off from 8/3/25 to 6/9/26. A review of R93's electronic medical record (EMR), dated 8/1/25 to 6/9/26, failed to reveal any documentation that R93's guardian had been informed in advance of R93 receiving diazepam, of the risks and benefits, of treatment and treatment alternatives, of other treatment options, or given the opportunity to choose an alternative treatment or the option she prefers. A review of R93's Medication Administration Records, dated 8/1/25 to 6/9/26, revealed that R93 had received diazepam in accordance with physician orders during this time period. During an interview on 6/9/26 at 10:15 AM, the Nursing Home Administrator (NHA) stated they do not have any documentation that R93's guardian had been informed of the risks and benefits of diazepam, of treatment and treatment alternatives or treatment options and to choose the alternative or option she prefers. The NHA stated that while they were reviewing resident charts last month they had found that R93 did not have any information that their guardian had been notified about a different psychotropic medication (mirtazapine) and they corrected that issue on 5/21/26. However, the facility failed to identify that the same information that was missing for mirtazapine was also missing for diazepam. A review of the facility's Psychoactive Medication Management Policy, revised 1/28/26, revealed, .4. Residents receiving psychoactive medications upon admission, those with new psychoactive medications orders or an increase in the dose of the medication, will have a psychotropic medication informed consent completed. Before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on observation, interview, and record review, the facility failed to initiate care and treatments in a timely manner for two of three residents (Resident #102 and Resident #70) reviewed for pressure wounds. Findings: Resident #102 (R102) Review of an admission Record revealed R102 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of acute kidney failure, dehydration, recent falls at home, diabetes mellitus type 2, congestive heart failure, morbid obesity, and dehydration. There were no skin concerns identified on the admission diagnoses list. Review of a Nursing Comprehensive admission Assessment for R102, completed 06/06/26, reflected the following skin concerns: (a) an open boil with a dressing on it in the left groin, (b) an unstageable coccyx pressure injury, and (c) bilateral open boils to the abdominal folds. The assessment did not include any measurements or characteristics of the wounds. During an interview on 06/07/26 at 3:30 PM, R102 stated she developed a coccyx wound after her first fall at home which was approximately six weeks ago. R102 then stated that nursing staff completed a skin assessment yesterday evening (6/6) and told her that the coccyx wound did not look very good. R102 verbalized that she is not able to reposition herself in bed due to pain and her size. Stated that staff do not come in every 2 hours to reposition her but have a couple of times because she asked them to when she was in pain. R102 also indicated that she was unsure if any dressing changes or treatments had been completed on her wounds. During an observation on 06/07/26 at 3:40 PM, R102 did not have an APM (alternating pressure mattress) on the bed. Review of an Electronic Treatment Administration Record (E-tar) on 06/07/26 at 4:00 PM reflected that there were no skin/wound treatment orders in place for R102. During an interview on 06/08/26 at 11:25 AM, R102 stated that staff had not completed any wound care since her admission, that staff are not repositioning her, and there is not an APM on her bed. Review of an Electronic Treatment Administration Record (E-tar) on 06/08/26 at 12:00 PM reflected that there were no skin/wound treatment orders in place for R102. During an interview on 06/08/26 at 3:07 PM, the Director of Nursing stated that admissions that have skin concerns are identified by the admission coordinator via a referral for placement or when the IDT (inter-disciplinary team) reviews new admissions the next morning and the nurse that completed the admission skin assessment should have called the physician for treatment orders. Resident #70 (R70) Review of an admission Record revealed R70 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of dementia, a stage 3 pressure ulcer to the sacrum, and history of a stoke that caused left sided weakness and paralysis. During an observation on 06/08/2026 at 4:12 PM, Certified Nurse Aides (CNA) E and F provided care to R70. The dressing on R70's sacral area was dated 6/5. During an interview on 06/08/26 at 4:30 PM, Unit Manager G stated that R70's sacral dressing was ordered to be completed by nursing staff daily. Review of an Electronic Treatment Administration Record (E-tar) for R70 dated June 2026, revealed an order for daily wound cleaning and dressing change for the sacral pressure ulcer. The E-tar was checked as completed by nursing on 06/06/26 and was blank on 06/07/26. Review of the facility policy Skin Management revealed .Residents with wounds and/or pressure injuries and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (5%) for 1 of 8 residents (R34) observed during the medication administration task, resulting in a medication error rate of 7.41%. Findings include: A review of R34's admission Record, dated 6/8/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R34's admission Record revealed they had multiple diagnoses that included dementia. During a medication administration observation on 6/8/26 at 7:35 AM, Registered Nurse (RN) B administered multiple medications to R34, including folic acid 400 micrograms (mcg) (1 tablet) and magnesium oxide 400 milligrams (mg) (1 tablet). RN B verbalized the medications, doses, and quantities of the tablets. A review of R34's Medication Administration Record (MAR), dated 6/1/26 to 6/8/26, revealed R34 was to receive folic acid 1 mg at 8:00 AM. However, RN B only administered 400 mcg (0.4 mg) of folic acid to R34. A review of R34's Medication Administration Record (MAR), dated 6/1/26 to 6/8/26, revealed R34 was to receive magnesium oxide 400 milligrams 2 tablets at 8:00 AM. However, RN B only administered 1 tablet of magnesium oxide to R34. During an interview on 6/8/26 at 12:33 PM, RN B verified she administered folic acid 400 mcg to Resident #34 at 7:35 AM. During an interview on 6/8/26 at 4:45 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the medication errors that occurred during the medication administration task. A review of the facility's Medication Administration policy and procedure, revised 10/17/23, revealed the nurse is to verify the medication label against the medication administration record for resident name, time, drug, dose, and route.

This citation pertains to intake # 2984523Based on interview and record review, the facility failed to (a) adequately monitor for medication side effects, (b) prescribe medications with an adequate/correct indication, and (c) frequently monitor and re-assess the effectiveness of the medications for one of three residents (Resident #100) reviewed for unnecessary medications. Findings:Resident #100 (R100)Review of an admission Record revealed R100 was a [AGE] year-old female, admitted to the facility on [DATE], with facility diagnoses of dementia, alcohol abuse with alcohol-induced mood disorder, and alcohol use, unspecified with alcohol-induced persisting dementia. During a telephone interview on 05/03/26 at 4:23 PM, Family Member (FM) T stated that almost two years ago R100 had genetic testing done for early onset Alzheimer's. R100 had the APOE-e4 marker with two copies which were very rare genetic markers. The testing was done due to R100 not acting like herself for some time, she lost her job due to poor performance that built up slowly over a couple of years, was forgetful most the time, would wander from the house, and would get mean towards family members. We thought she had a brain tumor or something, nobody could figure out what was the matter with her. After the testing, R100 was started on medication for Alzheimer's and lived at home with her husband until recently when he could no longer keep her from leaving the house and would be found walking in very busy streets. The husband took R100 to a local acute care hospital in search of help. R100 was admitted to the hospital from [DATE] until she was admitted to the skilled nursing facility sixteen days later on 10/20/25.According to the National Institute on Aging, .one well-known gene that influences Alzheimer's risk is the apolipoprotein E (APOE) gene. APOE comes in several forms called alleles (e.g. E2, E3, E4). APOE-E4 increases the risk for Alzheimer's and is associated with early age of disease onset. About 15% to 25% of people have this allele, and only 2% to 5% carry two copies. www.nia.nih.gov/alzheimers.Review of a History & Physical completed at the hospital on [DATE], reflected that R100 was diagnosed with dementia-Alzheimer's early on-set with behavioral disturbance and wandering behavior and a history of alcohol abuse. Review of a hospital Discharge Summary for R100 on 10/20/25, reflected the following medication orders: Memantine 10 mg (milligrams) one tab twice daily and Donepazil 10 mg one tab at bedtime (both medication previously prescribed prior to hospitalization to treat dementia), Seroquel 200mg one tab twice daily (an antipsychotic newly prescribed at the hospital to help treat the behavior disturbances associated with the dementia), and Ativan (lorazepam) 0.5 mg one tab twice daily (a benzodiazepine newly prescribed at the hospital to help reduce anxiety and agitation associated with the dementia).Review of nursing Progress Notes for R100 and dated 10/20/25 reflected: (a) resident arrived at the facility at 1:45 PM, (b) stated that she did not want to be there and threatened her husband if he left her there, (c) was difficult to redirect, called staff names, physically lashed out at staff, (d) was placed on a 1:1 (one staff person assigned to the resident), and (e) was given an injection of Haldol (an antipsychotic) 5 milligrams (mg) for psychosis, prescribed by Nurse Practitioner (NP) J.Review of a prescriber Progress Note dated 10/21/25 and written by Nurse Practitioner (NP) J reflected the following information was obtained from old medical records and nursing staff: (a) (R100) suffers from Alzheimer's dementia with behavioral disturbance and becomes combative at times, (b) height 5' 3 and weight 103.8 pounds, (c) physical exam findings-appears comfortable, negative for confusion or falls, and is agitated, (d) Assessment and Plans-increased Ativan to compensate for ETOH (alcohol) withdrawals. (R100 had been at a hospital for 16 days prior to being admitted to the nursing facility and had not consumed alcohol).According to the National Institute on Alcohol Abuse and Alcoholism, symptoms of alcohol withdrawal begin 6 to 24 hours from the last use.A review of R100's Electronic Health Record (EHR) revealed there was no information that indicated R100 was in acute alcohol withdrawal, when her last alcohol consumption was (R100 had been in the hospital since 10/04/25), how long R100 had been consuming alcohol (days, months, years etc), and how much (quantity) and what ( beer, liquor etc) had been consumed. According to the World Health Organization, benzodiazepines (Ativan) are recommended as the front-line medication for the management of alcohol withdrawal in alleviating alcohol discomfort and preventing seizures and delirium .the duration of benzodiazepine treatment should be limited to the first 3 to 7 days after stopping alcohol intake. who.int/teams/mental-health and substance use/treatment-care.Review of an Electronic Medication Administration Record (E-mar) for R100 dated 10/01/25 to 10/31/25 reflected an order to increase Ativan from 0.5 mg twice daily to 1 mg three times daily, starting 10/22/25 and ordered by NP J. This medication change tripled the dose of Ativan prescribed daily to R100. The order did not include a stop date within 3-7 days. Review of an Electronic Medication Administration Record (E-mar) for R100 dated 10/01/25 to 10/30/25 reflected (a) an order on 10/23/25 for R100 to start Depakote 125 mg three times daily for mood stabilization and (b) an order to discontinue Donepazil (a medication the resident had been taking long term for dementia), ordered by NP J. Review of R100's progress notes revealed NP J did not see nor assess the resident on 10/23/25 prior to starting the new medication (Depakote) and discontinuing the Donepazil. Review of nursing Progress Notes for R100 revealed after a note entered into the record on 10/25/25 at 1:48 AM, there were no additional nursing notes regarding assessments or observations made during the rest of the day on 10/25/25, 10/26/25 and 10/27/25. Review of a nursing Progress Note dated 10/28/25 reflected nursing requested for R100 to be seen by a contracted psychiatric specialist. R100 was not seen by the psych specialist until 11/08/25 (11 days after the request was made by nursing).Review of an E-mar for R100 dated 10/01/25 to 10/30/25 revealed an order on 10/28/25 to increase Seroquel from 200 mg twice daily to 300 mg twice daily. This medication increase was ordered by NP J. Review of R100's progress notes revealed NP J did not see nor assess the resident on 10/28/25, prior to increasing this medication and last saw and assessed R100 on 10/21/25. Review of a History and Physical (H&P) completed on 10/29/25 by Medical Doctor (MD) U revealed: (a) evaluating today for regulatory H&P visit, (b) incorrectly listed Donepazil as a current medication (was discontinued on 10/23/25 by NP J), (c) incorrectly listed the dose of Ativan as 0.5 mg one tab twice daily (Ativan was increased to 1 mg three times daily on 10/21/25 by NP J with an indication of acute alcohol withdrawal and no stop date), (d) did not list Depakote as a current medication (started on 10/23/25 by NP J), and (e) incorrectly listed the dose of Seroquel as 200 mg one tab twice daily (was increased to 300 mg twice daily on 10/28/25 by NP J). Review of a prescriber Progress Note for R100 dated 10/30/25 and written by NP J reflected the following regarding R100's current state: (a) positive for fatigue and low energy, (b) positive for loss of bladder control, (c) positive for falls and weakness (no documentation of the resident falling could be located in the electronic health record (EHR), and (d) NP J documented this patient's dementia was caused by the alcohol abuse. (Despite R100's positive APOE-e4 marker for early onset Alzheimer's)Review of nursing Progress Notes revealed no nursing notes regarding nursing assessments nor nursing observations of R100 on 10/29/25, 10/30/25, 10/31/25, 11/01/25, 11/02/25, 11/03/25, and 11/04/25. Review of a prescriber Progress Note for R100, dated 11/06/26 and written by NP J revealed: (a) resident was throwing lunch trays and hitting other residents, (b) resident received a Haldol injection 5 mg for the violent outbursts, (c) was positive for weight loss, (d) positive for confusion and falls, and (e) positive for tachycardia (increased heart rate). During an interview on 05/05/26 at 11:20 AM, the Administrator stated that there was no record/documentation of R100 throwing lunch trays or hitting other residents during her 27 day stay at the facility. Review of R100's EHR revealed an unwitnessed fall documented at 4:45 PM on 11/06/25.Review of nursing Progress Notes revealed no nursing notes regarding nursing assessments nor observations of R100 on 11/09/25 and 11/10/25. Review of an E-mar for R100, dated November 2025, revealed a new order for Risperdal Consta (an antipsychotic) intramuscular injection 12.5 mg every 14 days. The first injection of Risperdal Consta was given 11/11/25. Review of R100's EHR revealed an unwitnessed fall on 11/11/25 at 3:35 PM. Review of R100's EHR revealed an unwitnessed fall on 11/15/25 at 2:30 PM.Review of the E-mar's for R100 dated October and November 2025 reflected orders for direct care staff to monitor the resident twice daily for side effects of the Seroquel, Ativan, and Depakote i.e. appetite changes, blurred vision, confusion, dizziness, weight changes, nausea, drowsiness, fatigue, sedation, involuntary movement. If R100 had no side effects, nursing would document that by indicating 0 on the E-mar's. If side effects were observed, nursing would document that by entering the number that corresponded with each specific side effect ( for example-the number 3 would be documented if R100 experienced drowsiness that shift). No side effect documentation was completed starting the evening of admission [DATE]) until the time R100 was hospitalized (the morning of 11/16/25) as evidenced by staff placing a check mark on the E-mar's and not correctly following the order. Review of the Behavior Monitoring task documentation for R100, completed by certified nurse aides (CNA's), reflected any behaviors such as, abusive language, threatening behavior, kicking and hitting, yelling or screaming, wandering, refusing care. The following behaviors were documented from 11/01/25 to 11/16/25: *11/01/25- no documented behaviors *11/02/25-behaviors noted only in the evening *11/3/25- only wandering documented *11/04/25- no documented behaviors *11/05/25- no documented behaviors *11/06/26- behaviors noted only in the evening *11/07/26- no behaviors documented *11/08/25- behaviors noted only in the evening *11/09/25- behaviors only in the evening *11/10/25- behaviors only in the evening *11/11/15- only wandering in the evening documented *11/12/25- no behaviors documented *11/13/25- no behaviors documented *11/14/25- only behaviors with AM care documented *11/15/25- wandering and refusing care documented *11/16/25- no behaviors documentedDuring an interview on 05/05/26 at 11:35 AM, employee K recalled R100 as having very bad dementia, talked to pictures on the wall, would try to put on lipstick and it would be all over her face, walked the halls all the time, and declined very quickly in the last week or two; slept a lot and stayed in her room. Employee K reported seeing R100 at least 4-5 times a week during the resident's stay. During an interview on 05/05/26 at 11:40 AM, employee F recalled R100 as walking around all the time, wasn't very nice to the staff, nonsensical talk sometimes, and only worked with R100 a few times. During an interview on 05/05/26 at 11:47 AM, employee C recalled R100 as the alcoholic, was very busy on the unit and hard to redirect, went in and out of other resident's rooms, had a rapid decline over the last week R100 was there and was very lethargic the day R100 went to the hospital. During an interview on 05/05/26 at 11:51 AM, employee E recalled R100 as very busy and aggressive then there was a big change and a few days after that the resident was sent to the hospital. Employee E did not recall any other specifics. During an interview on 05/05/26 at 12:00 PM, employee G recalled R100 as having alcohol issues, became angry quickly, walked around a lot, could be uncooperative, and did not remember any other specifics. During an interview on 05/05/26 at 12:10 PM, employee L recalled R100 as a severe alcoholic, very busy, looked totally normal, and very active when she first got to the facility and then could barely keep her eyes open, would sit on the floor with her (R100) knee's bent and rock back and forth, started falling a lot, was pretty out of it, and declined quickly.During a telephone interview on 05/05/26 at 10:30 AM, NP J stated that the increase to R100's Ativan on 10/21/25 was due to withdrawal symptoms and any information used to make the medication change was found in R100's EHR. I wanted to take the edge off so she wouldn't have behaviors. NP J remembered R100 as very agitated, refused staff care, and wandered all the time. NP J did not recall the reason for the increase in Seroquel on 10/28/25 nor recall the reason for discontinuing the Donepazil on 10/23/25. NP J revealed not having access to R100's EHR due to being terminated from the facility and its governing corporation. Review of R100s EHR revealed no documentation that the behavioral management team implemented a dose reduction and/or discontinuation of R100's Ativan, Seroquel, and Depakote despite R100's confusion, increase in falls and an inadequate indication for the use of the psychotropic medications. Review of nursing Progress Notes for R100 dated 11/16/25 revealed:(a) at 12:49 AM no concerns were noted, (b) at 8:56 AM R100 was noted to have diarrhea, a fever, was weak, decreased mobility, had abnormal lung sounds, seemed different than usual, there was a noted change in skin color, (c) at 10:16 AM R100 was noted to have shortness of breath, pulse 122, respirations 34, temperature 100.8, and pulse oximetry 55% on room air.Review of an EMS (ambulance) run record for R100,dated 11/16/25, (information obtained from facility staff) revealed (a) patient had a norovirus type illness for 24 hours and has been vomiting, (b) lung sounds altered with audible rhonchi (a low pitched, course, rumbling, snore like sound heard during breathing) with suspected aspiration pneumonia, (c) patient found unresponsive, (d) staff reported patient has been hypoxic (low oxygen in the blood) and supplemental oxygen has not improved her, temperature is 101. Review of a physician emergency room note for R100, dated 11/16/25 revealed the following: (a) gurgling heard on respirations, (b) is critically ill appearing, (c) has copious amounts of what appears to be vomit in her mouth, as well as her ears and recess of the collar bone, and (d) mucous membranes are dry. This patient was brought in due to altered mental status, fever, and trouble breathing. Apparently some kind of viral gastrointestinal illness has been going on were people have been vomiting and the patient had been vomiting and was found this morning with trouble breathing. Patient has pretty severe dementia. No active vomiting in the ambulance. Review of a Drug Interaction Report which included Ativan (lorazepam) Depakote (divalproex sodium), Haldol (haloperidol), Risperdal Consta (risperidone), and Seroquel (quetiapine)The recommended maximum number of medicines in the 'CNS drugs' category to be taken concurrently is usually three. Your list includes five medicines belonging to the 'CNS drugs' category:Ativan (lorazepam)Depakote (divalproex sodium)Haldol (haloperidol)Risperdal Consta (risperidone)Seroquel (quetiapine)The recommended maximum number of medicines in the 'psychotropic agents' category to be taken concurrently is usually three. Your list includes four medicines belonging to the 'psychotropic agents' category: Ativan (lorazepam)Haldol (haloperidol)Risperdal Consta (risperidone)Seroquel (quetiapine)The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one. Your list includes three medicines belonging to the 'antipsychotics' category:Haldol Decanoate (haloperidol)Risperdal Consta (risperidone)Seroquel (quetiapine)Major Drug interactions (Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.) Haldol (haloperidol) & Risperdal Consta (risperidone) Haldol (haloperidol) & Seroquel (quetiapine)Haloperidol can cause dose-related prolongation of the QT interval. Theoretically, coadministration with other agents that can prolong the QT interval may result in additive effects and increased risk of ventricular arrhythmias including torsade de pointes and sudden death In addition, if combination therapy with agents with anticholinergic properties is required, caution is advised, particularly in the elderly and those with underlying organic brain disease.Moderate Drug InteractionsHaldol (haloperidol) & Ativan (lorazepam)Haldol (haloperidol) &, Depakote (divalproex sodium)Ativan (lorazepam) & Risperdal Consta (risperidone)Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. Sedation and impairment of attention, judgment, thinking, and psychomotor skills may increase .During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Cautious dosage titration may be required, particularly at treatment initiation.Ativan (lorazepam), Depakote (divalproex sodium)Close observation for clinical evidence of benzodiazepine toxicity (excessive sedation) is recommended if valproate and a benzodiazepine must be used together.Ativan (lorazepam) & Seroquel (quetiapine)quetiapine may enhance the CNS effects of lorazepam .The clinician may consider closer clinical monitoring of the patient for lorazepam toxicity if quetiapine and lorazepam are coadministered. Patients should be advised to notify their physician if they experience symptoms such as excessive sedation, confusion, dizziness, or incoordination.Risperdal Consta (risperidone) & Depakote (divalproex sodium)clinicians may consider monitoring the pharmacologic response and serum valproate levels more closely whenever risperidone is added to or withdrawn from therapy. Ambulatory patients should be made aware of the possibility of additive central nervous system effects (e.g., drowsiness, dizziness, lightheadedness, confusion)Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, One of the greatest challenges for older adults is safe medication use. Medication categories such as analgesics, anticoagulants, antidepressants, antihistamines, antihypertensives, sedative-hypnotics, and muscle relaxants create a high likelihood of adverse effects in older adults. They are at risk for adverse medication effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs, collectively referred to as the process of pharmacokinetics. Medications sometimes interact with one another, adding to or negating the effect of another drug. Examples of adverse effects include confusion, impaired balance, dizziness, nausea, and vomiting .Polypharmacy, the concurrent use of many medications, increases the risk for adverse drug effects. Although polypharmacy often reflects inappropriate prescribing .(the) role as a nurse is to ensure the greatest therapeutic benefit with the least amount of harm by collaborating with pharmacists and health care providers .(nurses) need to question the efficacy and safety of combinations of prescribed medications. Advocate for the older adult to prevent adverse reactions. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

This citation is related to intake #2741450Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 7 of 25 residents reviewed for accommodation of needs. Findings:During an observation on 05/04/26 at 5:00 AM, the resident in bed 100-1 laid resting in bed with her eyes closed and the call light touch pad hung over the back of the head board, out of sight and out of reach of the resident. The resident in bed 100-2 laid in bed resting with her eyes closed and the call light was curled up on top of the blanket at the foot of the bed out of sight and out of reach of the resident.During an observation on 05/04/26 at 5:02 AM, the resident in bed 104-1 laid resting in bed with her eyes closed and the call light sat on the floor at the head of the bed, out of sight and out of reach of the resident. During an observation on 05/04/26 at 5:04 AM, the resident in bed 105-1 laid resting in bed with her eyes closed and the call light sat on the floor between the bed and the wall, out of sight and out of reach of the resident.During an observation on 05/04/26 at 5:07 AM, the resident in bed 106-1 laid resting in bed with her eyes closed and the call light sat on the floor between the bed and the wall, out of sight and out of reach of the resident.During an observation on 05/04/26 at 5:14 AM, the resident in bed 310-1 laid resting in bed with her eyes closed and the call light sat on the floor on the right side of the bed, out of sight and out of reach of the resident.During an observation on 05/04/26 at 5:26 AM, the resident in bed 208-2 sat in a wheelchair positioned near the foot of the bed, resting with her eyes closed and slumped over to her right. The privacy curtain was pulled and the resident could not be observed from the hallway and the call light wrapped around the head of the bed out of sight and out of reach of the resident.During an interview on 05/04/26 at 9:20 AM, certified nurse aide (CNA) N indicated that the expectation was for staff to make sure call lights were within reach of the resident's each time staff enter the room. Review of the facility policy Call Lights, last reviewed on 03/12/25, revealed .when a resident is in bed or confined to a chair ensure the call light is within easy reach for the resident.

This citation pertains to intake #2715766Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #6) out of 3 residents reviewed for quality of care, resulting in a delay in medical treatment and surgical intervention for an unstable sacral fracture with spinopelvic dissociation and left superior/inferior ramus fractureFindings:Resident #6 (R6)Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: sacral and pelvic fractures from fall and Parkinson's Disease.Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 11/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated R6 was cognitively intact. Review of R6's Kardex revealed: Monitors: report to Nurse s/sx (signs and symptoms) of (the) following.change in normal behavior.decline in ability to help with/do adls (activities of daily living), continence. Transferring: (R6) requires one assistance with gait belt and 2ww (wheeled walker) for stand and pivot transfers.Review of a Complaint/Incident Investigation Report reported to the State of Michigan revealed R6 experienced a fall on 11/14/25 while receiving care from Certified Nursing Assistant (CNA) G. The complainant states CNA G told the resident not to tell anyone what happened. The complainant states that for 5 days the resident was in such bad pain that she couldn't sit in her wheelchair.the resident was sent to (name omitted) hospital and found to have a separated pelvis and her spine separated from her sacrum.the resident was sent to (name omitted) Hospital Trauma Center and had to have a 4-hour surgery to try to correct the damage. The complainant states the resident may never walk again.Complainant states when he inquired about the residents' change in condition, CNA G told him that nothing happened to her while the resident was on her watch. The complainant states this was reported to Licensed Practical Nurse (LPN) F the charge nurse, but he doesn't know if an internal investigation was completed or if the incident was reported.During an interview on 02/02/2026 at 12:55 PM, Family Member (FM) C reported that R6 had told him that she fell in the shower on 11/14/25. R6 reported to FM C that the aide told her not to tell facility staff that it had happened. FM C then asked R6 to point out the aide that was involved and she pointed to CNA G. FM C reported he asked CNA G about the alleged fall and she reported that R6 had not fallen and if she did, then she was not the aide that was with her. FM C reported he visited R6 that weekend (11/15/25 and 11/16/25) and R6 was in increased pain. He reported that on 11/17/25 he visited R6 and she had increased confusion. FM C reported that the nurse, LPN F, reported she was going to get R6 up to the bathroom and FM C asked if he could watch how she transferred R6 since he would need to do it by himself at home. LPN F allowed him to watch and when LPN F pulled down R6's pants they noticed a large bruise on her right hip. FM C reported to LPN F that it was likely related to R6's fall on 11/14/25 and stated (LPN F) freaked out and reported that she did not know that R6 had fallen. FM C reported R6 was then sent to the emergency room and was subsequently transferred to (name omitted) Hospital Trauma Center for substantial fractures which required extensive surgery.During an interview on 02/02/2026 at 3:20 PM, LPN F reported that she had worked 11/14/25 but had not been notified of a fall. LPN F reported CNA G found the bruise and reported that she was told by R6 that she had fallen in the shower room, and the aide knew about it. LPN F reported that CNA G stated that she was not the CNA that was involved with the fall. LPN F reported she had not worked the weekend of 11/15/25-11/16/25 and when she worked again on 11/17/25 a large bruise was found on R6's right hip. R6's husband reported R6 had fallen sometime on Friday or Saturday. LPN F reported she was told that Registered Nurse (RN) T was notified over the weekend of the bruise by CNA H.Review of R6's Nurses Note dated 11/1/25 revealed, .Resident is continent of bowel and bladder.Review of R6's Skin Check dated 11/12/25 revealed no irregularities or areas of bruising.Review of R6's Skin Issues dated 11/13/25 revealed no irregularities or areas of bruising.Review of R6's Skilled Care Note dated 11/14/25 at 9:25 AM revealed no irregularities/issues with her skin. Further review of the note revealed R6 was continent of bowel and bladder and that she was 1 assist for transferring, ambulation in wheelchair, toilet use, post elimination care, showers, and dressing.Review of R6's Electronic Medical Record revealed no documentation that CNA G notified the licensed nurses or management of an allegation of a fall on 11/14/25 following her interaction with FM C.Review of CNA G's Disciplinary Action Record dated 11/19/25 revealed, Staff member observed using the sit to stand mechanical lift to transfer a patient (R6) by herself, without assistance from another staff member. This was observed on 11/14/25.During an interview on 02/04/2026 at 12:25 PM, CNA H reported when she was providing morning care to R6 she found a large bruise on her hip and immediately notified RN I of her findings. CNA H reported that R6 had not fallen on her shift, but the injury occurred over the weekend on either 11/14/25 or 11/15/25.During an interview on 02/04/2026 at 12:56 PM, RN I reported that the rehabilitation unit has a high turnover of residents that only remain in the facility for a short period of time and because of that he could not recall if R6 had been found with a large bruise.Review of R6's Electronic Medical Record (EMR) revealed both CNA H and RN I had provided care for R6 on 11/15/25. There was no documentation that a physical assessment was completed or that an investigation was initiated to identify the cause of the bruising identified by CNA H. There was no documentation that FM C or the provider were notified of the new injury.Review of R6's Nurses Note dated 11/15/25 revealed, Sending to (name omitted) E.D. (emergency department) following confusion with hallucinations. Pain to BLE (bilateral lower extremities) resolved with repositioning from seated in wheelchair to lying in bed, HTN (hypertension) also decreased with this change in position. Hallucinations continued. On Call Provider contact, resident sent to E.D. Indicating a change in R6's baseline. R6's pain had increased and changed her functional ability (no longer able to sit in wheelchair without pain) and severe pain affecting causing her blood pressure to rise.Review of R6's Hospital Note dated 11/15/25 at 12:29 PM revealed, .There was a possible fall last night however (husband) is unsure of these details. R6's Electronic Medical Record did not include a copy of these comprehensive hospital medical records and only included the After Visit Summary which did not include the allegation that R6 fell on [DATE].)Review of R6's Nurses Note dated 11/15/25 revealed, Returned from (hospital) with finding of Low Potassium. E.D. Provider also recommended d/c (discontinuation) of meds that were started on 11/13/25 as they may have played a role in hallucinations.Review of R6's Electronic Medical Record revealed no documentation that a physical assessment was completed upon her return to the facility. There was no documentation that a fall investigation was initiated or that the provider and management were notified of the fall.Review of R6's Skilled Care Note dated 11/16/25 revealed, .2 assist with sit to stand d/t (due to) recent new onset Sciatic Pain. Indicating a change in her functional ability and the identification of new/increased pain.Review of R6's Electronic Medical Record revealed no documentation that LPN F notified the provider or management of the large bruise/injury observed or the allegation of a fall on 11/14/25 following her interaction with FM C on 11/17/25.Review of a Provider Note dated 11/18/25 at 8:00 AM revealed, Follow up after ED visit. Pt (patient) states that she is having sciatica pain on her right side.Sciatica, right side: Started a week ago, is not improving. Started on gabapentin (analgesic medication).Review of R6's Electronic Medical Record revealed no documentation that a comprehensive physical assessment was completed following R6's change of condition: documented change in functional ability (required the use of a sit to stand), the new onset right sciatic pain (11/16/25), newly identified injury (11/17/25 by LPN F), or the need for an additional pain medication (gabapentin).Review of R6's Nurses Note dated 11/18/2025 at 6:05 PM revealed, Resident reported to the nurse on 11/18/2025 at 5:55pm that she had a fall on 11/14/2025. When asked what time this occurred she could not give a specific time, just that it happened sometime between lunch and dinner. Resident stated that she was standing at the bathroom bar when she fell to her right side and landed in the shower stall. When asked how or who got her up off the floor she stated that a (name omitted) lifted her back into her wheelchair. Upon assessment of the resident it was noted that there was a hematoma to residents lower back with a bruise that surrounded it and continued down the right thigh. The area around the bruise shows signs of healing with yellow and green areas. No other skin issues noted or observed. VSS (vital signs stable). No c/o (complaints of) pain and or discomfort from baseline complaints. (R6 had experienced a change in pain documented on 11/16/25 and a pain medication was ordered that morning.)Review of R6's Nurses Note dated 11/19/2025 at 07:00 AM revealed, Upon assessment of residents lower back, there is a bruise that is located along the lower back and down the right thigh. It has spread from a site of a hematoma that can be felt under the skin. Around the edges of the bruise it has already started to heal and shows signs of being yellow/green in color. When asked where this bruise came from resident states it is from a previous fall. When asked if this resident has any pain resident states no. Upon palpitation of bruised area resident shows no s/s of pain and/or discomfort.Review of R6's Incident Report for a fall on 11/14/25 at 3:00 PM revealed the Nursing Home Administrator (NHA), Director of Nursing (DON), and Physician were notified of the fall on 11/18/25 at approximately 6:00 PM.Review of R6's Task Documentation revealed R6 received care from CNAs multiple times throughout each day with toileting, personal hygiene, and dressing which would have exposed the skin on R6's lower body. Additionally, R6 received a shower on 11/16/25 which would have exposed the entirety of her skin in a well-lit area.Review of R6's Electronic Medical Record revealed no documentation that the facility CNAs notified a licensed nurse or management of the significant bruising on R6's right hip. There was no documentation that a licensed nurse documented an assessment of the injury or notified the provider or management.Review of R6's Care Plan dated 11/7/25 revealed, (R6) is occasionally incontinent of Bladder. There were no entries/focus areas that R6 experienced bowel incontinence indicating that was not an active problem.Review of R6's Urinary Continence documentation completed on each shift (3 times a day) revealed:From 10/30/25 through 11/13/25 there were 13 entries of incontinence out of a total of 45 entries.From 11/14/25 through 11/19/25 there were 14 entries of incontinence out of a total of 16 entries. R6 was only continent of bladder for 1 shift on 11/14/25 and 11/17/25.Review of R6's Bowel Continence documentation completed on each shift revealed:From 10/30/25 through 11/13/25 no documentation of bowel incontinence out of 7 entries.From 11/14/25 through 11/19/25 there were 4 entries of bowel incontinence out of a total of 6 entries.Review of R6's Electronic Medical Record revealed no documentation that the CNAs or licensed nurses identified a significant change in R6's bowel and bladder continence or that the provider or management were notified of the change.Review of R6's Functional Status for personal hygiene and toileting hygiene on 11/19/25 revealed she was dependent on staff (she had previously been documented as Substantial/maximal assistance).Review of R6's Laboratory Reports revealed the following hemoglobin (hgb) levels (red blood cells):On 10/30/25 her hgb was 11.8On 11/7/25 her hgb was 11.5On 11/11/25 her hgb was 11.9On 11/15/25 her hgb was 10.1On 11/19/25 her hgb was 9.3Signifying a downward trend of her hemoglobin.R6 was transferred to the local hospital on [DATE] at 10:32 AM.Review of R6's Hospital Note dated 11/19/2025 at 10:58 AM revealed, We did observe a large area of ecchymosis to the right low back and flank area. EMS (Emergency Medical Services) denied any history of injury, trauma, or fall. When husband arrived he did report that there was a fall that occurred on Saturday, the 15th. The patient was seen in the emergency room on the 15th but it does not appear it was for a fall.Hemoglobin is 9.3 today, this is trending down from previous lab work. CT of the chest, abdomen, and pelvis along with the spine showed a mildly displaced oblique fracture through the anterior lateral left 5th rib. There is also comminuted displaced fractures through the inferior left pubic ramus and nondisplaced fracture of the superior left ramus near the acetabulum. There also comminuted mildly displaced fracture through both the right and left sacral ala with significant subluxation of the S1 segment on S2. There is also hematoma in the subcutaneous fat above the right buttock with no evidence of active bleeding. I did call and speak with the radiologist in regards to these findings. He was able to compare this to a CT of the left lower extremity that was done on the 24th. He felt that the fractures that appeared today were new and worse compared to previous imaging.The patient will be transferred by EMS to (name omitted) ER for further workup and management.Review of R6's Hospital Note dated 11/19/2025 beginning at 7:12 PM revealed:TRAUMA CONSULT Patient is a [AGE] year-old female who presents with a chief complaint of altered mental status, seizure, fall, pelvic fractures. She has a transfer from outside hospital. She was admitted to a rehab/nursing facility following a fall multiple weeks ago. Reportedly had a fall on Friday, uncertain circumstances. Transferred for further evaluation by Trauma.Patient was sent to (facility), where she experienced another fall this past Friday but was not reported and she was not seen for. At this time she gained a large hematoma on her right buttock.Patient currently denies any pain while stationary, but husband states that prior to admission she was unable to even sit in a wheelchair due to the pain.According to her husband she fell on 11/14, where she developed right buttock bruising but did not hit her head or lose consciousness and was not seen in the ED due to the fall being unreported by the rehab facility. Her buttock hematoma is likely at least as old as her most recent fall 11/14 .slight hemoglobin drift noted and consistent with the size/chronicity of the hematoma .A hematoma is present in the subcutaneous fat above the right buttock. This measures 7.3 x 4 x 6.3 cm .(Downward trend of R6's hemoglobin was not identified by the facility.)OTHOPEDIC TRAUMA CONSULTATION75 y.o. female who sustained an unstable U-type sacral fracture with spinopelvic dissociation and left superior/inferior ramus fracture after sustaining multiple recent falls. She has a history of Parkinson's and lives with her husband at home. She had cauda equina on presentation with no rectal tone and overflow incontinence.(Cauda equina syndrome is a serious medical condition caused by compression of the lower end of the spinal cord. Presents with low back pain, sciatica, sensorimotor deficits, and bowel and bladder dysfunction. cauda equina syndrome would elucidate the new sciatica, new bowel incontinence, and increased bladder incontinence that began on 11/14/25).decided that lumbopelvic fixation in addition to iliosacral or trans-iliac trans-sacral screws at S1 would provide her with the best stability.SPINE SURGERY CONSULTATIONBilateral Comminuted sacral injuries with anterior subluxation S1 on S2. Left-sided L3, L4, and likely bilateral L5 transverse process fractures.Comminuted displaced bilateral sacral alar fractures with anterior subluxation of S1 on S2Left L3, L4 and L5 TP fractureSpinal-pelvic dissociationPatient admits unable to urinateNo rectal toneLeft superior/inferior pubic ramus fracture.Right buttock subcutaneous hematoma without active extravasation.OPERATIVE NOTEShe underwent spinopelvic fixation with L4-S1 posterior spinal fusion and S1-2 laminectomy on 11/20.Orthopedics completed a transiliac transsacral screw fixation and spinal fusion of L4-5 and S1-2 laminectomy on 11/20 and she remained in the hospital. She received 2 unit of blood after the OR (operating room).During an interview on 02/04/2026 at 1:18 PM, the NHA confirmed the facility staff had not reported R6's injury following facility policy. The NHA reported an investigation into the injury was initiated on 11/18/25 when the management team was made aware but the root cause of the injury was difficult to determine based on the information provided by R6 and the lack of witnesses. The NHA reported that CNA G was disciplined for using a mechanical lift alone to toilet R6. The NHA reported staff were not to use mechanical lifts alone as it was difficult to maneuver the lifts in the bathrooms. The NHA confirmed that the facility staff should have identified the injury while performing daily cares for R6 and the expectation was for facility staff to report any injuries, falls, or allegations of a fall.During an interview on 02/04/2026 at 3:52 PM, a timeline of R6's injury/fall, beginning on 11/14/25 until her hospitalization on 11/19/25, was reviewed with the NHA. At 4:06 PM, The NHA confirmed there was a lack of documentation and follow-up following R6's alleged fall from 11/14/25 and the management team had not been notified of the alleged fall and injury until 11/18/25. The NHA reported that the expectation was for facility staff to immediately report an actual and/or allegation of a fall and any new injuries.A picture of R6's injury was reviewed with the NHA, and she confirmed that staff would have seen the bruise during ADL care based on the size and extent of the injury and management should have been notified.The NHA confirmed that a copy of the hospital records from 11/15/25 were not scanned into R6's Electronic Medical Record and reported that the ER providers allegation of a fall on 11/14/25 would have been followed up with had facility staff obtained the complete medical record and not just the After Visit Summary. The NHA reported that the expectation for the Unit Managers was to obtain pertinent records for residents following hospitalizations to ensure laboratory and diagnostic reports were reviewed and ensure that provider recommendations and changes in treatment plans were identified and completed. Cauda equina syndrome (CES) is a rare but life-altering disease resulting from compression of the nerve roots at the spinal cord's terminus. CES typically presents with low back pain, sciatica, sensorimotor deficits, and bowel and bladder dysfunction. Owing to its rarity, the condition is often missed, leading to significant morbidity and potential legal implications for physicians.The literature reveals variability in the reported prevalence of CES, with incidence rates ranging from 0.34 to 7 per 100,000 individuals annually. The timing of decompression remains debated. Some studies report no significant difference in outcomes between decompression within 24 hours vs. 48 hours, while others emphasize the importance of immediate intervention. Legal cases related to CES frequently involve delayed diagnosis, with significant ramifications for physicians.Surgical decompression remains the definitive treatment of CES, though the timing of surgery requires careful consideration to balance the urgency of intervention with the risks of complications. Further research is needed to explore strategies that would allow for improvement in identifying and treating patients with CES in a timely manner. Karikaran A, [NAME] AH, [NAME] L, [NAME] N, [NAME] CP, Puvanesarajah V, [NAME] A. Cauda Equina Syndrome: A Review of Classification, Diagnosis, Treatment, and Best Practices. JBJS Rev. 2025 [DATE];13(2). doi: 10.2106/JBJS.RVW.24.00156. PMID: 39937930.Review of the facility policy Fall Management last revised 7/8/25 revealed, The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls.Practice Guidelines: 4. The licensed nurse will complete: Incident/Accident Report.Document in the medical record and on the 24 Hour Report/ dashboard.The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record.The nurse will communicate via the 24-hour report /dashboard to the interdisciplinary team of the resident fall .Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A comprehensive assessment offers direction for health promotion recommendations and planning and implementing any acutely needed interventions. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are accountable to report any significant changes in your patient's condition in a timely manner to the health care provider and to document these changes in the patient's electronic health record (EHR). Timely and truthful documentation is important to provide communication necessary among health care team members. Documentation must be accurate. In the EHR, ensure that assessments are complete and consistent with those completed previously. Ensure that you conduct your own assessment rather than copying the previous assessment in the patient's medical record to ensure accuracy of information.Notify other team members in a timely manner when changes in condition are triggered within the record. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, starting at 7:15 AM on [DATE], an interview with Certified Dietary Manager (CDM) X, found that most food items are held for three days. An observation of the two door Victory refrigeration unit, at 7:25 AM on [DATE], found a bag of sliced turkey dated ,d+[DATE] to ,d+[DATE]. During a tour of the Masterside Kitchenette, starting at 8:24 AM on [DATE], an interview with CDM X found that dietary comes and checks the refrigeration unit daily for restock and housekeeping cleans the refrigeration unit. Further observation inside of the unit found 10 expired yogurts with best by dates of [DATE]th, [DATE]th, and [DATE]th. Observation of the J Wing Kitchenette, at 8:34 AM on [DATE], found 12 nutritional juice drinks and shakes stored in the unit with no date to indicate when to discard the product. Review of the products manufacture label states the items are good for 14 days upon thaw. When asked if she would know when they were thawed, CDM X was unsure, stating that most of the time they have a name and date and should be used for a snack at night. Further observation of the unit found two expired yogurts with best by dates of [DATE]th. According to the 2022 FDA Food Code section ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During an interview with CDM X, at 7:36 AM on [DATE], it was observed that the inside mechanism for creating ice was found to have hoses and surfaces with black accumulation. When asked who cleans the machine, CDM X stated staff clean the outside and we have vendor that deep cleans the inside. When asked when the last time the vendor was onsite, CDM X was unsure. During a tour of the clean utensils' drawers, at 7:48 AM on [DATE], two mechanical scoops were found stored with an accumulation of dried on food debris inside the scoop and behind the scoop arm. During a tour of the kitchen, at 8:03 AM on [DATE], it was observed that the inside top of the microwave was found with an accumulation of dried food debris. According to the 2022 FDA Food Code section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial tour of the kitchen, at 7:44 AM on [DATE], it was observed that a disposable Styrofoam coffee cup was stored in a large container of powdered milk. The cup was found with no handle and covered in powdered milk dust. During the initial tour of the kitchen, at 7:46 AM on [DATE], it was observed that five spatulas stored hanging over the preparation table, were found to be chipped and torn with missing pieces off the edge of the utensils. When asked if these spatulas were still used, CDM X stated yes. According to the 2022 FDA Food Code section ,d+[DATE].12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; . According to the 2022 FDA Food Code section ,d+[DATE].11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During a tour of the facility, at 8:25 AM on [DATE], it was observed that the ice chest cooler, near the Masterside Kitchenette, was found with a visible accumulation of water, with no means for the water to self-drain and not accumulate among the ice. When asked about how the facility takes care of the ice coolers, CDM X stated they get cleaned daily. During a tour of the J Wing Kitchenette, at 8:33 AM on [DATE], it was observed that the ice chest cooler was found with an accumulation of water in the ice chest, with no means the water to self-drain and not accumulation among the ice. According to the 2022 FDA Food Code section ,d+[DATE].12 Storage or Display of Food in Contact with Water or Ice.(B) Except as specified in (C) and (D) of this section, unPACKAGED FOOD may not be stored in direct contact with undrained ice .

Based on interview and record review, the facility failed to 1.) accurately document the administration of controlled medications and 2.) ensure controlled medications were administered following the providers order for 4 of 7 residents (Resident #75, #78, #62, and #80), reviewed for controlled medication administration. Findings: Resident #75 (R75) Review of an Admission Record revealed R75 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R75's Order Summary dated 8/9/24 revealed, Temazepam Oral Capsule 15 MG (Temazepam) *Controlled Drug* Give 1 capsule by mouth at bedtime for Severe Manic Bipolar 1 Disorder with Psychotic Behavior. Review of R75's Controlled Substances Proof of Use form revealed the temazepam was not documented as dispensed on 4/5/25. Review of R75's Medication Administration Record revealed the temazepam was documented as administered. Review of R75's Order Summary dated 2/9/25-2/12/25 revealed, LORazepam (Ativan) Oral Tablet 1 MG (Lorazepam) *Controlled Drug* Give 1 mg by mouth every 6 hours as needed for Anxiety and agitation for 3 Days. Review of R75's Controlled Substances Proof of Use form revealed: *On 2/8/25 at 8:00 PM a dose of Ativan was dispensed (prior to the start date of the Ativan). *On 4/6/25 at 7:53 PM a dose of Ativan was dispensed (without an active order for the Ativan.) Review of R75's Medication Administration Record revealed no documentation that the Ativan was administered. Review of R75's Electronic Medical Record revealed no documentation for the administration of the Ativan or a physicians one time order for the Ativan. Resident #78 (R78) Review of an Admission Record revealed R78 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R78's Order Summary revealed LORazepam Oral Tablet 0.5 MG (Ativan) Give 1 tablet by mouth every 04 hours as needed for Agitation for the following dates: *1/19/25-2/2/25 *2/13/25-2/14/25 *2/14/25-2/28/25 Review of R78's Controlled Substances Proof of Use form revealed: *On 2/9/25 at 7:00 AM a dose of Ativan was dispensed (without an active order for the Ativan.) *On 2/9/25 at 8:30 PM a dose of Ativan was dispensed (without an active order for the Ativan.) *On 2/13/25 at 8:00 PM a dose of Ativan was dispensed. *On an illegible date (later confirmed by Nursing Home Administrator [NHA] and Director of Nursing [DON] as 2/14/25 at 4:00 AM) a dose of Ativan was dispensed. Review of R78's Medication Administration Record revealed no documentation that the Ativan was administered. Review of R78's Electronic Medical Record revealed no documentation for the administration of the Ativan on 2/9/25 or a physicians one time order for the Ativan. Resident #62 (R62) Review of an Admission Record revealed R62 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R62's Order Summary dated 9/17/25 revealed, HYDROcodone-Acetaminophen (Norco) Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for Mild Pain. Review of R62's Controlled Substances Proof of Use form revealed: *On 3/6/25 at 8:00 PM a dose of Norco was dispensed. *On 3/30/25 at 1:29 PM a dose of Norco was dispensed. Review of R62's Medication Administration Record revealed no documentation that the Norco was administered on 3/6/25 at 8:00 PM or on /30/25 at 1:29 PM. (Documentation that as needed medication is administered is necessary to ensure the ongoing need for the medication and adequate control of symptoms). Resident #80 (R80) Review of an Admission Record revealed R80 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R80's Order Summary dated 3/25/25-3/26/25 and 3/26/25 revealed, LORazepam (Ativan) Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 0.5 mg orally every 4 hours as needed for anxiety/excessive crying . Review of R80's Controlled Substances Proof of Use form revealed: *On 3/26/25 at 9:45 AM a dose of Ativan was dispensed. *On 3/26/25 at 10:00 PM a dose of Ativan was dispensed. *On 3/31/25 at 9:00 PM a dose of Ativan was dispensed. Review of R80's Medication Administration Record revealed no documentation that the Ativan was administered on 3/26/25 at 9:45 AM, on 3/26/25 at 10:00 PM, or on 3/31/25 at 9:00 PM. During an interview on 4/09/25 at 02:56 PM, DON and NHA confirmed the medication errors (medications administered without an order) for R75 and R78 as well as the documentation errors for R75, R78, R62, and R80. DON and NHA reported that nurses should be administering medications with a physician's order and should be documenting the administration of medications. DON and NHA reported the licensed nurses that made medication administration errors would be receiving 1:1 education as well as all licensed nursing staff. Review of the facility policy Medication Administration last revised 10/17/23 revealed, .Physician's Orders - Medications are administered in accordance with written orders of the attending physician .1. Verify the medication label against the medication administration record for resident name, time, drug, dose, and route .2. Record the result of medications administered as necessary .Record the dose, route, and time of medication on the Medication/Treatment Administration Record. Document if the resident refused.

This citation had two deficient practice statements. DPS A Based on observation and record review, the facility failed to ensure call lights were within reach for 4 of 6 residents (Resident #18, Resident #31, Resident #36, Resident #63) reviewed for accommodation of needs. Findings: Resident #18 (R18) Review of an Admission Record revealed R18 was a [AGE] year old male with pertinent diagnoses of severe intellectual disabilities, seizure disorder, unsteadiness on feet, expressive language disorder, and muscle weakness. During an observation on 04/08/25 at 6:38 AM, R18 laid in bed resting with his eyes closed and the call light touch pad sat on the floor near the foot of the bed out of sight and out of reach of R18. Review of a fall prevention and safety Care Plan for R18 reflected the following intervention .provide R18 with a touch pad call light to assist in calling for staff assistance. Resident #31 (R31) Review of an Admission Record revealed R31 was an [AGE] year old male with pertinent diagnoses of Alzheimer's and right sided weakness, impaired vision, and the inability to speak (aphasia) following a stroke. During an observation on 04/08/25 at 6:54 AM, R31 laid in bed resting with his eyes closed and the call light laid on the floor between the wall and the bed, near the foot of the bed out of sight and out of reach of the resident. During an observation on 04/08/25 at 9:44 AM, R31 sat in a wheelchair bedside in his room and the call light hung clipped near the over bed light, out of reach of the resident. Review of a fall and safety Care Plan for R31 reflected the following intervention .put the call light within reach and encourage him to use it for assistance as needed. Resident #36 (R36) Review of an Admission Record revealed R36 was a [AGE] year old male with pertinent diagnoses of a stroke that caused difficulty speaking and right sided weakness. During an observation on 04/08/25 at 6:32 AM, R36 laid in bed resting with his eyes closed. The call light touch pad hung off the foot of the bed between the mattress and the footboard, out of sight and out of reach of the resident. During an observation on 04/08/25 at 8:49 AM, R36 laid in bed resting with his eyes closed. The door to his room was closed and the call light touch pad hung off the foot of the bed between the mattress and the footboard out of sight and out of reach of the resident. During an observation on 04/08/25 at 9:47 AM, R36 laid in bed resting with his eyes closed. The call light hung off the foot of the bed between the mattress and the footboard, out of sight and out of reach of R36. Review of a fall and safety Care Plan for R36 reflected the following intervention .keep (R36s) environment as safe as possible with the call light within reach .and put the call light within reach and encourage him to use it for assistance as needed. Resident #63 (R63) Review of an Admission Record revealed R63 was a [AGE] year old male with pertinent diagnoses of aphasia and muscle weakness following a stroke and dementia. Review of the facility policy Call Lights reflected .when a resident is in bed or confined to a chair ensure the call light is within reach of the resident. During an observation on 04/08/25 at 6:57 AM, R63 laid in bed resting with his eyes closed and the call light touch pad sat on at chair at the foot of the bed on top of two pillows, out of sight and out of reach of the resident. Review of a safety and fall Care Plan for R63 reflected the following intervention .put the call light within reach and encourage him to use it. 37573 DPS B Based on observation, interview and record review, the facility failed to assist in accommodating Durable Medical Equipment (DME) for one resident (R48) of one resident reviewed for DME to assist with an appropriate and comfortable fitting wheelchair that will accommodate his needs. Findings include: Review of a Face Sheet revealed R48 originally admitted to the facility on [DATE] with pertinent diagnoses of communicating hydrocephalus (excessive accumulation of cerebrospinal fluid (CSF) within your brain ventricles), hemiplegia and hemiparesis (one sided weakness), abnormal posture, stiffness of left hip, stiffness of left knee, contracture of right and left ankle. Review of the Minimum Data Set (MDS) dated [DATE] revealed R48 is cognitively intact and has limited range of motion (LROM) on one side of his upper and lower extremity. R48 requires a wheelchair for mobility and is dependent on staff for transfers. Review of an email correspondence dated from the Ombudsman (OB) Y dated 4/4/25 revealed concerns of R48 not receiving a proper DME assessment and consideration for an appropriate fitting wheelchair. Several attempts were made to assist in guiding the facility to get insurance to pay for it and the facility neglected to submit the paperwork in time. The resident (R48) wants to have an electric wheelchair, and the Medical Supply Providers are trained to fit residents for all types of DME which includes wheelchairs. The facility expressed concerns of safety for R48 in an electric wheelchair, but the Medical Supply Provider can equip the wheelchair with sensors and mirrors among other things to keep R48 comfortable, safe, and functional. The Ombudsman had talked with the Administration in the past advocating for R48 to be assessed for an appropriate fitting wheelchair and did not understand why the facility was not following through and doing what they need to do. The family had reached out to the Ombudsman several times with their concerns that the facility not addressing their needs. They have tried several different wheelchairs, but they were not a personalized approach to specifically fit R48's needs. The Ombudsman also stated that the DME Policy Specialist was also involved with assisting the facility getting insurance approved for an appropriate fitting wheelchair too. They have had several care conferences to explain the processes and the facility has failed to follow through. Review of an Email Correspondence between the Ombudsman and the Facility Social Worker on 1/7/25 revealed: Social Worker: We still have ongoing issues with the family of R48 complaining about wheelchairs again. They do not have an understanding of why we cannot order him a chair while he is in the facility. Insurance will not pay for a wheelchair while he is in facility. He has been assessed over and over and has changed wheelchairs several times. When he got his current chair, he liked it and would propel himself up and down the halls independently. We are reassessing him for a RoHo as he used to have one. Ombudsman response: Insurance actually will pay. I am happy to involve [DME Policy Specialist] again, if needed. The issue last time is that the paperwork was submitted late by the facility, and it must be submitted within the window given by Medicaid. Review of an Email Correspondence dated 2/28/25 revealed the Facility Social Worker had reached out to the Ombudsman regarding insurance coverage for wheelchairs (No resident was mentioned) and the Ombudsman responded with attachments which included power points, fact sheets and an application with instructions for an Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices. Review of an Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices- Completion Instructions revealed: This form should be completed for NEW or REPLACEMENT mobility device(s) and seating systems. It must be submitted with the Complex Seating and Mobility Device Prior Approval - Request/Authorization (MSA-1653-D). The evaluation and justification must be submitted within 90 days of the date the evaluation was completed. During an observation and an interview on 4/8/25 at 9:00 AM, R48 is in the dining room sitting in a soft back wheelchair with no head support. He is sitting upright at the table waiting for his breakfast with his mother who is also his Guardian. They reported they are not happy and have filed several grievances with the facility that are not being addressed and do not communicate with her. One concern was regarding a wheelchair that would fit R48 appropriately. R48 cannot sit in a regular wheelchair for long periods of time because of his pressure points and contractures. He does have painful bladder spasms that interfere with his movements. There is no cushion that is comfortable for him, and he needs a headrest to hold up/support his head. When R48 is leaning back in his wheelchair that tilts back, he is unable to hold his head up. He reported he is in pain all the time and said his pain is in his shoulder and his left hip mostly, but he has overall generalized pain. R48 wants an electric wheelchair, and the facility refuses to let him have one. The wheelchairs he has tried do not fit him appropriately and are uncomfortable. He can only be up so long in his current wheelchair before he lays down in bed to relieve the pressure in his body and his neck. In an interview on 4/9/25 at 1:53 PM, Occupational Therapist (OT)/Manager Z reported R48 was assessed for a high-backed wheelchair with no headrest due to the potential of losing his neck control. OT Z reported R48 can recline in his wheelchair but reiterated there is no headrest. OT Z reported the electric wheelchair is not good for R48 because he cannot turn his head and encourages him to use his neck muscles (even though he is contracted). He has had several wheelchairs in the past that did not work for him because he would either slide out of them or they were uncomfortable. His current wheelchair now is a High Back 22 and does not have a headrest. When asked if there was a way to get a head rest, OT Z reported there is one in the closet in the therapy room. When asked if she, having no contractures, would be comfortable in a recliner holding her head up without support after a while, she agreed she would not be comfortable. OT Z pulled out the head rest for R48's wheelchair that presented as a sling type device that slides on to the back of R48's wheelchair. OT Z reported they have not tried it before but will try it on his wheelchair today. OT Z then reported that the facility does not always have the resources for needed equipment and has discussed R48's wheelchair concerns in the Interdisciplinary (IDT) meetings and said, if they give the family what they want, they always want more. In an interview on 4/9/25 at 2:42 PM, the Director of Nursing (DON) reported she has had conversations about a head rest for R48 with his Guardian about a month ago, but not with R48 himself. The DON reported therapy saw R48 in the past and only knows what therapy had reported and is recommending. They are trying to help R48 keep good muscle and truck control so he can keep being as independent as possible. During an observation and an interview on 4/9/25 at 3:30 PM, R48 was lying in bed and reported he likes being in his wheelchair as long as he can but needs something to take the edge off his tailbone. When he reclines his chair to relieve the pressure from his tailbone, he must hold up his neck with no support and reported it is hard to do. In an interview on 4/10/25 at 9:44 AM, Social Worker (SW) U reported she is aware of the grievances from R48 and his mother (Guardian). R48 is young and has unrealistic expectations for endless therapy. R48 is not safe for a power wheelchair because of his left sided deficit. The therapy department did assessments for R48 to evaluate him for safety and said he is not safe in an electric wheelchair. The family is upset and now they want to go someplace else for care. When asked about R48's wheelchair not having any head support especially when he is reclined back, SW U reported he does look uncomfortable and then said he needs a specialty wheelchair. SW U then reported she thinks there is a way to get him approved for a new fitted wheelchair and said she reached out to the Ombudsman back in January. SW U then pulled up her emails to show she did reach out to the Ombudsman who replied to her on how to proceed but SW U had more questions and reported the Ombudsman never replied to the follow up email. When asked why she didn't follow up with it, she reported she will reply now at this time. During an observation and an interview on 4/10/25 at 10:47 AM, R48 was observed in the dining room with his sling headrest attached to his wheelchair. His head is contracted forward and does not touch the headrest. R48 reported he needs something between his head and the headrest so his neck and head would be supported. Review of a Grievance Form dated 2/24/25 for R48 revealed: INFORMATION ABOUT YOUR CONCERN: Getting (R48) a wheelchair that he can sit in without being in so much pain. Pressure point relief chair. (sic) Who else know about the problem or incident? The whole staff. Then the concern proceeded to explain how R48 was in so much pain, and this has been an ongoing problem for 3 years. The facility responded on 3/12/25 with Resident was provided with a high back, tilting wheelchair with a roho (pressure relieving device) cushion on 2/10/25 (before this complaint). ACTION TO BE TAKEN: Staff education on inflating ROHO cushion as needed. Resident continues to work with therapy for positioning and various other things to help relieve pressure. R48's Guardian marked the box at the end of this grievance I am not satisfied with the response to my request for assistance. I request that the administrator review my complaint and provide me with a response. No follow up response from the NHA is documented on the grievance form. Review of a Grievance From dated 3/12/25 for R48 revealed: INFORMATION ABOUT YOUR CONCERN: (R48) needs a headrest on his wheelchair to be able to lay back and rest his tail bone. (Staff name) says she wants him to hold his head up. The wheelchair still doesn't fit him right. He needs to be able to adjust himself, not have to wait until someone comes to help him. When did this problem or incident occur? Every day when he's up and laying back in his chair. Is this an ongoing problem? Yes, for 3 years. Have you contacted us in the past about this issue? Yes, All of the staff. Facility Response: Resident evaluated by Therapy for a headrest. Therapy not currently recommending a headrest because it will negatively affect what muscle tone resident has. Action to be Taken: Therapy will follow up and re-evaluate as needed. Documents signed by the Guardian on 3/31/25 that she is not satisfied with the outcome and requested the Administrator to review her complaint and provide a response. No follow up response from the NHA is documented on the grievance. In an interview on 4/10/25 at 11:35 AM, the Nursing Home Administrator (NHA) reported they are now setting up a care conference with the Ombudsman and the DME Policy Professional for R48 regarding his wheelchair needs. The NHA confirmed the family really wants him to have a power wheelchair, but he cannot be safe in the building with one. R48 has had several wheelchairs since he has been at the facility. One wheelchair hurt his buttocks too much, so they got him a high back wheelchair that tips back to relieve pressure, but he could not self-propel when it is tipped back. R48 wants to propel himself but he has pain sitting in the upright position. The NHA reported she is not sure what kind of wheelchair will help him. The NHA reported the Medical Supply Company did fit him for wheelchair but R48 needs to be at his maximum function before he can be fitted for one so they can establish a baseline. When asked when the last time the Medical Supply Company came in to assess R48, the NHA did not have an answer. When the NHA was asked to explain the process for getting an appropriate fitting wheelchair, the NHA reported that once the original paperwork is sent to the DME Provider, they assess the resident and try to build a potential wheelchair to see how the resident can fit in it and adjust accordingly. A timeline was requested for the efforts by the facility to find an appropriate wheelchair to accommodate R48's needs. No assessments provided to show the Medical Supply Company came out to assess the residents' special needs for an appropriate fitting wheelchair and no documentation provided to show the facility tried to submit the appropriate paperwork needed to the insurance provider by the end of this survey.

Based on observation, interview, and record review, the facility failed to safely transport residents in wheelchairs for 6 residents (Resident #50, #43, #31, #1, #7, and #37) out of 6 residents reviewed for accidents and hazards. Findings: Resident # 50 (R50) Review of an Admission Record revealed R50 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease, unsteadiness on feet, history of falling, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for R50, with a reference date of 2/3/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R50 was severely cognitively impaired. During an observation on 04/09/25 at 09:04 AM, Certified Nursing Assistant (CNA)F pushed R50 in a wheelchair without footrests from the dining room to the nurses station on the 500 hall. At 09:06 AM, CNA F pushed R50 in a wheelchair without footrests from the nurses station down the hall to her room. During an observation on 04/09/25 at 1:43 PM, CNA F pushed R50 in a wheelchair without footrests from the nurses station to the middle of the 500 hall. During an interview on 04/09/25 at 1:50 PM, Licensed Practical Nurse (LPN H) stated that for safety reasons, residents must have their feet securely on footrests when being pushed by staff. Resident #43 (R43) Review of an Admission Record revealed R43 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease, unsteadiness on feet, history of falling, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for R43, with a reference date of 1/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated R43 was severely cognitively impaired. During an observation on 04/09/25 at 08:53 AM, Activities Aide (AA) L pushed R43 in a wheelchair without her feet on footrests with her left foot dragging on the ground from the nurses' station to the activities/dining room. R43 was wearing grip socks. Resident #31 (R31) Review of an Admission Record revealed R31 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease and muscle weakness. Review of a Minimum Data Set (MDS) assessment for R31, with a reference date of 3/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated R31 was severely cognitively impaired. During an observation on 04/09/25 at 09:15 AM, CNA N pushed R31 in a wheelchair without his feet on footrests from the main dining room to nurses station. R31 was wearing tennis shoes, and his feet were dragging on the floor. CNA N put his feet up on the footrests when his tennis shoes prevented her from pushing him further in the wheelchair. 37577 Resident #1 (R1) Review of an Admission Record revealed R1 was a [AGE] year old male with pertinent diagnoses of left sided weakness following a stroke, seizure disorder, and mood fluctuations related to a traumatic brain injury. During an observation on 04/09/25 at 1:36 PM, Certified Nurse Aide (CNA) F pushed R1 in a wheelchair without footrests from his doorway to the 400 hall spa room. Resident #7(R7) Review of an Admission Record revealed R7 was an [AGE] year old female with pertinent diagnoses of dementia, restlessness and agitation, and anxiety disorder. During an observation on 04/08/25 at 8:59 AM, CNA D pushed R7 in a wheelchair without footrests from the nurses station to the resident's room on the 500 hall. Resident #37 (R37) Review of an Admission Record revealed R37 was a [AGE] year old female with pertinent diagnoses of dementia and epilepsy. During an observation on 04/08/25 at 12:22 PM, employee E pushed R37 in a wheelchair without any footrests from the nurses station to the resident's room at the end of the 400 hall.

Based on observation, interview, and record review, the facility failed to respond to grievance issues raised by the Resident Council resulting in an ineffective forum for the presentation of grievances and recommendations to the facility affecting all facility residents. Findings: On 4/8/25 at 9:59 AM an interview was conducted with R60 who reported she was the Resident Council President. R60 reported two main issues are regularly raised by the Resident Council at monthly meetings. R60 reported one issue is delayed call light response. R60 also reported that call lights are often turned off and staff leave the room without meeting the resident's needs but claiming they will return shortly. R60 reported staff frequently fail to return to the resident's room after turning off a call light and indicated the Resident Council attendees have expressed frustration over this. The second issue is that meals are not served on time and that the Dining Room would be filled with residents waiting for long periods of time for food to be served. R60 reported the facility will say they will investigate these concerns but that the group is never given a follow up report on the issues. R60 reported that, consequently, these two issues are recurring topics at Resident Council meetings. On 4/9/25 at 1:40 PM an interview was conducted with Activities Director (AD) L who reported she acted as the facilitator for monthly Resident Council meetings. AD L reported that during the Resident Council meeting all departments were reviewed. AD L reported she documents the issues discussed and if there are any concerns a Concern Form is generated on the spot for the given issue. AD L reported the concerns are addressed with the appropriate departments and the response is reviewed at the next Resident Council meeting. AD L was asked to provide the Resident Council documentation for the previous six months. AD L reported she will provide the documentation and include any Concern Forms generated. The monthly Guest/Resident Council minutes for October 2024 through March 2025 were reviewed. The review did not reveal any documentation of resident concerns of delayed assistance requests or slow meal services. Review of generated Concern Forms revealed one resident had raised an individual concern of room cleanliness in February 2025 and this issue was revisited in March 2025. The documentation of the other four months reflected We didn't have any concerns from last council or this council. All Guest/ Resident Council minutes provided reflected a signature of the Nursing Home Administrator (NHA) indicating the minutes had been reviewed by the NHA. On 4/10/25 at 9:45 AM a Resident Council meeting was convened in the Dining Room. Members of the confidential group reported that call light timeliness is an ongoing issue. Members reported that staff will come into the room, turn off the light, and don't come back. One member reported she gets frustrated when you need a diaper, or you need to go to the bathroom, and you just sit there. The confidential group agreed that mornings are the worst time of the day to need assistance because of the slow response stating, we wait a lot. One member stated that she has not complained directly to staff and did not want her name mentioned because the staff might take it offensively. The confidential group also reported it is generally believed that residents must be in the Dining Room early especially for breakfast but end up waiting an hour to an hour and a half before the meal is served. One member stated that the long wait cuts into my personal time. The members of the confidential group also reported that when food starts to come out of the kitchen not everyone at a table will be served at the same time. The members reported that residents at the same table will finish their meal and leave the dining room before other residents, that have waited for an hour or more, have not been served. Another resident reported sometimes breakfast isn't served until almost 9;00 AM and that lunch follows soon after indicating a short time span between meals. The confidential group reported that AD L does take notes but that concerns raised at previous Resident Council meetings are not rehashed. The members reported that the group is not informed of any actions taken to address their concerns. Summary timeline of observations of morning meal Dining Service on 4/8/25 in the [NAME] Dining Room: 7:37 AM - 13 residents present. No staff present. Some residents have beverages. 7:55 AM -17 residents present. No staff in room. Some residents getting beverages for other residents from a cart. 8:04 AM- 20 residents present. Staff bringing residents in by wheelchair then leave after positioning the residents at tables. One staff member dispensing silverware. 8:27 AM- 28 residents in Dining Room. No meal has been served. 8:37 AM - First meal out of kitchen. 8:50 AM- 6 tables of 11 tables have been served. Two staff passing meals. One staff member taking orders for the noon meal. 9:00 AM - Last resident served meal. This resident was one of the 13 residents present in the room when the initial observation was documented at 7:37 AM. On 4/10/25 at 12:04 PM an interview was conducted with the NHA. The NHA was informed of the issues raised by the confidential group and that the group reported facility was not responding to their concerns. The NHA indicated she was not aware of the Resident Council's concerns. As of survey exit no further information was provided.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments in 1 (R23) of 18 residents reviewed for accuracy of MDS assessment, from a total sample of 18. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, October 2024, Chapter 3 Section O: Special Treatments, Procedures and Programs, revealed .The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods .The treatments, procedures, and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life .Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs . J1. Dialysis, J2. Hemodialysis, J3. Peritoneal dialysis Review of the Facility Matrix provided at the beginning of this survey revealed R23 receives hemodialysis. In an interview on 4/8/29 at 11:40 AM, R23 reported he leaves the facility 3 days a week to go to dialysis. Review of an admission MDS assessment, with a reference date of 6/6/24, Section O for Special Treatments and Programs, entry J1 Dialysis, J2 Hemodialysis, revealed R23 was not checked for receiving dialysis. Review of an MDS assessment, with a reference date of 9/5/24, Section O for Special Treatments and Programs, entry J1 Dialysis, J2 Hemodialysis, revealed R23 was not checked for receiving dialysis. Review of an MDS assessment, with a reference date of 3/4/25, Section O for Special Treatments and Programs, entry J1 Dialysis, J2 Hemodialysis, revealed R23 was not checked for receiving dialysis. In an interview on 4/10/25 at 9:28 AM, the MDS Coordinator/ Registered Nurse (RN) W verified R23 was not triggered/marked for dialysis even though he does receive dialysis and reported it should have been marked on the MDS.

Based on interview and record review, the facility failed to formulate and implement a comprehensive communication Care Plan for one non-English speaking resident (R61) of one resident reviewed for communication. Findings: Review of the Admission Record reflected R61 admitted to the facility 3/20/25 with diagnoses that included absence of left and right legs. The medical record reflected R61 was her own responsible party and was a Spanish speaking resident. Review of the Electronic Medical Record (EMR) for R61 did not reveal a communication Care Plan to provide guidance to staff on meeting the needs of this Spanish speaking Resident. Review of the medical provider documentation of 4/4/25 acknowledged the Resident is Spanish speaking only. The documentation reflected that She (R61) says she is painful today but cannot rate it. Denies chest pain, shortness of breath. The documentation reflected Exam Findings appears painful and Resident was weaning off narcotics, will try to continue this with family approval despite the medical record indicating R61 was her own decision maker. The documentation does not indicate the medical provider was Spanish speaking or if translation services were attempted to include input from the Resident in her evaluation. Review of the EMR Progress Note entry dated 4/1/25 at 4:07 AM reflected R61 fell on [DATE]. The documentation reflected Resident is Spanish speaking and could not described (sic) what happened. This entry indicates the Resident could not describe what happened because she was Spanish speaking and does not reflect attempts were made to communicate with the Resident in a way she can communicate. On 4/9/25 at 4:17 PM an interview was conducted with the Director of Nursing (DON) in her office. The DON reported that the medical provider is not Spanish speaking, but some staff do speak the language. The DON was informed that no Care Plan to assist staff in communication with the Resident was located. The DON indicated she would conduct a review. On 4/20/25 at 10:53 AM in the conference room the Nursing Home Administrator (NHA) acknowledged that R61 did not have a communication Care Plan prior to 4/9/25. The NHA reported the facility has one Certified Nurse Aide (CNA) and an Activities Aide that speak Spanish but could not say if these staff worked directly with R61.

Based on observation and record review, the facility failed to maintain the dignity of one of three residents (Resident #29) reviewed for dignity and respect. Findings: Resident #29 (R29) Review of an Admission Record revealed R29 was a [AGE] year old male, last admitted to the facility on [DATE], who suffered from severe cognitive impairment and depended on staff to meet all of his daily needs. During an observation on 04/09/25 at 11:56 AM, R29 sat in a broda chair at the dining room table and his pants were visibly wet with urine. During an observation on 04/09/25 at 01:04 PM, R29 remained in the broda chair at the dining room table, his pants were visibly wet with urine. During an observation on 04/09/25 at 01:07 PM staff brought R29 from the dining room to the nurses station and placed him next to two other residents. R29's sweat pants remained visibly wet in the crotch area. During an observation on 04/09/25 at 01:23 PM staff took R29 to his room to change his clothing and provide peri-care.

Based on interview and record review, the facility failed to 1.) ensure comprehensive nursing assessments were completed and 2.) identify and notify the provider of a change in condition for 1 resident (Resident #85) out of 3 residents reviewed for quality of care. Findings: Resident #85 (R85) Review of an Admission Record revealed R85 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Progressive multifocal leukoencephalopathy (progressive damage/inflammation of brains white matter.) Review of R85's provider Progress Note dated 1/9/25 revealed, .Resident guardian has continued to request resident be sent to hospital for any acute changes in health status. Due to resident decline it is expected that he will be resent to hospital at some point . Review of R85's Hospital Discharge Records revealed the following hospitalization s since his admission to the facility: *10/31/24-11/6/25 severe sepsis *11/9/24-11/10/24 fever with unspecified fever cause *11/21/24-11/26/24 recurrent aspiration pneumonia *12/4/24-12/10/24 sepsis and acute hypoxic respiratory failure *12/11/24-12/14/24 sepsis and recurrent aspiration pneumonia *12/29/24-1/8/25 acute respiratory distress *1/14/25-1/17/25 sepsis and recurrent aspiration pneumonia Review of R85's Electronic Health Record revealed R85 required suctioning on 12/11/24, 12/29/24, and 1/14/25 Confirming R85 had significant chronic respiratory conditions which required multiple hospitalization s and nursing interventions. Review of R85's Respiratory Care Plan revealed, Interventions .Observe for s/sx (signs and symptoms) of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB (shortness of breath) at rest, Cyanosis, Somnolence. Report abnormal findings to the physician .Observe for s/sx of respiratory infection: elevated temp, change in level of consciousness, malaise, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Report abnormal findings to the physician . Review of R85's Nurses Notes dated 1/21/25 revealed, Resident was reddened in color. pulse 119 alerted on call . (Normal adult heart rate is between 60-100 per [NAME] and [NAME]: Fundamentals of Nursing) Indicating a change in R85's condition. Review of R85's vital signs Summary revealed the last full assessment of vital signs (temperature, pulse, blood pressure, oxygen level, respirations) was completed on 1/21/25 at 3:10 PM. Review of R85's Temperature Summary revealed R85's last documented temperature was on 1/23/25 at 2:23 PM. Review of R85's Sepsis Screening Evaluation dated 1/24/25 at 1:33 AM revealed, Does the resident have two or more symptoms checked? Yes . This had not been previously identified on the evaluations following R85's return to the facility on [DATE]. Indicating a change in R85's condition and the possibility of sepsis should have been further assessed/evaluated. Additionally, R85's last full set of vital signs (temperature, pulse, blood pressure, oxygen level, respirations) were noted in this assessment. There were no additional Sepsis Screening Evaluations completed prior to 1/26/25. Review of R85's Nurses Notes dated 1/24/25 at 12:21 PM revealed, Resident presenting with fever of 101.6, Tylenol given immediately. P.A (Physician's Assistant) notified and wants to manage fever in house for now, if unable to get fever to break will need to send him out to hospital. Will continue to monitor. (a fever is a temperature above 100.4 F (38 C) for an adult per [NAME] and [NAME]: Fundamentals of Nursing). Indicating temperature monitoring was to be implemented to ensure R85 was physiologically stable to remain in the facility. Review of R85's Order Summary dated 1/17/25 revealed, Acetaminophen (Tylenol) Liquid 160 MG/5ML Give 20 ml enterally every 8 hours as needed for Pain . Review of R85's Medication Administration Note dated 1/24/25 at 12:14 PM revealed a dose of Tylenol was administered for Fever 101.6. Review of R85's Medication Administration Note dated 1/24/25 at 12:51 PM revealed fever improving with no temperature results noted. Review of R85's Medication Administration Note dated 1/25/25 9:51 AM revealed a dose of Tylenol was administered for given for fever prevention with no temperature results noted. Review of R85's Electronic Medical Record from 1/17/25-1/26/25 revealed no documentation of a provider assessment following his readmission to the facility. There was no comprehensive respiratory assessment (lung sounds, rate, rhythm, depth, dyspnea, pain, sputum) completed by licensed nurses following his readmission assessment on 1/17/25 despite his significant and chronic respiratory conditions. Review of R85's Nurses Notes dated 1/26/25 revealed, Went into resident's room to change drain sponge and observed him non responsive, checked for a pulse and called (additional) nurse for assistance, checked code status. RN (Registered Nurse) pronounced time of death at 0535 (5:35 AM) . During an interview on 04/10/25 at 09:22 AM, Nursing Home Administrator (NHA) (NHA is a Registered Nurse and the previous Director of Nursing) reported that she would expect nurses to assess temperatures if administering Tylenol for a fever as well as the provider reporting he wanted to treat R85's fevers in the facility. NHA reported she would expect licensed nurses to complete respiratory assessments on someone that returned to the facility due to sepsis from a respiratory illness. NHA reported that the providers were to assess residents upon their return from a hospitalization but confirmed there was no provider assessment for R85. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Perform respiratory assessment, including symmetry of chest wall expansion, chest wall abnormalities (e.g., kyphosis), temporary conditions (e.g., pregnancy, trauma) affecting ventilation, respiratory rate and depth, sputum production, lung sounds, and signs and symptoms associated with hypoxia .Observe for cognitive and/or behavioral changes (e.g., apprehension, anxiety, confusion, decreased ability to concentrate, decreased LOC, fatigue, and dizziness). CLINICAL JUDGMENT: Patients with sudden changes in their vital signs, LOC, or behavior may be experiencing profound hypoxia. Patients who demonstrate subtle changes over time may have worsening of a chronic or existing condition or a new medical condition ([NAME] et al., 2020). [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1003). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to ensure dignified care and treatment of two facility residents (R136 and R66) and failed to ensure communication for self-determination of care for one resident (61) of three residents reviewed for dignity. Findings: R136 Review of the Admission Record reflected R136 admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (bone infection) of the left ankle and foot. The medical record reflected R136 was able to make his own medical decisions. Review of the Care Plan for R136 reflected Toileting. (name of R136) will require assistance to the toilet every two hours and as needed. He may utilize a urinal, bed pan, or use the full body lift to the toilet. Initiated 4/4/25. The Care Plan reflected Ambulation/Locomotion (name of R136) is unable to ambulate at this time (due to) NWB (non-weight bearing) status of BLE (bilateral lower extremities) initiated 4/4/25. And the Care Plan reflected Put the call light within reach and encourage him to use it for assistance as needed. Initiated 4/4/25 On 4/8/25 at 7:03 AM an observation and interview were conducted with R136 in his room at the end of the hall. R136 reported he recently admitted to the facility and that he is not a happy camper. R136 reported when he uses his call light staff don't come (to the room) or if staff do come they turn off his call light and don't come back and you have to turn on the light again. R136 reported he could not bear weight on his feet and was unable to walk to the bathroom. R136 displayed his legs which were wrapped with elastic bandages. A urinal was observed within reach. R136 reported he had difficulty holding the urinal in place and has wet himself and the bedding when he has tried to use it on his own. R136 reported he had told staff of this difficulty, but staff did not offer a solution which he reported frustrated him. R136 reported two days prior to this interview he had to have a bowel movement and asked for a bed pan since one had not yet been provided on admission. R136 reported staff could not find one and he was told no one had a key for the room where the bed pans were kept. R136 reported staff told him to 'just poop in the bed and they would clean him up later. R136 voiced harsh criticism of the facility for him having to do this adding, It's humiliating. R136 reported that, although he is continent, he started wearing a brief beginning the previous night (4/7/25) because I never know if they are coming back in five minutes or five hours. The policy provided by the facility titled Call Lights last revised 3/12/25 was reviewed. The policy reflected Call lights will be placed within the resident's reach and answered in a timely manner. And Responding to a Call Light: 1. Identify the location and answer the resident promptly 3. Go to the location of the call light and turn off the light if you are able to meet the resident request .5. When finished, turn the call light off and replace the call light within resident's reach. On 4/9/25 at 4:12 PM an interview was conducted with the Director of Nursing (DON) in her office. The DON reported she feels the facility have enough staff to meet the needs of the residents. The DON was informed of the issues raised by R136. The DON indicated that call lights should not be turned off until the need of the resident is met. On 4/10/25 at 9:32 AM a second interview was conducted with R136 in his room. R136 reported the DON had talked to him and that he told her just what I told you. R136 reported he continues to wear a brief because if they don't get to me in time I can just go (void in the brief). R66 Review of the admission record reflected R66 admitted to the facility 3/18/25 with pertinent diagnoses that included difficulty in walking and need for assistance with personal care. The medical record reflected R66 made her own medical decisions and is cognitively intact. On 4/10/25 at 9:44 AM an interview was conducted with R66 in her room. R66 reported delayed call light response or that staff will turn off the call light but not return to help. R66 reported that the due to the delays she has wet herself and reported this has made her feel terrible. R61 Review of the electronic Medical Record (EMR) Admission Record reflected R61 admitted to the facility 3/20/25 with diagnoses that included absence of left and right legs. The Minimum Data Set (MDS) dated [DATE] reflected in Section GG the Resident was dependent on staff for toileting hygiene and all transfers. The medical record reflected R61 was her own decision maker and was a Spanish-speaking only resident. Review of the EMR for R61 did not reveal a communication Care Plan was in place to provide guidance to staff on how to engage this Spanish speaking Resident in her own care. Review of the EMR medical provider documentation of 4/4/25 at 0000 acknowledged the Resident is Spanish speaking only. The documentation reflected that She (R61) says she is painful today but cannot rate it. Denies chest pain, shortness of breath. The documentation reflected Exam Findings appears painful and Resident was weaning off narcotics, will try to continue this with family approval despite the medical record indicating R61 was her own decision maker. The documentation does not indicate the medical provider was Spanish speaking or if translation services were attempted to include input from the Resident in her evaluation. Review of the EMR Progress Note entry dated 4/1/25 at 4:07 AM reflected R61 fell on [DATE]. The documentation reflected Resident is Spanish speaking and could not described (sic) what happened. This entry indicated the Resident could not describe what happened because she was Spanish speaking and does not reflect attempts were made to communicate with the Resident in a way she can communicate. On 4/9/25 at 4:17 PM an interview was conducted with the Director of Nursing (DON) in her office. The DON reported that the medical provider is not Spanish speaking, but some staff do speak the language. The DON indicated that translation services are available but could not indicate if these had been implemented to ascertain the concerns directly from R61 and engage the Resident in her own care. On 4/10/25 at 10:53 AM in the conference room the Nursing Home Administrator (NHA) acknowledged that R61 did not have a communication Care Plan prior to 4/9/25. The NH reported that R61 can tell staff if she is having pain by rubbing the area and stating Ow. The NHA reported the facility has one Certified Nurse Aide (CNA) and an Activities Aide that speak Spanish but could not say if these staff worked directly with R61.

This citation is related to intake #MI00137878 Based on interview and record review, the facility failed to follow facility policy and best practice standards related to fall management for two residents (Resident #3 and Resident #2) by (a) not providing increased supervision, (b) not notifying the physician of low blood pressures, (c) not completing and/or maintaining neurological assessments after falls, (c) not correctly completing a fall assessment, (d) moving a resident after a fall before being assessed by a nurse, and (e) not updating or accurately completing care plans, resulting in falls with injury. Findings: Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year old female, admitted to the facility on [DATE], after a fall at home that required surgical intervention, and with pertinent diagnoses of end stage renal failure with dependence on dialysis, high blood pressure, and weakness/ paralysis of left arm and leg following a stroke. R3 was her own responsible person. Review of a Physician Note for R3, dated [DATE], listed R3's past medical history as follows: numerous falls, gout, diabetes, and decreased vision in both eyes. Review of Physician Orders for R3 reflected the following orders for medication taken for high blood pressure: (a) Amlodipine 10 mg (milligrams) one tab by mouth once daily-start date [DATE] and discontinue date [DATE] and (b) Lisinopril 20 mg one tab once daily-start date [DATE] and discontinue date [DATE]. Review of blood pressures for R3 reflected the following low blood pressures that were not immediately re-assessed: (a) ,d+[DATE] recorded on [DATE] at 2:34 PM- the next blood pressure check was not documented until [DATE] at 2:35 PM, (b) ,d+[DATE] recorded on [DATE] at 2:37 PM- the next blood pressure check was not documented until [DATE] at 1:49 AM, (c) ,d+[DATE] recorded on [DATE] at 9:55 PM- the next blood pressure check was not documented until [DATE] at 3:26 PM, (d) ,d+[DATE] recorded on [DATE] at 4:42 AM- the next blood pressure check was not documented until [DATE] at 2:19 PM, and (e) ,d+[DATE] recorded on [DATE] at 10:19 AM- the next blood pressure was not documented until [DATE] at 10:46 AM. Review of a Nursing Comprehensive-Quarterly Assessment for R3, dated [DATE], revealed 7 questions used to determine a residents risk for falls. Instructions on the assessment direct staff as follows: if yes is selected for any question, the resident is at risk for falls. The assessment completed by nursing staff reflected that R3 answered yes to 4 of the 7 questions. However, R3 received a total score of 4 and was determined to be at no risk for falls. Review of an Incident/Accident Report (IR) for R3 dated [DATE] at 1:40 AM, revealed the following: (a) fall occurred in R3's room when staff assisted R3 from the wheelchair to the bed, (b) R3's legs gave out and was lowered to the floor by staff, (c) no injuries were noted however injury location was documented as top of scalp, (d) did not indicate whether staff used a gait belt for the transfer, (e) did not list the names of staff who witnessed the fall, and (f) listed Predisposing Physiological Factors as drowsy and gait imbalance. Review of a Nursing Progress Note, dated [DATE] at 2:49 AM, revealed: resident did not fall, lowered to the floor. Review of the facility policy/procedure Fall Management, last reviewed on [DATE], reflected: FALL DEFINED-Fall refers to unintentionally coming to rest on the ground, floor, or other lowered level .an episode where where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Review of a facility Physician Progress Note dated [DATE], reflected the following: (a) R3 was seen by a facility prescriber following a staff witnessed fall the early morning of [DATE], (b) neuro assessment was at baseline, (c) no injuries were noted, and (d) plan- continue to monitor for change. The Physician Progress Note did not address the 3 low blood pressure readings, noted above, that were not immediately re-assessed by staff, and that occurred prior to the fall, on dates [DATE], [DATE], and [DATE]. During an interview on [DATE] at 9:40 AM, the Director of Nursing (DON) indicated that after a resident falls, the report and circumstances surrounding the fall were reviewed, and a post- fall assessment was completed by the IDT (interdisciplinary team). The DON stated that a post-fall assessment/evaluation was not completed for R3's fall on [DATE]. The intervention put into place by staff on [DATE] to prevent further falls was to refer R3 to for a therapy screen. No immediate intervention was put into place by staff to ensure R3's safety until the therapy screen was completed. Review of a Fall Care Plan for R3 printed [DATE], initiated [DATE] and a target date of [DATE], reflected the following for R3: (a) was at risk for falls, (b) was not updated after fall on [DATE], nor updated after evaluated by therapy, (c) and was not updated after the fall on [DATE]. Review of the facility policy/procedure Fall Management, last reviewed on [DATE], revealed: OVERVIEW-If a fall occurs, the (IDT) conducts an evaluation to ensure appropriate measures are in place to minimize the risk for future falls. Review of an Incident/Accident Report (IR) for R3, dated [DATE] at 7:28 AM, revealed the following: (a) the fall occurred in R3's restroom while being assisted by one staff, certified nurse aide (CNA) C, (b) R3 was holding onto a grab bar in the bathroom and fell from a standing position, (c) at the time of the fall, R3 indicated some pain in her left upper extremity, (d) nursing assessment indicated that R3 had no abrasions, no areas of open skin, no lumps, and no bumps. The only injury noted on the IR was reddened skin to the face and left cheek, (e) neurological assessment was started and vitals obtained (no vitals listed on the IR nor in the EHR-electronic health record), (f) no detailed account was documented from CNA C , who witnessed the fall, (g) the portion of the IR where staff would document R3's mental status was left blank, (h) the portion of the IR where staff would document if there were any predisposing environmental factors that may have contributed to R3's fall, was left blank, (i) the portion of the IR where staff would document if there were any predisposing physiological factors that may have contributed to R3's fall, was left blank, (j) the portion of the IR where staff would document if there were any predisposing situation factors that may have contributed to R3's fall, only had the box indicating other checked, and no additional narrative to describe what the other situation factor may have been, (k) and that CNA C had moved and repositioned R3, after the fall and prior to the nurse arriving to the bathroom to assess R3 ( resident laying on right side with pillow under her head). Review of the facility policy/procedure Fall Management, last reviewed on [DATE], revealed: PRACTICE GUIDELINES-When a fall occurs, the licensed nurse will evaluate the resident for injury. Do not move the individual until he/she has been examined by a nurse. During an interview on [DATE] at 10:20 AM, CNA C indicated that after R3 fell , CNA C placed a pillow under R3's head before the nurse entered the room to assess R3. Review of R3's EHR, specifically; task monitoring blood pressure documentation and Electronic Medication Administration Record (Emar) for [DATE], revealed that R3's only blood pressure documented on [DATE] was a blood pressure obtained on [DATE] at 10:33 PM. (,d+[DATE]). The next documented blood pressure after the fall on [DATE] at 7:28 AM, was recorded on [DATE] at 11:00 AM (,d+[DATE]) and again on [DATE] at 11:41 AM (,d+[DATE]). During an interview on [DATE] at 9:40 AM, the Director of Nursing (DON) stated the following related to R3's fall on [DATE]: (a) a neurological assessment, that should have been completed by nursing due to R3 hitting her head on the floor, could not be located, and (b) the immediate intervention put into place by staff to ensure R3's safety was to change R3's transfer status to 2 staff person assist and to refer to therapy. Per DON, the fall actually occurred on [DATE] and the IR was not completed until 24 hours after the fall. To help alleviate confusion in this report related to the fall, it will be referred to as the fall that occurred on [DATE]. Review of a Post Fall Evaluation for R3 was completed by the IDT regarding fall on [DATE] (date listed on the form). Review of R3's EHR revealed only 1 nursing note entered into the record on [DATE], time stamped 1:12 PM and it contained verbatim the information that was documented on the IR completed [DATE] at 7:28 AM. No nursing progress notes for R3 were found in the EHR on [DATE]. Review of a nursing progress note for R3, dated [DATE] and time stamped 5:45 AM, reflected that R3 was complaining of left upper arm pain and that an x-ray of the left arm was ordered. Whether or not the x-ray was completed was unclear in the EHR. Review of a nursing progress note for R3, dated [DATE] and time stamped 11:20 AM, reflected that R3's pain was increasing, blood pressure was ,d+[DATE] and the Physician Assistant was in the facility and assessed R3. Review of a physician progress note for R3, dated [DATE], revealed the following information regarding R3's fall on [DATE]: (a) R3 fell backwards and to the left, (b) R3 hit her head on the left side and left arm, (c) R3 describes a crushing chest pain, difficulty breathing due to the pain on the left side, (d) R3 is on 3.5 liters of oxygen via nasal cannula, has not been able to exceed 78% oxygen saturation, and was taking short shallow breaths, (e) positive for left arm and rib pain, and (f) send to the emergency department. Review of a Kardex ( bedside care guide that told staff how to care for each resident) for R3, as of [DATE] reflected the following assistance R3 needed to go to the bathroom: Toilet Use: (R3) requires extensive assist x 1 to use toilet. Review of Ambulance run records for R3, dated [DATE], revealed the following: (a) EMT (emergency medical technician) on scene at facility at 11:52 AM, (b) reason for dispatch-sick person, not alert, (c) fall on Saturday ([DATE]) with complaints of left arm and chest wall pain since, (d) paramedic comments include-EMS called to (facility) for a female with chest pain and elevated blood pressure, staff reported (R3) fell yesterday ([DATE]) and was not evaluated further do to no available x-ray, (e) (R3) advised that fall occurred on Saturday ([DATE]) not Sunday ([DATE]) as reported by facility, and (f) bruising noted on (R3) left side. Review of Emergency Department Records for R3, dated [DATE] reflected: (a) R3 had a ground level fall on Saturday [DATE], (b) complained of shortness of breath, (c) x-rays in ER showed left sided rib fractures in ribs ,d+[DATE] (each fractured in 2 places), (d) x-ray also showed left humerus (bone in the upper arm) fracture, (e) obvious bruising noted to left upper arm, (f) decreased oxygen saturation requiring supplemental oxygen-usually does not wear oxygen, and (g) hemoglobin level of 6.6, requiring blood transfusions. R3 transferred to [NAME] Michigan trauma center on [DATE] for trauma care. Review of a Trauma Center Hospital H&P (history and physical), dated [DATE] and dictated by Medical Doctor (MD) L , reflected the following medical concerns and treatment plans for R3: (a) life threatening rib fractures of left ribs # ,d+[DATE]-treatment plan: APS (adult protective services) consult, nerve block for pain (b) acute hypoxic (low oxygen level) respiratory insufficiency-treatment plan: admit to ICU for aggressive pulmonary hygiene and close monitoring as given age and underlying medical co-morbidities, there is a high risk for respiratory decompensation secondary to rib fractures (c) left humerus (upper arm) fracture-treatment plan: sling for comfort and consult orthopedic specialist. Resident #2 (R2) Review of an Admission Record revealed R2 was an [AGE] year old male, admitted on [DATE], following treatment in a local hospital from [DATE] to [DATE] for Atrial-Fibrillation, shortness of breath, decreased fluid intake, lightheadedness, and visual hallucinations over the previous week. R2 admitted to the facility for subacute rehabilitation. During a telephone interview on [DATE] at 5:50 PM, confidential informant and family member Q identified the following areas of concern regarding the care of R2: (a) family with R2 throughout the day visiting and staff entered the room once in 9 hours to check on R2, (b) on one occasion with family visiting, the call light was activated and not answered for 40 minutes, and (c) on one occasion the nurse handed R2 his medications in a small plastic cup and then left the room without making sure R2 took the medications correctly. Review of a Care Plan for R2, created on [DATE], revealed: (R2) is at risk for fall related injury and falls related to: left blank. INTERVENTIONS-did not include interventions and staff guidance related to R2's admission diagnoses of hallucinations, lightheadedness, and shortness of breath. Review of a Physician Progress Note, completed on [DATE] for R2's admission exam, included information regarding the fall, indicated that R2 had 2 small tears near the right elbow, vital signs were stable and that neurological assessments had been started. Also noted; R2 was minimally verbal and not responding to questions, R2 appeared to be struggling to breath and had shallow breathing, 02 (oxygen saturation) was in upper 90's. Review of a Post Fall Evaluation for R2, completed by the IDT, revealed: R2 attempted to self-transfer 3 times prior to the fall during the shift,, and that R2 was confused prior to the fall. R2 was not provided increased supervision to ensure his safety after the 3 attempts to self-transfer. During an interview on [DATE] at 9:40 AM, the Director of Nursing (DON) stated the following related to R2's fall on [DATE]: (a) a neurological assessment, that should have been completed by nursing due to R2's fall not being witnessed, could not be located, and (b) the immediate intervention put into place by staff to ensure R3's safety was to change R3's call light to a touch pad. Review of an emergency room Physician Progress Note for R2, dated [DATE] and time stamped 11:54 AM, indicated R2 .was brought to the ER today by EMS. Facility staff stated that R2 fell at 4:00 AM at the facility, but facility staff are unable to provide information as to how it is known that he fell . Apparently he was later found with a decreased level of consciousness in his room and he was brought tot the ER for further evaluation. EMS reported R2 was bradypneic ( abnormally slow breathing) EN route to the ER. Presented to the ER today with acute respiratory failure and hypercapnia (increased level of carbon dioxide in the blood) and altered mental status. Review of a 'Hospital Physician Clinical Note dated [DATE], revealed R2 expired at 4 AM on [DATE].

Based on observation, interview and record review, the facility failed to prevent a pressure ulcer and prevent the worsening of a pressure ulcer for 2 Residents (R51 and R62), resulting in R51 developing an unstageable pressure ulcer on her buttock and R62's pressure ulcer on his left heel increasing in size. Findings include: R51 Review of R51's face sheet dated 6/28/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R51 was not her own responsible party. Review of R51's care plan for skin breakdown date initiated 9/18/18 and revised on 5/25/22 revealed under interventions, Assist (Resident Name) with reposition in her Broda chair (specialized wheelchair) on ROHO cushion (specialized pressure relieving seat cushion) as needed, she sometimes has poor position from sliding down. Dated 9/19/18. Review of R51's care plan for ADL (Activities of Daily Living) self-care performance deficit and requires total caregiver assistance with ADL's and mobility r/t (related to) HX (history) of [CONDITION(S)] ([CONDITION(S)]) with left sided [CONDITION(S)], left hand contracture dated 9/19/18 and revision on 2/28/22 revealed required assistance of 2 people for transfers and assistance of 1 person for bed mobility. On 6/27/22, R51 was observed up in her broda chair from 1:15 PM to 3:30 PM. R51 was on a black foam cushion (care plan was for a roho cushion). On 6/28/22 at 8:15 AM, Certified Nurse Aide (CNA) O was observed leaving R51's room. R51 was up in her broda chair (no roho cushion) in the seat. CNA O said she had just finished R51's morning care and got her up in her chair. On 6/28/22 at 10:46 AM, CNA O and P were observed putting R51 back to bed. The black cushion on R51's chair was black and solid firm foam style (no name brand noted). This was not the pressure relieving seat cushion listed in her care plan. R51 was up in her chair for almost 3 hours. On 6/28/22 at 11:00 AM, Registered Nurse (RN) N came in to do dressing changes on R51's buttock. R51 had an open area on her sacrum that did not have a dressing on it. No dressing was noted to be in R51's brief when removed just prior to this dressing change. R51 had a dressing on her left buttock dated 6/27/22, 11-7 shift. RN N said R51 should have had a dressing on her sacrum. RN N put a new dressing on R51's sacrum and her left buttock. The wound on the left buttock was approximately 2 inches in diameter and 2 inches deep. The base of the wound was covered with black tissue. During an interview with the Director of Nursing (DON) on 6/29/22 at 12:46 PM, R51's wound assessments and measurements were reviewed. The DON said R51's pressure ulcer on her left buttock was first noted on 4/11/22 as a deep tissue injury that measured 1.6 cm x 1.3 cm. The DON could not locate any root cause documentation, or any new interventions placed to reduce R51's pressure on her left buttock that was noted to have a deep tissue injury. The DON said this wound was last assessed on 6/27/22 and the wound was now unstageable and measured 5.5 cm x 4.7 and did not have a depth measurement. The DON said that hospice had provided a roho cushion for R51 on 4/22/22 and she would look into why R51 was not using the roho cushion. The DON was asked what her expectations were for a finding of a new deep tissue injury and the DON said she would have to get back to me. Prior to exit the DON did not provide a policy of procedure for pressure ulcers or indicate what her expectations would have been for a finding of a new pressure ulcer injury. Review of R51's wound assessments confirmed the measurements the DON provided on 6/29/22 at 12:46 PM for R51's wound on her left buttock were accurate. Review of R51's care plan for skin breakdown revealed no new interventions were placed after 4/11/22 when the facility noted a new deep tissue injury was located on R51's left buttock. R62 Review of R62's face sheet dated 6/28/22 revealed R62 was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R62 was listed as his own responsible party. Review of R62's Minimum Data Set (MDS), nursing assessment tool dated 3/8/22 revealed he had a Brief Interview of Mental Status (BIMS) score of 10/15 (moderate cognitive impairment) and required extensive to total assistance with all of his Activities of Daily Living (ADL). Review of R62's Minimum Data Set (MDS), nursing assessment tool dated 6/6/22 revealed he had a Brief Interview of Mental Status (BIMS) score of 99 (not able to answer questions (severe cognitive impairment) and required extensive to total assistance with all of his Activities of Daily Living (ADL). R62 was observed up in a broda chair (specialized chair) on 6/29/22 at 10:50 AM. Both feet were in blue colored cushioned boots. Heels of the boots were pressing into a blue foam pad that was made for positioning someone upright in a wheelchair (firm foam not made for pressure relief). Certified Nurse Aide (CNA) said she help get R62 out of be at 8:00 AM and said he goes back to bed around 12:30 PM. During an interview with the Director of Nursing (DON) on 6/29/22 at 1:20 PM, the DON reviewed R62 pressure ulcer assessments and measurement on both heels. The DON said R62 was admitted with unstageable pressure ulcers on both heels. The right heel measured 1.7 cm x 1.5 cm and left was 1.3 cm x 1.4 cm. Both were covered with black eschar. The last assessment was done on 6/27/22 and the right heel was 1.14 cm x 1.82 and the left was 4.14 cm x 1.73 cm. The DON said the left heel ulcer did have depth, but the measurement was not recorded. The DON was not able to locate any new interventions to reduce pressure on R62's heels. The DON was not able to locate any seating evaluations or assessments to evaluate the pressure on R62's heels. There was no documentation to determine why R62's heels were being placed on a firm foam pad (non-pressure relieving surface) while up in his chair. Review of R62's wound assessments confirmed the DON's measurements were correct. On 6/29/22 at 1:35 PM, R62 was in his room up in his wheelchair (had been up since 8:00 AM). R62 said both of his feet hurt. R62 was placed in bed with an electronic lift and assistance of 2 staff. Every time they moved his left leg he cried out in pain and said his entire leg hurt. Registered Nurse (RN) N removed the dressings on both feet and every time she moved his left leg he cried out in pain. The ulcer on the left heel looked like two ulcers and RN N said she measured it as one ulcer due to only a small amount of tissue separated the wound. The wound appeared if measured as one wound it appeared to be about 2 inches long by about 1.5 inches wide and an inch deep. Review of R62's care plan revealed a care plan for Actual impairment of skin integrity r/t (related to) skin integrity r/t Unstageable pressure areas on both heels dated 3/2/22. The only pressure relieving intervention was, apply reducing mattress to protect the skin while in bed. There was no mention of off loading the pressure on his heels or any equipment use to reduce the pressure.

Based on interview and record review, the facility failed to notify the physician and responsible party in a timely manner of an acute change in condition for 1 resident (Resident #1) resulting in ongoing, untreated pain and functional limitations from an undiagnosed comminuted and displaced intertrochanteric proximal right femoral fracture. Findings: Review of a facility Admission Record reflected Resident #1 (R1) admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 was severely cognitively impaired and needed extensive assistance from one person for bed mobility, transfers, walking, dressing, eating, toileting and personal hygiene. Review of a Care Plan initiated on 10/4/2018 reflected R1 was at risk for acute pain and has chronic pain related to [CONDITION(S)], osteopenia, recent fracture of right femur and history of rhabdomyolysis and [CONDITION(S)]. The goal of the care plan was to ensure R1 did not have an interruption in normal activities due to pain through the review date. Interventions included: Assess for existence of pain, signs and symptoms, location, intensity, quality, pain relief etc. on admission and quarterly; Administer [MEDICATION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .; Notify Physician PRN if interventions are unsuccessful or if current complaint is a significant change from [R1's] past experience of pain; Anticipate [R1's need for pain relief PRN and respond immediately to any complaint of pain; Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased ROM, withdrawal or resistance to care as needed; Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o (complaints of) pain or discomfort. Review of a Care Plan initiated on 10/04/2018 reflected [R1] has an ADL (Activity of Daily Living) Self Care Performance Deficit and requires extensive assistance with most ADL's and mobility r/t (related to) weakness, HX (history) of kidney injury, OA ([CONDITION(S)]), [CONDITION(S)], HLD (high cholesterol), recent right femur fracture with surgical repair and a history of dizziness. Interventions listed in the care plan included TRANSFER: [R1] requires x1 (one person) extensive assistance with transfers using walker and gait belt. She often self-transfers despite reinforcing education to call or wait for assistance. If she is unable to stand, do no use sit-to-stand (a type of mechanical lift) due to [R1's] functional abilities. Use full body mechanical lift if she is unable to stand; Assess/record change in ADL status and report to physician. Review of an Incident and Accident Report dated 11/15/21 reflected R1 complained of pain with associated discoloration of the right hip. An x-ray was ordered by the physician and revealed a fracture. According to the incident report, R1 denied any injury and was sent to the emergency room . Review of a Radiology Results Report dated 11/15/21 reflected R1 had a unilateral right hip x-ray with or without a pelvic view at the facility. The Findings revealed Limited study, marked DJD ([CONDITION(S)] joint disease), apparent fracture with avulsion (a tendon or ligament pulls part of the bone off) of the greater trochanter. During an interview on 12/2/21 at 11:00 a.m., Unit Manager, LPN F said she was working the 3rd shift on 11/7/21 when she was told that R1 complained of pain with movement to her right lower extremity. LPN F assessed R1 and there were no signs of fracture, just knee pain that was relieved with Tylenol. LPN F said that she would hear about R1 complaints of pain in daily meetings but knew that the right knee x-ray was negative for evidence of injury. LPN F said that R1 used to be a one person stand-pivot for transfers and after the knee was found to be without injury, therapy screened R1 for positioning in her wheelchair. Review of a Nurses Note dated 11/7/21 at 4:50 a.m., reflected Resident with reports of RLE pain. PRN Tylenol (acetaminophen) given as ordered. No obvious deformity or injury present, no s/sx (signs of symptoms) of skin infection, she states nothing happened to cause the pain it just hurts. Mild pain with ROM (Range of Motion) of knee. No pain at rest. Provider notified. Review of a Radiology Results Report dated 11/08/21 reflected R1's right knee was x-rayed and revealed No acute findings. [CONDITION(S)] changes. Consider a repeat study if symptoms continue to persist or progress. During an interview on 12/2/21 at 2:36 p.m., Certified Occupational Therapy Aide (COTA) L reported she did a screening evaluation on R1 on 11/09/21 and recommended therapy services to assist R1. COTA L said that when she screened R1, she was seated in her wheelchair in a common area at the facility and seemed to be in acute pain. COTA L said that when she approached R1 with the lightest touch, R1 would cry out Ow! Ow! Ow! and she noted R1's knee was swollen. According to COTA L, Physical Therapy was also going to work with R1, but did not have to opportunity to do so until after the fracture was identified on 11/15/21. Review of an Interdisciplinary Therapy Screen dated 11/09/2021 reflected 1. Reason for the Therapy Screen - b. Significant Change; d. Positioning. The screening form indicated R1 had a change in positioning, posture and transfer status since the last screen had been completed. Comments on the screening form entered by COTA L reflected Nursing reports res (resident) has right knee pain and may require seating/positioning eval (evaluation). Observed res right and left knee with [CONDITION(S)] present right knee and res reporting pain with gentle touch. Staff reports lift is being used for t/f's (transfers) now. The Results of Interdisciplinary Rehab Screen were that R1 would require skilled physical and occupational therapy. Review of an Occupational Therapy (OT) OT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Reason for Referral indicated Patient with decline in function limiting ability to complete fxl (functional) t/fs (transfers). Patient with new pain in LE (Lower Extremity) limiting ability to engage in functional activities. Staff requesting therapist to position w/c (wheelchair). According to the evaluation, R1's right lower extremity Range of Motion (ROM) and Strength/Manual Muscle Testing could not be tested due to increased pain. The Pain assessment portion of the evaluation reflected R1 reported constant pain in her RLE (right lower extremity) with movement. The Evaluation Summary of the OT assessment completed 11/11/21 reflected Therapist trialing alternate foot placement on w/c to increase comfort though pt (patient) increase c/o pain with touch of LE, no movement able to complete. Additional comments indicated Subjective/Objective: Patient asleep in chair and indicating high level of pain in R (right) hip area limiting fxl activities. During an interview on 12/2/21 at 9:27 a.m., Certified Nurse Aide (CNA) B reported she cared for R1 in the days preceding R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to CNA B, R1 would complain of pain with the lightest touch and cry out Ow! You're hurting me!. CNA B said she observed bruising and noticed the pain and would report the findings to the nurses. CNA B said she could tell R1 was having increased pain because when she would observe R1 lying in bed, R1 just didn't look right. During an interview on 12/2/21 at 9:49 a.m., CNA D reported that R1 was in pain for a week before she was diagnosed with a fracture on 11/15/21. According to CNA D, R1 would scream in pain and did not want to get out of bed. CNA D said R1 would normally complain/object to being cared for or transferred but that this pain was different. CNA D said she was not comfortable transferring R1 as she normally would (extensive assistance of one person to stand and pivot from bed to chair and chair to bed) and opted to use the mechanical lift instead. CNA D said she told nursing staff about R1's pain but they would tell her the right knee x-ray didn't show any injury. During an interview on 12/2/21 at 1:10 p.m., CNA H reported she noticed R1's right knee was swollen on 11/8/21 and cared for R1 in the days leading up to the discovery of the fracture on 11/15/21. According to CNA H, R1's pain was through the roof and she would not transfer R1 without a mechanical lift due to her obvious discomfort. Review of CNA task Documentation Survey Report v2 for the month of November 2021 reflected that between 11/7/2021 when R1 began complaining of significant pain with movement and 11/15/2021 when the right hip fracture was diagnosed with an x-ray, R1 was transferred with the extensive assistance (resident involved in activity, i.e., bearing weight on her legs) of one person at least 10 times. R1 was transferred with the extensive assistance of two people at least 4 times during the week leading up to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Clinical Alerts and Order Listing Report dated 11/5/21-12/2/21 reflected the following pertinent alert and customized alert charting (per the Director of Nursing (DON), CNA's can free text custom alerts that are to be reviewed by Licensed Nurses, in addition to pre-populated selections): 11/5/21: Yelling/Screaming 11/6/21: Yelling/Screaming 11/8/21: Pain-new or worsening: Participated less in activities; Yelling/Screaming; Frequent Crying; Pushing; Grabbing 11/11/21: Resident continues to scream in pain, saying her leg even when no one is around or touching it; Yelling/Screaming 11/12/21: Yelling/Screaming 11/14/21: Yellow/green bruising on pelvic area, hip area, and near the knee. She also screams in pain when barely touching her leg. (Yellow/green bruising can be an indication of the age of injury, typically not acute.) Review of Progress Notes after the entry dated 11/7/2021 at 4:50 a.m., revealed no additional Nurses Notes pertaining to R1's ongoing right lower extremity leg pain, functional limitations or evidence a physician or provider was notified were entered until the discovery of the fracture with avulsion of the greater trochanter and subsequent transfer to the hospital on 11/15/2021. Review of R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR, R1 received a dose of the pain reliever once on 11/6/21, twice on 11/7/21, once on 11/10/21 and did not receive another dose of the pain reliever again until 11/15/21 at 5:26 a.m., despite R1's ongoing signs and symptoms of pain, staff reports of R1's pain or documented alerts from CNA's to licensed nurses of R1's ongoing signs and symptoms of pain. During an interview on 12/2/21 at 10:15 a.m., Physician Assistant (PA) E reported that on 11/8/21 he physically assessed R1 when nursing staff reported R1 was complaining of pain. PA E recalled that R1 was painful when staff attempted to transfer R1 and ordered an x-ray to evaluate the right knee. PA E said he would assume the increased pain in the right knee was related to the fracture that was diagnosed on [DATE]. PA E reported he was not involved with ordering the right hip x-ray on 11/15/21 and did not have specific documentation pertaining to R1's ongoing increased pain or functional limitations after assessing R1 on 11/8/2021. Review of [Facility] Physician Notification forms (non-emergent notices placed in a binder for the physician to review during the next visit to the facility) for R1 reflected nurses notified the physician on 11/8/2021 R1 was painful to touch and movement of her RLE, prompting the x-ray evaluation of R1's knee on 11/8/21. Another undated Physician Notification form was completed for R1 identifying the concern as R (right) leg severe pain with palpation and movement at R lateral inferior to trochanter-bruise of unknown origin or history. The physician response was to order a STAT (right away) x-ray of the right hip and pelvis. No other notifications to the physician from 11/8/21-11/15/21 (1 week) were made, despite R1's ongoing change in condition. No evidence a physician was contacted via telephone pertaining to R1's acute change in condition was noted. Review of hospital documentation included an Inpatient Internal Medicine Consult that reflected This is a [AGE] year-old female who presented to the Emergency Department via EMS (Emergency Medical Services) on 11/15/2021 after sustaining a fall 1 week ago at her living facility [name of facility]. She has persistently complained of right hip pain. CT (computerized tomography) pelvis without contrast completed in the emergency department revealed a comminuted (the bone shatters into several different pieces) and displaced (a gap forms where the bone breaks) intertrochanteric proximal right femoral fracture extending into the base of the right femoral neck with a moderate size acute hematoma surrounding the proximal fracture with ongoing hemarthrosis. She was admitted by orthopedic surgery with plans to undergo surgical intervention tomorrow, 11/16/2021.

This citation pertains to intake MI- 3 Based on interview and record review, the facility failed to implement care plans based on a comprehensive assessment for 1 resident (Resident #1) resulting in a delay in physician notification, assessment, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of a facility Admission Record reflected Resident #1 (R1) admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 was severely cognitively impaired and needed extensive assistance from one person for bed mobility, transfers, walking, dressing, eating, toileting and personal hygiene. Review of a Care Plan initiated on 10/4/2018 reflected R1 was at risk for acute pain and has chronic pain related to [CONDITION(S)], osteopenia, recent fracture of right femur and history of rhabdomyolysis and [CONDITION(S)]. The goal of the care plan was to ensure R1 did not have an interruption in normal activities due to pain through the review date. Interventions included: Assess for existence of pain, signs and symptoms, location, intensity, quality, pain relief etc. on admission and quarterly; Administer [MEDICATION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .; Notify Physician PRN if interventions are unsuccessful or if current complaint is a significant change from [R1's] past experience of pain; Anticipate [R1's need for pain relief PRN and respond immediately to any complaint of pain; Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased ROM, withdrawal or resistance to care as needed; Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o (complaints of) pain or discomfort. Review of a Care Plan initiated on 10/04/2018 reflected [R1] has an ADL (Activity of Daily Living) Self Care Performance Deficit and requires extensive assistance with most ADL's and mobility r/t (related to) weakness, HX (history) of kidney injury, OA ([CONDITION(S)]), [CONDITION(S)], HLD (high cholesterol), recent right femur fracture with surgical repair and a history of dizziness. Interventions listed in the care plan included TRANSFER: [R1] requires x1 (one person) extensive assistance with transfers using walker and gait belt. She often self-transfers despite reinforcing education to call or wait for assistance. If she is unable to stand, do no use sit-to-stand (a type of mechanical lift) due to [R1's] functional abilities. Use full body mechanical lift if she is unable to stand; Assess/record change in ADL status and report to physician. Review of a Care Plan initiated on 11/14/2019 reflected R1 had osteopenia that placed her at an increased risk for traumatic or spontaneous injury. One of the goals identified in the care plan was [R1] will remain free from or at a level of discomfort acceptable to [R1] through review date. Interventions in the care plan included Give analgesics PRN (as needed) for pain. R1 may complain of pain, stiffness or weakness. Document complaints. Review of an Incident and Accident Report dated 11/15/21 reflected R1 complained of pain with associated discoloration of the right hip. An x-ray was ordered by the physician and revealed a fracture. According to the incident report, R1 denied any injury and was sent to the emergency room . Review of a Radiology Results Report dated 11/15/21 reflected R1 had a unilateral right hip x-ray with or without a pelvic view at the facility. The Findings revealed Limited study, marked DJD ([CONDITION(S)] joint disease), apparent fracture with avulsion (a tendon or ligament pulls part of the bone off) of the greater trochanter. During an interview on 12/2/21 at 11:00 a.m., Unit Manager, LPN F said she was working the 3rd shift on 11/7/21 when she was told that R1 complained of pain with movement to her right lower extremity. LPN F assessed R1 and there were no signs of fracture, just knee pain that was relieved with Tylenol. LPN F said that she would hear about R1 complaints of pain in daily meetings but knew that the right knee x-ray was negative for evidence of injury. LPN F said that R1 used to be a one person stand-pivot for transfers and after the knee was found to be without injury, therapy screened R1 for positioning in her wheelchair. Review of a Nurses Note dated 11/7/21 at 4:50 a.m., reflected Resident with reports of RLE pain. PRN Tylenol (acetaminophen) given as ordered. No obvious deformity or injury present, no s/sx (signs of symptoms) of skin infection, she states nothing happened to cause the pain it just hurts. Mild pain with ROM (Range of Motion) of knee. No pain at rest. Provider notified. During an interview on 12/2/21 at 9:29 a.m., Licensed Practical Nurse (LPN) C reported R1 would yell out in pain about a week prior to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN C said R1 would point to her knee and reach down to her knee area which prompted her to report the change to the Unit Manager (LPN F) and an x-ray of the right knee was ordered but did not show there was an injury to R1's knee. According to LPN C, she noticed bruising to R1's right hip area a week later and that was when another x-ray of the right hip was ordered. Review of a Radiology Results Report dated 11/08/21 reflected R1's right knee was x-rayed and revealed No acute findings. [CONDITION(S)] changes. Consider a repeat study if symptoms continue to persist or progress. During an interview on 12/2/21 at 2:36 p.m., Certified Occupational Therapy Aide (COTA) L reported she did a screening evaluation on R1 on 11/09/21 and recommended therapy services to assist R1. COTA L said that when she screened R1, she was seated in her wheelchair in a common area at the facility and seemed to be in acute pain. COTA L said that when she approached R1 with the lightest touch, R1 would cry out Ow! Ow! Ow! and she noted R1's knee was swollen. According to COTA L, Physical Therapy was also going to work with R1, but did not have to opportunity to do so until after the fracture was identified on 11/15/21. Review of an Interdisciplinary Therapy Screen dated 11/09/2021 reflected 1. Reason for the Therapy Screen - b. Significant Change; d. Positioning. The screening form indicated R1 had a change in positioning, posture and transfer status since the last screen had been completed. Comments on the screening form entered by COTA L reflected Nursing reports res (resident) has right knee pain and may require seating/positioning eval (evaluation). Observed res right and left knee with [CONDITION(S)] present right knee and res reporting pain with gentle touch. Staff reports lift is being used for t/f's (transfers) now. The Results of Interdisciplinary Rehab Screen were that R1 would require skilled physical and occupational therapy. Review of an Occupational Therapy (OT) OT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Reason for Referral indicated Patient with decline in function limiting ability to complete fxl (functional) t/fs (transfers). Patient with new pain in LE (Lower Extremity) limiting ability to engage in functional activities. Staff requesting therapist to position w/c (wheelchair). According to the evaluation, R1's right lower extremity Range of Motion (ROM) and Strength/Manual Muscle Testing could not be tested due to increased pain. The Pain assessment portion of the evaluation reflected R1 reported constant pain in her RLE (right lower extremity) with movement. The Evaluation Summary of the OT assessment completed 11/11/21 reflected Therapist trialing alternate foot placement on w/c to increase comfort though pt (patient) increase c/o pain with touch of LE, no movement able to complete. Additional comments indicated Subjective/Objective: Patient asleep in chair and indicating high level of pain in R (right) hip area limiting fxl activities. During an interview on 12/2/21 at 9:27 a.m., Certified Nurse Aide (CNA) B reported she cared for R1 in the days preceding R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to CNA B, R1 would complain of pain with the lightest touch and cry out Ow! You're hurting me!. CNA B said she observed bruising and noticed the pain and would report the findings to the nurses. CNA B said she could tell R1 was having increased pain because when she would observe R1 lying in bed, R1 just didn't look right. During an interview on 12/2/21 at 9:49 a.m., CNA D reported that R1 was in pain for a week before she was diagnosed with a fracture on 11/15/21. According to CNA D, R1 would scream in pain and did not want to get out of bed. CNA D said R1 would normally complain/object to being cared for or transferred but that this pain was different. CNA D said she was not comfortable transferring R1 as she normally would (extensive assistance of one person to stand and pivot from bed to chair and chair to bed) and opted to use the mechanical lift instead. CNA D said she told nursing staff about R1's pain but they would tell her the right knee x-ray didn't show any injury. During an interview on 12/2/21 at 1:10 p.m., CNA H reported she noticed R1's right knee was swollen on 11/8/21 and cared for R1 in the days leading up to the discovery of the fracture on 11/15/21. According to CNA H, R1's pain was through the roof and she would not transfer R1 without a mechanical lift due to her obvious discomfort. Review of CNA task Documentation Survey Report v2 for the month of November 2021 reflected that between 11/7/2021 when R1 began complaining of significant pain with movement and 11/15/2021 when the right hip fracture was diagnosed with an x-ray, R1 was transferred with the extensive assistance (resident involved in activity, i.e., bearing weight on her legs) of one person at least 10 times. R1 was transferred with the extensive assistance of two people at least 4 times during the week leading up to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Clinical Alerts and Order Listing Report dated 11/5/21-12/2/21 reflected the following pertinent alert and customized alert charting (per the Director of Nursing (DON), CNA's can free text custom alerts that are to be reviewed by Licensed Nurses, in addition to pre-populated selections): 11/5/21: Yelling/Screaming 11/6/21: Yelling/Screaming 11/8/21: Pain-new or worsening: Participated less in activities; Yelling/Screaming; Frequent Crying; Pushing; Grabbing 11/11/21: Resident continues to scream in pain, saying her leg even when no one is around or touching it; Yelling/Screaming 11/12/21: Yelling/Screaming 11/14/21: Yellow/green bruising on pelvic area, hip area, and near the knee. She also screams in pain when barely touching her leg. (Yellow/green bruising can be an indication of the age of injury, typically not acute.) Review of Progress Notes after the entry dated 11/7/2021 at 4:50 a.m., revealed no additional Nurses Notes pertaining to R1's ongoing right lower extremity leg pain, functional limitations or evidence a physician or provider was notified were entered until the discovery of the fracture with avulsion of the greater trochanter and subsequent transfer to the hospital on 11/15/2021. Review of R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR, R1 received a dose of the pain reliever once on 11/6/21, twice on 11/7/21, once on 11/10/21 and did not receive another dose of the pain reliever again until 11/15/21 at 5:26 a.m., despite R1's ongoing signs and symptoms of pain, staff reports of R1's pain or documented alerts from CNA's to licensed nurses of R1's ongoing signs and symptoms of pain. During an interview on 12/2/21 at 10:15 a.m., Physician Assistant (PA) E reported that on 11/8/21 he physically assessed R1 when nursing staff reported R1 was complaining of pain. PA E recalled that R1 was painful when staff attempted to transfer R1 and ordered an x-ray to evaluate the right knee. PA E said he would assume the increased pain in the right knee was related to the fracture that was diagnosed on [DATE]. PA E reported he was not involved with ordering the right hip x-ray on 11/15/21 and did not have specific documentation pertaining to R1's ongoing increased pain or functional limitations after assessing R1 on 11/8/2021. Review of [Facility] Physician Notification forms (non-emergent notices placed in a binder for the physician to review during the next visit to the facility) for R1 reflected nurses notified the physician on 11/8/2021 R1 was painful to touch and movement of her RLE, prompting the x-ray evaluation of R1's knee on 11/8/21. Another undated Physician Notification form was completed for R1 identifying the concern as R (right) leg severe pain with palpation and movement at R lateral inferior to trochanter-bruise of unknown origin or history. The physician response was to order a STAT (right away) x-ray of the right hip and pelvis. No other notifications to the physician from 11/8/21-11/15/21 (1 week) were made, despite R1's ongoing change in condition. No evidence a physician was contacted via telephone pertaining to R1's acute change in condition was noted. Review of hospital documentation included an Inpatient Internal Medicine Consult that reflected This is a [AGE] year-old female who presented to the Emergency Department via EMS (Emergency Medical Services) on 11/15/2021 after sustaining a fall 1 week ago at her living facility [name of facility]. She has persistently complained of right hip pain. CT (computerized tomography) pelvis without contrast completed in the emergency department revealed a comminuted (the bone shatters into several different pieces) and displaced (a gap forms where the bone breaks) intertrochanteric proximal right femoral fracture extending into the base of the right femoral neck with a moderate size acute hematoma surrounding the proximal fracture with ongoing hemarthrosis. She was admitted by orthopedic surgery with plans to undergo surgical intervention tomorrow, 11/16/2021.

This citation pertains to intake MI- 3 Based on interview and record review, the facility failed to respond to an acute change in condition in a timely manner for 1 resident (Resident #1) resulting in ongoing, untreated pain from an undiagnosed comminuted and displaced intertrochanteric proximal right femoral fracture. Findings: Review of a facility Admission Record reflected Resident #1 (R1) admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 was severely cognitively impaired and needed extensive assistance from one person for bed mobility, transfers, walking, dressing, eating, toileting and personal hygiene. Review of a Care Plan initiated on 10/4/2018 reflected R1 was at risk for acute pain and has chronic pain related to [CONDITION(S)], osteopenia, recent fracture of right femur and history of rhabdomyolysis and [CONDITION(S)]. The goal of the care plan was to ensure R1 did not have an interruption in normal activities due to pain through the review date. Interventions included: Assess for existence of pain, signs and symptoms, location, intensity, quality, pain relief etc. on admission and quarterly; Administer [MEDICATION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .; Notify Physician PRN if interventions are unsuccessful or if current complaint is a significant change from [R1's] past experience of pain; Anticipate [R1's need for pain relief PRN and respond immediately to any complaint of pain; Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased ROM, withdrawal or resistance to care as needed; Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o (complaints of) pain or discomfort. Review of a Care Plan initiated on 10/04/2018 reflected [R1] has an ADL (Activity of Daily Living) Self Care Performance Deficit and requires extensive assistance with most ADL's and mobility r/t (related to) weakness, HX (history) of kidney injury, OA ([CONDITION(S)]), [CONDITION(S)], HLD (high cholesterol), recent right femur fracture with surgical repair and a history of dizziness. Interventions listed in the care plan included TRANSFER: [R1] requires x1 (one person) extensive assistance with transfers using walker and gait belt. She often self-transfers despite reinforcing education to call or wait for assistance. If she is unable to stand, do no use sit-to-stand (a type of mechanical lift) due to [R1's] functional abilities. Use full body mechanical lift if she is unable to stand; Assess/record change in ADL status and report to physician. Review of a Care Plan initiated on 11/14/2019 reflected R1 had osteopenia that placed her at an increased risk for traumatic or spontaneous injury. One of the goals identified in the care plan was [R1] will remain free from or at a level of discomfort acceptable to [R1] through review date. Interventions in the care plan included Give analgesics PRN (as needed) for pain. R1 may complain of pain, stiffness or weakness. Document complaints. Review of an Incident and Accident Report dated 11/15/21 reflected R1 complained of pain with associated discoloration of the right hip. An x-ray was ordered by the physician and revealed a fracture. According to the incident report, R1 denied any injury and was sent to the emergency room . Review of a Radiology Results Report dated 11/15/21 reflected R1 had a unilateral right hip x-ray with or without a pelvic view at the facility. The Findings revealed Limited study, marked DJD ([CONDITION(S)] joint disease), apparent fracture with avulsion (a tendon or ligament pulls part of the bone off) of the greater trochanter. During an interview on 12/2/21 at 11:00 a.m., Unit Manager, LPN F said she was working the 3rd shift on 11/7/21 when she was told that R1 complained of pain with movement to her right lower extremity. LPN F assessed R1 and there were no signs of fracture, just knee pain that was relieved with Tylenol. LPN F said that she would hear about R1 complaints of pain in daily meetings but knew that the right knee x-ray was negative for evidence of injury. LPN F said that R1 used to be a one person stand-pivot for transfers and after the knee was found to be without injury, therapy screened R1 for positioning in her wheelchair. Review of a Nurses Note dated 11/7/21 at 4:50 a.m., reflected Resident with reports of RLE pain. PRN Tylenol (acetaminophen) given as ordered. No obvious deformity or injury present, no s/sx (signs of symptoms) of skin infection, she states nothing happened to cause the pain it just hurts. Mild pain with ROM (Range of Motion) of knee. No pain at rest. Provider notified. During an interview on 12/2/21 at 9:29 a.m., Licensed Practical Nurse (LPN) C reported R1 would yell out in pain about a week prior to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN C said R1 would point to her knee and reach down to her knee area which prompted her to report the change to the Unit Manager (LPN F) and an x-ray of the right knee was ordered but did not show there was an injury to R1's knee. According to LPN C, she noticed bruising to R1's right hip area a week later and that was when another x-ray of the right hip was ordered. Review of a Radiology Results Report dated 11/08/21 reflected R1's right knee was x-rayed and revealed No acute findings. [CONDITION(S)] changes. Consider a repeat study if symptoms continue to persist or progress. During an interview on 12/2/21 at 2:36 p.m., Certified Occupational Therapy Aide (COTA) L reported she did a screening evaluation on R1 on 11/09/21 and recommended therapy services to assist R1. COTA L said that when she screened R1, she was seated in her wheelchair in a common area at the facility and seemed to be in acute pain. COTA L said that when she approached R1 with the lightest touch, R1 would cry out Ow! Ow! Ow! and she noted R1's knee was swollen. According to COTA L, Physical Therapy was also going to work with R1, but did not have to opportunity to do so until after the fracture was identified on 11/15/21. Review of an Interdisciplinary Therapy Screen dated 11/09/2021 reflected 1. Reason for the Therapy Screen - b. Significant Change; d. Positioning. The screening form indicated R1 had a change in positioning, posture and transfer status since the last screen had been completed. Comments on the screening form entered by COTA L reflected Nursing reports res (resident) has right knee pain and may require seating/positioning eval (evaluation). Observed res right and left knee with [CONDITION(S)] present right knee and res reporting pain with gentle touch. Staff reports lift is being used for t/f's (transfers) now. The Results of Interdisciplinary Rehab Screen were that R1 would require skilled physical and occupational therapy. Review of an Occupational Therapy (OT) OT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Reason for Referral indicated Patient with decline in function limiting ability to complete fxl (functional) t/fs (transfers). Patient with new pain in LE (Lower Extremity) limiting ability to engage in functional activities. Staff requesting therapist to position w/c (wheelchair). According to the evaluation, R1's right lower extremity Range of Motion (ROM) and Strength/Manual Muscle Testing could not be tested due to increased pain. The Pain assessment portion of the evaluation reflected R1 reported constant pain in her RLE (right lower extremity) with movement. The Evaluation Summary of the OT assessment completed 11/11/21 reflected Therapist trialing alternate foot placement on w/c to increase comfort though pt (patient) increase c/o pain with touch of LE, no movement able to complete. Additional comments indicated Subjective/Objective: Patient asleep in chair and indicating high level of pain in R (right) hip area limiting fxl activities. During an interview on 12/2/21 at 9:27 a.m., Certified Nurse Aide (CNA) B reported she cared for R1 in the days preceding R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to CNA B, R1 would complain of pain with the lightest touch and cry out Ow! You're hurting me!. CNA B said she observed bruising and noticed the pain and would report the findings to the nurses. CNA B said she could tell R1 was having increased pain because when she would observe R1 lying in bed, R1 just didn't look right. During an interview on 12/2/21 at 9:49 a.m., CNA D reported that R1 was in pain for a week before she was diagnosed with a fracture on 11/15/21. According to CNA D, R1 would scream in pain and did not want to get out of bed. CNA D said R1 would normally complain/object to being cared for or transferred but that this pain was different. CNA D said she was not comfortable transferring R1 as she normally would (extensive assistance of one person to stand and pivot from bed to chair and chair to bed) and opted to use the mechanical lift instead. CNA D said she told nursing staff about R1's pain but they would tell her the right knee x-ray didn't show any injury. During an interview on 12/2/21 at 1:10 p.m., CNA H reported she noticed R1's right knee was swollen on 11/8/21 and cared for R1 in the days leading up to the discovery of the fracture on 11/15/21. According to CNA H, R1's pain was through the roof and she would not transfer R1 without a mechanical lift due to her obvious discomfort. Review of CNA task Documentation Survey Report v2 for the month of November 2021 reflected that between 11/7/2021 when R1 began complaining of significant pain with movement and 11/15/2021 when the right hip fracture was diagnosed with an x-ray, R1 was transferred with the extensive assistance (resident involved in activity, i.e., bearing weight on her legs) of one person at least 10 times. R1 was transferred with the extensive assistance of two people at least 4 times during the week leading up to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Clinical Alerts and Order Listing Report dated 11/5/21-12/2/21 reflected the following pertinent alert and customized alert charting (per the Director of Nursing (DON), CNA's can free text custom alerts that are to be reviewed by Licensed Nurses, in addition to pre-populated selections): 11/5/21: Yelling/Screaming 11/6/21: Yelling/Screaming 11/8/21: Pain-new or worsening: Participated less in activities; Yelling/Screaming; Frequent Crying; Pushing; Grabbing 11/11/21: Resident continues to scream in pain, saying her leg even when no one is around or touching it; Yelling/Screaming 11/12/21: Yelling/Screaming 11/14/21: Yellow/green bruising on pelvic area, hip area, and near the knee. She also screams in pain when barely touching her leg. (Yellow/green bruising can be an indication of the age of injury, typically not acute.) Review of Progress Notes after the entry dated 11/7/2021 at 4:50 a.m., revealed no additional Nurses Notes pertaining to R1's ongoing right lower extremity leg pain, functional limitations or evidence a physician or provider was notified were entered until the discovery of the fracture with avulsion of the greater trochanter and subsequent transfer to the hospital on 11/15/2021. Review of R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR, R1 received a dose of the pain reliever once on 11/6/21, twice on 11/7/21, once on 11/10/21 and did not receive another dose of the pain reliever again until 11/15/21 at 5:26 a.m., despite R1's ongoing signs and symptoms of pain, staff reports of R1's pain or documented alerts from CNA's to licensed nurses of R1's ongoing signs and symptoms of pain. During an interview on 12/2/21 at 10:15 a.m., Physician Assistant (PA) E reported that on 11/8/21 he physically assessed R1 when nursing staff reported R1 was complaining of pain. PA E recalled that R1 was painful when staff attempted to transfer R1 and ordered an x-ray to evaluate the right knee. PA E said he would assume the increased pain in the right knee was related to the fracture that was diagnosed on [DATE]. PA E reported he was not involved with ordering the right hip x-ray on 11/15/21 and did not have specific documentation pertaining to R1's ongoing increased pain or functional limitations after assessing R1 on 11/8/2021. Review of [Facility] Physician Notification forms (non-emergent notices placed in a binder for the physician to review during the next visit to the facility) for R1 reflected nurses notified the physician on 11/8/2021 R1 was painful to touch and movement of her RLE, prompting the x-ray evaluation of R1's knee on 11/8/21. Another undated Physician Notification form was completed for R1 identifying the concern as R (right) leg severe pain with palpation and movement at R lateral inferior to trochanter-bruise of unknown origin or history. The physician response was to order a STAT (right away) x-ray of the right hip and pelvis. No other notifications to the physician from 11/8/21-11/15/21 (1 week) were made, despite R1's ongoing change in condition. No evidence a physician was contacted via telephone pertaining to R1's acute change in condition was noted. Review of hospital documentation included an Inpatient Internal Medicine Consult that reflected This is a [AGE] year-old female who presented to the Emergency Department via EMS (Emergency Medical Services) on 11/15/2021 after sustaining a fall 1 week ago at her living facility [name of facility]. She has persistently complained of right hip pain. CT (computerized tomography) pelvis without contrast completed in the emergency department revealed a comminuted (the bone shatters into several different pieces) and displaced (a gap forms where the bone breaks) intertrochanteric proximal right femoral fracture extending into the base of the right femoral neck with a moderate size acute hematoma surrounding the proximal fracture with ongoing hemarthrosis. She was admitted by orthopedic surgery with plans to undergo surgical intervention tomorrow, 11/16/2021.

Based on interview and record review, the facility failed to develop and implement person centered care plans for one resident (R 57) out of 20 residents reviewed for care planning. This deficient practice resulted in multiple falls with injury and canned, nonresident specific interventions. Findings include: According to the Minimum Data Set (MDS) assessment, dated 3/1/21, R 57 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 57 required extensive assistance of two staff members to move in bed, transfer, and for hygiene needs including using the bathroom. Staff assessed R 57 as severely cognitively impaired. This same assessment indicated R 57 had two or more falls without injury and one fall with a minor injury since the most recent admission on 12/17/20. Review of an Incident and Accident Report dated 10/1/20, R 57 was found on the floor by staff. There was no injury and R 57's care plan was updated on 10/2/20 to offer to assist (name R 57) to lay down after meals. According to an Incident and Accident Reports, dated 10/1/20 through 1/14/21, staff found R 57 on the floor at the following times when R 57 was care planned to be in bed: 12/2/20 at 10:00 AM 1/14/21 at 9:50 AM 1/28/21 at 10:30 AM 3/11/21 at 12:30 PM The facility posted meal serving times as follows: Breakfast at 7:30 AM, Lunch at 11:30 AM, and Dinner at 5:30 PM. According to an Incident and Accident Report, dated 1/28/21, R 57 was found on the floor by staff. Staff observed (R 57) on floor on L (left) side, in fetal position c (with) pool of blood under head. Was in Broda chair, which was noted in upright position. (R 57) sustained 3 cm (centimeter) lac (laceration) to the L forehead requiring sutures. Another Incident and Accident Report, dated 3/11/21, staff found R 57 on the floor, the report read, Resident was in Broda chair eating lunch. When finished he attempted to climb out and was found on floor. He did hit his head c (with) no other injuries. During an interview on 3/25/21 at 3:49 PM, the Director of Nursing (DON) stated that there could have been other things going on at those times that prevented staff from lying R 57 down during the care planned time after meals. The DON also stated that it was likely R 57 had refused to lie down. The DON was asked to provide any information regarding R 57's refusals. During an interview on 3/25/21 at 7:50 AM, Certified Nursing Assistant (CNA) S stated that R 57 lays down after meals and that R 57 does not refuse to lay down. During a follow up interview on 3/26/21 at 9:30 AM, the DON was asked for additional information regarding falls for R 57 and behavior or refusal documentation, the DON stated she did not have anything, and no additional information was received by the end of the survey. R 57's Trauma care plan revised 9/1/20, an intervention read Staff will assist (Name of R 57) in avoiding his potential trauma triggers. During interview on 3/25/21 at 7:50 AM and 8:05 AM, Certified Nursing Assistant (CNA) S and Licensed Practical Nurse (LPN) V, respectively, stated R 57 did not have any trauma triggers. During an interview on 3/26/21 at 10:45 AM Registered Nurse (RN) B stated that the care plan was developed by a former social worker and that the intent was that R 57 had a potential for triggers and that staff should be monitoring for trauma triggers. RN B agreed that the care plan was not specific to R 57's needs and did not indicate what triggers staff were to avoid.

Based on observation, interview, and record review the facility failed to 1). prevent falls for one of three residents (R 57) reviewed for falls, and 2). implement sufficient safety measures for one of one resident (R 9) reviewed for accidents and hazards. This deficient practice resulted in multiple falls (R 57), a laceration requiring sutures (R 57), and improper wheelchair transport of a resident (R 9). Findings include: Resident 57 According to the Minimum Data Set (MDS) assessment, dated 3/1/21, R 57 had multiple diagnoses that staff documented as medically complex and included [CONDITION(S)], diabetes, and dementia. R 57 required extensive assistance of two staff members to move in bed, transfer, and for hygiene needs including using the bathroom. Staff assessed R 57 as severely cognitively impaired. This same assessment indicated R 57 had two or more falls without injury and one fall with a minor injury since the most recent admission on 12/17/20. Review of an Incident and Accident Report dated 10/1/20, R 57 was found on the floor by staff. There was no injury and R 57's care plan was updated on 10/2/20 to offer to assist (name R 57) to lay down after meals. Staff found R 57 on the floor, after attempting to self-transfer, four more times in the next three months, there were no injuries. According to an Incident and Accident Report, dated 1/14/21, R 57 was found on the floor by staff. There was no injury, the immediate intervention was staff to assist to bed p (after) assisting with eating. Staff updated R 57's Fall care plan on 1/15/21 with, staff to lay down after assisting with eating. The facility posted meal serving times as follows: Breakfast at 7:30 AM, Lunch at 11:30 AM, and Dinner at 5:30 PM. According to an Incident and Accident Report, dated 1/28/21, R 57 was found on the floor by staff. Staff observed (R 57) on floor on L (left) side, in fetal position c (with) pool of blood under head. Was in Broda chair, which was noted in upright position. (R 57) sustained 3 cm (centimeter) lac (laceration) to the L forehead requiring sutures. Staff documented the time of the fall was at 10:30 AM, which was between meals when R 57 was care planned to be in bed. Another Incident and Accident Report, dated 3/11/21, staff found R 57 on the floor, the report read, Resident was in Broda chair eating lunch. When finished he attempted to climb out and was found on floor. He did hit his head c (with) no other injuries. Staff documented this incident occurred at 12:30 PM and after R 57 had finished lunch, when R 57 was care planned to be in bed. During an interview on 3/25/21 at 3:49 PM, the Director of Nursing (DON) stated that there could have been other things going on at those times that prevented staff from lying R 57 down during the care planned time after meals. The DON also stated that it was likely R 57 had refused to lie down. The DON was asked to provide any information regarding R 57's refusals. During an interview on 3/25/21 at 7:50 AM, Certified Nursing Assistant (CNA) S stated that R 57 lays down after meals and that R 57 does not refuse to lay down. During a follow up interview on 3/26/21 at 9:30 AM, the DON was asked for additional information regarding falls for R 57 and behavior or refusal documentation, the DON stated she did not have anything, and no additional information was received by the end of the survey. The facility policy Fall Management, revised 10/2019, read, Each guest /resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Guests/residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. Resident #9 A review of Resident #9's Admission Record, dated 3/25/21, revealed Resident #9 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 9's Admission Record revealed Resident #9 had multiple diagnoses that included Alzheimer's Disease, dementia, unsteadiness on feet, and a history of falling. A review of Resident #9's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/5/21, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which revealed Resident #9 was severely cognitively impaired. In addition, Resident #9's MDS revealed Resident #9 needed the physical assistance of one person for wheelchair ambulation. During an observation on 03/23/21 at 02:30 PM, certified nursing assistant (CNA) I was observed pushing Resident #9 in the hallway from Resident #9's room to the shower room without foot pedals. After CNA I had pushed Resident #9 to the shower room, and as she was getting ready to push Resident #9 through the open shower door, Registered Nurse (RN) G told CNA I she needed to go get Resident #9's wheelchair foot pedals. RN G informed CNA I she should not be pushing residents in their wheelchairs without foot pedals. During an interview on 3/24/21 at 4:00 PM, a copy of the facility's wheelchair ambulation policy, specifically the policy covering the use of foot pedals, was requested from the Director of Nursing (DON). During a second interview on 03/24/21 at 5:00 PM, the DON stated she could not locate a policy on the use of foot pedals while ambulating a resident. She stated she would still look for it. During a third interview on 03/25/21 at 07:50 AM, the DON stated she could not locate a policy about ambulating a resident with foot pedals. She stated she would expect that if staff are pushing a resident in the wheelchair, then staff should ensure the resident has foot pedals on their wheelchair. During an interview on 3/25/21 at 8:25 AM, CNA J stated residents are supposed to have foot pedals on their wheelchairs when staff push them down the halls. During an interview on 03/25/21 at 08:35 AM, CNA K stated residents should have foot pedals on their wheelchairs when staff push them in their wheelchairs.

Based on observation, interview, and record review, the facility failed to prevent the abuse of 2 Residents (#2 and #9) of 9 Residents reviewed for abuse, of a total of 9 Residents, resulting in Resident #2 being physically assaulted twice by Resident #5 and Resident #9 being physically and verbally assaulted by Resident #5, when the facility failed to increase supervision of Resident #5 when he was known to have problems with physical/emotional control and had a history of [REDACTED]. Resident #5 Review of Resident # 5's face sheet dated 4/3/17 revealed he was [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #5 had court appointed guardian. Review of Resident #5's progress notes for March 2017 revealed Resident #5 had 3 resident to resident incidents that resulted in physical contact and injuries. 2 incidents were witnessed and Resident #5 was the aggressor and one incident was not witnessed but the other resident was found to have a bloody lip and Resident #5 was in the other resident's room when the injury was discovered. The progress notes indicated that the incidents on 3/15/17 and 3/19/17 involved resident #2. The incident on 3/29/17 involved resident #9. This Surveyor asked Director of Nursing (DON) A on 4/11/17 at 8:35 AM, for all of Resident #5's incident reports and resident to resident altercations for 6 months. DON A said there were only 2 resident to resident incidents during that time frame and both had been reported to the State and had already been provided. On 4/11/17 at 10:20 AM, DON B was asked if Resident #5 had ever injured any staff. DON B said yes but did not have the details at that time. DON B had Nursing Home Administrator (NHA) A provide the information on the staff injury. NHA A provide a hospital copy of an Employer Discharge Summary for Certified Nurses Aide (CNA) R dated 11/10/16. The report documented that CNA R reported she had been choked and punched in the side of the head by a resident last night. and a CT scan was ordered and no work for 24 hours was ordered. Review of CNA R's Employee Incident Report dated 11/9/16 documented under description of occurrence. I calmly walked into (name of Resident #5) room because his alarm was going off. He was urinating in the middle of the room. (name of Resident #5) said I'm sorry I couldn't hold it. I said That's okay (name of Resident #5) I will clean it up and it will be fine his eyes got huge and he choked me then used his arm to choke me further while punching me 3 times. When he stopped he said sorry I felt like hitting someone and went back to bed. On 4/11/17 at 10:20 AM, this Surveyor showed DON A Resident #5's progress note dated 3/15/17 that documented, Resident #5 was in the the hall and was observed to be standing behind Resident #2's wheel chair and Resident #5 used the palm of his right hand to hit Resident #2 on the side of her head. The note also documented Resident #5 was agitated prior to the incident as evidence by pacing and talking about work. This Surveyor ask if there was any incident report or investigation for this incident. DON B returned with a file and incident report. This Surveyor asked why this file was not provided when it was requested earlier and DON B said the file was in a different location because it was one that was not reported to the State. This Surveyor asked why this one was not reported to the State and DON B said because there was no intent of harm. DON B said corporate decides what abuse allegation are reported to the State. Resident #2 Review of Resident #2's face sheet dated 4/10/17 revealed she was an [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #2 was not her own responsible party. Review of Resident #2's progress note dated 3/15/17 documented Resident #2 was observed at 7:15 PM being hit by Resident #5 on the right side of her head. Vital signs and neurological checks with completed. Resident #2 was angry after she was hit. Resident #2 called Resident #5 names and was cursing at him. Resident #2' physician was notified. Review of a facility reported incident dated 3/26/17 revealed there was an unwitnessed resident to resident incident with Resident #2 and Resident #5. Resident #5 was found in Resident #2's bed and Resident #2 had a bloody lip and Resident #5 had bite marks on his hand. Review of Resident #2's progress note dated 3/26/17 documented at 8:00 PM Resident #2's family and doctor were notified of an incident of swelling to the left upper lip and Resident #2 was unable to recall the episode after the occurrence. (no indication of a resident to resident altercation). Review of Resident #2's progress note dated 3/29/17 documented at 3:30 am Resident #2 had a resident to resident incident (other resident not identified). The note documented that resident to resident contact resulted in Resident #2 having a swollen lip. At 2:00 PM, Resident #2 was upset for having trauma to her mouth and her mouth was sore and red. The note indicated Resident #2 was staying to herself and keeping other residents away to help her with her fear. At 7:00 PM Resident #2's lip remained swollen and bruised. Resident #9 Review of Resident #9's face sheet dated 4/10/17 revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #9 was not her own responsible party. Review of the facility reported incident date 3/22/17 at 4:10 PM Resident #5 became aggressive with Resident #9, he became loud and pushed her into the hallway wall. Review of Resident #9's progress note dated 3/22/17 documented Resident #5 was observed to grab resident #9 by both arms and pushed her into the wall. Resident #5 told Resident #9 to take of your clothes Resident #5 was give 10 mg of [MEDICATION NAME] IM (shot). Resident 5 was supervised until he went to sleep but was back up wandering the in the hall by 6:15 PM and had to be redirected out of other residents rooms. On 4/7/17 at 1:15 PM two CNA's were the only staff working on the locked until were Resident #2, #5 and #9 lived. At total of 20 residents were listed as being on that unit on 4/7/17. CNA S was interviewed and said this was her 4th day working in the facility and her first day off orientation. CNA S said she was not aware of Resident #5 having any aggressive behavior or any special care/supervision. CNA T was interviewed and said she worked Resident #5's unit one day a week. CNA T was not aware of Resident #5 having any aggressive behaviors or special care/supervision During an interview with NHA A on 4/11/17, at 8:40 AM NHA was asked what the facility had done to increase the supervision of Resident #5 due to having physical altercations with Residents on the locked unit. NHA A said they had placed a baby monitor in the hall and at the nurses station out side the locked door but the Residents keep moving the monitor and we have to look for it daily. NHA A said when the incident happened on 3/22/17, according to Resident #5's progress note the incident was, Resident #5 was observed grabbing Resident #9 by her arms and pushed her into the wall and stated take off your clothes, only one staff person was on the unit at that time because one person took a break at an unscheduled time. NHA A the person that took the break leaving only one person on the unit received discipline. NHA A did not acknowledge that the other incidence had at least 2 people on the unit and the altercations were not prevented. During a telephone interview with CNA U on 4/11/17 at 12:05 PM. CNA U said she was working on the locked unit when a Resident was injured but did not want to give the date as she did not want the facility to identify who she was. CNA U said she had witness Resident #5 attempt to hit staff in the past. CNA U said the baby monitor does not help because the nurses are passing medications on 2nd shift and cannot hear calls for help. CNA U said there are only 2 staff on the unit on second shift and it takes 2 people to feed 20 residents and we cannot follow Residents when they leave the dinning room on there own. CNA U said some Residents need two people to assist with care and they have to pull the curtains and close doors during care so they cannot hear or see the other resident. CNA U said it is not safe for just two people to be on the locked unit. During an telephone interview with CNA V on 4/11/17 at 1:00 PM CNA V said she was working on the locked unit when Resident #5 injured a Resident. CNA V did not want any details provided that would help the facility identify her. CNA V said Resident #5 goes in/out of the dinning room multiple time during dinner and they cannot follow him out of the dinning room and assist all the other residents eat as there are only 2 staff on the unit. CNA V said she feels safe because she knows when Resident #5 gets that look in his eyes you just back off. CNA V said the baby monitor does not help as there is no one to respond at the desk when help is needed because everyone is working. CNA V provided a name of a CNA that had been injured by Resident #5 in the past 6 months. During an interview with Resident #5's Physician W on 4/11/17 at 3:30 PM, Physician W said Resident #5 has to be approached with care. Physician W always moves in slowly and looks Resident #5 in the eyes to see if he can approach. Physician W said there are many triggers that set off Resident #5 and gave examples of sight, sounds, individuals and strangers. Physician W was concerned that 1:1 supervision could increase Resident #5's aggressive behaviors but did agree more supervision was needed as the residents on the unit do not know when it is safe to approach Resident #5.

This citation pertains to MI 990. Based on observation, interview, and record review, the facility failed to report to the State Agency and thoroughly investigate allegations of abuse and injuries of unknown origin for 17 residents (Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) out of a total sample of 22 residents reviewed for abuse and neglect, resulting in immediate jeopardy when abuse allegations and injuries of unknown origin for Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 were not reported or investigated causing the potential for abuse, neglect, injury, harm and/or death due to resident incidents not being thoroughly investigated and reported to the State Agency to determine origin of, or identification of staff or residents, who may be mistreating or not providing services to residents. This deficient practice places all 100 facility residents, who were identified by the facility as at risk for falls, at risk for serious harm, injury, and/or death Findings include: Review of the facility's Resident Abuse Policies and Procedures, revised 6/1/2015, revealed, An abusive act is any act or omission, which may cause or causes actual physical, psychological or emotional harm or injury to a resident .Acts of abuse directed against residents are absolutely prohibited .All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent other from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse to a resident, is obligated to report such information immediately to their supervisor .The supervisor is obligated to immediately report to the Executive Director (Nursing Home Administrator) who is designated abuse coordinator .Once an allegation of abuse is reported, the Executive director, as the abuse coordinator, is responsible for ensuring that reporting in completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .In all cases, the Executive Director or Director of Clinical Services (Director of Nurses) will ensure notification of the resident's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse .and the attending physician . On 6/3/16 the facility was made aware of an allegation of abuse in which abuse was substantiated by a Certified Nursing Assistant. As part of that investigation, on 6/7/16, all residents were asked two questions by social work (SW) staff SW C and SW D, in which they documented the residents' response on an untitled form, 1. Do you have any concerns with how staff treats you at THS (Transitional Health Services) Fremont? In review of these forms, the following was revealed: Resident #4 stated, Certified Nursing Assistant (CNA) E popped her shoulder out. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #4 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Resident 5, stated they treat me like[***] All of them are mean, (Licensed Practical Nurse (LPN) F) is something else. Review of the Face Sheet and MDS dated [DATE], revealed Resident #5 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Resident #6 stated he was treated a little rough, and was told it was his fault. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #6 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #6 scored 12 out of 15 (Moderately Impaired Cognitively) on the Brief Interview for Mental Status (BIMS). Resident #7, wife and roommate of Resident #6 stated, CNAs are rough with me when they take care of me (CNA G). Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #7 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #7 scored 10 out of 15 (Moderately Impaired Cognitively) on the Brief Interview for Mental Status (BIMS). Resident #8 stated CNAs are lazy, shutting off the light and not helping when food trays come. (CNA H) is rude about opening door when she wants to smoke. When food trays come, CNAs get upset about having to get something extra. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #8 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #8 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Resident #9 stated With some of the staff, I'm not good with names. Review of the Face Sheet and MDS dated [DATE], revealed Resident #9 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #9 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). During an interview on 6/23/16 at 12:15 p.m. when asked if the allegations of abuse that were documented by social work staff were investigated, SW C stated, No, I gave them to my new boss (SW D). I just asked her today about the follow up with the resident concerns and (SW D) said no, hadn't heard anything about them. During an interview on 6/23/16 at 12:25 p.m., when asked if the allegations of abuse that were documented by social work staff were investigated, SW D stated, No, I did not do anything with them other than hand them over to the (Nursing Home Administrator (NHA) A). During an interview on 6/23/16 at 12:35 p.m., when asked if the allegations of abuse that were brought forth by Residents #4, #5, #6, #7, #8 and #9, NHA A stated that she had not investigated them, as she was not aware of these allegations, this was the first I knew about these allegations. When asked if the Social Workers gave her the slips with the questions about abuse on them, NHA A stated, Yup, they put them on my desk about a week ago. When asked if the staff members that were alleged to be abusive towards the residents were suspended, NHA A stated, no they were not, they are still here. Furthermore, NHA A confirmed that two of the staff members were actually working today (6/23/16). NHA A stated that on 6/3/16, the entire facility was inserviced on proper reporting of allegations of abuse. When asked if SW C and SW D were at the inservices, NHA A stated that yes both of them were there. Further review of the investigation revealed that the facility also completed skin sweeps on 6/3/16 on all of the residents in the facility, and were documented on Skin Care Alert sheets. Review of these sheets revealed that there were new findings of bruising on 12 residents. On 6/23/16 at 12:55 p.m., when asked if these bruises were investigated as Injuries of Unknown Origin, Director of Nursing (DON) B stated that charge nurses had completed the skin sweeps, and had reported to her that there were no new skin issues. On 6/23/16 at 12:35 p.m., when asked about the skin sweeps indicating new bruising, NHA A stated that (DON B) told her there were no new skin issues on any of the residents. Further review of these skin sweeps revealed that the following bruises were indeed new, and where not investigated as new injuries of unknown origin: Resident #4's Skin Care Alert sheet indicated 4 little bruises on the left backside of the arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, It's not there, it's not documented elsewhere. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #4 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Resident #10's Skin Care Alert sheet indicated, spotty bruise on the left arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I can't speak to that one, I did not actually see that bruise. Review of the Face Sheet and MDS dated [DATE], revealed Resident #10 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#10 had severely impaired cognition. Resident #11's Skin Care Alert sheet indicated, busies on the left arm, multiple little bruises on the right arm and right hand/wrist area. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I never saw the little bruises .no they are not previously documented. Review of the Face Sheet and MDS dated [DATE], revealed Resident #11 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #11 had severely impaired cognition. Resident #12's Skin Care Alert sheet indicated, multiple bruises on both the left and right arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, There are no bruises previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #12 was an [AGE] year old male, admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed Resident #11 scored 13 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Resident #13's Skin Care Alert sheet indicated a little bruise on the buttock. Further review of the medical chart failed to reveal where this bruise was previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, It was not previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #13 was a [AGE] year old female, admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed Resident #13 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Resident #14's Skin Care Alert sheet indicated bruises on the left arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I don't see it previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #14 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #14 scored 7 out of 15 (Severely Impaired Cognitively) on the Brief Interview for Mental Status (BIMS). Review of Resident #15's Skin Care Alert sheet indicated bruises on both the left and right upper arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated that these ones are above the ones previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #15 was an [AGE] year old female, admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed Resident #15 scored 13 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Review of Resident #16's Skin Care Alert sheet indicated multiple bruises on both arms and face. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, There was nothing noted prior to 6/3/16. Review of the Face Sheet and MDS dated [DATE], revealed Resident #16 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #16 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of Resident #17's Skin Care Alert sheet indicated bruises on both arms and the right hand. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, Nothing shows that it was previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #17 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #17 was severely impaired cognitively. Review of Resident #18's Skin Care Alert Sheet indicated bruises on the left elbow, bruise looks new on (right) elbow. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, She had fallen on 5/10 or 17, but it didn't say anything as to where the bruise was. Review of the Face Sheet and MDS dated [DATE], revealed Resident #18 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #18 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of Resident #19's Skin Care Alert sheet indicated multiple bruises on both arms and right upper thigh region. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, None of these bruises were previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #19 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #19 was moderately impaired cognitively. Review of Resident #20's Skin Care Alert sheet indicated a bruise on the left hand. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I don't have anything on this. Review of the Face Sheet and MDS dated [DATE], revealed Resident #20 was an [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #20 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The facility was notified of IJ/Immediate Jeopardy at F-225 on 6/23/16 at 10:45 AM, was identified on 6/23/16 and began on 6/3/16, due to the facility's failure to report and investigate allegations of abuse and injuries of unknown origin for Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20, who had made allegations of abuse and been recognized as having new bruises of unknown origin, resulting in abuse allegations and injuries of unknown origin for Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 not reported or investigated and the potential for abuse, neglect, injury, harm and/or death due to resident incidents not being thoroughly investigated and reported to the State Agency to determine origin of, or identification of staff or residents, who may be mistreating or not providing services to residents. This deficient practice places all 100 facility residents, who were identified by the facility as at risk for falls, at risk for serious harm, injury, and/or death On 6/27/16, the surveyors verified the facility had done the following to remove the Immediate Jeopardy: - On 6/23/16, Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 were assessed by the primary care physician/Medical Director. - On 6/23/16, Residents #4, #5, #6, #7, #8, and #9 were assessed and interviewed by the Director of Clinical Services and/or Executive Director. - On 6/23/16, Residents #10, #11, #12, #13, #14, #15, #16, #17, #19, and #20 were assessed and interviewed by the Nurse Management Team. - On 6/23/16 at 4:15 pm, Social Workers C and D were immediately suspended. - On 6/23/16 at approximately 4:35 pm, Certified Nursing assistants E, G, and H were immediately suspended. - On 6/23/16 at 4:30 pm, Licensed Practical Nurse F was immediately suspended. - On 6/23/16, current facility residents were interviewed regarding abuse. - On 6/23/16, skin sweeps were completed on current facility residents. Any new skin conditions were investigated and addressed according to the facility Policy and Procedure. - On 6/23/16, the facility began re-education of facility staff on the facility abuse policy and appropriate reporting. - On 6/23/16, the facility began re-education of Licensed Nurses on the facility skin policy and reporting and recording of skin injuries. - On 6/23/16, the facility began re-education of Certified Nursing Assistants on reporting skin injuries to Licensed Nurse beginning June 23, 2016. - On 6/23/2016 an adHOC QAPI meeting was held. Although the Immediate Jeopardy (IJ) was removed on 6/23/16, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency. ( , )

This citation pertains to MI 990. Based on observation, interviews, and record review, the facility failed to operationalize its Resident Abuse Policies and Procedures for 17 residents (Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) out of a total sample of 22 residents reviewed for abuse and neglect, resulting in immediate jeopardy when abuse allegations and injuries of unknown origin for Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 were not reported or investigated causing the potential for abuse, neglect, injury, harm and/or death due to resident incidents not being thoroughly investigated and reported to the State Agency to determine origin of, or identification of staff or residents, who may be mistreating or not providing services to residents. This deficient practice places all 100 facility residents, who were identified by the facility as at risk for falls, at risk for serious harm, injury, and/or death. Findings include: Review of the facility's Resident Abuse Policies and Procedures, revised 6/1/2015, revealed, An abusive act is any act or omission, which may cause or causes actual physical, psychological or emotional harm or injury to a resident .Acts of abuse directed against residents are absolutely prohibited .All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent other from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse to a resident, is obligated to report such information immediately to their supervisor .The supervisor is obligated to immediately report to the Executive Director (Nursing Home Administrator) who is designated abuse coordinator .Once an allegation of abuse is reported, the Executive director, as the abuse coordinator, is responsible for ensuring that reporting in completed timely and appropriately to appropriate officials in accordance with Federal and State regulations .In all cases, the Executive Director or Director of Clinical Services (Director of Nurses) will ensure notification of the resident's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse .and the attending physician . On 6/3/16 the facility was made aware of an allegation of abuse in which abuse was substantiated by a Certified Nursing Assistant. As part of that investigation, on 6/7/16, all residents were asked two questions by social work (SW) staff SW C and SW D, in which they documented the residents' response on an untitled form, 1. Do you have any concerns with how staff treats you at THS (Transitional Health Services) Fremont? In review of these forms, the following was revealed: Resident #4 stated, Certified Nursing Assistant (CNA) E popped her shoulder out. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #4 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Resident 5, stated they treat me like[***] All of them are mean, (Licensed Practical Nurse (LPN) F) is something else. Review of the Face Sheet and MDS dated [DATE], revealed Resident #5 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Resident #6 stated he was treated a little rough, and was told it was his fault. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #6 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #6 scored 12 out of 15 (Moderately Impaired Cognitively) on the Brief Interview for Mental Status (BIMS). Resident #7, wife and roommate of Resident #6 stated, CNAs are rough with me when they take care of me (CNA G). Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #7 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #7 scored 10 out of 15 (Moderately Impaired Cognitively) on the Brief Interview for Mental Status (BIMS). Resident #8 stated CNAs are lazy, shutting off the light and not helping when food trays come. (CNA H) is rude about opening door when she wants to smoke. When food trays come, CNAs get upset about having to get something extra. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #8 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #8 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Resident #9 stated With some of the staff, I'm not good with names. Review of the Face Sheet and MDS dated [DATE], revealed Resident #9 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #9 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). During an interview on 6/23/16 at 12:15 p.m. when asked if the allegations of abuse that were documented by social work staff were investigated, SW C stated, No, I gave them to my new boss (SW D). I just asked her today about the follow up with the resident concerns and (SW D) said no, hadn't heard anything about them. During an interview on 6/23/16 at 12:25 p.m., when asked if the allegations of abuse that were documented by social work staff were investigated, SW D stated, No, I did not do anything with them other than hand them over to the (Nursing Home Administrator (NHA) A). During an interview on 6/23/16 at 12:35 p.m., when asked if the allegations of abuse that were brought forth by Residents #4, #5, #6, #7, #8 and #9, NHA A stated that she had not investigated them, as she was not aware of these allegations, this was the first I knew about these allegations. When asked if the Social Workers gave her the slips with the questions about abuse on them, NHA A stated, Yup, they put them on my desk about a week ago. When asked if the staff members that were alleged to be abusive towards the residents were suspended, NHA A stated, no they were not, they are still here. Furthermore, NHA A confirmed that two of the staff members were actually working today (6/23/16). NHA A stated that on 6/3/16, the entire facility was inserviced on proper reporting of allegations of abuse. When asked if SW C and SW D were at the inservices, NHA A stated that yes both of them were there. Further review of the investigation revealed that the facility also completed skin sweeps on 6/3/16 on all of the residents in the facility, and were documented on Skin Care Alert sheets. Review of these sheets revealed that there were new findings of bruising on 12 residents. On 6/23/16 at 12:55 p.m., when asked if these bruises were investigated as Injuries of Unknown Origin, Director of Nursing (DON) B stated that charge nurses had completed the skin sweeps, and had reported to her that there were no new skin issues. On 6/23/16 at 12:35 p.m., when asked about the skin sweeps indicating new bruising, NHA A stated that (DON B) told her there were no new skin issues on any of the residents. Further review of these skin sweeps revealed that the following bruises were indeed new, and where not investigated as new injuries of unknown origin: Resident #4's Skin Care Alert sheet indicated 4 little bruises on the left backside of the arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, It's not there, it's not documented elsewhere. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #4 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Resident #10's Skin Care Alert sheet indicated, spotty bruise on the left arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I can't speak to that one, I did not actually see that bruise. Review of the Face Sheet and MDS dated [DATE], revealed Resident #10 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#10 had severely impaired cognition. Resident #11's Skin Care Alert sheet indicated, busies on the left arm, multiple little bruises on the right arm and right hand/wrist area. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I never saw the little bruises .no they are not previously documented. Review of the Face Sheet and MDS dated [DATE], revealed Resident #11 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #11 had severely impaired cognition. Resident #12's Skin Care Alert sheet indicated, multiple bruises on both the left and right arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, There are no bruises previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #12 was an [AGE] year old male, admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed Resident #11 scored 13 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Resident #13's Skin Care Alert sheet indicated a little bruise on the buttock. Further review of the medical chart failed to reveal where this bruise was previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, It was not previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #13 was a [AGE] year old female, admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed Resident #13 scored 15 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Resident #14's Skin Care Alert sheet indicated bruises on the left arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I don't see it previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #14 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #14 scored 7 out of 15 (Severely Impaired Cognitively) on the Brief Interview for Mental Status (BIMS). Review of Resident #15's Skin Care Alert sheet indicated bruises on both the left and right upper arm. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated that these ones are above the ones previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #15 was an [AGE] year old female, admitted to the facility with [DIAGNOSES REDACTED]. The MDS revealed Resident #15 scored 13 out of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). Review of Resident #16's Skin Care Alert sheet indicated multiple bruises on both arms and face. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, There was nothing noted prior to 6/3/16. Review of the Face Sheet and MDS dated [DATE], revealed Resident #16 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #16 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of Resident #17's Skin Care Alert sheet indicated bruises on both arms and the right hand. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, Nothing shows that it was previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #17 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #17 was severely impaired cognitively. Review of Resident #18's Skin Care Alert Sheet indicated bruises on the left elbow, bruise looks new on (right) elbow. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, She had fallen on 5/10 or 17, but it didn't say anything as to where the bruise was. Review of the Face Sheet and MDS dated [DATE], revealed Resident #18 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #18 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of Resident #19's Skin Care Alert sheet indicated multiple bruises on both arms and right upper thigh region. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, None of these bruises were previously documented. Review of the Face Sheet and Minimum (MDS) data set [DATE], revealed Resident #19 was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #19 was moderately impaired cognitively. Review of Resident #20's Skin Care Alert sheet indicated a bruise on the left hand. Further review of the medical chart failed to reveal where these bruises were previously documented. During an interview on 6/23/16 at 2:38 p.m., when asked if this was accurate, DON B stated, I don't have anything on this. Review of the Face Sheet and MDS dated [DATE], revealed Resident #20 was an [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #20 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The facility was notified of IJ/Immediate Jeopardy at F-225 on 6/23/16 at 10:45 AM, was identified on 6/23/16 and began on 6/3/16, due to the facility's failure to report and investigate allegations of abuse and injuries of unknown origin for Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20, who had made allegations of abuse and been recognized as having new bruises of unknown origin, resulting in abuse allegations and injuries of unknown origin for Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 not reported or investigated and the potential for abuse, neglect, injury, harm and/or death due to resident incidents not being thoroughly investigated and reported to the State Agency to determine origin of, or identification of staff or residents, who may be mistreating or not providing services to residents. This deficient practice places all 100 facility residents, who were identified by the facility as at risk for falls, at risk for serious harm, injury, and/or death On 6/27/16, the surveyors verified the facility had done the following to remove the Immediate Jeopardy: - On 6/23/16, Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 were assessed by the primary care physician/Medical Director. - On 6/23/16, Residents #4, #5, #6, #7, #8, and #9 were assessed and interviewed by the Director of Clinical Services and/or Executive Director. - On 6/23/16, Residents #10, #11, #12, #13, #14, #15, #16, #17, #19, and #20 were assessed and interviewed by the Nurse Management Team. - On 6/23/16 at 4:15 pm, Social Workers C and D were immediately suspended. - On 6/23/16 at approximately 4:35 pm, Certified Nursing assistants E, G, and H were immediately suspended. - On 6/23/16 at 4:30 pm, Licensed Practical Nurse F was immediately suspended. - On 6/23/16, current facility residents were interviewed regarding abuse. - On 6/23/16, skin sweeps were completed on current facility residents. Any new skin conditions were investigated and addressed according to the facility Policy and Procedure. - On 6/23/16, the facility began re-education of facility staff on the facility abuse policy and appropriate reporting. - On 6/23/16, the facility began re-education of Licensed Nurses on the facility skin policy and reporting and recording of skin injuries. - On 6/23/16, the facility began re-education of Certified Nursing Assistants on reporting skin injuries to Licensed Nurse beginning June 23, 2016. - On 6/23/2016 an adHOC QAPI meeting was held. Although the Immediate Jeopardy (IJ) was removed on 6/23/16, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency. ( , )

This citation pertains to intake MI 692 Based on observation, interviews, and record review, the facility failed to prevent resident to resident physical abuse for 1 resident (Resident #101) resulting in a painful 4 centimeter (cm) by 12 cm skin tear to Resident #101's right upper arm when resident #101 and #102 were left unsupervised and Resident #102 grabbed Resident #101's upper arm, resulting in physical harm and ongoing psychosocial distress due to Resident #101's cognitive status. Findings: Review of the facility Policies and Procedures-Resident Abuse last revised 6/01/2015 indicated It is inherent in the nature and dignity of each resident at The Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. The policy goes on to define physical abuse as Striking the resident with a part of the body or with an object; nontherapeutic shoving, pushing, pulling, or twisting any part of the resident's body; burning, or sticking a resident with an object. Physical contact intentionally or through carelessness that results in or is likely to result in death, physical injury, pain or psychosocial harm to the resident. Indications of psychological harm include a noticeable level of fear, anxiety, agitation or emotional distress in the resident. The policy also specifies that the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors or volunteers. Resident #101 Review of a facility Face Sheet dated 12/27/15, indicated Resident #101 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident #101 had short and long term memory problems and was severely cognitively impaired. Resident #101 did not exhibit verbal or physical behaviors toward others and needed extensive assistance from one person for bed mobility and transfers and was independent or needed one person to assist with locomotion on the unit. Resident #102 Review of a facility Face Sheet dated 3/10/16, indicated Resident #102 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #102 had short and long term memory problems and was moderately cognitively impaired. Resident #102 required extensive assistance from one person for locomotion on the unit. Review of a Care Plan dated 4/27/16, indicated Resident #102 had Alteration in mood and behavior, resident has a history of depression, shows signs of excessive worrying and anxiety, a history of rummaging and hoarding, crying, attention seeking, history of smearing bowel movement on floors walls, bed, clothes, throwing drinks at TV, a history of depression. Exhibits hitting, kicking, grabbing, biting, pushing, scratching, pinching, spitting and swearing. Interventions on the care plan included: Attempt to keep other residents out of residents personal space. Review of Interdisciplinary Progress Notes dated 5/5/16, reflected (Resident #102) has been exhibiting verbal and physical behaviors with staff and other residents. Review of a Daily Skilled Nurse's Note dated 5/13/16, reflected Resident #102 had Short and long term memory loss, 1-2 assist with transfers and ADL's (activities of daily living). Able to feed self and propel wheelchair. Incontinent of bowel and bladder at times, increase in negative behaviors. Review of a Daily Skilled Nurse's Note dated 5/16/16, indicated Resident #102 Woke up a little cranky. Behavior continues but cursing has improved . Review of a Behavior Symptom Monitoring Flow Record for the month of May 2016 indicated staff documented Resident #102's behaviors on 5/2/16 when she was noted to be pinching, hitting out, increased agitation and yelling. Staff documented on 5/4/16 that Resident #102 was refusing care. No documentation was found on the Behavior Symptom Monitoring Flow Record regarding the behaviors noted in Interdisciplinary Progress Notes dated 5/5/16 or Daily Skilled Nurse's Note dated 5/13/16 and 5/16/16. Review of an Occurrence Report dated 5/27/16 at 11:40 a.m., indicated Resident #101 sustained a skin tear on her right forearm (this is incorrect, Resident #101 sustained the skin tear to her right upper arm). A Witness statement attached to the occurrence report written by Certified Nursing Assistant (CNA) C indicated I was coming back from my lunch break and went into the shower room to help (CNA D) with a resident. When we came out and started walking down the hall towards the dining room I seen (sic) (Resident #102) grabbing (Resident #101's) arm and shaking it. I ran down, got them apart and seen (sic) she had a skin tear on her left (this is incorrect, the skin tear was on the right) upper arm. Went and got the nurse. A witness statement written by CNA D reflected Was coming down hall, saw (Resident #102) holding onto (Resident #101) shaking her arm. Got (Resident #101) out of harms was and we got the nurse. Review of a Skin Tear Root Cause Investigation Report dated 5/27/16, indicated Licensed Practical Nurse (LPN) E summarized the incident as A resident reached out for help, grabbed at resident, (Resident #101) pulled away, resulting in a skin tear. During an interview on 6/1/16 at 2:05 p.m., CNA D said she had been working on the unit where Resident #101 and #102 lived on 5/27/16. CNA D said there had been three CNA's assigned to the locked dementia unit the morning of the incident but that one staff person had been sent home at 10:30 a.m. CNA D said that there was not enough staff to meet resident needs on 5/27/16 due to the number of residents who require 2 people to assist with transfers, supervise aggressive residents and residents who are at risk for falls. CNA D said staff are not taking full breaks and they don't want someone to get hurt. CNA D reported that on the morning of 5/27/16 at approximately 11:30 a.m., CNA C had been on a lunch break, leaving her alone to care for and supervise 23 residents. When CNA C returned from her break, CNA D needed her to assist her with toileting a resident in the shower room. When CNA D and CNA C emerged from the shower room after assisting a resident, CNA C reported she saw CNA D run down the hall to separate Resident #101 and Resident #102. CNA C said she saw Resident #102 Shaking Resident #101 like a rag doll. CNA C said that Resident #101 had been having an exceptionally good day the morning on 5/27/16, but that after the incident with Resident #102 was not good. During an interview on 6/1/16 at 2:30 p.m., LPN E said she had been assigned to care for residents on the 400-500 hall. LPN E explained that the 500 hall is the locked dementia unit and that the nurse's station and all the residents who live on the 400 hall are on the other side of the locked doors. LPN E said she was not on the 500 hall when the incident between Resident #101 and Resident #102 had occurred. LPN E said she did not witness the incident. LPN E reported she had observed Resident #102 earlier on the morning of 5/27/16 reaching out to anything and anyone and asking for help. LPN E said she did not report the resident to resident incident as an allegation of abuse, but did tell Director of Nursing (DON) B the incident had occurred. During an observation on 6/1/16 at 3:05 p.m., Resident #101 was observed with a dried, bloody, adhesive bandage on her right upper arm. LPN E attempted to remove the bandage and was unsuccessful. Resident #101 was pulling away from LPN E as she tried to remove the dressing, grimacing in pain, pinching and hitting the nurse as she tried to remove the dressing. LPN F came to assist and at 3:20 p.m., LPN G (the second shift nurse) administered a dose of [MEDICATION NAME] (liquid [MEDICATION NAME], a potent narcotic) to help manage the pain. At 3:50 p.m., LPN G again attempted to remove the adhesive dressing and said This is so hard because she doesn't understand what we're doing. At 4:30 p.m., LPN G was able to remove the adhesive dressing. The dressing was covered with wet and dried blood and was very malodorous. No steri-strips were observed and a large skin flap was described by LPN G as Dead, not viable and had rolled up at the edge of the wound. LPN G measured the wound with the assistance of LPN F and it was found to be 4 cm X 12 cm in diameter.

This citation pertains to intake MI 692 Based on observation, interviews, and record review, the facility failed to provide adequate supervision to prevent resident to resident abuse resulting in resident to resident physical abuse for 1 resident (Resident #101) who sustained a painful 4 centimeter (cm) by 12 cm skin tear to the right upper arm when resident #101 and #102 were left unsupervised and Resident #102 grabbed Resident #101's upper arm, resulting in physical harm and ongoing psychosocial distress due to Resident #101's cognitive status. Findings: Review of the facility Policies and Procedures-Resident Abuse last revised 6/01/2015 indicated It is inherent in the nature and dignity of each resident at The Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. The policy goes on to define physical abuse as Striking the resident with a part of the body or with an object; nontherapeutic shoving, pushing, pulling, or twisting any part of the resident's body; burning, or sticking a resident with an object. Physical contact intentionally or through carelessness that results in or is likely to result in death, physical injury, pain or psychosocial harm to the resident. Indications of psychological harm include a noticeable level of fear, anxiety, agitation or emotional distress in the resident. The policy also specifies that the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors or volunteers. Additional information found in the facility Resident Abuse policy and procedure indicated All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or had knowledge of an act of abuse or an allegation of abuse to a resident, is obligated to report such information immediately to their supervisor. If the immediate supervisor is not available, the employee is to notify the designated Nursing Supervisor on duty at the time of the event. The supervisor is obligated to immediately report to the Executive Director who is the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. An employee shall be deemed to have violated his obligations in paragraph 1A (above) if he does any of the following: Fails to report an incident of abuse witnessed by or known to him/her. Makes a false or misleading or incomplete report of abuse. Falsifies records relating to an incident of abuse . The policy goes on to specify The Company is committed to the prevention of abuse, neglect, or misappropriation of property. The following systems have been implemented: Sufficient numbers of staff to meet the needs of the residents. Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse for indications of changes in behavior, changes in condition or other non-verbal indications of abuse. The policy spells out the procedure for identifying and reporting abuse and indicated All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services. Patterns or trends will be identified that might constitute abuse. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of a crime has occurred. Resident #101 Review of a facility Face Sheet dated 12/27/15 indicated Resident #101 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident #101 had short and long term memory problems and was severely cognitively impaired. Resident #101 did not exhibit verbal or physical behaviors toward others and needed extensive assistance from one person for bed mobility and transfers and was independent or needed one person to assist with locomotion on the unit. Resident #102 Review of a facility Face Sheet dated 3/10/16 indicated Resident #102 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #102 had short and long term memory problems and was moderately cognitively impaired. Resident #102 required extensive assistance from one person for locomotion on the unit. Review of a Care Plan dated 4/27/16 indicated Resident #102 had Alteration in mood and behavior, resident has a history of depression, shows signs of excessive worrying and anxiety, a history of rummaging and hoarding, crying, attention seeking, history of smearing bowel movement on floors walls, bed, clothes, throwing drinks at TV, a history of depression. Exhibits hitting, kicking, grabbing, biting, pushing, scratching, pinching, spitting and swearing. Interventions on the care plan included: Attempt to keep other residents out of residents personal space. Review of Interdisciplinary Progress Notes dated 5/5/16 reflected (Resident #102) has been exhibiting verbal and physical behaviors with staff and other residents. Review of a Daily Skilled Nurse's Note dated 5/13/16 reflected Resident #102 had Short and long term memory loss, 1-2 assist with transfers and ADL's (activities of daily living). Able to feed self and propel wheelchair. Incontinent of bowel and bladder at times, increase in negative behaviors. A description of the negative behaviors was not noted. Review of a Daily Skilled Nurse's Note dated 5/16/16 indicated Resident #102 Woke up a little cranky. Behavior continues but cursing has improved . A description of Resident #102's Behavior was not noted. Review of a Behavior Symptom Monitoring Flow Record for the month of May 2016 indicated staff documented Resident #102's behaviors on 5/2/16 when she was noted to be pinching, hitting out, increased agitation and yelling. Staff documented on 5/4/16 that Resident #102 was refusing care. No documentation was found on the Behavior Symptom Monitoring Flow Record regarding the behaviors noted in Interdisciplinary Progress Notes dated 5/5/16 or Daily Skilled Nurse's Note dated 5/13/16 and 5/16/16, calling into question facility clinical staff's ability to adequately and effectively monitor Resident #102's behaviors that put other residents at risk for abuse. Review of an Occurrence Report dated 5/27/16 at 11:40 a.m., indicated Resident #101 sustained a skin tear on her right forearm (this is incorrect, Resident #101 sustained the skin tear to her right upper arm). A Witness statement attached to the occurrence report written by Certified Nursing Assistant (CNA) C indicated I was coming back from my lunch break and went into the shower room to help (CNA D) with a resident. When we came out and started walking down the hall towards the dining room I seen (sic) (Resident #102) grabbing (Resident #101's) arm and shaking it. I ran down, got them apart and seen (sic) she had a skin tear on her left (this is incorrect, the skin tear was on the right) upper arm. Went and got the nurse. A witness statement written by CNA D reflected Was coming down hall, saw (Resident #102) holding onto (Resident #101) shaking her arm. Got (Resident #101) out of harms way and we got the nurse. During an interview on 6/1/16 at 2:05 p.m., CNA D said she had been working on the unit where Resident #101 and #102 lived on 5/27/16. CNA D said there had been three CNA's assigned to the locked dementia unit the morning of the incident but that one staff person had been sent home at 10:30 a.m. CNA D said that there was not enough staff to meet resident needs on 5/27/16 due to the number of residents who require 2 people to assist with transfers, supervise aggressive residents and residents who are at risk for falls. CNA D said staff are not taking full breaks and they don't want someone to get hurt. CNA D reported that on the morning of 5/27/16 at approximately 11:30 a.m., CNA C had been on a lunch break, leaving her alone to care for and supervise 23 residents. When CNA C returned from her break, CNA D needed her to assist her with toileting a resident in the shower room. When CNA D and CNA C emerged from the shower room after assisting a resident, CNA C reported she saw CNA D run down the hall to separate Resident #101 and Resident #102. CNA C said she saw Resident #102 Shaking Resident #101 like a rag doll. CNA C said that Resident #101 had been having an exceptionally good day the morning of 5/27/16, but that after the incident with Resident #102 was not good. During an interview on 6/1/16 at 2:30 p.m., LPN E said she had been assigned to care for residents on the 400-500 hall. LPN E explained that the 500 hall is the locked dementia unit and that the nurse's station and all the residents who live on the 400 hall are on the other side of the locked doors. LPN E said she was not on the 500 hall when the incident between Resident #101 and Resident #102 had occurred. LPN E said she did not witness the incident. LPN E reported she had observed Resident #102 earlier on the morning of 5/27/16 reaching out to anything and anyone and asking for help. LPN E said she did not report the resident to resident incident as an allegation of abuse, but did tell Director of Nursing (DON) B the incident had occurred. Review of a Skin Tear Root Cause Investigation Report dated 5/27/16 indicated Licensed Practical Nurse (LPN) E summarized the incident as A resident reached out for help, grabbed at resident, (Resident #101) pulled away, resulting in a skin tear. The summary failed to take into account the witness statements written by the CNA D and CNA F indicating they had to separate Resident #101 from Resident #102, did not take into account Resident #102's known behaviors and did not reflect inadequate supervision was in place at the time of the occurrence. The Skin Tear Root Cause Investigation Report did not identify the root cause of the incident and did not specify immediate interventions to prevent the recurrence of resident to resident abuse, instead indicated Resident #101 had no fear following the incident despite indication from staff Resident #101 did have a negative change in her mood/demeanor after the incident and failed to take into account Resident #101's known short and long term memory problems. During an interview on 6/1/16 at 2:35 p.m., the Director of Clinical Services, (DCS) B said she had been informed of the incident between Resident #101 and Resident #102 and notified Executive Director (ED) A. DCS B said she always asks if there was any intent to harm and believing there was no intent to harm did not report to the state agency. DCS B did not indicate she considered the element of neglect or failure to supervise resident's who are at risk of abusing other residents or of being abused. During an interview of 6/1/16 at 5:15 p.m., ED A said she did not make a report of resident to resident abuse to the State Agency as required due to she did not think Resident #102 meant to harm Resident #101. ED A reported she did not know the residents were unsupervised at the time of the incident and did not consider the element of neglect or failure to supervise resident's who are at risk of abusing other residents or of being abused. ED A reported that as soon as she decided there was no intent, she did not pursue an investigation into the matter. During an observation on 6/1/16 beginning at 3:05 p.m., Resident #101 was observed with a dried, bloody, adhesive bandage on her right upper arm. LPN E attempted to remove the bandage and was unsuccessful. Resident #101 was pulling away from LPN E as she tried to remove the dressing, grimacing in pain, pinching and hitting the nurse as she tried to remove the dressing. LPN F came to assist and at 3:20 p.m., LPN G (the second shift nurse) administered a dose of Roxanol (liquid morphine, a potent narcotic) to help manage the pain. At 3:50 p.m., LPN G again attempted to remove the adhesive dressing and said This is so hard because she doesn't understand what we're doing. At 4:30 p.m., LPN G was able to remove the adhesive dressing. The dressing was covered with wet and dried blood and was very malodorous. No steri-strips were observed and a large skin flap was described by LPN G as Dead, not viable and had rolled up at the edge of the wound. LPN G measured the wound with the assistance of LPN F and it was found to be 4 cm X 12 cm in diameter.

Based on observation, interviews, and record review, the facility failed to prevent avoidable pressure ulcers, assess for and identify new pressure ulcers for 2 Residents (#1 and #2) sampled for pressure ulcers, of a total of 4 residents sampled, resulting in Resident #1 developing an unstageable ulcer on the ball of his right foot, an unstageable ulcer on the right second toe, an unstageable ulcer on the right 3rd toe, an unstageable ulcer on the right 5th toe, a stage II open area on the right shin, and two unstageable ulcers on the top of the right foot (developed 7 avoidable pressure ulcers) and Resident #2 developing an unstageable pressure ulcer on his left heal. Findings include: Resident #1 Review of Resident #1's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1 was not his own responsible party. Review of Resident #1's Pressure Ulcer Record dated 2/28/16, documented Resident #1 had an unstageable ulcer on the ball of his right foot that measured 0.8 cm by 1.0 cm and was unchanged in size when it was measured on 3/13/16 prior to his hospital transfer on 3/14/16. Review of Resident #1's Pressure Ulcer Record dated 2/28/16 documented he had an unstageable ulcer on his right foot great toe that measured 0.6 cm x 0.6 cm and when measured on 3/13/16 prior to his hospital transfer on 3/14/16 it measured 0.5 cm x 0.5 cm. Review of Resident #1's Pressure Ulcer Record dated 2/28/16 documented he had an unstageable ulcer on his right second toe that measured 3.4 cm x 1.2 cm and when measured on 3/13/14 prior to his hospital transfer on 3/14/16 it measured 3 cm x 1.2 cm. Review of Resident #1's Pressure Ulcer Record dated 2/28/16 documented he had an unstageable ulcer on his right 3rd toe that measured 0.2 cm x 0.2 cm and was unchanged is size when it was measured on 3/13/16 prior to his hospital transfer on 3/14/16. Review of Resident #1's Pressure Ulcer Record dated 2/28/16 documented he had an unstageable ulcer on his right 5th toe that measured 0.4 cm x 0.8 cm and was unchanged is size when it was measured on 3/13/16 prior to his hospital transfer on 3/14/16. Review of Resident #1's interdisciplinary progress note, dated 3/14/16 at 6:00 AM, revealed Resident #1 rolled out of bed and landed on his right hip and was sent to the hospital. Review of Resident #1's Admission/Readmission Data Collection, dated 3-22-16, revealed he returned from the hospital with an incision on his right hip, his left leg wrapped and an open area on his left buttock that measured 5 cm x 3 cm. During an interview with the Director of Nursing (DON) B on 3/28/16 at 2:00 PM, DON B was asked if Resident #1's pressure ulcers were developed in house and DON B said resident #1 had developed pressure ulcers in the facility on his right foot and developed a pressure ulcer while in the hospital on his right buttock. DON B was asked for the facility documentation that would have investigated the cause of the in house pressure ulcers and documentation as to whether the pressure ulcers were avoidable or unavoidable and DON B was not able to locate any of this documentation. Resident #1 was observed in bed on 3/28/16 at 2:55 PM, lying on his back with his right foot flat on the bed. Registered Nurse (RN) C removed an ace wrap from Resident #1's right leg and foot. The dressing under the ace wrap was not dated or signed. RN C removed the dressing and there were 4 unstageable wounds on his right foot and a stage II ulcer that covered most of his right shin. Resident #1's entire arch of his foot was bright red. The bright red color did not go away during the observation. Review of Resident #1's treatment record dated 3/22/16, documented Resident #1 was to have his right lower leg cleansed with soap and water daily and a xeroform /gauze cover with a Kling dressing done between 7:00 AM and 3:00 PM daily. The box for March 27th and March 28th were blank (treatment not done if not signed). During an interview with Licensed Practical Nurse (LPN) D on 3/28/16 at 3:10 PM, LPN D reviewed Resident #1's treatment record for March 27th and said she worked March 27th from 7:00 AM to 3:00 PM and should have changed the dressing on Resident #1's right leg but saw it was blank. LPN D said work was hectic on 3/27/16 and she did not recall if she did Resident #1's dressing. LPN D said she was assigned to Resident #1 today from 7:00 AM to 3:00 PM and said it was very busy today and she did not get to Resident #1's treatment for [REDACTED]. LPN D was informed RN C removed an ace wrap and dressing from Resident #1's right leg a few minutes ago and that Resident #1's arch of his foot was bright red (can occur when ace wraps are applied too tight). LPN D said she can normally get to treatments by 2:30 PM but was unable today, but, would provide the dressing change prior to leaving today. During an interview with DON B on 3/28/16 at 3:15 PM, this Surveyor showed DON B Resident #1's treatment documentation for his right leg and she commented that the right leg treatment was not documented for 3/27/16 or 3/28/16 and said if it is not documented it is not done. This Surveyor informed DON B that RN C had removed an ace wrap and the dressing from Resident #1's right leg/foot a few minutes ago and the arch of Resident #1's foot was bright red (appeared to have too much pressure with the ace wrap). DON B said she would follow up on Resident #1's right leg ulcer concerns. Review of Resident #1's daily skilled nursing notes for 3/28/16 revealed no new concerns for Resident #1's right foot/leg and no indication that there was to be any increased monitoring or change in treatment. Review of Resident #1's Pressure Ulcer Record on 3/30/16 did not reveal any changes in wounds or any new wounds from 3/28/16 to 3/30/16. Resident #1's right leg/foot were observed again on 3/30/16 at 11:00 AM when LPN E removed Resident #1's dressing from his right leg/foot to do a dressing change. This observation revealed the top of Resident #1's foot near the base of his toes was red and open with scaly skin. The entire area at the base of the toes was red and open. There was also a dark purple oblong area about an inch long and ½ an inch wide over the arch of the foot. These wounds were not present during the observation on 3/28/16. This Surveyor asked LPN E if the 2 areas the Surveyor did not observe on 3/28/16 were new and LPN E said he did not know and had not done Resident #1's dressing changes in several days. LPN E reviewed the treatment sheet for Resident #1 and could not find any new treatment documented and did not find any documentation to indicate Resident #1 had any new wounds. During an interview with DON B on 3/30/16 at 11:35 AM, this Surveyor told DON B she had observed two new wounds on Resident #1's right foot that were not present on 3/28/16, and could not find any documentation that showed any increased monitoring was done on 3/28/16 when it was discovered that Resident #1 had an ace wrap on his right foot that was not ordered and Resident #1's arch on his right foot was found to be bright red when the ace wrap was removed on 3/28/16. DON B was unable to locate any documentation that showed Resident #1's new foot problem was identified on 3/28/16, that the physician or family were notified of the change in Resident #1's right foot or any documentation that showed the facility was monitoring the changes in Resident #1's right foot that were observed on 3/28/16. DON B said LPN D should have completed an SBAR (form that notifies the physician of a medical change) on 3/28/16 when Resident #1 was discovered to have an ace wrap on his right foot that was not ordered and his right foot arch was found to be bright red. DON B said she would have the physician assistant and a nurse evaluation Resident #1's right foot today. Review of an interdisciplinary progress note dated 3/30/16 at 2:30 PM, documented Resident #1 had a 17 cm x 12 cm open area (no location). Multiple unstageable areas on his right foot, 2nd, 3rd, 4th 5th and between 4th and 5th digits and lateral side of the 5th digit. There were two unstageable ulcers on the top of the right foot measuring 5 cm x 4 cm and 1.5 cm x 1.8 cm. There was another wound that was dark red/purple on the medial top foot that measured 2.5 cm x 4.2 cm. There was another unstageable wound on the medial side of the right foot at the base of the 1st digit measuring 3 cm x 2.8 cm. Wound documentation prior to this only identified 5 unstageable areas on Resident #1's right foot. The 3/30/16 document reveal Resident #1 now had 11 open areas on his right foot and leg. Resident #1 was observed on his back in bed with his right leg/foot on the bed (heel not floated or off the bed surface) on tour on 3/28/16, on 3/28/16 at 2:55 PM, on 3/30/16 at 8:20 AM, on, 3/30/16 at 10:20 AM, on 3/30/16 at 11:00 AM. Resident #1 had a heel bridge sitting on a box near his window during all of the observations. Resident #1 was observed on his back in bed on 3/30/16 at 8:20 AM, and again at 10:20 AM. On 3/30/16 at 10:25 AM, this Surveyor asked Certified Nurse's Aide (CNA) F if she was caring for Resident #1 today and she said, yes This Surveyor asked CNA F if Resident #1 could turn and reposition himself in bed and CNA F said, No. This Surveyor asked how often she was to turn and reposition Resident #1 and she said only when he puts his call light on to let them know he wants to turn. This Surveyor asked if Resident #1 was to be using the heel bridge sitting in the room and CNA F said, No, it makes him uncomfortable . Review of Resident #1's Nurse Tech Information Kardex, no date, revealed Resident #1 required assist of 1 person for bed mobility and had a trapeze bar on the bed to assist with bed mobility. Review of Resident #1's care plan revealed he had a care plan for skin break down and there was not a turn or repositioning schedule identified on the care plan. There was no care plan to float Resident #1's foot. During an interview with DON B on 3/30/16 at 11:35 AM, this Surveyor questioned why Resident #1 would not have an intervention for turning and repositioning related to his skin break down and DON B said it is the standard of care to turn Residents every two hours if they cannot turn themselves. ( ) Resident #2 Review of Resident #2's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #2 was not his own responsible party. Review of Resident #2's treatment record dated 2/16, no year revealed, indicated that he was to have a weekly skin sweep completed by the charge nurse on the 11-7 shift and the boxes for 2/18 and 2/25 were outlined but not marked as completed. There was no documentation that any skin sweeps were completed in February. Review of Resident #2's, Pressure Ulcer Record dated 3/5/16 revealed Resident #2 had an ulcer on his left heel that measured 4.5 cm x 6.5 cm x 0.1 and nothing was marked in the stage area of the form. Measurements of the left heel wound continued up to 3/27/16 and measured 4.5 cm x 6 cm x 0.2 cm and still was not staged. Review of Resident #2's treatment record hand written for March 2016, revealed he was to have his left heel cleaned and [MEDICATION NAME] Dressing applied daily on the 7-3 shift and it was marked as completed on 3/6/16 through 3/8/16 than noted as having an unaboot (medical boot to treat wounds and [MEDICAL CONDITION]). On 3/10/16 through 3/27/16 the treatment for [REDACTED]. Review of another treatment record for Resident #2 dated 3/1/16 to 3/31/16 documented Resident #2 had [MEDICATION NAME] applied to his left heel on 3/1/16 and 3/2/16 on the 7-3 shift. (Pressure ulcer measurements started 3/5/16. (The medical record is not clear on the start date of the pressure ulcer on the left heel or the staging of the pressure ulcer on the left heel) Resident #2 was on the In House Acquired Pressure Ulcer list provided by the DON on 3/28/16. There was no documentation as to how the pressure ulcer occurred and the avoidable/unavoidable pressure ulcer document was not located for Resident #2. Resident #2 was observed in bed on 3/28/16 at 1:45 PM, in bed, on his back with both heels touching the heel bridge in the bed (heel bridge is to support the legs and lift the heels so that they are not touching the bridge or the bed). Resident #2 was observed again in bed on 3/28/16 at 3:45 PM in the same position as the observation at 1:45 PM. CNA G and H were interviewed on 3/28/16 at 3:35 PM. CNA G and H said they were assigned to care for Resident #2 and 25 other Residents today starting at 2:30 PM. CNA G and H said they had 5 Residents that required repositioning in bed within the 1st hour on shift, 5 Residents that required a lift and 2 person assist, had to pass water for all 26 residents, answer call lights, and take residents to the bathroom. This Surveyor asked CNA's G and H if they would be able to turn all 5 Residents as required and they said some days it is possible but it depends on how many residents request assistance during that time and that there are days that they cannot do the two hour turning and repositioning, and the other cares that the residents request, in a timely manner. LPN I was observed setting up wound treatment for [REDACTED]. Resident #2 still had his heels in contact with the heel bridge. This Surveyor asked LPN I if Resident #2's heels were supposed touch the heel bridge and LPN I said, we do not like these bridges, we need to add a pillow and lift the heels up higher using a pillow. LPN I readjusted the pillow and bridge and was able to float Resident #2's heel. The left heel was visible as the ace wrap did not cover the heel and the left heel was black (unstageable). When LPN I went to find all the treatment supplies for Resident #2 she could not locate Resident #2's [MEDICATION NAME] (wound medication) so she was not able to complete the treatment. Initially LPN I had set out another Resident's [MEDICATION NAME] with the other supplies. When this Surveyor asked to read the medication bottle, LPN I said, oh this is not Resident #2's medication. Approximately 30 minutes later LPN I came to this Surveyor with a tube of [MEDICATION NAME] with Resident #2's name on it. The tube of [MEDICATION NAME] was dated 3/1/16 and appeared to be unused. Resident #2 was not in the facility on 3/30/16 and his medical record indicated he was sent to the hospital on [DATE] at 4:00 PM. ( )

Based on observation, interviews, and record review, the facility failed to prevent accident/injuries and follow the fall care plan for one Resident (#1) of 2 Residents sampled for falls, of a total of 4 Residents sampled, resulting in Resident #2 rolling out of bed and fracturing his right hip. Findings: Resident #1 Review of Resident #1's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1 was not his own responsible party. Review of Resident #1's falls for the last 6 months revealed he fell out of bed 3 times (11/3/15, 11/8/16, and 3/14/6). After the first two falls, new interventions were initiated to prevent falls and injuries which included a mat on the floor and a triangular pillow on the outside of the bed. The Occurrence Report dated 3/14/16 for Resident #1 indicated that Resident #2 rolled out of bed at 5:05 AM and was sent to the emergency room for an x-ray for right hip pain. Under Resident statement was documented, I rolled out of bed in my sleep and felt myself falling and grabbed at the sheets and landed sitting up. There was only one staff statement for Resident #1's fall on 3/14/16 by Licensed Practical Nurse J. LPN J documented she heard Resident #2 yell out at 5:15 AM and went to investigate and found him on the floor next to his bed. LPN J and the Certified Nurse's Aides were not able to move Resident #1 without causing more pain so he was transferred to the emergency room and the ambulance arrived at 5:55 AM. There was no indication that Resident #1 was on a mat on the floor or if any triangular pillow was present. Review of an Occurrence Report for Resident #1 dated 3/14/16 completed by LPN J contained a check list of preventive measures at the time of the fall and there was no mention of a triangular pillow and next to mattress on floor was documented, no. There was no indication for a mat on the floor. This form documented Resident #1 was admitted to the hospital. Review of Resident #1's Nurse Tech Information Kardex no date, documented under safety that Resident #1 was to have a mat on the floor with a start date of 11/8/15 and a triangular pillow to the outside of the bed with a start date of 11/8/16. During an interview with the Director of Nursing (DON) B on 3/28/16 at 2:00 PM Resident #1's three falls were reviewed. DON B was unable to locate any investigation for Resident #1's fall on 3/14/16 and only had one staff statement. DON B was unable to say if Resident #1's fall care plan was being followed at the time of the fall on 3/14/16 due to no investigation. DON B was unable to locate any new intervention in Resident #1's fall care plan after 3/14/16. Review of the facility policy and procedures of for accidents/incident investigations date 11/30/14 documented, Certain Accidents and Incidents, including injuries of unknown origin will be investigated to determine root cause and provide for opportunity to decrease future occurrence of the event. Any happening that is not consistent with routine operations of the facility or care of the resident will warrant the completion of an incident report. The following events warrant the completion of designated investigative forms: a. Falls - using the Fall Root Cause Investigation. (The DON was unable to locate the root cause investigation for any of Resident #1's falls). Resident #1 was observed in bed without any mat on the floor on tour on 3/28/16 and on 3/28/16 at 2:55 PM. ( )

Based on observation, interview and record review the facility failed to appropriately assess, develop an integrated care plan, adequately monitor, implement appropriate interventions, follow the facility processes related to significant weight loss and prevent significant weight/fluid loss in 2 of 5 residents (Residents #10 and 3) reviewed for weight loss in a total sample of 24 residents resulting in an Immediate Jeopardy for Resident #10 who sustained a significant weight loss of 11% in 23 days (27 lbs. weight loss from 10/5/15 - 10/28/15), and subsequently had worsening of a Stage 4 pressure ulcer on 10/20/15. Resident # 10's Brief Interview for Mental Status declined from a 13 out of 15 ( intact cognition) on 6/1/2015 to a score of 0 out of 15 on 10/5/2015 ( severe cognition) without a reason for the decline. This significant weight loss without the appropriate monitoring has the potential to cause fluid and electrolyte imbalance affecting the heart, kidneys, skeletal and muscle connectivity that may lead to organ failure ( coma and death). The facility was notified of the Immediate Jeopardy on 10/29/15 at 11:55 AM and removed but not corrected on 10/29/2015 when a correction plan was initiated including an medical assessment of resident #10. The deficient practice remained at a potential for more than minimal harm at an isolated scope. Findings include: Resident #10 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #10 was a [AGE] year-old female, who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10 ' s MDS, dated [DATE], for Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents severe cognitive impairment. Resident #10 required 1-2 staff assistance and a mechanical lift for all activities of daily living. Resident #10 had a feeding tube and did not take anything by mouth. Review of the Occurrence Report dated 7/15/15 at 3:10 PM, reflected that a new wound was observed on Resident #10 ' s coccyx and Resident #10 reported, It ' s sore .I didn't ' t know I had a sore . Under the header of Conclusion reflected, Root Cause: No Fault . It was unclear if there was a care plan to address or modifications done to a previous care plan that treated the new wound and prevented it from worsening to a stage 3 prior to the hospitalization . In an interview on 10/26/15 at 2:50 PM, Licensed Practical Nurse (LPN) F stated that prior to Resident #10 ' s hospital admission (9/24/15) Resident #10 was alert and oriented and since return from the hospital on [DATE] was disoriented and sleeps a lot. There was no documented reason for the change in physical and mental cognition. Review of the MDS dated [DATE] reflected a BIMS score of 13 out of 15 which represents that Resident #10 was cognitively intact. Review of the MDS dated [DATE] reflected a BIMS score of 5 which represents severe cognitive impairment. This contradicted the information provided by her primary care nurse. The BIMS score noted a decline in mental status but unclear as to how the facility staff were monitoring the course of the decline and the rationale. This was not provided during the interview on 10/26/2015. Record review of the physician orders from 10/5/15 - 10/26/15 reflected an order for [REDACTED]. It was unclear how Promote to run at 70 milliliters pre hour met the nutritional status of Resident # 10 given her body mass, weight, fluid and caloric needs. This tube feeding was the only method Resident #10 was fed since she could not take anything by mouth. The U.S. Department of Health and Human services, Agency for Health Care Policy and Research Publication No. 92-0047, p. 21 stated, two cohort studies ( Berlowitz and Wilking, Bergstrom and Braden ) document the role of poor diet intake in the development of pressure ulcers particularly the intake of inadequate calories, protein and iron. authorities recommend supplementing or supporting intake of protein, calories, Vitamin C and zinc in particular . The facility provided the following weights for review: 10/6/15 (day after readmission to facility) 245 lbs., 10/7/15 239.8 lbs., (no weight for 10/8/15-facility was to obtain a daily weight for 3 days in a row), 10/13/15 235.4 lbs., and 10/18/15 228.2 lbs. There were no further weights recorded from 10/18/15 - 10/27/15 (9 days). After this surveyor identified Resident #10 was missing a weekly weight the staff obtained a new weight on 10/28/15 ( survey date) of 218 lbs. There were no specific interventions that were added to indicate the facility was monitoring and/or addressing the weight/fluid loss of 27 lbs in 23 days. It was unclear how the resident's medical condition of [MEDICAL CONDITION] (irregular heart beat), facility- acquired Stage 3 pressure ulcer (bed sore) to the coccyx (tailbone) that worsened to a stage 4 , depression, anxiety and chronic pain were considered in lieu of the weight/fluid loss. During an observation and interview on 10/26/15 at approximately 3:40 PM, Resident #10 ' s tube feeding container had approximately 775 ml remaining in the container and the pump was infusing at a rate of 70 ml/hr. This surveyor and UM LPN E observed that the container was started at 9:30 AM on 10/26/15. UM LPN E agreed that by approximately 3:40 PM., Resident #10 should have received 420 ml (but only 225 ml was gone from the container). It was unclear how staff were monitoring the intake or output of the feeding since there was no documentation available to review when this observation was brought up on 10/26/2015. During an interview on 10/27/15 at 9:15 AM with Dietary Manager (DM) C , Registered Dietician (RD) D , and Licensed Practical Nurse (UM, LPN) E the following information was provided: Resident #10 was sent to the hospital on [DATE] for fever and foul smelling urine. The hospital obtained cultures and x-rays that ruled out a urinary tract infection and pneumonia but determined the source of the infection to be the Stage 4 coccyx wound (the pressure ulcer evolved from a Stage 3 to a Stage 4). On 10/5/15 Resident #10 was sent back to the facility with a urinary catheter (system to drain the bladder), IV (intravenous) antibiotics, a new feeding tube and was no longer able to take nutrition by mouth. The RD reviewed the nutrition assessment and stated that Resident #10 ' s tube feeding was calculated based on a planned weight loss. Staff explained that the facility procedure was to obtain a daily weight for 3 days for new admissions and then weekly. UM LPN E stated that she reviews all weights obtained by the staff weekly and stated that the staff had missed a scheduled weight on 10/25/15. The RD D stated that Resident #10 ' s weight loss was gradual and acceptable (documents reflect loss of 17 lbs. in 13 days at the time of this interview). There was no physician order for [REDACTED]. The staff agreed that it should have infused by 11:30 PM on 10/26/15. Staff were made aware of an observation on 10/27/15 at 8:23 AM by this surveyor of the new tube feeding container that had a start date (written on the container)of 10/27/15 at 4:10 AM (approximately 4 hours after estimated completion of the previous container). The staff stated that they could not determine how much tube feeding formula was given to Resident #10 since she returned from the hospital. The staff stated that there was no flowsheet or input and output documentation to review during the period of the survey. When asked if Resident #10 was consistently weighed on the same scale, staff reported that they could not answer to that because the staff do not document what type of scale was used. The staff stated that the facility measured wounds weekly on Tuesdays. During an interview on 10/28/15 at approximately 4:45 PM, Doctor P (Resident #10 ' primary physician) stated that he intended to diuresis Resident #10 and that he was not notified of the weight loss. Review of the Skin Integrity/Decubitus Meeting tool dated 7/15/15 reflected new facility acquired stage 2 pressure ulcer development on 7/15/15 that measured 1 cm x 0.5 cm x 0.2 cm. The measurements were documented weekly and increased to 4 cm x 5.5 cm 2.3 cm stage 3 ulcer prior to her transfer to the hospital on [DATE]. Record review of the measurement of the coccyx pressure ulcer (after return from the hospital on [DATE]) reflected the following measurements: 10/8/15, 5 cm x 8 cm x 2.5 cm with tunneling of 1 cm and undermining of 1 cm. There was no other measurement until 12 days later (according to the physician order was to be measured every week on Tuesday). O it measured 10/20/15, 6.5 cm x 7.5 cm x 5 cm with slough covering the tunneling area and 1.5 cm undermining, which reflected worsening of the Stage 4 pressure ulcer. During an interview and observation on 10/28/15 at approximately 12:10 AM (Wednesday), Registered Nurse (RN) G stated that she would be doing the dressing change for Resident #10 and since the dressing change was a painful process for Resident #10, she added that she will provide pain medication prior to the procedure. When asked if she would be measuring the wound, RN G stated, No, I did not intend on it . When asked if RN G could measure the wound for this surveyor, RN G stated she would and obtained the measuring tools. During an observation of the dressing change, the following measurements were obtained and revealed measurements of 7.5 cm x 8 cm x 4.7 cm with slough covering approximately ¼ of the wound and undermining of 2 cm with tunneling, which represents continued worsening of the stage 4 pressure ulcer. The facility was notified of the Immediate Jeopardy on 10/29/15 at 11:55 AM and removed but not corrected on 10/29/2015 when a correction plan was initiated for Resident #10. The correction plan to remove but not correct the Immediate Jeopardy was accepted on 10/30/2015 at 2:00 PM that included the following interventions: assessment of resident #10's condition by the primary physician ; care plan reviewed and updated including notification to the physician and registered dietitian if there is a loss of 5 pounds and or greater; Nutritional care plan will integrate nursing needs; resident #10 agreed with a current weight loss plan with a goal of 175 pounds; feeding pump was changed to ensure pump functioning properly; implemented intake documentation on 10/29/2015 for feeding every shift; physicians' order to check residual every 6 hours; add 2 packs of Juven to aid in wound healing ( supplement); increase Promote tube feeding to 84 cc/hr X 20 hours daily ; CBC & CMP every 2 week ( lab work); weekly weights; education and training initiated on 10/29/2015. The deficient practice continues at a potential for more than minimal harm and at a isolated case since facility will monitor these interventions in their Quality Assurance/Performance Improvement Committee on a monthly basis, will complete their training and revisions to their care plans. ( See also F 314) (# ) Resident #3 According to the Face sheet dated 10/6/15 and the October 2015 Physician's orders, Resident #3 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of weights for Resident #3 revealed a 9% weight loss in 36 days from 119 pounds on 5/10/15 to 108.2 pounds on 6/15/15. This constituted a significant weight loss according to the State Operations Manual, Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% The Alteration in Nutrition Care Plan for Resident #3 dated 4/11/15 stated, marginal intake to prevent weight loss and increased nutrient needs r/t (related to) fx (fracture) and hx (history of) wt (weight) loss. The interventions of 4 ounces of shakes twice a day, Juice at breakfast, and 2 ounces of Med Pass (a supplement) three times a day were dated 4/15/15 - before the weight loss. A dietary note dated 6/17/15 stated that Resident #3 had been admitted with a cast on her arm . cast noted to be taken off in Dr's Progress notes dated 5/9/15 (before the weight of 119 on 5/10/15) just about the time the weight loss shows . There were no further dietary notes until 10/1/5 and no weights were monitored during the month of September. There was no indication in the record that the physician was ever notified of the weight loss. His Progress Notes dated 7/8/15 said, no concerns raised on the part of staff. and she is medically stable and no changes are made. In an interview with the Director of Nursing, B on 10/28/15 at 8:25 AM., she was asked if the Doctor was ever notified of the weight loss, reason why there were no weights in September and why there were no new interventions to address the weight loss. Director of Nursing B said she would check and have someone get back with this surveyor. There were no new documentation or explanation given by the end of the survey. (# )

Based on observation, interview and record review the facility failed to prevent a facility acquired Stage 2 pressure ulcer and failed to promote the healing of a pressure ulcer for 1 of 5 residents (Resident #10) reviewed for pressure ulcer, in a total sample of 24 residents resulting in Resident #10 developing a facility acquired Stage 2 pressure ulcer that progressed to a Stage 3 with complaints of discomfort and pain, and was hospitalized and treated for [REDACTED]. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #10 was a [AGE] year-old female, who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's MDS, dated [DATE], for Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents severe cognitive impairment. Resident #10 required 1-2 staff assistance and a mechanical lift for all activities of daily living. Review of the Occurrence Report dated 7/15/15 at 3:10 PM, reflected that a new wound was observed on Resident #10's coccyx and Resident #10 reported, It's sore .I didn't know I had a sore Under the header of Conclusion reflected, Root Cause: No Fault. It was unclear if there was a care plan to address or modifications done to a previous care plan that treated the new wound and prevented it from worsening to a stage 3 prior to the hospitalization . Record review of the Skin Integrity/Decubitus Meeting dated 7/15/15 reflected, that a new facility acquired Stage 2 pressure ulcer developed to the coccyx on 7/15/15 that measured 1.0 cm x 0.5 cm x 0.2 cm. The following measurements were listed on the monitoring record: 7/21/15 1 x 0.5 x 0.2 7/28/15 1 x 0.5 x 0.2 7/28/15 1 x 0.5 x 0.4 8/4/15 1 x 0.5 x 0.4 8/11/15 0.8 x 1 x 0.2 (According to the physician orders dated 8/15/15 a new dressing and wound treatment were obtained) 8/17/15 1.5 x 1.5 x 0.2 8/25/15 3 x 2 x 0.2 8/31/15 3 x 2 x 0.2 9/8/15 2 x 2.5 x 0.2 9/14/15 3 x 4 x 0.2 (now documented as a Stage 3) 9/21/15 4 x 5.5 x 0.2 Despite the physicians orders on 8/15/15, the pressure ulcers worsened. A copy of the policy/procedure for prevention of pressure ulcers and for the management and healing of pressure ulcers was requested from the facility. The facility provided two documents for review titled General Wound Care Principles and Nutrition Interventions for Wound Healing neither contained a date, facility name nor were the documents signed. Review of the General Wound Care Principles reflected, DOCUMENT no less than WEEKLY, Worsening wounds or those wounds that have not shown improvement in or more weeks (no time frame and unclear language) should be evaluated for change in treatment orders for wound care and or other interventions as deemed appropriate by the IDT (Interdisciplinary Team). During an interview and record review on 10/28/15 at 8:50 AM, when asked if the facility had a policy/procedure for prevention and healing of pressure ulcers that was reviewed by the medical director, the DON B stated, I will recheck. At 9:30 AM, the DON B stated that the facility did not have a policy/procedure for pressure ulcers and used the document titled General Wound Care Principles. When asked to clarify the language of the document regarding the length of time when the wound shows no improvement or worsening, the DON B stated treatment should be changed if the wound showed 2 or more weeks of no improvement. The DON B stated that the physician orders from 7/15/15 through 9/24/15 (date that Resident #10 was transferred to the hospital) were reviewed and provided only two dressing/treatment orders, one on 7/16/15 for the initial treatment order and one on 8/15/15). There were no changes in the dressing/treatment order past 8/15/15 to promote the healing of the Stage 2 pressure ulcer as it evolved to a Stage 3 pressure ulcer (per wound measurements listed above). The DON B agreed that according to the facility's wound guide there should have been a change in the treatment order when the wound did not improve or respond to the current treatment. When asked if the facility did a root cause analysis (system to identify the causative factors, promote healing and prevent the development of additional pressure ulcers) the DON B stated, yes and provided a copy of Guidelines for Unavoidable Wounds signed on 7/16/15 by the DON B. The document identified risk factors but did not contain a conclusion or root cause for the development of the pressure ulcer. The DON B stated that the Assistant Director of Nursing (ADON) K could assist with review of the pressure ulcer development. During an interview on 10/28/15 at 3:45 PM, the ADON K stated that Resident #10 had factors that put her at risk for pressure ulcers and explained the care for all of the identified factors. Review of the weekly skin assessments reflected that Resident #10's skin was intact on the 7/13/15 weekly assessment and on 7/15/15 a wound was noted to the coccyx. When asked if Resident #10 had a change in condition during that period, the ADON K stated, No. When asked if the facility tracks, trends and determines root causes for pressure ulcers for the purpose of quality assurance the ADON K stated the facility did not have documentation to support this analysis. Review of the nursing notes dated 7/6/15 through 7/15/15 did not reflect a change in Resident #10's condition. In an interview on 10/26/15 at 2:50 PM, Licensed Practical Nurse (LPN) F stated that prior to Resident #10's hospital admission (9/24/15) Resident #10 was alert and oriented and since return from the hospital on [DATE] was disoriented and slept a lot. There was no documented reason for the change in physical and mental cognition. Review of the MDS dated [DATE] reflected a BIMS score of 13 out of 15 which represents that Resident #10 was cognitively intact. Review of the MDS dated [DATE] reflected a BIMS score of 5 which represents severe cognitive impairment. This contradicted the information provided by her primary care nurse. The BIMS score noted a decline in mental status but unclear as to how the facility staff were monitoring the course of the decline and the rationale. This was not provided during the interview on 10/26/2015. Record review of the measurement of the coccyx pressure ulcer (after return from the hospital on [DATE]) reflected the following measurements: 10/8/15 5 cm x 8 cm x 2.5 cm with tunneling of 1 cm and undermining of 1 cm. There was no other measurement until 12 days later ; according to the physician order this was to be measured every week on Tuesday. On 10/20/15, 6.5 cm x 7.5 cm x 5 cm with slough covering the tunneling area and 1.5 cm undermining. Review of the physician order dated 10/16/15 (untimed) reflected an order to measure the wound progress every Tuesday. According to the documented wound measurements, the last time the wound was measured was on 10/20/15 and according to the physician order was due to be measured every Tuesday (next due on 10/27/15). During an interview and observation on 10/28/15 at approximately 12:10 AM (Wednesday), Registered Nurse (RN) G stated that she would be doing the dressing change for Resident #10 and since the dressing change was a painful process for Resident #10, she was provided pain medication prior to the procedure. When asked if she would be measuring the wound, RN G stated, No, I did not intend on it. When asked if RN G could measure the wound for this surveyor, RN G stated she would and obtained the measuring tools. During an observation of the dressing change, the following measurements were obtained and revealed measurements of 7.5 cm x 8 cm x 4.7 cm with slough covering approximately ¼ of the wound and undermining of 2 cm with tunneling, which represented worsening of the stage 4 pressure ulcer. Record review of the physician orders from 10/5/15 - 10/26/15 reflected an order for [REDACTED]. The facility provided the following weights for review: 10/6/15 (day after readmission to facility) 245 lbs., 10/7/15 239.8 lbs., (no weight for 10/8/15-facility was to obtain the weight for 3 days in a row), 10/13/15 235.4 lbs., and 10/18/15 228.2 lbs. There were no further weights recorded from 10/18/15 - 10/27/15 (9 days-facility was to obtain a weekly weight). After this surveyor identified Resident #10 was missing a weekly weight the staff obtained a new weight on 10/28/15 of 218 lbs. There were no specific interventions that were added to indicate the facility was monitoring and/or addressing the weight/fluid loss. During an observation and interview on 10/26/15 at approximately 3:40 PM, Resident #10 ' s tube feeding container had approximately 775 ml remaining in the container and the pump was infusing at a rate of 70 ml/hr. This surveyor and UM LPN E observed that the container was started at 9:30 AM on 10/26/15. UM LPN E agreed that by approximately 3:40 PM that Resident #10 should have received 420 ml (but only 225 ml was gone from the container). It was unclear how staff were monitoring the intake or output of the feeding since there was no documentation available to review when this observation was brought up on 10/26/2015. During an interview on 10/27/15 at 9:15 AM with Dietary Manager (DM) C, Registered Dietician (RD) D, and Licensed Practical Nurse (UM, LPN) E the following information was provided: Resident #10 was sent to the hospital on [DATE] for fever and foul smelling urine. The hospital obtained cultures and x-rays that rule out a urinary tract infection and pneumonia but determined the source of the infection to be the Stage 4 coccyx wound (the pressure ulcer evolved from a Stage 3 to a Stage 4). On 10/5/15 Resident #10 was sent back to the facility with a urinary catheter (system to drain the bladder), IV antibiotics, a new feeding tube, and was no longer able to take nutrition by mouth. The RD reviewed the nutrition assessment and stated that Resident #10 ' s tube feeding was calculated based on a planned weight loss. Staff explained that the facility procedure was to obtain a daily weight for 3 days for new admissions and then weekly. UM LPN E stated that she reviews all weights obtained by the staff weekly and stated that the staff had missed a scheduled weight on 10/25/15. The RD D stated that Resident #10's weight loss was gradual and acceptable (documents reflected loss of 17 lbs. in 13 days at the time of this interview). There was no physician order for [REDACTED]. Staff were made aware of an observation on 10/27/15 at 8:23 AM by this surveyor of the new tube feeding container that had a start date (written on the container)of 10/27/15 at 4:10 AM (approximately 4 hours after estimated completion of the previous container). The staff stated that they could not determine how much tube feeding formula was given to Resident #10 since she returned from the hospital. The staff stated that there is no flowsheet or input and output documentation to review. When asked if Resident #10 was consistently weighed on the same scale, staff reported that they could not answer to that because the staff do not document what type of scale was used. The staff stated that the facility measured wounds weekly on Tuesdays. The U.S. department of health and Human services, Agency for Health Care Policy and Research, Clinical Practice Guideline : Pressure Ulcers in Adults: Prediction and Prevention, chapter 2 described the role of nutrition in the prediction, prevention and early treatment of [REDACTED]. It further stated that nutritionally compromised individuals, a plan of nutritional support/ supplementation should be implemented that meets the individual needs and is consistent with the over all goals of therapy. During an interview on 10/28/15 at approximately 4:45 PM, Doctor P (Resident #10's primary physician) stated that he intended to diuresis Resident #10 and that he was not notified of the weight loss. (See also F 325) (# )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT POSITIONING INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS AND PROMOTE HEALING OF PRESSURE ULCERS FOR TWO OF THREE RESIDENTS (#2 AND #8) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN THE DEVELOPMENT OF A PAINFUL STAGE III PRESSURE ULCER FOR RESIDENT #8 AND AN UNSTAGEABLE ULCER FOR RESIDENT #2 AND THE POTENTIAL FOR DELAYED WOUND HEALING. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET (UNDATED) RESIDENT #8 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. ACCORDING TO THE FEBRUARY 2012 "physician's orders [REDACTED]. DURING AN OBSERVATION OF A DRESSING CHANGE ON 03/01/2012 AT 08:05 A.M. IN RESIDENT #8'S ROOM, LICENSED PRACTICAL NURSE "O" REMOVED [MEDICATION NAME] (ROPE-TYPE GAUZE USED AS PACKING) FROM A WOUND IN THE FOLD OF THE RESIDENT'S LEFT BUTTOCK. THE WOUND WAS A DEEP CRATER WITH A CIRCUMFERENCE APPROXIMATELY THE SIZE OF A WALNUT. STAFF NURSE "O" CLEANSED AND REPACKED THE ULCER WITH [MEDICATION NAME] AND THEN PLACED A CLEAN DRESSING OVER THE SURFACE. RESIDENT #8 WAS HEARD TO STATE, "OUCH, THAT HURTS" TWICE WHILE THE WOUND WAS BEING REPACKED AND DRESSED. ACCORDING TO RESIDENT #8'S "SKIN GRID - PRESSURE" SHEET" DATED 09/22/2011, THE FACILITY HAD IDENTIFIED A STAGE III PRESSURE ULCER WOUND IN RESIDENT #8'S LEFT BUTTOCK "FOLD" THAT WAS "NO" (NOT) "PRESENT ON ADMISSION". (A STAGE III PRESSURE ULCER IS A WOUND THAT IS CHARACTERIZED BY FULL-THICKNESS SKIN LOSS INVOLVING DAMAGE OR NECROSIS OF TISSUE THAT MAY EXTEND DOWN TO UNDERLYING MUSCLE TISSUE.) PHYSICIAN'S NOTES DATED 11/11/2011 REFLECTED "...RADICAL DEBRIDEMENT (SURGICAL REMOVAL OF DEAD TISSUE FROM THE WOUND TO PROMOTE HEALING) OF A LEFT ISCHIAL DECUBITUS ULCER THAT WAS DOWN INTO THE ISCHIUM (LOWER BACK PART OF THE HIP BONE)." ACCORDING TO THE MDS (MINIMUM DATA SET) ASSESSMENT, DATED 12/15/11, RESIDENT #8 DID NOT WALK, HAD COGNITIVE IMPAIRMENTS AND RECEIVED EXTENSIVE ASSISTANCE FROM STAFF IN ORDER TO MEET HER MOBILITY NEEDS. HOWEVER, RESIDENT #8'S "ALTERATION IN SKIN INTEGRITY" CARE PLAN (DATE INITIATED 08/29/2011) DID NOT REFLECT ANY INTERVENTIONS TO ASSIST RESIDENT #8 WITH POSITIONAL CHANGES IN HER BED OR WHEEL CHAIR IN ORDER TO MINIMIZE THE PRESSURE ON HER LEFT HIP. A CARE PLAN ENTRY DATED 10/4/11 REFLECTED THAT RESIDENT #8 WAS "NON-COMPLIANT WITH POSITIONING." THERE WAS NO INFORMATION DOCUMENTED IN THE CARE PLAN TO SHOW THAT POSITIONAL INTERVENTIONS HAD BEEN TRIED PRIOR TO CONCLUDING THAT RESIDENT #8 WAS NON-COMPLIANT. THERE WAS NO DOCUMENTATION TO EXPLAIN HOW FACILITY STAFF HAD IDENTIFIED NON-COMPLIANCE AS A RISK FACTOR FOR PRESSURE ULCER DEVELOPMENT, AND THE NOTATION ON THE CARE PLAN WAS NOT ADDED UNTIL AFTER THE RESIDENT'S LEFT ISCHIAL WOUND DEVELOPED. THE "RESIDENT INFORMATION SHEET" (CERTIFIED NURSING ASSISTANT INFORMATION SHEET), UNDATED, FOR RESIDENT #8 DID NOT SHOW ANY DOCUMENTATION REGARDING CHANGING RESIDENT #8'S POSITION TO REDUCE PRESSURE TO SKIN AREAS IN ORDER TO MINIMIZE THE RISK OF PRESSURE ULCERS. DURING AN INTERVIEW AT 12:10 P.M. ON 3/1/12, REGISTERED NURSE UNIT MANAGER "B" WAS NOT ABLE TO SHOW WHERE INTERVENTIONS TO MINIMIZE PRESSURE TO THE RESIDENT'S SKIN BY ASSISTING HER WITH POSITIONAL CHANGES WAS DOCUMENTED ON THE CARE PLAN. ( ) ACCORDING TO THE (UNDATED) ADMISSION FACE SHEET, RESIDENT #2 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE] AND REadmitted on [DATE]. ACCORDING TO THE physician's orders [REDACTED]. FACILITY NURSING NOTES, DATED 1/18/12, DOCUMENTED THAT RESIDENT #2 HAD A "STAGE II PRESSURE AREA FOUND ON RIGHT HIP. TREATMENT INITIATED AFTER SITE MEASURED." (A STAGE II PRESSURE ULCER IS A WOUND CHARACTERIZED BY PARTIAL THICKNESS SKIN LOSS INVOLVING THE DERMIS AND/OR EPIDERMIS LAYERS OF THE SKIN.) ACCORDING TO ENTRIES DATED 11/17/11 THROUGH 1/12/12 ON THE FACILITY'S "SKIN GRID-PRESSURE" FORM, THE RESIDENT ALSO had a history of [REDACTED]. ACCORDING TO AN ENTRY ON THE "SKIN GRID-PRESSURE" FORM, DATED 1/18/12, RESIDENT #2'S RIGHT HIP STAGE II PRESSURE ULCER MEASURED 2 CM (CENTIMETERS) BY 2 CM. ON 1/25/12, A WEEK LATER, THE RIGHT HIP PRESSURE ULCER WAS DOCUMENTED ON THE "SKIN PRESSURE GRID" AS AN "UNSTAGEABLE" PRESSURE ULCER MEASURING 2 CM BY 1.5 CM. THE WOUND BED WAS DESCRIBED AS HAVING RED SLOUGH (DEAD TISSUE) WITH A SMALL AMOUNT OF SEROUS (WATERY) DRAINAGE. THE WOUND EDGES AND PERI-WOUND AREA WAS DESCRIBED AS RED. THE NEXT "SKIN-GRID" ENTRY SKIN ON 2/8/12 SAID THE WOUND HAD YELLOW SLOUGH AND THERE WAS YELLOW GREENISH DRAINAGE. ON 2/28/12 AT 2:00 P.M., THE DRESSING CHANGE TO RESIDENT #2'S RIGHT HIP WAS OBSERVED IN HIS ROOM. LICENSED PRACTICAL NURSE "A" REMOVED THE OLD DRESSING FROM THE RESIDENT'S RIGHT HIP WHILE HE WAS STANDING UP. THE WOUND WAS LOCATED BELOW THE ILIAC CREST (HIP BONE) TOWARD THE MIDDLE OF THE RESIDENT'S BUTTOCK. THE WOUND BED WAS COVERED WITH YELLOW SLOUGH AND LOOKED TO BE ABOUT 1.0 CM X 1.0 CM. THE SURROUNDING TISSUE AND THE WOUND EDGES WERE DARK RED. NURSE "A" APPLIED "SANTYL" (A CHEMICAL [MEDICATION NAME] AGENT) AFTER SHE CLEANSED THE WOUND WITH SALINE SOLUTION. NURSE "A" COVERED THE AREA WITH A THICK FOAM DRESSING AFTER CLEANING. THE AREA WHERE THE RESIDENT'S LEFT HIP PRESSURE ULCER HAD BEEN COULD ALSO STILL BE EASILY OBSERVED, AND IT WAS IN JUST ABOUT THE SAME AREA OF THE LEFT BUTTOCK AS THE PRESSURE ULCER ON THE RIGHT BUTTOCK. DURING THE OBSERVATION, RESIDENT #2 STATED THAT THE WOUND DID NOT HURT ALL THE TIME, BUT IT GOT SORE WHEN HE SAT DOWN IN A CHAIR. ACCORDING TO AN OCCUPATIONAL THERAPY NOTE, DATED 1/26/11, RESIDENT #2 HAD BEEN REFERRED TO THERAPIES FOR EVALUATION RELATED TO A "TOO TIGHT FITTED WHEEL CHAIR AT HIPS." THE NOTES DOCUMENTED THAT THE RESIDENT EXHIBITED DISCOMFORT AND JOINT MISALIGNMENT WHILE SEATED FOR 60 MINUTES IN AN 18 INCH WIDE WHEELCHAIR WITH A GEL CUSHION. A 20 INCH WIDE WHEEL CHAIR WAS RECOMMENDED, BUT THE DOCUMENTATION DID NOT EXPLAIN IF IT WAS IMPLEMENTED. THE RESIDENT'S SKIN INTEGRITY CARE PLAN, INITIATED 2/15/06 AND UPDATED ON 1/18/12, DID NOT INDICATE THAT ANY NEW INTERVENTIONS WERE ADDED TO PREVENT PRESSURE ULCERS AND/OR PROMOTE HEALING OF EXISTING ULCERS DURING THE PERIOD BETWEEN THE LEFT HIP ULCER DEVELOPING (11/17/11) AND THE RIGHT HIP DEVELOPING (1/18/12). THERE WAS NO EVIDENCE THAT EXISTING INTERVENTIONS HAD BEEN REVISED TO MEET THE RESIDENT'S NEEDS AND PREFERENCES. ON 2/29/12 AT 12:00 P.M., RESIDENT #2 WAS INTERVIEWED IN HIS ROOM REGARDING HIS PRESSURE SORE. THE RESIDENT STATED HE USUALLY STAYED UP ABOUT 18 HOURS A DAY, BECAUSE HE DID NOT WISH TO WASTE ANY REMAINING HOURS OF HIS LIFE BY SLEEPING. THE RESIDENT STATED HE ATTEMPTED TO TURN HIMSELF IN BED. HE SAID HE SHIFTED HIS WEIGHT THROUGHOUT THE DAY, WHILE HE SAT IN HIS WHEEL CHAIR, BECAUSE THE WHEEL CHAIR CUSHION FLATTENED UP AND HIS BUTTOCKS GOT SORE. DURING AN INTERVIEW ON 3/1/12 AT 9:00 A.M., THE UNIT MANAGER REGISTERED NURSE "C" SAID AN ALTERNATE PRESSURE RELIEVING CUSHION FOR THE RESIDENT'S WHEEL CHAIR HAD NOT BEEN CONSIDERED. NURSE "C" STATED THAT RESIDENT #2 WAS NON-COMPLIANT WITH POSITIONING IN BED. NURSE "C" SAID THAT RESIDENT #2 HAD BEEN PROVIDED WITH AN AIR MATTRESS ABOUT A WEEK AGO, WHICH HE DID NOT LIKE, SO THE FOAM MATTRESS WAS RETURNED. THE CARE PLAN INDICATED THE AIR MATTRESS WAS APPLIED ON 1/18/12. HOWEVER, THE CARE PLAN WAS NOT UPDATED TO REFLECT WHEN IT WAS CHANGED BACK TO THE FOAM MATTRESS. NURSE "C" ALSO STATED THE RESIDENT'S BED POSITION WAS CHANGED SO THE RESIDENT COULD STAY OFF HIS RIGHT SIDE AND, AT THE SAME TIME, WATCH TELEVISION IN BED. HOWEVER, DURING AN OBSERVATION ON 3/1/12 AT 9:15 A.M. IN RESIDENT #2'S ROOM, HIS BED WAS OBSERVED PLACED AGAINST THE WALL WITH THE HEAD OF THE BED POSITIONED SO THAT HE WOULD HAVE ACTUALLY HAVE HAD TO LIE ON HIS RIGHT SIDE (PRESSURE ULCER LOCATION) TO WATCH THE TELEVISION. ( )