Every finding on record at Regency at Grand Blanc

Based on observation, interview, and record review, the facility failed to properly store food, mitigate pests, and maintain sanitizer concentrations in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 07/13/2026 at 9:15AM during the initial kitchen tour, a buildup of ice was observed at the back of the walk-in freezer. During this observation, Certified Dietary Manager (CDM) Y partially removed a portion of the ice. In addition, CDM Y was interviewed how often the walk-in cooler is cleaned, and she stated it's checked visually every day and it's cleaned Mondays and Thursdays. On 07/13/2026 at 9:18AM chopped peppers, chopped onion, diced and sliced tomato, and diced cucumber were date marked 7/10-7/17, stored in the top unit of the grill refrigerator. During this observation, CDM Y was interviewed on how long food is kept for, and she stated the prep date is counted as Day 1 and food is kept for a maximum of 7 days. On 07/13/2026 at 9:22AM a whisk utensil was observed with burn marks and pitting on the handle, near the metal prongs. During this observation, CDM Y stated she will have the utensil replaced. On 07/13/2026 at 9:23AM a dark green sticky residue was observed on a clean dish, stored in the clean storage rack. During this observation, CDM Y acknowledged the dirty dish and put it back into the dishwashing area. On 07/13/2026 at 9:25AM the quaternary ammonia sanitizer concentration result was zero parts per million (ppm) for the wiping cloth sanitizer bucket located at the three-compartment sink. During this observation, CDM Y was interviewed on how often the sanitizer is changed and she stated it's changed every two hours, and the concentration is kept at 150-200 ppm. On 07/13/2026 at 9:26AM a gnat was observed flying around the clean dish storage area. On 07/13/2026 at 9:29AM a few gnats were observed flying around underneath the microwave area. During this observation, CDM Y acknowledged the gnats and said she could see them. On 07/13/2026 at 9:30AM two gnats were observed flying around underneath the prep sink area and near the rice storage container. On 07/13/2026 at 9:37AM the ice machine drain line was observed sitting directly into a pump in the nourishment room in Pine Creek hallway. On 07/13/2026 at 9:39AM the ice machine drain line was observed sitting directly in the drain in the nourishment room in [NAME] Hill hallway. On 07/13/2026 at 11:18AM during lunch observation, a fly was observed flying around the food prep area. On 07/13/2026 at 11:27AM the wiping cloth sanitizer bucket was tested with quaternary ammonia test strips and the result was zero ppm, located at the three-compartment sink in the kitchen. During this observation, CDM Y was interviewed on the result of the sanitizer concentration, and she stated she wasn't happy about it and that it was ready to be changed because it had been two hours since the last change.According to the FDA 2022 Food Code, 6-501.12 Cleaning, Frequency and Restrictions, Physical facilities shall be cleaned as often as necessary to keep them clean. Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, 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.According to the 2022 FDA Food Code, 4-101.11 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.Safe.Durable, corrosion-resistant, and nonabsorbent, Sufficient in weight and thickness to withstand repeated ware washing, Finished to have a smooth, easily cleanable surface; and.Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the FDA 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.According to the FDA 2022 Food Code, 6-501.111 Controlling Pests, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by .Routinely inspecting incoming shipments of food and supplies .Routinely inspecting the premises for evidence of pests .Using methods, if pests are found, such as trapping devices or other means of pest control . Eliminating harborage conditions.According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include: On 07/13/2026 at 9:48AM a partially ripped garbage bag full of trash hanging from the dumpster was observed and the contents of the garbage bag were falling onto the surrounding area. Dirty cups, lids, and a buildup of residue were observed on the ground surrounding the dumpster. In addition, fast food wrappers were found behind the dumpster. During this observation, Certified Dietary Manager (CDM) Y was interviewed on how often the dumpster area is cleaned and she stated, they check the area multiple times a day and it is cleaned every day.According to the FDA 2022 Food Code, 5-501.115 Maintaining Refuse Areas and Enclosures A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items.Record review of the facility's policy Trash policy, revealed, Trash will be removed from all areas on a specific schedule to prevent spillage and odors. and The area surrounding the dumpster will be kept free of debris. When transporting garbage to the dumpster staff will ensure the area is clean and free of debris.

Based on interview and record review the failed to maintain clean and homelike room conditions for one resident (Resident #82) of one resident reviewed for homelike conditions. Findings Include: Resident #82:During Resident Council on 7/14/2026 at 3:00 PM, Resident #82 asked what frequency housekeeping should mop resident rooms. The resident was informed upon receiving an answer it would be provided to her. On 7/15/2026 at approximately 10:00 AM, a review was conducted of Resident #82's record, and it revealed she admitted the facility on 5/11/2016 with diagnoses that included, Congestive Heart Failure, Anxiety, Diabetes, Chronic Kidney Disease, Atrial Fibrillation and Lymphedema. On 7/15/2026 at 12:41 PM, Housekeeper R reported they are supposed to vacuum or mop the resident room floors on daily. They recently had a staff meeting where this was reinforced. She shared cleaning a discharged resident room can take approximately 45 minutes to one hour. On 7/15/2026 at 4:00 PM, Housekeeping Supervisor S explained if they observe a resident floor to be soiled his staff should be moping or vacuuming. The issue arises when they cannot vacuum/mop every room when there are staffing concerns. Fully staffed is six housekeepers and a floor technician and when they have five housekeepers they each pick up an additional 6 rooms each plus their scheduled discharges. There are approximately 7-8 discharges per day.Supervisor S was provided with the concern from Resident Council, and he stated he was made aware and observed Resident #82's room. He stated there was dry skin and other debris on her floor that indicated the assigned housekeeper had not cleaned the resident's room. Supervisor S swept and mopped the resident's room prior to leaving the evening of 7/14/26. He was asked if Resident #82's room was the only room not cleaned, and he stated there were about five other rooms that were not cleaned on 7/14/2026 by the same housekeeper. He continued it appeared she is struggling with time management as upon completing an audit it was found she was not consistently completing her cleaning assignments. Prior to Resident #82 voicing the concern he was not aware of any issues. On 7/16/2026 at 9:26 AM, Resident #82 reported on Tuesday evening, Supervisor S did sweep and mop her room but cleaning and mopping of her floor has been a continuous issue. Prior to the supervisor completing the task her room had not been cleaned in a few days. On 7/16/2026 at 10:55 AM, Housekeeper T reported she is assigned about 22 rooms per day (which includes discharges and common areas). Housekeeper T reported she has been cleaning rooms more thoroughly which has caused her to move slower and not complete all assigned room on somedays. She offered she is cleaning the rooms to the standards the facility set and previously she may have skipped certain cleaning tasks in resident rooms. Housekeeper T admitted to not cleaning Resident #82's room for a few days but it was not purposeful and it was due to her being thorough in other rooms and moving a little slower to ensure she is doing all that is expected of her. She explained if rooms are not completed at the end of her shift the housekeeper the next days is supposed to clean those rooms first, but she was unsure how they would know which rooms were not completed. She was asked if she had the same set why she did not clean the rooms from the day prior and she stated it was because she had forgotten by the time she came back in the next day. Housekeeper T was asked if she alerted anyone to not completing her assignment and she reported she had not. She stated the first time she was alerted to a concern was today. On 7/16/2026 at 11:16 AM, Housekeeping Supervisor S stated all his housekeepers currently work from 7:00 AM- 3:30 PM. There are currently two open positions with one beginning an afternoon shift. Supervisor S explained if his staff did not complete their assigned room cleanings, they are supposed to communicate that to him and typically they circle back to those rooms the next morning to clean them before beginning the new assignment. Supervisor S was asked if Housekeeper T ever communicated to him that she was struggling to keep up and that room assignments were not completed daily and he stated that he was not aware. Review was conducted of Housekeeper T's Departement Orientation dated 2/20/26. The following was marked off as completed:How to deep clean a resident roomProper use of all floor care equipment Review was conducted of Housekeeper T's daily housekeeping room assignment sheets a and it revealed the following: 7/8/2026Did not clean 7 of the 16 resident rooms assigned.7/9/2026Did not clean 11 of the 19 resident rooms assigned which included Resident #82's room.7/10/2026Did not clean 6 of the 19 resident rooms assigned which included Resident #82's room.7/14/2026Did not clean 11 of the 19 resident rooms assigned which included Resident #82's room. Review was conducted of the facility 's Housekeeping/Aide Job Description and it stated the following, .Cleans (dust, dry mop, wet mop, sanitize, scrub) assigned resident rooms, bathrooms and common areas daily according to facility procedure.

Based on observation, interview and record review, the facility failed to ensure that a shower and shaving was provided to one resident (Resident #95), of one resident reviewed for Activities of Daily Living (ADL) care. Findings include:Resident 95 (R95):On 7/14/26 at 10:23 AM, an interview was conducted with R95 who answered questions and engaged in conversation. An observation was made of R95 with a full beard. When asked about their preference of shaving, the Resident reported they liked to be close shaven with a mustache. The Resident reported having a trimmer that was brought from home, had asked staff to assist with the shaving and reported he could not perform his own shaving due to tremors of his upper extremities, showed how his hand was not steady enough to do the shaving and stated, I have asked them, but they have not done it yet. The Resident was asked about bathing preference and the Resident reported preference of showering but indicated he had a bed bath instead. The Resident reported the CNA had come in the last time, but the Resident was too tired since they just came back from therapy and stated, They came once after therapy and I was whipped! The Resident reported the CNA left out of the room, threw her hands up, she said, 'Ok you don't want it, and said the Resident refused. When asked if the Nurse came in to discuss it or if another time or day was set up, the Resident reported no one came back or rescheduled the shower and indicated he had gone without it. When asked how long the resident had been at the facility, the Resident reported admitting on June 23rd and has had a bed bath but not a shower and no shaving assistance. A review of Resident 95's medical record revealed an admission into the facility on 6/23/26 with diagnoses that included acquired absence of right leg above knee, atherosclerosis of arteries of left and right leg, polyneuropathy, and history of falling and disorders of muscle. A review of the Minimum Data Set assessment for R95 revealed a Brief Interview of Mental status score of 15/15 that indicated intact cognition and the Resident was dependent on helper for shower/bathe self, toileting hygiene and needed substantial/maximal assistance with transfer bed/chair. On 7/15/26 at 1:30 PM, an observation was made of R95 in their room. The Resident was observed to have a full beard and mustache. The mustache hair was long, curling over his upper lip and was in the mouth. The Resident reported it was too long and it needed to be trimmed, did not like it that long, did not like the full beard, and wanted a shower not a bed bath. The Resident also reported a lack of not getting cleaned up in the morning and needed assistance due to bad tremors and was unable to shave himself. On 7/15/26 at 1:40 PM, an interview was conducted with the Unit Manager, Nurse (UM) U regarding R95 lack of showering and shaving. The UM was asked about facility policy with showering versus bed bath. The UM reported the Residents should be getting a shower over a bed bath and bed bath given only when they refuse the shower. When asked about refusals for showering, the UM reported the Nurse should be made aware, discuss with the Resident and should put a progress note in the medical record. A review with the Unit Manager of the Resident's task for bathing revealed completion of bathing on 7/2, 7/6 and on 7/13 that the resident had refused. A review of the progress notes lacked documentation regarding the refusals for showering versus bed bath, lacked documentation of the refusal on 7/13 or the rescheduling of the bathing activity. The Unit Manager reviewed the activities evaluation and reported the resident liked a shower. When asked about the facility policy on shaving, the UM reported the CNA should be offering to assist with shaving during bathing activities. On 7/15/26 at 1:54 PM, an observation was made with the Unit Manager, Nurse U of R95. The Resident reported he had not showered since being admitted , had bed bath but preferred to shower and had not been assisted with shaving. The UM asked the Resident how he preferred his facial hair and he stated, I like it gone, indicated the sides of his cheeks, and reported the mustache needed to be trimmed. The UM reported to the Resident that she would have someone assist with his shaving today.On 7/15/26 at 4:07 PM, an interview was conducted with the Director of Nursing (DON) regarding R95's lack of assistance with shower and shaving. The DON reported that when a Resident refuses, a custom alert was to be documented for the refusal and then it can be followed up on by someone like the Unit Manager. The DON reported speaking with the Staff and indicated the Staff member had not documented the custom alert; the refusal was not followed up and reported the Nurse should have followed up on the resident not wanting the shower. When asked why give a bed bath and not a shower, the DON reported staff were to offer the shower and if the resident does not want the shower, then do a bed bath. The DON reported that if the Resident preferred the bed bath over a shower, then that would be incorporated into the care plan. When asked about facility policy on shaving, the DON reported that shaving would be offered when they are there to assist with cleaning the Resident up and indicated the CNA should be asking the Resident. The DON indicated that if the Resident refused the shave, the CNA was to let the nurse know and follow the procedure for refusal of care with documentation.A review of the facility policy titled, Routine Resident Care, revised 3/12/25, revealed, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Guidelines: .2. Showers, tub baths, and/or shampoos are scheduled according to person centered care or state specific guidelines. 3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their face and hands, shaving, nail care.

Based on interview, and record review the facility failed to ensure staff were provided a current Vaccine Information Sheet/VIS per Standards of Practice, for Covid-19 vaccinations for 3 staff of 3 reviewed for Covid-19 vaccinations, which could result in the Staff lacking the necessary information to make an informed decision about consent or declination of the Covid-19 vaccination.Findings Include: Facility Infection Control On 7/15/2026 at 10:47 AM, during an interview with Infection Control Practitioner/ICP B about staff vaccinations, she said Covid-19 vaccinations were discussed with employees on hire. She said staff members were provided with educational information about the Covid-19 vaccination, and it was reviewed with them where they could receive the vaccination, such as their doctor/providers office or a pharmacy, but the facility did not provide Covid-19 vaccinations to staff. During the interview with the ICP B on 7/15/2026 at 10:47 AM, she said the facility-maintained Consent forms for employee Covid-19 vaccinations, including whether they chose to have the vaccination or declined. The ICP was asked for Covid-19 Consent/Declination forms and Covid-19 education material (VIS-Vaccine Information Statements) provided to 3 staff members: Nurse DD, Nurse EE and Nurse FF. On 7/15/2026 at 2:20 PM, ICP B provided copies of the Covid-19 Employee Vaccine Consent Forms for Nurses DD and EE; both declined the vaccinations. Nurse FF was newly hired on 6/9/2026. She did not have a consent or declination form for vaccinations including the Covid-19 vaccination. Nurse FF signed a document titled, Covid-19 Vaccine Staff Education on 6/9/2026. The document provided, . By signing this form, I am stating that I have been educated on the COVID vaccine utilizing the CDC (Centers for Disease Control and Prevention) VIS sheet. Further review of the Covid-19 staff vaccination information identified the facility provided the employees a Covid-19 VIS dated 10/19/2023. Upon review of the CDC online VIS for Covid-19, the most recent version was dated 1/31/2025. The Covid-19 VIS provided to the staff was not current. Nurse DD's Vaccine consent form was signed on 9/24/2025, Nurse EE's form was dated September 24, 2025. On 7/15/2026 at 3:01 PM, ICP B was interviewed about the outdated Covid-19 VIS. The most recent Covid-19 VIS dated 1/31/2025 was reviewed with her and she said she did not realize there was a newer VIS for Covid 19. A policy for employee vaccinations was not received prior to exit.

Based on interview, and record review the facility failed to ensure Pneumococcal vaccinations were offered and documentation was recorded that the vaccinations were accepted or declined for one resident (#44) of 5 reviewed for vaccinations, resulting in the potential for Resident #44 to be exposed to Pneumococcal illnesses. Findings Include: Infection ControlPneumococcal Vaccinations On 7/15/2026 at 10:55 AM, the Infection Control Practitioner/ICP B was interviewed about Pneumococcal/Pneumonia vaccinations for residents. The ICP said the residents were assessed for vaccinations beginning on admission. She said if the resident had not received the most updated Pneumococcal vaccination, it was offered. She said the residents' acceptance or declination was documented on a consent form and the information was placed in the resident's medical record. Resident #44 A review of the electronic medical record indicated Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Heart disease, prediabetes, dementia, anxiety, depression, anemia and on 5/27/2025 a cough. Upon review of Resident #44's vaccination records in the Immunization tab of the electronic medical record/emr, it was identified that Resident #44 had refused a PCV20 Pneumonia vaccination. Further review of the medical record for Resident #44 indicated there was a declination signed on 3/5/2024 that the resident did not want the Pneumonia vaccination. There were no additional consents or declinations for the vaccination. On 7/15/2026 at 1:30 PM, ICP B was interviewed and asked if the resident had been reassessed for the vaccination. She said she could not find a more recent consent or declination for the Pneumonia vaccination for Resident #44. The ICP said the last time he was offered the vaccination was 2024. The ICP said she would usually offer the vaccination yearly and the resident could have it sooner if they were eligible. She said she went to talk to him this day (7/15/2026) and he declined the vaccination but refused to sign the form. She was asked if this information would be placed in the medical record and she said it should be. A review of the facility policy titled, Immunizations: Pneumococcal Vaccination (PPV) of Residents, dated revised 11/4/2024 and effective 9/8/2025 provided, 1. Guideline: The Advisory Committee on Immunization Practices (ACIP) recommends vaccinating persons at high risk for serious complications from pneumococcal pneumonia, including those 65 years and older and all residents of nursing homes. Every year, a log will be maintained documenting the number of residents who received the vaccine, as well as the number who refused or did not get vaccinated. Each resident's pneumococcal immunization status will be determined upon admission or soon afterwards and will be documented in the resident's medical record. Residents may refuse vaccination. Vaccination refusal and reasons why. should be documented by the facility. If the resident/family/legal representative chooses to exercise the right to decline the vaccination, it will be re-evaluated annually.

Based on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1) Personal Protection Equipment/PPE use during care and medication administration with a feeding tube for 2 residents (#14 and #44), and Care of and medication administration via a Peripherally Inserted Central Line/PICC Line for one resident (#94), of 5 residents reviewed for a feeding tube or PICC line while in Enhanced Barrier Precautions and 2.) Laundering of Kitchen cleaning cloths to prevent the spread of infectious organisms, Findings Include: Resident #44 (R44): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R44 was admitted to the facility on [DATE] diagnoses included: percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach), atherosclerotic heart disease (ASHD), gastro-esophageal reflux disease (GERD), dysphasia (impaired ability to eat and drink), history of esophageal obstruction. The MDS assessment dated [DATE] indicated the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 1 of 15 and was dependent on care for needs. On 07/14/2026 at 9:28 AM, observation of enhanced barrier precautions (EBP) sign on R44 door. During the observation of tube feeding and medication administration for R44, Nurse A was observed as she prepped the tube feeding formula at the medication cart and did not wear gloves. Nurse A primed the tubing and then laid the connection end uncover/uncapped directly on the medication cart, no barrier was used on top of the medication cart for the set up to be placed on either and that exposed the tube feeding connection (end that directly hooked into the resident) to become contaminated. During the attempt by Nurse A to administer medication via PEG tube she handled the tube with open end and inserted syringe into PEG tube, unsuccessfully tried gravity administration and manipulated the stop cock (open and close valve) multiple times at no time did she wear a gown during care, and at no time did she use a clean barrier to place the syringe or tube on during care. On 07/14/2026 at 9:50 AM, during an observation at 9:28 Am Nurse A was unsuccessful at operating the PEG tube to administer medications and needed assistance and left the room then returned at this time. Nurse C entered the room and talked to Nurse A about troubleshooting and Nurse A then attempted to insert and push the plugger into the syringe to force the medications out of the syringe and into PEG tube without success Nurse A had no personal protective equipment (PPE) of gloves or gown on. Nurse C suggested that Nurse A get assistance from the Unit Manager (UM) D and both nurses exited the room. On 07/14/2026 at 9:55 AM, observed Nurse A and infection control prevention (ICP) Nurse B enter the room, neither donned (applied) gown. Nurse A placed a paper towel over the wet spot on the resident's bed where the medication had poured out earlier. ICP observed Nurse A manipulate the stop cock on the PEG tube and attempt to administer the rest of the medication, it was unsuccessful. ICP asked Nurse A if she had flushed the line prior to attempt to administer medications, Nurse A admitted she did not and said she had pulled back on it. ICP Nurse B said to Nurse A to always flush the line first to make sure it was clear and that it should be done by gravity and not force. On 07/14/2026 at 9:59 AM, during a brief interview as she exited R44 room ICP Nurse B was asked why R44 was in EBP (and pointed to the sign on R44's door) and she said for his PEG tube. ICP B was further queried about PPE and she stated, I was not doing direct care. When ICP B was asked if Nurse A had just performed direct care and in a frustrated tone stated Yes, and (Nurse A) should have worn PPE and agreed that Nurse A had not and walked away. On 07/14/2026 at 1:34 PM, Nurse L was observed during medication administration for R44, she performed medication administration and wore gloves with no other PPE. Nurse B was asked why R44 was in EBP (and pointed to the sign on R44's door) and she said for his PEG tube. Nurse L was asked what PPE was needed for R44 during medication via PEG tube and she stated, gloves and gown, Nurse L' acknowledged she did not wear a gown during observation. A record review of R44 care plan revealed:Focus: is at risk for further impaired skin integrity/pressure injury. peg tube. with Interventions: Enhanced Barrier Precautions. A record review of R44 orders revealed: Enhanced Barrier Precautions. A record review of R44's orders revealed: Enteral Feed two times a day Infuse and pump via PEG (brand of formula) 1.5 @85 mL/hr. X 16 hrs until1360mL/2040 kcal (calories) infused. and Enhanced Barrier Precautions Resident #94: (R94): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R94 was admitted to the facility on [DATE] diagnoses included: Multiple drug resistant organism (MDRO) and was on Vancomycin IV antibiotics with a peripherally inserted central catheter (PICC/ for long term IV antibiotic use), The MDS assessment indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15. On 07/15/2026 at 9:00AM, observed EBP sign on R94's Door. During the observation of medication administration task Nurse G administered IV Vancomycin (antibiotic) via PICC line to R94 and wore gloves with no other PPE. Nurse G was asked to verify the PICC dressing date and she said it was 07/07/2026, Nurse G offered that R94 was to be discharged home today (07/15/2026) with home health care and complete the rest of the IV antibiotic regimen and that she planned to change the dressing before she left. On 07/15/2026 at 9:13AM, during an interview with Nurse G she was asked why R94 was on EBP's and she said because of the PICC line. Nurse G was asked what PPE should be worn for IV PICC medication administration and she replied Gloves, when further queried about a gown Nurse G said her PICC line is a mid-line not a central line. Nurse G was asked to read the door signage and policy for clarity. Nurse G state Oh, I did not realize I needed one (a gown) for IV administration; I definitely wear a gown when I change the dressing. A record review of R94 orders revealed: to change PICC dressing every week and Enhanced barrier precautions. On 07/16/2026 at 8:19AM, during a follow up interview with ICP Nurse B she agreed that EBP's were not followed by Nurse A or Nurse L with PEG tube use and medication administration with R44, and that neither wore the proper PPE. The ICP Nurse B admitted that the DON also had not used proper PPE with another surveyor present during another observation and resident. The ICP Nurse B stated obviously education needs to be done to follow the EBP and wear appropriate PPE. The ICP Nurse B was asked about R 94 and was told R94 had EBP's for PICC line presence. The ICP Nurse B was then asked about the observation on 07/15/2026 of Nurse G who only wore gloves during the administration of Intravenous (IV) antibiotic medication via the PICC line and wore PPE of gloves only. The ICP B said it was her understanding that gown is not needed to administer medications, and she was then asked if that applied to IV medications given through the PICC line also, and she replied yes, they are not in direct contact with the resident. After more discussion on CDC guidelines and policies the ICP Nurse B said she would investigate it more because if she was not right, she had taught the staff wrong. The ICP Nurse B was asked how often PICC line dressings needed to be changed, and she said weekly, but the order was different for each resident. The ICP Nurse B was advised on the date observed of 07/07/2026 on R94's dressing on 07/15/2026. The ICP Nurse B reviewed R94 orders and she stated, I don't know how that would happen, there is definitely an order there; it should have been done on Tuesday (07/14/2026). On 07/16/2026 at 8:55AM, the ICP Nurse B approached and said that she was wrong, that staff was required to wear gown and gloves when they accessed the PICC line for medication administration and explained I am sorry; I was so hyper focused on the direct contact part; I was not thinking. A record review of the facilities policy titled Enhanced barrier precautions (EBP) revealed:POLICY: 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 (MDROs). Enhanced Barrier Precautions are indicated for residents with any of the following: 1) infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply.; Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies.; Implementation: A. Health care personnel caring for residents on Enhanced Precautions should wear gloves and gowns during high-contact resident care. Examples of high contact resident care activities requiring gown and glove use. Device care or use; central line, urinary catheter, feeding tube, tracheostomy/ventilator; Wound care: Chronic wounds. A record review of the facilities posted center of disease control (CDC) sign posted on the doors of R44 and R94's revealed: Enhanced barrier precautions everyone must: clean their hands, including before entering and when leaving the room. And Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. Infection Control: On 7/15/2026 at 11:47 AM during a tour of the laundry area with Infection Control Practitioner/ICP B and Maintenance Assistant BB, wash cloths in various colors were observed hanging to dry on several racks stretched along one wall in the Laundry room near the dryers. Maintenance Assistant BB said the washcloths were used as kitchen cleaning cloths. During the interview on 7/15/2026 at 11:47 AM, Laundry Aide CC said the washcloths were washed in a separate washing machine, with no bleach. Maintenance Assistant BB pointed to the washing machine and said it was not a commercial machine, as there were several larger commercial machines in the room also. Maintenance Assistant BB said the larger machines used bleach during the cycles, and the water was a hotter temperature. He said the smaller washing machine was used to launder resident items that could not tolerate the heat (the temperature used was less than 160 degrees Fahrenheit) or the bleach. He said it was also used to launder the washcloths because the facility did not want them to be washed in bleach or dried at a higher temperature because a different nursing home facility had stored their laundered kitchen cloths in a plastic bag after laundering them in bleach and drying them in the dryer and they had combusted in the plastic bag and caused a fire. The Maintenance Assistant said since the fire at the other facility, they had laundered the kitchen cloths in the smaller low heat washer with a different laundering process. The detergent observed for the smaller washing machine was Sunburst- ultimate solid laundry detergent. The Maintenance Assistant was asked if the kitchen cloths used for cleaning kitchen surfaces, including food preparation surfaces were disinfected or sanitized during the laundering process, as they were not subject to chemical treatment, high wash heat or high dryer heat to eliminate infectious organisms. He was asked if the detergent used on the kitchen cloths was able to substitute for this process and he said he wasn't sure, but he would check on it. On 7/15/2026 at 3:02 PM, the ICP B was interviewed about the laundry detergent and laundering process for the kitchen cloths. She said she couldn't find information that the laundry detergent for the kitchen washcloths was sanitizing or disinfecting the cloths. A request was made to speak with the Laundry Manager S at that time. The Safety Data Sheet/ SDS for the laundry detergent Sunburst- ultimate solid laundry detergent was reviewed. The document did not mention the chemical disinfecting or sanitation properties. On 7/15/2026 at 4:05 PM, the Maintenance Director S was interviewed about the kitchen washcloths used for cleaning in the kitchen. He said the rags were no longer laundered- washed and dried, as they previously were because at another facility, the rags combusted and caught fire after drying and being stored in a plastic bag. The Maintenance Director was asked for additional information about the cleaning detergent used on the washcloths. He was asked if the vendor supplying the product would have additional information and he said he had the SDS/Safety Data Sheet, but it didn't mention cleaning. The Maintenance Director S said the kitchen cloths would be placed in a bucket, and a sanitizing agent would be added to the water, that could sanitize the cloths. Reviewed with him that during the survey, a Surveyor identified a sanitizing bucket at the 3-compartment sink in the kitchen used to wash dishes registered 0% sanitizer when tested. The Maintenance Director said he would check with the vendor of the laundry soap. On 7/16/2026 at 11:30 AM, during an interview with Maintenance Director S, he said he received a message from the laundry detergent vendor and the laundry detergent used to wash the kitchen washcloths did not sanitize or disinfect. The Maintenance Director was asked if the facility had looked into or tried a different laundering detergent for the washcloths that would work without high temperature washing or high temperature drying. He did not respond. The facility continued to not sanitize, or heat dry the kitchen washcloths used to wipe down the kitchen counters, equipment and dishes. A review of the facility policy titled, Cleaning Towels, date effective and revised 3/11/2026 provided It is the policy of this facility to use cleaning towels for cleaning and sanitization. 4. The towels should be laundered separately from other laundry. 5. The towels will be dried, folded, and returned to the kitchen in a clean container, and stored in a clean area. The policy did not mention the cleaning agent, or heat settings for the washer or dryer. A review of the facility policy titled, Microfiber Laundering Instructions, Proper Care and Maintenance, dated 7/2023 provided, . Washing: Maximum washing temperature 194F/90C. Bleaching: Periodic light bleaching only, Oxygen bleach approved, Liquid bleach in Moderation.Drying: Maximum drying temperature 140F/60C, Tumble Dry at Low temperature. Resident 14 (R14): On 7/14/26 at 10:57 AM, an interview was conducted with Resident 14 who answered questions and engaged in conversation. The Resident indicated she was not supposed to drink water though she was thirsty and that she was fed through a tube in her stomach (PEG tube-Percutaneous Endoscopic Gastrostomy tube placed through the abdominal wall into the stomach to deliver nutrition, fluids and medications). Upon leaving the room, the Director of Nursing (DON) came into the room with medication for Resident 14's medication administration. An observation was made of R14's door with an Enhanced Barrier Precaution sign on the door for bed 2 that revealed the following that included: Stop Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Device care or use: central line, urinary catheter, feeding tube. An observation was made upon re-entering the room with the DON accessing R14's PEG tube. Staff AA was in the room with the DON at that time. An observation was made of both the DON and Staff without the identified needed PPE (personal protective equipment) of the gown while accessing the feeding tube. After leaving the room, the DON was asked about not donning the proper PPE as identified on the signage on the door. The DON reported going in to help the nurse catch-up and indicated she should have put on the PPE prior to accessing the PEG tube.

Based on observation, interview and record review, the facility failed to maintain the storage of nebulizer equipment (a medical device that turns liquid medication into a fine mist to be inhaled directly into the lungs for treatment of respiratory conditions) in a sanitary manner for 1 resident (Resident 11) and failed to ensure that a physician's order for oxygen use was followed for 1 resident (Resident #59) of four residents reviewed for oxygen/respiratory care. Findings include:Resident 11 (R11):On 7/13/26 at 2:27 PM, an observation was made in Resident 11's room. The Resident was not in the room at this time for an interview. An observation was made of R11's nebulizer mask and nebulizer medication chamber assembled together, placed in a bag that hung on the bedside table drawer handle. The medication chamber was visible through the bag and was wet inside the medication chamber. A review of Resident 11's medical record revealed an admission on [DATE] and readmission on [DATE] with diagnoses that included left tibia fracture, heart failure and diabetes. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status score of 12/15 that indicated moderately impaired cognition.Further review of R11's progress notes revealed a noted dated 7/9/26, that revealed, .Follow-up pneumonia management and hypertension management. Discussed with the patient that chest x-ray showed mild right lobe infiltrated and was put on oral antibiotics. Assessments and Plans: . Pneumonia, unspecified organism: Lungs are wheezing in both sides today which is changed. She also has cough with mucus. Medications: Continue-Doxycycline Monohydrate 100 MG capsule. Start New-Albuterol Sulfate Nebulization Solution.R11's orders revealed, with a start date on 7/9/26, Albuterol Sulfate Nebulization Solution. inhale orally via nebulizer three times a day for Pneumonia for 7 days. On 7/15/26 at 1:31 PM, an interview was conducted with R11 who was in their room. The Resident answered questions and engaged in conversation. An observation was made of the nebulizer mask and medication chamber disassembled and drying on a paper towel. When queried about the nebulizer storage, the Resident stated, This nurse washes it and sets it out to dry. I told the other nurses that's what they were to do. The Resident reported that the other nurses were putting it in the bag after getting the breathing treatment, they did not clean it or let it dry, that it went back into the bag all together until it was given again. The Resident reported she didn't know it was supposed to be set out until this nurse did it. Resident 59 (R59):On 7/13/26 at 2:44 PM, Resident 59 is sitting in her wheelchair in her room. An observation was made of the Resident's back towards the bed. An interview was conducted with the Resident who answered questions and engaged in conversation. An observation was made of the Resident wearing a nasal cannula for oxygen administration that was connected to a concentrator. The concentrator was between the wall, the bed and the bedside table and not within reach of the resident. The oxygen concentrator was set to deliver 6 liters/minute of oxygen. The tubing was the regular clear plastic tubing and there was no humidification on the oxygen. The Resident was asked what liter of oxygen she was to be on and the Resident stated, I was at 3 but they turned it down to 2. When asked if her nose was dry, the Resident stated, Yes my nose is dry, I have to take it out for awhile or it bleeds. The Resident reported that staff put her back on the concentrator when she was in her room and she uses the portable tanks when she leaves the room. Nurse W was in the hallway and was asked what liter of oxygen R59 was ordered to be at. The Nurse looked on the computer and reported the order was for .5 to 4 (Liters per minute (L/min)). The Nurse was informed of the oxygen concentrator set to administer 6 L/min. The Nurse reviewed the medical record and was unable to find documentation of a change in the oxygen and there was not an order for the oxygen to be at 6 L/min. The Nurse evaluated the Resident and reported her O2 saturation was 100% and stated, I don't know why she was up at 6 Liters, indicated she turned the O2 down to 4 L/min, the Resident stayed at 100% oxygen saturation, and she will continue to monitor the Resident. A review of R59's medical record revealed an admission on [DATE] and a readmission on [DATE] with diagnoses that included pleural effusion, chronic respiratory failure with hypoxia, pulmonary heart disease, chronic obstructive pulmonary disease and congestive heart failure. A review of R59's MDS revealed BIMS score of 14/15 that indicated intact cognition. A review of R59's order for Oxygen revealed 0.5-4L (liters/min) O2 (oxygen) via nasal cannula to maintain SPO2 (oxygen saturation) over %89 with a start date on 7/2/26. On 7/15/26 at 4:27 PM, an interview was conducted with the Director of Nursing (DON) regarding storage of nebulizer equipment. The DON was asked about facility policy on the storage of the nebulizer equipment. The DON reported they should be cleaned out, set out to dry and then can be stored in the bag once dry. R59's oxygen at 6 L/min was reviewed with the DON. A review of facility policy titled, Oxygen administration, long-term care, revealed, Implementation: .Verify the practitioner's order. Adjust the oxygen flow rate, as ordered.

Based on observation, interview and record review, the facility failed to implement interventions and treatments for pressure ulcer management for one resident (Resident #56) of three residents reviewed for pressure ulcers. Findings include: Resident #56 (R56):On 7/13/26 at 11:08 AM, an observation was made of R56 lying in bed on her back, awake. The Resident was interviewed, answered simple questions and engaged in limited conversation. The Resident was asked about wounds, but the Resident was unsure if she had a wound on her buttock. An observation was made of an air mattress on the bed, but the air mattress machine was not functioning. The Resident reported she didn't think that the mattress was deflated underneath her. At 11:17 AM, Nurse V was asked if there was a problem with the air mattress and it had been shut off. The Nurse observed that the air mattress machine was not on, turned it on and did not get any alarm sounds. The Nurse reported that it was possibly shut off on accident and indicated she was unsure how long it had been off. A review of R56's medical record revealed an admission into the facility on 7/2/25 and readmission on [DATE] with diagnoses that included pressure ulcer of sacral region, right heel and left heel, anxiety disorder, noninfective gastroenteritis and colitis, short bowel syndrome, end stage renal disease, and dependence on renal dialysis. A review of the Resident's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status score of 06/15 that indicated severely impaired cognition and the Resident needed substantial/maximal assistance to roll left and right, and dependent on staff for bathing, toileting hygiene and transfers. A review of Section H-Bladder and Bowel of the MDS revealed urinary continence and bowel continence was documented as Always incontinent. On 7/15/26 at 10:20 AM, an observation was made during wound care with Nurse D and another Nurse assisting. The Resident was turned onto her side to change the wound to her coccyx area. An observation was made of no dressing to the area. When asked if the Resident should have had a dressing on the area, Nurse D reported there should have been a dressing to the wound and indicated she was unsure why there was not a dressing. The Nurse indicated she was not aware the dressing was off prior to doing the dressing change. The Resident had a brief on that was not observed to be soiled. On 7/15/26 at 10:32 AM, an interview was conducted with CNA X who indicated they had changed the brief on Resident 56 about 10:00 AM. The CNA was asked about the lack of a dressing to the coccyx wound. The CNA reported that when she had changed the resident, there was no dressing and she had told the Nurse that there was no dressing. The CNA reported that when she had changed the Resident earlier at the beginning of the shift, the Resident did not have a dressing on the wound at that time, and she had reported it to the Nurse at that time as well. Nurse U was witness to the conversation and reported that there should be a dressing on the wound and indicated she would talk to the Nurse about it. On 7/15/26 at 10:50 AM, CNA X was interviewed regarding the lack of a dressing on Resident 56's coccyx wound. The CNA was asked what time she had provided incontinence care in the morning, and the CNA reported it was right after she had started in the morning and she started at 6AM. The CNA reported the Resident was incontinent of bowel movement (bm) and stated, It (bm) was not in the wound, but it was really close. I told the nurse right afterwards that she did not have a dressing on. It was the nightshift nurse who was still here when I got here. The CNA reported that when she had changed her again at 10:00 (AM), she saw that there still was not a dressing on it and stated, I told the nurse who is here now to let her know. I don't know if it was passed on in report that there was not a dressing. The CNA was unsure how long the Resident did not have a dressing on the coccyx wound since she discovered it on the first change for the resident on her shift and she did not have a dressing on it at that time. On 7/15/26 at 2:21 PM, an interview was conducted with Unit Manager, Nurse F regarding Resident 56's wounds. The Resident's medical record of wounds was reviewed. The Resident had an unstageable right heel pressure wound that was facility acquired that originated on 5/20/26, a facility acquired left heel pressure wound that was unstageable that originated on 3/12/26 and a facility acquired pressure wound to the coccyx that originated on 5/27/26 that the Nurse indicated was staged as a stage III yesterday. The skin and wound interventions were reviewed that included, boots on bilateral feet, repositioning as the resident allows, pillows and an alternating air mattress. The observation made of the air mattress turned off was reviewed. When asked if the air mattress was turned off to do care or turning of the Resident, the UM stated, There would be no reason to turn it off, and indicated that the mattress would not collapse down but it would not give the benefit of the alternating air. It was reviewed with the UM of no dressing on the coccyx wound. The Unit Manager indicated that there should be a dressing on and that the Resident had chronic incontinence with loose stools. On 7/15/26 at 4:07 PM, an interview was held with the Director of Nursing regarding R56's pressure ulcers. It was discussed of the development of the wounds, acquired at the facility and deterioration of the coccyx pressure ulcer from a stage II to a stage III, the air mattress having been off and the wound left without a dressing. A review of facility policy titled, Skin Management, revealed, .Overview: Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes.

This citation pertains to Intake Number 3104173. Based on observation, interview and record review the facility failed to follow standards of care during provision of services and 1) Ensure the prompt reporting of an acknowledged new skin issue for one resident (Resident #157) and 2) Ensure the proper handling and use of percutaneous endoscopic gastrostomy (PEG) tubes, which deliver nutrition and medications directly into the stomach, for one resident (Resident #44) of two residents reviewed for quality care standards. Findings include: Resident #157 (R157):A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R157 was admitted to the facility on [DATE] diagnoses included: Stoke, hemiplegia affecting left (non-dominant) side following a stroke, atrial fibrillation (AFIB/ irregular rapid heart rate), presence of a pacemaker, hyponatremia (low sodium) and dementia. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 1 of 15 and was dependent on care for needs.On 07/13/2026, during entrance conference with NHA was advised they had filed on 07/11/2026 a facility reported incident (FRI) with an ongoing open investigation for R157. On 07/13/2026 at 1:29 PM, R157 was observed sitting up bedside in a wheelchair with her feet propped up on the bed, legs were in constant motion. R157 was covered with blankets making it hard to fully observe skin, her left hand swollen and bruising was seen on the area, the left arm had an ice pack over it with a blanket on top and was propped on a pillow. R157 was asked about the injury, she proved not a good historian to recall, R157 confirmed when asked that no one was mean to her, no one hurt her and she did not fall, R157 could not explain how the left arm became injured. On 07/14/2026 at 8:47 PM, during an interview with UM D, she confirmed that R157 had an Xray and dopplar done on the left arm for a bruise and swollen area that was reported on the morning of 07/11/2026 by CNA M. UM D said that there was no known fall for the resident and that if R157 had fallen she functionally would not be able to get up or move on her own. On 07/14/2026 at 8:58 AM, during an interview with family member I he said that the facility contacted him on the morning of 07/11/2026 and said that 'CNA M was in the restroom with R157 and that R157 winced' and that 'CNA M reported to Nurse H that R157 left arm was swollen and discolored'. Family member M said that the practitioner had later told him it was caused by tissue trauma. During an observation and interview with R157 and family member I, R157 was observed with extensive dark purple bruising on her left arm from the area above the wrist to the elbow and was swollen in the same area. R157 denied remembrance of hitting/bumping her arm, falling or being physically hurt.On 07/15/2026 at 12:24 PM, during an interview with CNA M she said that she worked first shift and that during morning rounds at 6AM she had not received any concerns about R157 from the third shift. CNA M said that at a little after 7AM she was passed breakfast trays. CNA M stated that I noticed (R157) arm was swollen through her shirt; I could see it through her the long sleeves; I could not push the sleeve up because it was tight; I went and got the nurse. CNA M said that Nurse H came in and they removed R157 shirt and that's when we saw it. When asked to describe what it was CNA M said a big bruise on R157 arm that was royal to dark purple from her wrist to her elbow. CNA M was again queried if she had received report during shift change walk through about the finding and she stated No, nobody said anything that is why I was surprised when I saw it. On 07/15/2026 at 12:43 PM, during an interview with Nurse J who was the nurse for R157 during day shift on 07/10/2026. Nurse J she did not observe or had awareness that there any issue with R157's arms and offered that she wore long sleeves most days. Nurse J she had not received any report from the CNA Q about concerns or issues with R157 arm that shift, who was also worked with R157. Nurse J was asked about any deficits with R157's posture and she said that R157 sat in the wheelchair straight and had not noticed and was not advised that R157 favored or leaned to either side. On 07/15/2026 at 1:01 PM, during an interview with Nurse H who worked with R157 on 07/11/2026 she said she was still in repot with the third shift Nurse N when CNA M came to her about R157 arm being swollen. Nurse H said that when she entered R157 room that she was in the restroom and that she could not observe the skin because her long sleeve shirt was tight and that she had to remove it. Nurse H said that when she removed R157 shirt the left arm was warm to the touch, swollen from her elbow to wrist and dark purple. Nurse H said that R157 winced when she touched it. Nurse H said she asked Nurse N to observe R157 arm and said she stated that she asked Nurse N, what was up with (R157's) arm? Nurse H said that Nurse N he replied, 'I have no clue what it was about' and that 'it was news to him.' On 07/15/2026 at 1:55 PM, attempt to phone interview with Nurse N was unsuccessful. On 07/15/2026 at 2:00 PM, during an interview with the DON she said that no photos taken for the chart had been taken and indicated an investigation was in progress. On 07/15/2026 at 3:00 PM, during an interview with CNA O who was the CNA for R157 during third shift from 07/10/2026 to the morning of 07/11/2026, CNA O said that she started he shift by doing rounds with CNA Q and that there was nothing about (R157) reported off to me. CNA O said that R157 was in her pajamas before she came on shift. CNA O said that she performed checks every 2hours and that R157 appeared comfy all night; with no complaints. CNA O said that her last check around 4AM that she removed R157's pajama top to get her top dressed with morning care that she noticed the purple/blue and puffy left arm and indicated it was from the wrist to mid-way up the forearm. When asked if she had reported the finding to anyone CNA O stated I did not tell anyone because I there was no way they have not seen this and know about it already. When CNA O was asked if she had seen R157's arm like that before, she said no. CNA O further stated looking back now I know I broke protocol and it was my mistake in not reporting it. On 07/15/2026 at 4:43 PM, during an interview with CNA P who was the CNA for R157 during second shift on 07/10/2026, she reported that when she got R157 dressed in her pajamas she smooshed her face but did not say anything, CNA P said she mentioned it to family member I who said R157 had a history of shingle and sometimes had pain. CNA P said there was nothing unusual about the skin on R157's arm that she noticed. On 07/15/2026 at 4:47 PM, during an interview with CNA Q who was the CNA for R157 during first shift on 07/10/2026, CNA Q said that R157 was found to be leaning in her wheelchair to the left side and that she had adjusted R157 with pillows in the chair several times through out her shift. CNA Q was asked if she asked the resident about pain or positioning and admitted ly did not query the resident about pain or leaning and did not report it and stated, I don't work with her a lot, I was not sure if that was normal for her and I would just mainly readjust her. A record review of R157's MDS functional status revealed the resident was dependent on toileting hygiene; shower/bathe self; upper and lower body dressing; application/removal of footwear and required partial to moderate assistance with personal hygiene. A record review of R157's care plan revealed: Focus: (R157) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Antiplatelet Date Initiated: 05/18/2026 with Interventions: Complete daily skin inspection. Report abnormalities to the nurse; Monitor bruising as indicated; Observe and report to physician PRN s/sx (signs and symptoms) of complications: .muscle joint pain, lethargy, bruising. And Focus: (R157) is at risk for impaired skin integrity/pressure injury R/T: decreased mobility, incontinence. Date Initiated: 05/10/2026 with Interventions: Observe skin with showers/care. Notify nurse immediately of any new areas of skin; breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; Turn/reposition resident frequently and PRN (as needed). And Focus: (R157) is at risk for pain and/or has acute/chronic pain r/t generalized pain, polyneuropathy (decreased nerve sensation) Date Initiated: 05/10/2026. With Interventions: Anticipate resident's need for pain relief PRN and respond immediately to any complaint of pain. And Focus: (R157) has a functional ability deficit and requires assistance with self-care/mobility R/T: weakness with Interventions: BED MOBILITY: Resident requires__ Substantial/ helper(s) with 1 helper. This is including rolling side to side, lying to sitting on side of bed and sitting to lying.A record review of R157's progress notes: 7/11/2026 07:30 Nurses Notes Note Text: Reported to this writer by CNA while she had guest on toilet this AM, getting her dressed, that her left forearm was bruised and swollen.According to the facilities policy titled Skin management: Overview: Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. with Guidelines: 11 .The CNA /STNA (nursing aides) will report any new skin impairment to the licensed nurse that is identified during daily care; 2. If a new area of skin impairment is identified, notify the resident, responsible party, practitioner, DON/designee.According to a record review of the facilities accident and incident report with 5 day investigation: conclusion. mechanical compression of the left forearm (between the resident's body and the recliner armrest) during the observed leaning episode on first shift July 10; The bruise was not prominently visible during second shift (due to long sleeves) but became more evident by third shift and was fully identified on first shift July 11. And Staff has been re-educated on proper reporting and has had reinforcement on following Resident Kardex.Resident #44 (R44): A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R44 was admitted to the facility on [DATE] diagnoses included: percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach), atherosclerotic heart disease (ASHD), gastro-esophageal reflux disease (GERD), dysphasia (impaired ability to eat and drink), history of esophageal obstruction. The MDS assessment dated [DATE] indicated the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 1 of 15 and was dependent on care for needs.On 07/14/2026 at 9:28 AM, during an observation of tube feeding and medication administration for R44, Nurse A was observed as she prepped the tube feeding formula at the medication cart and she said she had already crushed R44's medications and placed them all in the red Guaifenesin liquid to administer them together via the PEG tube. Nurse A was asked what medications she had already crushed and mixed in the red Guaifenesin liquid and she replied, Claritin and pantoprazole. After she prepped, Nurse A entered R44 room, set her supplies on the nightstand, no clean barrier used. During the attempt by Nurse A to administer medication she hooked up the medication syringe, no placement check, no checking for residual, no PEG flush first. Once in place the medication would not drain to gravity, she manipulated the connections and stop cock and tried to push the medications as she pushed to administer (mixed) medications the medications poured out the side opening onto the bed, the stop cock (open and close lines valve) was not in proper position. Nurse A then laid the whole set syringe (slightly propped because it still contained some liquid medication) still connected down on the resident's wet bed and left the room. Nurse A said she had to get another nurse because she didn't understand this connector and stated, I've never seen one like this before.On 07/14/2026 at 9:50 AM, during an observation at 9:28 Am Nurse A was unsuccessful at operating the PEG tube to administer medications and needed assistance and left the room then returned at this time. Nurse C entered the room and talked to Nurse A about troubleshooting and Nurse A then attempted to insert and push the plugger into the syringe to force the medications out of the syringe and into PEG tube without success. Nurse A had no PPE of gloves or gown when she attempted to operate the PEG tube. Nurse C suggested that Nurse A get assistance from the UM D and both nurses exited the room. On 07/14/2026 at 9:55 AM, observed Nurse A and infection control prevention (ICP) Nurse B enter the room, neither donned gown. Nurse A placed a paper towel over the wet spot on the resident's bed where the medication had poured out earlier. ICP observed Nurse A manipulate the stop cock on the PEG tube and attempt to administer the rest of the medication, it was unsuccessful. ICP asked Nurse A if she had flushed the line prior to attempt to administer medications, Nurse A admitted she did not and said she had pulled back on it. ICP Nurse B said to Nurse A to always flush the line first to make sure it was clear and that it should be done to gravity not by force. ICP B exited the room and said that she would be back and that she was going to ask UM D if there was a trick to this PEG tube.On 07/14/2026 at 10:04 AM, ICP B returned to R44 room and advised Nurse A that UM B said 'the long way is off' and referred to stop cock and that UM B also said 'if that doesn't work to call the provider for assistance'. On 07/14/2026 at 1:34 PM, Nurse L was observed during medication pass for R44, she was asked about the PEG tube, and she said she got report from the other shift that the provider came in and cleaned it and it worked fine. On 07/16/2026 at 8:19AM, during a follow up interview with ICP Nurse B she agreed that standards of care for R44 PEG tube use and medication pass where not followed by Nurse A as she observed. When the ICP Nurse B was asked if it was acceptable to mixed medications administration for PEG tubes administration and to not assess and flush the line prior and she stated I absolutely agree that neither (standard) was followed medications should not be mixed and given together via PEG tube the PEG was not assessed and flushed. The ICP Nurse B was asked about R44 PEG tube, and she reported that the provider was here about 30 minutes after the observation on 07/14/2026 and they cleaned the stop cock and that the PEG worked fine. A record review of R44's care plan revealed: Focus: (R44) has potential alteration in nutritional and/or hydration status r/t (related to) hx (history) BMI (body mass index) of 19, swallowing difficulties and h/o (history of) mech altered diet with interventions: Administer medications as ordered; Administer tube feeding and water flushes per MD orders.; Check for tube placement and residuals per facility parameters. A record review of R44' orders revealed: Enteral Feed every shift Flush Peg Tube with at least 15cc of water before and after medication administration and at least 15cc of water in between each medication And Enteral Feed every shift Check resident for residual, if greater than 250cc hold tube feeding for1 hour and recheck, if still greater than 100cc call the physician. And every shift Check Peg Tube for placement by aspirating stomach contents and patency by instilling at least15cc of water.According to the facilities policy titled Medication Administration-Enteral (through a fixated tube): To administer medications through a NG-tube, G-tube, Dobhoff and/or J-tube (all of those are fixated tubes that empty into specific areas of gastrointestinal tract) in an accurate, safe, timely, and sanitary manner. With Procedure: 7. Wash hands and apply gloves and personal protective equipment if applicable; 8. Expose the tube and place a barrier pad under the tube to prevent soiling the resident's linens or clothing when accessing the tube; 11. Verify placement of tube by using a piston syringe to aspirate stomach contents. Re-clamp tube if present. Verify Dobhoff and Jejunal placement per policy. Once placement is verified release clamp from tube, if present, and instill at least 15 ml of water into the tube through the syringe to check for patency via Gravity Flow. If water flows in easily, tube is patent. IF it flows in slowly, raise the syringe to increase pressure. If water does not flow properly, stop the procedure and notify the physician. 13. Preparing medications. c. Each medication should be prepared in its own medication cup; 14. And still at least 15 ML of water into syringe. Tilt the syringe tube to allow air to escape.;15. Just before the syringe empties of water, add medication as needed, and flush between each medication with at least 15 ML of water.

Based on interview and record review, the facility failed to implement interventions to prevent falls for one resident (Resident #3) of three residents reviewed for falls, resulting in a fall from bed.Findings include:This citation pertains to intakes 2971486 and 2985660.Resident #3 (R3):R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include rheumatoid arthritis, morbid obesity, inability to ambulate and primary generalized osteoarthritis.On 4/6/26 at 10:30AM, record review was conducted of a fall report from 03/26/26. On 03/26/26 at 14:00PM, Certified Nursing Assistant (CNA) C was providing care to R3 without the assistance of an additional staff member. CNA C rolled R3 away from and R3 kicked her right leg over the side of the bed, causing R3 to roll from the bed on to the floor. There was bruising noted to the right knee, ice was applied, the physician, responsible party and Director of Nursing (DON) were notified of the fall. X-rays of the right knee were ordered on 3/26/26 at 17:55PM and results were received at 18:42PM and the x-ray revealed a recent impacted healing right knee fracture. The family did not want R3 sent out to the hospital and instead chose to manage the pain and keep R3 in the facility.On 4/6/26 at 10:45AM, a review of the electronic medical record (EMR) was conducted. The EMR revealed a care plan that indicated that R3 is dependent x2 staff with bed mobility.On 4/6/26 at 11:50AM, an interview was conducted with CNA C. CNA C was asked about the fall with R3. CNA C stated, I was doing peri-care, I was on the left side of the bed, I cleaned her up to change her brief, I went to the other side of the bed and pulled her towards me and she held on the rail, she is capable of holding on to the rail, then I went back to the other side of the bed and tried to finish the care, her ankles were crossed and she lifted her leg up to try and uncross them and her body weight took her over the side of the bed. CNA C stated that there had never been any issues with her (R3) being able to hold the rail, the bed was in a low position. It wasn't a big drop, but a drop, nonetheless. CNA C was asked if they should've had another staff member with them when providing care. CNA C stated, yes, I should have had another staff member with me. CNA C stated, I pulled R3 towards me so she could hold the rail like I have many times before. I received a write up, because the Kardex says she's a two-person assist with bed mobility. On 4/6/26 at 2:00PM, an interview was conducted with the DON. The DON explained the incident with R3 and the steps the facility took afterwards. The DON was asked if the CNA should have used two staff members for the care she was providing? The DON stated, yes, she should have had two people with her. We wrote CNA C up and re-educated her as well. The DON stated, we had all the CNA's and nursing staff come in and receive education on ensuring they are using the correct amount of staff assistance to complete care.Record review of the policy titled, Fall Management, revealed:Practice Guidelines:2. Residents identified at risk for fall will have an initial plan of care developed to meet each resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.On 04/6/2026 at 2:05PM, during the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the non-compliance which included: 1. The facility implemented interventions for the resident involved.2. An audit was completed by the unit manager/designee of residents who require the assistance of two staff with bed mobility to ensure that staff are performing bed mobility with two people doing personal care.3. The facility fall process was reviewed and deemed appropriate. Education was completed with the nursing staff to ensure when we are providing care, that we review the plan of care and if it says 2-person assist for mobility, that we use two people, and when a resident requires 1-person assist, we never turn the resident away from us when performing care.4. The UM/Designee will review nursing staff, when providing personal care with residents requiring assistance with bed mobility, to ensure that staff are not turning residents away from them when performing care with 1 staff member, weekly x4 weeks and monthly x2 months. Any areas of non-compliance will be reviewed immediately. With findings submitted to the DON who will report findings to the QAPI committee for review and recommendation. The administrator will be responsible for sustaining compliance.5. Date of compliance: 04/02/2026.

This citation pertains to Intake Number 2710871. Based on the interview and record review, the facility failed to maintain complete, accurate, and timely clinical documentation for one resident (Resident #301) of 3 residents reviewed for accuracy and timeliness of clinical documentation. Findings include:Resident #301 (R301): According to the Electronic Medical Record review, R301 was admitted to the facility on [DATE] and expired there on [DATE]. A Medical Examiner's (ME) Report dated [DATE] revealed R301 was [AGE] years old with a past medical history consisting of a recent hip fracture with repair at the hospital (mentioned initials of the hospital), Diabetes Mellitus, Dementia, Anxiety Disorder, Coronary Angioplasty with stents, and Malignant Neoplasm of the eye in addition to other diagnoses. Due to the R30's medical history and his recent hip fracture, a suspicion of foul play was ruled out, and the cause of death was ruled a natural death. An interview with Nurse A was conducted by phone on [DATE] at 3:00 PM. She recalled working from 11:00 PM to 7:30 AM. R301 had a subcutaneous hydration that she initiated before her shift. The 3-11 shift nurse reported that the patient had shallow breathing. He looked pale, and his breathing was shallow. R301 was still breathing at around 1:00 am, as confirmed by the Nursing Assistant assigned, and at around 2:30 PM, he was found unresponsive. We overhead paged for a code and started Cardio-pulmonary Resuscitation (CPR). Nurse A admitted that she did not follow the standards of the nursing document, the time CPR started, or what the assessment was before starting CPR. She admitted that she failed to describe R301's condition as assessed: absent pulse, no blood pressure, and not breathing. She failed to note the time the staff started CPR, as well as the time the 911 ambulance arrive and took over resuscitation, and when they stopped. Nurse A stated. I did not document much. I apologize that I did not document well. I had 21 patients that night. R301 Progress Notes written by Nurse A dated [DATE] indicated: [DATE] at 3:16 AM: Note text: Guest coded at appr. 02:30, 911 alerted guest pronounced @ 0244 EMS Physician (name of physician mentioned) Hospital (name of hospital establishment written). Notified (Provider group mentioned) and daughter (name of mentioned) . DTR requesting Funeral Home in [NAME] (Business name specified). Awaiting Medical Examiner at this time.R301 Sepsis Screening Evaluation performed by Nurse B on [DATE] at 17:18 (5:18 PM) revealed:R301 Sepsis Screening EvaluationSepsis ScreeningCurrent Temperature: 98.21a. Route: tympanic [The National Institute of Health (NIH) defines tympanic temperature measurement as using an infrared thermometer to detect thermal radiation from the eardrum (tympanic membrane) in the ear canal.]Heart Rate: 89Respiratory Rate: 18Does the resident have a suspected or documented infection? (Signs of Suspected Infection: Fever, Chills, Cough, Dyspnea, Change in Sputum Character, Cellulitis, Wound Drainage, Flank Pain, Dysuria, Weakness): NoIs the resident on antibiotic therapy? NoDoes the resident have at least one of the above answered yes? NoThe above assessment was signed by Nurse B on [DATE]. Nurse B's assessment of R301 was documented on [DATE]. There was no indication of a strike-out or any late entry notification. R301's Medical Examiner and death certificate revealed R301 passed away on [DATE]. An interview with Nurse B was conducted by phone on [DATE] at 4:19 PM. She revealed that she was unaware that she made an error documenting an assessment on R301 after he had expired for a couple of days. She added that she had no access or was not allowed to do a strikeout. She further explained that: Only the managers have the strikeout option. I did not know I made an error until today. It might even be an assessment for another patient, or a late entry where I forgot to enter the actual assessment date. It happened over a month ago. I can't exactly remember what happened on that day. An interview with the Unit Manager C was conducted on [DATE] 10:52 AM. She revealed R301 had expired in the early morning of [DATE]. Nurse Manager C agreed that Nurse A should have more details in her documentation on the night R301 expired. Nurse Manager C indicated that she will review the vitals and other assessments to see if she could have documented her assessment and R301's CPR. The nurse A should have documented them in the progress notes. Besides R301's vitals, Nurse Manager C confirmed that 911 pronounced, and the Medical Examiner arrived before R301 was released to the funeral home. On [DATE], at 04:00 PM, the Director of Nursing (DON) explained:Regarding Nurse A documentation, there were no assessments recorded for R301's vitals, nor whether they initiated CPR in the documentation.However, the DON explained regarding Nurse B: Nurse B must have made a mistake in either not entering the correct date when she entered the data, or it could be for a totally different resident and not for R301. The DON further stated, We are not sure what happened. Resident #301 passed away on [DATE], and Nurse B entered the assessment on [DATE]. Facility Policy review conducted on [DATE] at 3:30 PM confirmed:Death of a Resident Policy (Last Revised on [DATE])DOCUMENTATION (page 2/2): 1. The nurse documents in the progress notes:Absence of audible/palpable blood pressure,Absence of audible/palpable heartbeat,Absence of respirations,General observations, such as degree of cyanosis or pallor, skin temperature (warm or cool), stiffness or pooling of blood in the extremities, and any other pertinent information leading to the determination of death. 2. Pronouncement of death is documented in the progress notes and must include:Who made the pronouncement.Circumstances of making the pronouncement (by telephone, in person, etc.)Date and Time of Pronouncement,Notification of family and physician,Disposition of the resident's belongings, including jewelry, dentures, glasses, and other valuable items,The date and time transported to the mortuary.Name of Mortuary transported to.Death of a Resident. Retrieved [DATE]. Official Copy at http://cienagroup.policystat.com/policy/14134778/. Copyright(C)2026 Ciena HealthcareThe second policy reviewed is entitled: Documentation Expectations Policy (Last Revised [DATE])Policy: Healthcare personnel will complete documentation requirements as outlined by the company and recorded in the medical record using accepted principles of documentation.Procedure: General: 1. Chart events as they occur and maintain chronological order. 2. The person providing the service enters the information into the medical record. Entries should not be signed by someone other than the author of the entry. 10. Entries in the Medical Record: Entries in the Medical Record should be completed in a timely manner. Entries should be made at the time of the occurrence, or as soon as possible thereafter.Charting Errors and/or Omissions:1. For electronic medical records, entry errors will be corrected per the Electronic Medical Record system utilizing the strike-out feature. 3. If it is necessary to change or add information to the resident's medical record, it shall be completed by means of an addendum. A. Write clarification or addendum and state the reason and refer to the entry being amended. B. Sign the addendum. C. Date and time stamps will occur per the Electronic Medical Record System.4. If a late entry is necessary:The new entry will be identified as a Late entry per Electronic Medical Record system standards.Enter the current date and time.Identify or refer to the date and incident/events for which the late entry is written.Complete a late entry as soon as possible, as memory of incidents/events decreases over time. Late entries should not be completed 30 days after discharge .Documentation Expectation. Retrieved [DATE]. Official copy at http://cienagroup.policystat.com/policy/13671768/. Copyright (C)2026 Ciena Healthcare

This citation pertains to Intake Number 2697789.Based on observation, interview and record review the facility failed to complete thorough respiratory assessments for one resident (Resident #1) and establish a completed oxygen order for one resident (Resident #2). Findings Include:Resident #1:On 1/2/2026 at approximately 12:20 PM, an interview was conducted with Resident #1's daughter. She stated her mother admitted to the facility for strengthening after she fractured her tibia and fibula, while at the facility it was discovered she had pneumonia and utilized oxygen daily. Concern was expressed that as Resident #1's time at the facility progressed, she required increased oxygen supplementation. In addition, the two antibiotic courses did not appear to be effectively treating her pneumonia. When Resident #1 began the second antibiotic the facility was unable to get her breathing under control and her oxygen was consistently being increased to 4 Liters or higher. She stated they believe there was delay in the facility transferring Resident #1 to the hospital for further evaluation and treatment. On 1/2/2026 at approximately 1:30 PM, a review was conducted of Resident #1's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, displaced fracture of left lower leg, Acute Respiratory Failure, Depression, Diabetes and Atrial Fibrillation. Resident #1 required the assistance of staff for some of her daily care but was cognitively intact and able to make her needs known. Further review yielded the following:Radiology Results:11/13/2025: .There is modest infiltrate in the right upper lobe. The osseous are unremarkable. Modest right upper lobe infiltrate.11/28/25: .There is interval worsening of the right mid upper lung opacities as well as left apical opacites.Worsening bilateral opacities concerning for pneumonia. Progress Notes:11/11/2025 at 18:27: Guest has been admitted from (hospital) for fall.Guest has ace wrap and immobilizer to L (left) extremity.Guest tolerates supplemental oxygen at 2L (liters) via NC (nasal cannula).11/12/2025 at 23:26: .Provider was notified of this guest requesting something for a cough, she was noted to have a occasional non-productive wet cough. Lungs are clear and diminished bilaterally, slight wheezing noted to right upper lung.11/13/2025 at 08:00: .Patient on supplemental oxygen, patient feels cough and sob (shortness of breath) is worsening.11/14/2025 at 08:00: .Patient had chest xray due to worsening cough, reviewed xray with patient.Avelox (antibiotic). labs revealed elevated WBC (White Blood Count).11/15/2025 at 22:32: Guest is currently on Avelox (Moxifloxacin) once daily for Pneumonia. Guest complaining of cough and asking if there is something we can get to help, and requested cough syrup.on-call notified of request and new order for PRN (as needed) Guaifenesin liquid 10mL (milliliters) every 6 hours ordered and guest was added for rounding to evaluate. 11/19/2025 at 08:00: .Denies any sob, reports not needing oxygen supplementation. Only needed acutely during exacerbation of respiratory issues. 11/27/2025 at 19:56: Guest vitals were taken for daily charting.BP-100/64, P-98, R-18, o2 82-88% on Room air. Guest was recently on 2-3L continuous oxygen therapy at admission via N/C.Writer checked VS again and still between 82-87% on Room air and guest c/o some SOB (shortness of breath). Writer applied 02 at 3L. o2 after oxygen applied and guest up to 94% on 3L of o2.11/28/25 at 08:00: .Patient was seen today for follow up of low oxygen saturation. She was lying in the bed with no acute distress. She has shortness of breath at times. Left lung is diminished. She has cough with mucus at times.11/29/2025 at 08:00: .Chest xray results follow up. Showed pneumonia, started patient on antibiotics, breathing treatments. Patient reports shortness of breath, on assessment SpO2 was 83% on room air,, placed on oxygen, lung sounds are diminished to right upper lobe. SpO2 now >92% on 2L via nasal cannula. Levofloxacin 750 mg (milligram) p.o (by mouth) once daily for 5 days. 12/2/2025 at 08:00: Nurse reports pt (patient) was ordered a chest xray due to cough and congestion, results concluded bilateral Pneumonia. Pt will be started on Levofloxacin 750 mg (milligram) tablet. 12/4/2025 at 02:00: Vitals taken at T99.1, R 36, O2 75%, BP 121/69 HR 114 Pt was pale ad tired, struggling to breathe PRN rescue inhaler given. (Oncall) notified ordered O2 increase to 5 liters, Mucinex give 400 mg and ordered another Duoneb RN Q 4hrs. After breathing tx (treatment) O2 82-84% pt still did not feel better. (on call) notified again ordered to send out to ER for eval & tx.Ambulance came picked left at 2 AM. 12/4/2025 at 08:00: Nurse reported SpO2 was 78% on 3L; increased to 4: spO2 improved to 82%. Pt currently being treated for PNA (pneumonia). Nurse reported bilateral wheezes 121/69 HR 114, temp 99.1, RR 18. Pt had breathing treatment at 2200 and prn albuterol 000. VO (verbal order) to start Mucinex 400 BID x 10days.facility stock of Mucinex is 400mg gave ok to change Mucinex to 400mgBID x 10 days. O2 at 5L SpO2 still staying 82-84%. VO for pt to be sent to ER for further eval.It can be noted nursing notes were reviewed from admission to discharge and there were minimal thorough respiratory assessments that included lung sounds. Physician Orders:Avelox Tablet 400 MG- 1 tablet by mouth one time a day for Pneumonia. Ordered on 11/14/2025 and discontinued on 11/23/2025. Levofloxacin Oral Tablet 750 MG- give one table a day for PNX (pneumonia) for 5 days. Ordered on 11/29/25.Trelegy Ellipta Inhalation Aerosol- 1 inhalation inhale orally one time a day. Ordered on 11/12/2025.Ipratropium- Albuterol Solution 0.5- 2.5 MG/3 ML- 3 ml inhale orally three times a day.evaluate HR and lung sounds pre & post treatment. If abnormal findings, document in progress notes. ordered 11/11/2025 ProAir HFA inhalation Aerosol Solution 108 ( 90 base) MCG/ACT (Albuterol Sulfate- 2 puff inhale orally every 6 hours as needed for shortness of breath/wheezing.Oxygen Orders:02 0.5-2L via NC to maintain spo2 >89%. Order was initially entered on 11/12/2025 and discontinued on 11/20/2025.It can be noted when Resident #1's oxygen therapy was reinstated on 11/27/2025 due to decrease in oxygen levels, the physician order for supplemental oxygen was never reentered into the medical record. Skilled Care Notes:12/2/2025 at 16:28:.Respiratory: Oxygen .12/3/2025 at 18:30: .Respiratory: None. Sepsis Screening Evaluation:12/3/2025 at 18:31The evaluation indicated Resident #1 did not have a documented infection nor was receiving antibiotic therapy.The skilled care notes and sepsis evaluation notes did not capture the full respiratory status of Resident #1. The note on 12/3/25 was inaccurate so it was unknown what the residents respiratory status was prior to 3rd shift. On 1/2/2025 at 3:55 PM, an interview was conducted with Nurse C regarding Resident #1. Nurse C shared she was assigned to provide for Resident #1 a decent amount of time and upon admission she was none weight bearing and utilizing supplemental oxygen. The resident graduated off oxygen, the boot was removed and she became stronger. Around 11/29/25 her oxygen levels were lower than usual (about 88%) and her supplemental oxygen was reinitiated, it was discovered shortly after she had bilateral pneumonia. Review was conducted of Resident #1's chart with Nurse C and it indicated Resident #1 was started on an antibiotic for pneumonia on 11/14/2025 (3 days after her admission), on 11/20/2025 her supplemental oxygen was discontinued and the 2nd antibiotic for diagnosis of bilateral pneumonia was started on 11/29/25 after Resident #1 displayed shortness of breath and low oxygen saturation levels. On 1/2/2026 at 4:50 PM, CNA (Certified Nursing Assistant) D shared Resident #1 did have difficulty breathing and during her stay her supplemental oxygen was discontinued and then reinitiated. CNA D continued the resident would have shortness of breath even with her oxygen. On 1/6/2026 at 10:10 AM, Nurse K reported his shift beings at 11 PM and concludes at 7:30 AM. There was nothing that he recalls being communicated in report regarding Resident #1 that would have alerted him to check on the resident more frequently. He provided CNA J with a list of vitals to check and around 12/12:30 AM reported the residents saturation level was around 75 and heart rate at 110. Nurse K stated he went down to the room and Resident #1 was visibly pale but did not complain regarding her breathing. Upon calling the on- call provider he administered Mucinex, a beathing treatment and increased her oxygen but that was not effective as her levels only increased to about 82. Nurse K listened to her lung sounds which made a low woooo sound. On 1/7/2026 at 1:55 PM, Nurse F was interviewed regarding her care of Resident #1 on 12/3/2025. Nurse F stated typically that is not her unit and she picked up on second shift to assist from 3 PM-11:30 PM. During report she recalled being informed the residents antibiotic had not arrived from pharmacy and to pull it from backup. Additionally, 1st shift nurse reported that Resident #1, did not sound too good. The nurse was asked to clarify if the statement meant the previous nurse assessed the resident's lung sounds or from a visual assessment. Nurse F stated she was unsure as she did not ask for further clarification.Nurse F recalled administering medications without incident, holding a conversating and her vitals not being of concern. Resident #1 did not appear to be in distress nor did the resident or aides alert her to any issues with her breathing during her shift. A review was completed of the MAR and Nurse F recalled administering a breathing treatment about 9:00 PM. The nurse stated she did not assess Resident #1's lung sounds before or after the treatment was administered. Nurse F was queried if at anytime during her shift did she assess the residents lungs and she stated she did not. It is unclear based on the lack of assessment when Resident #1 began to experience a change in condition as she was not thoroughly assessed prior to third shift. On 1/7/2026 at 2:50 PM, an interview was conducted with Unit Manager H and review was conducted of Resident 1's oxygen orders. Manager H stated the resident was admitted with oxygen and it was discontinued on 11/20/25. On 11/27/25 their medical team was notified Resident #1was placed back on oxygen via nasal canula but the order was not reignited. On 1/7/2026 at 3:40 PM, an interview was conducted with Infection Preventionist I regarding Resident #1. She shared she reviewed the hospital records and found she was symptomatic (prior to admitting to the facility), and they received her chest x-ray which showed infiltrates. Her first course of antibiotics was from 11/14/25 to 11/24/25. On 11/28/2025, Resident #1 began to have onset of symptoms ranging from cough, abnormal lung examination and Sp02 </94%. The resident then began her second course of antibiotics.Preventionist I was asked what is included in lung assessment. She reported listening to the lungs and observing the resident for any outward signs of distress. A discussion was held with Preventionist I regarding the lack monitoring of Resident #1 during this time. While there was some charting it was inconsistent and failed to provide a an accurate depiction of her respiratory status. It was agreed her lung sounds would be abnormal given she had pneumonia, and the expectation would be for nurses to complete a thorough lung assessment prior to after inhaler and nebulizer treatments to ensure continued assessment throughout the infection period. ON 1/7/2026 at 4:10 PM, CNA J reported she provided care for Resident #1 frequently and during report on 12/3/2025 it was stated Resident #1 had not been feeling well and but they were aware she had pneumonia. She was maintaining a watchful eye on the resident and when she completed Resident #1's vitals, her oxygen level were in the low 80's and she informed Nurse K who requested a recheck for accuracy. The second saturation level was still in the low 80's. Resident #1 appeared to have difficulty breathing and Nurse K assessed the resident shortly after and administered a breathing treatment but it was not effective. Resident #1 was alert and communicating with the nurse and stated she did not feel any relief and was agreeable to being transferred to the emergency room for evaluation. Further review of Resident #1 hospital course yielded the following:Hospital Records: The patient states that she is staying at (nursing facility) when she began to experience fever, chills approximately 1 weeks ago. This progressed to productive cough which was producing clear sputum.She developed difficulty breathing and needed more oxygen than her baseline. Her baseline is 3L and she was requiring around 5L to sustain oxygen saturation of around 90% . CT Chest w/o contrast.Small right and trace left sided pleural effusions. There is extensive and confluent geographic ground glass opacities throughout both lungs suggesting extensive bilateral pneumonia or edema.patient intubated yesterday for worsening hypoxia due to pneumonia and COPD exacerbation. Patient initially admitted with bilaterally pneumonia, acute-on- chronic respiratory failure and acute heart failure. Clinical deterioration occurred when patient developed A-fib (Atrial Fibrillation) with RVR (rapid ventricular response), worsening respiratory symptoms. Patients condition has deteriorated since yesterday with worsening hypoxia and hypotension.patient remains critically ill on mechanical ventilation, multiple vasopressors and CRRT. with multisystem organ failure including Acute Respiratory Distress Syndrome, Septic Shock, severe metabolic acidosis.Called to see patient for unresponsiveness. On exam the patient did not responds to verbal or physical stimuli. Absent heart and breath sounds for over 1 minute.Patient pronounced dead at 11:38 AM (on 12/6/2025). Family were present at bedside. Resident #2:On 1/2/2026 at 2:40 PM, a walkthrough of facility residents utilizing supplemental oxygen was completed with Unit Manager L. Resident #2 was observed in his room with his oxygen concentrator set at 2 Liters. A review was completed of the order and found the order omitted the specified Liter amount. Manager L verified the liter amount was not listed in the order. On 1/2/2026 at approximately 3:00 PM, a review was conducted of Resident #2's records and it revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Fracture of Sacrum, Acute Respiratory Failure with Hypoxia, Pneumonia and End Stage Disease. Further review of the chart yielded the following:Physician Orders:O2 via NC to maintain SPO2 greater than 89%- order completed on 12/23/2025. On 1/7/25 at 4:45 PM, an interview was conducted with the DON (Director of Nursing) regarding the lack of complete respiratory assessments for Resident #1 when she had pneumonia twice while a resident at the facility. We Discussed Resident #'2's oxygen order not having the amount/range of liters listed. The DON reported she understood the concerns.

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition and 2) Maintain a clean and sanitary environment (refrigerator, microwave and floor drains), resulting in an increased potential for food borne illness, with the potential to affect all residents who consumed oral nutrition. Findings Include: On 6/10/25 at 10:28 AM, a tour of the kitchen was completed with Certified Dietary Manager D the following was identified as areas of concern: Ice Machine: Puddle of water was observed being the ice machine. The drain grate was a dark orange/brown color on the slacks. The tubing from the back of the ice machine the filter connected on the wall was riddled with visible brown colored dust spanning the length of the tubing. Microwave: The inside of the door, sides and top of the microwave were splattered with unknown food particles. Cooks Refrigerator: Both corners of the refrigerator had dried food particles and smudges in various areas on the outside and inside of the door. Cereal Dispenser: The three cereal chutes for [NAME] Krispies, Corn Flakes, and Cheerios had a film of debris. Tray Line refrigerator: The seal on the right door is not secured to the door. There was ice/frost build up at the top of the refrigerator The drain/grate underneath the sink ( closet to the stove) was soiled with brown/dark orange residue. Three- crates of ready to use cups (about 75 cups) were resting against a soiled step stool. Three -ready for use baking sheets were wet. Walk-in Freezer: Ice/frost build up on the fan blades Staff were observed actively washing dishes and for proper wash and sanitization It took eight racks for the final rinse temperature to reach 180°. Dishwasher F reported prior to they had already washed four warming carts that were full of dirty dishware. On 6/11/2025 at 2:30 PM, CDM D stated the ice machine does not have a leak, but the machine was not lined up with the drain, and the water was not draining into the appropriate area. She stated the puddle of water should not have been there. On 6/11/2025 at 2:40 PM, Environmental Services Director E reported the drain covered behind the ice machine and underneath the side sink is plastic, and he will see if they are able to be removed and cleaned. He reported since his inception that is not task that he or his staff have completed. Dish Machine High Temperature Logs June 2025: Review was completed of June 2025 dishwashing temperature log and at the bottom it stated, Rinse Temp: Minimum 180° Rinse 6/1/2025: 160° 6/2/2025: 160° 6/4/2025: 170° 6/8/2025: 170° There were no subsequent notes or documentation related to the dates above and what action was taken when the final rinse was not at the minimum temperature of 180°. Dishwasher Reactive Service Call Summary Receipt dated 6/10/2025: Notes to customer: On the dish machine for final rinse state came through and they said it took him eight racks to get it over 180° so I made an adjustment and now it stops at 190°. It only took me three racks to get there . Review was completed of the facility policy entitled, Dietary Cleaning and Sanitation, revised 11/12/2021. The policy stated, It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing station food service equipment .

Based on observation, interview and record review, the facility failed to ensure five residents' (#1,#7, #13, #37 and #42) wheelchairs/Amigos were regularly cleaned, sanitized and free from damaged areas of six reviewed for a homelike environment. Findings Include: During Resident Council held on 6/11/2025 at 10:20 AM, five residents' wheelchairs or amigos were observed to have packed substances in the crevices, worn cushions, and varying areas of dried on substances. When asked if their wheelchairs were cleaned on a regular basis, they stated they were not. None could recall when the last time their wheelchair had been cleaned. Review was completed of Resident #1, #7, #13, #37 and #42's wheelchair cleaning task log for the last 30 days. The documentation indicated their wheelchairs were being cleaned weekly, but observations made indicated they were not being consistently cleaned. The following was documented: Resident #1: Wheelchair was last cleaned on 6/5/2025. Resident #7: Wheelchair was last cleaned on 6/3/2025. Resident #13: Wheelchair was last cleaned on 6/5/2025. Resident #37: Wheelchair was last cleaned on 6/5/2025. Resident #42: Wheelchair was last cleaned on 6/5/2025. On 6/11/2025 at 4:10 PM, Environmental Services Director E reported his staff typically inspect and clean resident wheelchairs monthly. Residents' wheelchairs were observed with Director E. Resident #1 Was in the dining room and she reported it was unknown the last time her motorized wheelchair was cleaned. Dust/debris were visible in various areas on her chair. Resident #37 Resident was in her room and the back seat cushion had four 3-4-inch ripped areas and multiple areas of dust/debris build up in crevices. The wheelchair was visibly soiled in multiple area and she reported she does not recall the last time it was cleaned. Resident #42 Resident was visiting with family/friends in the dining room and her wheelchair had crusted on substances, dust and other debris. The resident reported staff do not clean their wheelchairs. Resident #13 Resident was in the common area playing solitaire on the computer. The crevices of the foot rest had varying debris and dust particles. Resident #1 stated she does not recall the last time her [NAME] was cleaned. Resident #7 Resident was in the dining room and her [NAME] had thick buildup of substances in between the wheels and handles. Director E stated he understood the concern, as the wheelchairs were observed to be visibly soiled in multiple areas and it did not appear regular cleaning was being addressed.

Resident #70 On 6/10/25 at 1:13 PM, an interview was completed with Resident # 70 in their room. The Resident was sitting up in their bed with the overbed tray positioned over the bed in front of them. A nebulizer machine was present on the dresser beside the bed. The nebulizer mask was sitting directly on the top of the dresser and was not contained. There was visible fluid in the medication cup chamber of the nebulizer mask. Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, depression, anxiety, and colostomy (surgically created opening in the abdomen allowing for the passage of stool into an external bag). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance to complete Activities of Daily Living (ADLs) with the exception of set-up assistance for eating and oral hygiene. Review of Resident #70's care plans in the Electronic Medical Record (EMR) revealed the Resident did not have a care plan and/or intervention in place related to nebulizer use and/or treatments. An interview was completed with the Acting Director of Nursing (DON). When queried regarding observation of nebulizer mask in Resident #70's room with fluid in the medication cup /chamber, the DON stated, Should be cleaned after use and indicated the nebulizer mask should be separated and left out to dry. Based on observation, interview and record review, the facility failed to ensure appropriate storage and labeling of respiratory devices for five residents (R12, R50, R70, R392 and R397) of six residents reviewed for respiratory care. Findings include: Resident #12 R12 is [AGE] years old and re-admitted to the facility on [DATE] with diagnoses that include unspecified asthma, chronic obstructive pulmonary disease (COPD), shortness of breath and generalized anxiety. On 06/10/25 at 02:00PM, observation revealed a nebulizer t-bar at the bedside with fluid in the medication chamber. On 06/11/25 at 01:59PM, observation revealed a nebulizer t-bar next to the bed with fluid in the medication chamber. These findings were verified with Unit Manager (UM) G that there was fluid in the medication chamber of the nebulizer. UM G was asked when was the last time R12 received a nebulizer treatment. UM G stated that R12 is no longer receiving nebulizer treatments. UM G removed the t-bar and nebulizer machine from the room at this time. On 06/11/25 at 02:37PM, record review revealed a physician's order for ipratropium-albuterol, 3ml inhale orally three times a day for shortness of breath and wheezing. This order was for 5 days and was discontinued on 6/3/25. Resident #50 R50 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include COPD, shortness of breath, depression and acute kidney failure. On 06/10/25 at 11:59AM, observation revealed a nebulizer next to the bed on a bedside table. Fluid is observed in the medication chamber. R50 stated they got a treatment one time, but it stopped working after a few minutes and they never got another and that was on 06/07/25. On 06/11/25 at 09:47AM, observation revealed a nebulizer next to the bed on a bedside table. Fluid is observed in the medication chamber. Record review revealed that R50 last received a nebulizer treatment on 06/07/2025. On 06/11/25 at 01:55PM, the findings of the nebulizer were verified with UM G. UM G noted there was fluid in the medication chamber. UM G was asked what the nursing staff should do with the nebulizer equipment when the treatment is complete. UM G stated that the nurse should separate the components, clean them and lay them on a paper towel until they are dry and then store them in a bag. Resident #392 R392 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include COPD, cough, acute and chronic respiratory failure and heart failure. On 06/10/25 at 02:31PM, observation revealed that R392 was receiving 5L of oxygen via a nasal cannula, there was no label and date located on the tubing. On 06/11/25 at 01:51PM, UM G was asked if the facility labels oxygen tubing. UM G stated yes, we label it, UM G showed this surveyor where the label should be located on the oxygen tubing, there was no label present. On 06/11/25 at 02:20PM, an interview was conducted with UM G. UM G was asked what the procedure is for labeling and dating of oxygen tubing. UM G stated, we have an oxygen company that comes to the facility once a week on Wednesday. They change and label the tubing. UM G was asked why there wasn't a label on the oxygen tubing currently and what do you do with residents on oxygen on admission. UM G stated, there is no label on it currently, he just admitted on [DATE], the staff would label it on admission. It has not been a week yet, but the staff should have labeled and dated it on admission. Resident #397 R397 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic heart failure, acute respiratory failure, atrial fibrillation and fluid overload. On 06/10/25 at 12:43PM, observation revealed a nebulizer on the bedside table with fluid in the medication chamber. On 06/11/25 at 09:04AM, observation revealed a nebulizer on the bedside table with fluid in the medication chamber. Record review of the policy titled, Nebulizer Therapy, Small Volume, revealed, Implementation: -Rinse the nebulizer with water and allow it to air-dry. Alternatively, discard it after the treatment. Record review of the policy titled, Use of Oxygen, revealed, I. The O2 cannula or mask should be changed weekly and dated. It should be changed when soiled or dirty.

Based on observation, interview and record review the facility failed to timely respond to two residents' (#28 and #47) pharmacy recommendations of five residents reviewed for unnecessary medications. Findings Include: Resident #28: On 6/13/2025 at 9:30 AM, a review was conducted of Resident #28 medical records, and it indicated she readmitted to the facility on [DATE] with diagnoses that included, Chronic Respiratory Failure, Major Depressive Disorder, Adjustment Disorder, Anxiety and Gastro-Esophageal Reflux Disease. Further review was conducted and yielded the following: On 6/13/2025 at approximately 10:45 AM, a review was conducted of Resident #28's Medication Regime Reviews (MRR) from August 2024 - May 2025. The following was found: January 13, 2025: (Resident #28) receives Eliquis 5 mg BID and Aspirin Low Dose 81 mg daily. Her last HBG is noted at 8.543 on 1-3-25. Please reevaluate the continued use of their combination therapy and perhaps stop using ASA therapy . Practitioner B accepted the recommendation above with modifications on 1/15/2025, Will discuss with patient and adjust the treatment. May 8, 2025: The resident has received a H2R2, famotidine 20 mg twice daily, which may increase risk of adverse effects (e.g., confusion). Please decrease to maintenance dose of famotidine 20mg once daily at bedtime. Practitioner B disagreed with the recommendation on 5/10/2025 and provided the following rationale GDR (gradual dose reduction) was done and ineffective, continue current treatment plan. January 2025 MAR (Medication Administration Record): Aspirin EC Tablet Delayed Release 81 MG- give one tablet by mouth one time day for Heart Health. Started on 10/11/2024 and discontinued on 1/17/2025. Aspirin Oral Tablet- Give 81 mg by mouth one time a day for prophylactic. Ordered on 1/30/2025 and discontinued on 6/11/2025. May 2025 MAR: Famotidine Oral Tablet 20 MG - Give one tablet by mouth two times a day for GERD. Ordered on 1/29/2025. On 6/13/2025 at 11:57 AM, Resident #28 shared prior to admission she only took famotidine (Pepcid) once a day. On 6/13/2025 at 12:05 AM, review was completed of the MRR for GDR of Pepcid for with the DON (Director of Nursing). The DON was asked when the GDR was completed and for the documentation that it was unsuccessful. The DON confirmed a GDR was not completed on Pepcid and stated the response could have been worded better. The DON was asked why there was delay in discontinuing the resident's usage of Aspirin after the recommendation was agreed with in January 2025. The DON reported she did not know why there was delay. On 6/13/2025 at 12:10 PM, Practitioner B stated there was not a GDR completed on Resident #28's Pepcid but she has a history of gastrointestinal bleed and low hemoglobin. The Pepcid order was based on the order from when she returned from the hospital in January 2025. Resident #28 was still receiving Aspirin as the facility discontinued the medication on 1/17/25 but shortly after she had a hospital stay and upon return, they restarted the medication on 1/30/2025. Resident #47: On 6/13/25 at approximately 11:35 AM, a review was conducted of Resident #47's medical record and it revealed he was admitted to the facility on [DATE] with diagnosis that included, Diabetes, Anxiety Disorder, Chronic Kidney Disease, Hypertension, Bipolar Disorder and Dementia. Further review was completed and yielded the following: Review was conducted of Resident #47's Medication Regime Reviews (MRR) from August 2024 - May 2025 and the following was found: April 15, 2025: This resident frequently requires insulin pers sliding scale. Please consider increasing the Humalog to 13u with meals. Rationale for Recommendation: Prolonged use of sliding scale insulin is not recommended as it often results in wide variations in blood glucose, increased prolonged periods of hyperglycemia or hypoglycemia . Practitioner B signed the recommendation on 4/16/2025 and stated, Will discuss with the patient and adjust Humalog dose and discontinue ISS (insulin sliding scale). Physician Orders: Humalog Injection Solution 100 Unit/ML -inject 10 unit subcutaneously with meals for DM II in addition to sliding scale. Initiated on 01/06/2025 and discontinued on 6/12/2025. The recommendation the practitioner agreed with on 4/16/2025 was not completed until two months after. Progress Notes: 4/21/2025 at 00:00: .Blood sugar reviewed in (medical chart) with the trending in 200?s. He feels depressed and would like to discussed about medications .Continue Glargine 26 U at HS and Humalog 10 U TID with meals and ISS. Discussed with the patient about blood sugar runs in 200?s and calorie control. Monitor Blood sugar . On 6/13/2025 at 11:05 AM, Unit Manager C was asked why it took two months to update Resident #47's insulin order based on the pharmacy recommendation Practitioner C agreed with. Manager reviewed the subsequent documentation and stated she was unsure why it took that long to adjust as indicated. On 6/13/2025 at 1:40 PM, an interview was conducted with Practitioner B regarding Resident #47's regime review. She reported she signed the regime review with her intentions prior to discussing the changes with the resident. After speaking with the resident, he wanted to make changes to diet and it was decided to maintain his current insulin regime. It was expressed the change was never indicated within the progress note or on the regime review. Review was completed of the facility policy entitled, Timeliness of Medication Regimen Review (MRR) Reports, revised 9/7/2023. The policy stated, .The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt . The policy does not address the process or timeliness of acting upon the MRR's (if agreed with).

Resident #18 (R18): Accidents On 06/12/25 at 12:34 PM, a review of R18's Electronic Medical Record (EMR) was conducted. R18 was [AGE] years old, admitted to the facility on [DATE] under hospice care with the diagnosis of Congestive heart failure, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Vascular Dementia, Difficulty in Walking, weakness, and End Stage Renal Disease ESRD)in addition to other diagnoses. R18's Minimum Data Set (MDS) assessment, dated March 15, 2025, revealed a Brief Interview for Mental Status score of 07/15. A score of 0-7 indicates that the individual has severe cognitive impairment. The R18's plan of care, dated 2/12/25, did not include ensuring safety and monitoring body placement in a chair or bed after the Resident's dialysis or when up on a chair unsupervised. R18 goes to dialysis treatment three (3) times a week and has a functional ability deficit requiring assistance with self-care and mobility. R18 required substantial/maximum assistance with a 2-person assist for bed mobility and transfers. R18's care plan revealed that he has visual function impairment due to open-angled glaucoma of the right eye. R18 was care planned to use the call light for assistance; the call light must be within reach, and the patient must maintain an appropriate bed positioning. According to the fall incident report (IR) dated 6/11/2025 at 18:25 (6:25 PM), it revealed: During rounds, a nurse found a guest lying on the floor in front of a wheelchair with the left side of the head on the bottom railing of the bedside table. The Resident is unable to give a description. Immediate Action: The guest (R18) was assessed for injury. A small abrasion above the left eyebrow with swelling around the eye was noted. Vitals obtained . The IR under Predisposing Environmental Factors indicated that the Wheelchair brakes were found unlocked. The IR also revealed that R18's Predisposing Physiological Factors specified that R18 was confused. The incident report did not specify if the Resident activated the call light or if the call light was within reach. There was no indication of when R18 was last toileted, nor of R18's whereabouts or activities from the time he arrived from dialysis to the time he was observed on the floor. On 6/12/25 at 12:30 PM, R18's Electronic Medical Record was reviewed. According to the Nurse's Notes on 6/11/2025 at 19:26 (7:26 PM), the nurse wrote: During rounds, a nurse found guest (R18) lying on the floor in front of a wheelchair with the left side of the head on the bottom railing of the bedside table. Guest (R18) was unable to describe what he was trying to do before the fall. Guest(R18) was assessed for injury. A small abrasion above the left eyebrow was found. Vitals obtained. Guest assisted bed with Hoyer lift . R18 was observed in his room, lying in bed on 6/12/25 at 12:43 PM. During an interview, R18 described that he fell recently and tried to explain how he sustained a small cut on his left eyebrow. He had indicated that he had fallen but was having difficulty explaining how it had happened. An interview with Nurse M was conducted on 6/12/25 at 1:10 PM. She revealed that R18 fell yesterday (on 6/11/25 at around 7 PM after her shift. The nurse further described that R18 came back from dialysis after 4:00 PM and fell out of his wheelchair after dinner. Nurse M stated, he must have been tired, as he had just returned from dialysis. But there were no witnesses, so we don't know what had actually happened. During an interview with the Unit Manager Nurse E on 06/13/25 at 10:01 AM, R18 returned from dialysis after 4:00 PM on 6/11/25 and was later found on the floor in his room. He sustained an abrasion on his eyebrow, but since the fall was unwitnessed, we were not sure what had happened. R18 was unable to describe the incident. The Unit Manager was unable to identify the nursing assistant during the fall because the incident report did not specify the names of staff involved at the time of the incident, and there were no statements from the aide assigned at the time. Unit Manager E commented, I don't know why CNA did not put him in bed right after he arrived from dialysis. Residents often become extremely tired after returning from dialysis. Staff needed to check on him. The Unit Manager, E, after reviewing the logs, indicated that R18 arrived from dialysis at 5:10 PM on June 11, 2025, and fell an hour later at 6:25 PM. According to Unit Manager E, a post-fall statement by the nurse aide revealed that R18 was dry after the fall. There was no description of any fall interventions implemented to prevent falls after coming back from dialysis. Based on observation, interview and record review, the facility failed to ensure the provision of adequate supervision and implementation of meaningful interventions to prevent falls for two residents (#14, #18) of four residents reviewed, resulting in Resident #14 experiencing a fall with a hip fracture. Findings include: Resident #14: On 6/10/25 at 12:54 PM, Resident #14 was observed sitting near the nurse's station in their wheelchair. An overbed table with a meal tray was positioned in front of the Resident and they were eating. The Resident's right leg was positioned on the wheelchair leg rest and their left leg was off the wheelchair leg rest with their left foot on the base of the overbed table. The Resident began moving their left leg and appeared restless. When spoke to, Resident #14 was pleasantly confused and unable to provide meaningful responses to questions. An interview was conducted with Licensed Practical Nurse (LPN) J on 6/10/25 at 12:59 PM. When queried why Resident #14 was eating alone in the central area near the nurses' station, LPN J stated, (Resident #14) self-transferred a couple weeks ago and broke their hip. That's why they're out here. When asked if they needed to be supervised when they ate, LPN J responded, (Resident #14) still tries to self-transfer. (Resident #14) is confused. LPN J was asked if Resident #14 attempted to self-transfer before they fell and fractured their hip and replied, Yeah. When queried if the Resident attempted to get up without assistance frequently prior to the fall with fracture, LPN J stated, They did. LPN J revealed Resident #14 would try to get up by themselves all the time. With further inquiry, LPN J revealed the intervention to keep the Resident in the area by the nurses' station was implemented following the fall with hip fracture. When queried regarding the Resident moving their left leg and appearing either restless, LPN J indicated the Resident frequently moved around and was still attempting to self-transfer. Record review revealed Resident #14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart disease, history of falls, and displaced intertrochanteric fracture of the right femur (specific type of hip fracture involving the top of the femur bone). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial/maximum assistance with rolling from side to side, sitting up, and standing. The MDS further detailed the Resident had a history of falls. Review of Resident #14's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #14) is at risk for fall related injury and falls R/T (related to): weakness, decreased mobility, hx (history) of falls, medication side effects, new environment, attempts at self transfer (Created and Initiated: 5/8/25; Revised: 6/4/25). The care plan included the interventions: - Encourage resident to wear non-skid foot wear when out of bed. Assist resident as needed (Initiated: 5/9/25) - Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position (Initiated: 5/8/25) - Offer toileting when rounding during nighttime hours (Initiated: 5/15/25) - Provide resident with activities that minimize the potential for falls while providing diversion and distraction (Initiated: 5/8/25) - Put the call light within reach and encourage . to use it for assistance as needed (Initiated: 5/8/25; Revised: 6/4/25) - Red tape around call light (Initiated: 5/22/25) - Staff to assist (Resident) to stay covered with a blanket while in recliner (Initiated: 5/28/25) - Staff to assist to bathroom frequently (Initiated: 5/23/25) - RESOLVED: Keep residents w/c (wheelchair) next to bed in the middle of the night in case attempts to get up . could use the wheelchair for assist (Initiated: 5/15/25; Revised and Resolved: 5/15/25) Another care plan entitled, (Resident #14) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): weakness, decreased mobility (Created: 5/8/25; Initiated: 6/4/25) included the intervention, Transfer: Resident is substantial/maximum with 2 helpers for transfers (Created: 5/8/25; Initiated: 6/9/25). Review of Resident #14's Census information in the EMR revealed the Resident was discharged from the facility on 5/29/25 and returned on 6/4/25. A review of progress note documentation in Resident #14's EMR revealed the following: - 5/15/25 at 4:00 AM: Nurses Notes . resident was heard yelling help from (their) room. Upon entering resident was observed laying on the floor on back parallel to the dresser at the foot of bed. Resident c/o right knee pain . - 5/15/25: Health Care Provider Encounter . Telehealth - Asynchronous . Situation: Nurse reports pt was just observed on the floor in room . was trying to walk to the bathroom and doesn't walk, fall protocol initiate . 5/22/25 at 10:30 PM: Nurses Notes . resident observed on floor next to bed in room . assessed for injury, none at this time. resident assisted into wheelchair x2 staff . assisted into recliner in common area for monitoring . - 5/28/25 at 7:14 AM: Nurses Notes . Patient was observed on the floor by recliner that sits by nursing station. Patient was previously observed lying in (their) recliner and later toileted at 0435. After patient was then placed back into recliner and shortly morning medications were passed at 0509. At 0520 patient was then observed on the floor lying on back with legs flexed toward body . arms were by side and head lying on floor. Patient was then observed for any immediate injuries ROM (Range of Motion) was attempted. Patient did complain of pain in right hip. Patient was then placed into wheelchair and further assessed for injuries which none were noted at this time . - 5/29/25: Health Care Provider Progress Notes . Acute . seen for follow up on x-ray. Patient had fall from recliner, Xray was ordered and states acute right femoral neck fracture . patient to be sent to ER to address acute issue . Review of Resident #14's x-ray report dated as reported on 5/29/25 at 1:29 AM revealed, Findings: There is an acute right femoral neck fracture with mild displacement (bone broken and not aligned) . Conclusion: Acute right femoral neck fracture. Review of Resident #14's Hospital Medical Records revealed: - 5/29/25 at 12:47 PM: History and Physical . presented to ER with complaint of a fall at (Facility) with a possible hip fracture . patient is poor historian so most information is taken from (family member) at the bedside . (Family member) stated that (Resident #14) was up in a wheelchair at the nurse station at about 5:30 yesterday morning and tried to get up and became twisted in the blanket and fell . Review of Symptoms . Neuro: Positive: confusion/memory loss, falls, weakness . Musculoskeletal: Positive: joint swelling, pain, stiffness . Physical Examination . Acutely ill appearing . Diagnostic Result . XR (Xray) Femur right . Femoral neck irregularity likely nondisplaced fracture . XR Right Hip . Slightly impacted right femoral neck fracture . - 5/30/25: Operative Summary Report . Right closed displaced femoral head fracture . Procedure performed: 1. Right hip hemiarthroplasty (placement of prosthetic femoral head which is the ball section of the hip joint) . Application of incisional VAC (Vacuum Assisted closure) right hip (device which uses negative pressure to assist in wound healing) . On 6/11/25 at 8:00 AM, Resident #14 was observed sitting in their wheelchair near the nurses' station alone. The Resident did not have any activities to occupy themselves and did not have a call light and/or other method to contact staff. On 6/11/25 at 2:39 PM, Resident #14 was observed sitting in a recliner near the nurses' station. The Resident did not have any activities in place and did not have a call light and/or other method to contact staff. An observation of the nurses' station revealed the Resident was not able to be visualized when sitting due to the height of the nurses' station counter. On 6/11/25 at 4:39 PM, Resident #14's Incident and Accident forms, as well as any associated investigation documentation was requested from the facility Administrator via email. The requested I and A forms for Resident #14 were received on 6/12/25 at 9:00 AM but no additional associated investigation documentation was provided. On 6/12/25 at 9:40 AM, Resident #14 was observed sitting in their wheelchair near the nurses' station. The resident was fidgeting in their chair. The Resident did not have anything to do and/or to occupy them. No staff were present at the nurses' station or within view of where Resident #14 was positioned in their wheelchair and Resident #14 did not have a call light and/or any other method to contact staff. The first staff to approach the nurses' station was Activity Staff K at 9:48 AM. Staff K approached Resident #14 and asked them if they would like to go to an activity. Resident #14 told Staff K they were unable to hear them. Staff K repeated themselves at the same tone and volume and Resident #14 repeatedly told Staff K they could not understand what they were saying. At 9:50 AM, Staff K then walked away from the Resident and left the Resident alone with nothing to do and/or no entertainment and no call light. There were no staff present at the nurses' station and/or near the Resident. At 12:42 PM on 6/12/25, Resident #14 was observed sitting alone in the same place in their wheelchair by the nurses' station alone. The Resident did not have anything in place to do and/or activities in place. They did not have a call light and/or any other method to contact staff if needed. Review of facility provided I and A forms revealed Resident #14 had three falls in May 2025. The I and A forms detailed the following: - 5/15/25 at 3:15 AM: Fall . Resident Room . Resident was observed laying on back parallel to the dresser at the out of bed .was hollering help and discovered there Resident Description: I was trying to go to the bathroom . Immediate Action Taken . Resident was lifted to a standing position and eased into the bed with assist . c/o (complain of) right knee pain of which had c/o about prior to this admission . Staff to offer toileting with rounding during nighttime hours . The I and A did not specify when the Resident was last toileted, what type of footwear they were wearing, continence status, if the call light was on, and/or when they were last observed by staff. - 5/22/25 at 10:00 PM: Fall . Resident Room . Resident was found on the floor between the half wall and bed on back with head at the end of bed with bilateral knees bent in the air. Resident description: Resident was trying to go to the restroom . Immediate Action Taken: Resident assessed for injury, none at this time . assisted into wheelchair X2 staff . Resident assisted to common area for closer supervision. Staff to assist guest to bathroom frequently and encourage out of room activities for closer supervision . Injury Type: Reddened Skin: Top of Scalp . Unable to Determine: Top of Scalp . No Injuries Observed Post Incident . The I and A did not specify when the Resident was last toileted, what type of footwear they were wearing, continence status, if the call light was on, and/or when they were last observed by staff. - 5/28/25 at 5:20 AM: Observed on floor . Nursing Station . Patient was observed on the floor by recliner that sits by nursing station. Patient was previously observed lying in recliner and later toileted at 4:35 AM. After patient was then placed back into recliner and shortly morning medications were passed at 5:09 AM. At 5:20 MA, patient was then observed on the floor laying on back with legs flexed towards body . arms were by side and head lying on floor. Patient was then observed for any immediate injuries and ROM was attempted. Patient did complain of pain in their right hip. Patient was then placed into wheelchair and further assessed for injuries which non were noted . Resident Description: Patient stated was trying to place blanket into the recliner . Immediate Actions Taken: Patient was observed for any injuries,,, Staff to assist (Resident) to keep a blanket in place while in the recliner . Level of Pain: 5 (out of 10, with 10 being the worst possible pain) . The I and A did not specify where staff were at the time of the fall, what type of footwear the Resident was wearing, continence status, if they had a call light and/or bell available, if they had a blanket covering them previously, and/or where the blanket was. An interview and review of Resident #14's I and A forms were completed with the Acting Director of Nursing (DON) on 6/13/25 at 10:15 AM. The fall on 5/15/25 was reviewed. When queried what time Resident #14 was last toileting, what type of footwear they were wearing, and when they were last seen by staff, the DON indicated that information would probably be in the facility investigation and not the I and A form. When asked why the investigation documentation was not provided when requested, the DON responded that they were unaware it had been requested. Any investigation documentation pertaining to Resident #14's falls were requested again at this time. Review of received Post Fall Evaluation form for Resident #14's fall on 5/15/25 indicated the Resident was wearing gripper socks and was continent at the time of the fall. The post fall form designated the Root Cause of the fall was confusion and the initial intervention was to Keep residents w/c next to bed at night in case they attempt to get up. The intervention after IDT (Interdisciplinary Team) review was, Offer toileting during nighttime hours. A statement from Certified Nursing Assistant (CNA) N was included which specified, Worked from 10PM to 6AM. Just observed resident in bed prior to fall doing check/change. Toileting offered and declined. The DON was asked if Resident #14 had been offered and declined toileting approximately 15 minutes prior to the fall on 5/15/25, per the documentation, the DON confirmed. When asked if the Resident was sleeping and woke up by the CNA during their check and change rounds, the DON was unable to provide a response. When queried how the intervention of offering toileting during the nighttime hours was a meaningful intervention to prevent future falls when they had been offered and declined toileting 15 minutes prior to falling, the DON did not provide an explanation. When queried if the call light was on, the DON confirmed the documentation did not say and verbalized Resident #14 does not really use their call light because of their confusion. Review of received Post Fall Evaluation form for Resident #14's fall on 5/22/25 revealed the Resident had an unobserved fall at 10:20 PM in their room while trying to go to the bathroom. (Note: The I and A specified the fall occurred at 10:00 PM). The Resident had gripper socks in place and was incontinent at the time of the fall. Per the Post Fall form, Resident #14 was last seen at 10:00 PM during check and change rounds and were dry at that time. The Post Fall Evaluation specified the root cause of the fall was Alarm and initial interventions to prevent further falls included Staff to assist to common are when awake, toilet frequently, Red tape over call light so guest will use it . New Intervention after IDT review included increased opportunity for observation and socialization . There were no staff statements included. The DON was asked if Resident #141 had an alarm in place on 5/22/25 and responded they did not. When asked why the Post Fall Evaluation specified the root cause of the fall was an alarm, the DON indicated it must have been an error. When queried how a meaningful intervention was implemented when the root cause of the fall had not been accurately identified, the DON did not provide a response. When asked what intervention the facility implemented following this fall, the DON verbalized the Resident was to be placed near the nurses' station where they were able to be observed by staff when they were awake. When queried regarding the time discrepancy of the fall, 10:00 PM or 10:20 PM, an explanation was not provided. Review of the Post Fall Evaluation form for Resident #14's fall on 5/22/25 revealed the Resident had an unwitnessed fall while sitting in the recliner chair by the nurses' station at 5:20 AM. The Resident was wearing gripper socks and was continent at the time of the fall. The Post Fall Evaluation indicated the Resident was last observed at 5:09 AM when their morning medications were administered. The initial intervention to prevent future falls was keeping patient entertained and the intervention following IDT review was Staff to assist (Resident) to stay covered when in recliner. The Re-Creation of Last 3 Hours Before Fall section of the Post Fall Evaluation specified: - 4:20 AM: Patient was observed lying in recliner. - 4:35 AM: Patient was attempting to self-transfer . was taken to the bathroom . was continent . placed back in recliner. - 5:09 AM: Patient was lying in recliner and given morning medication. - 5:20 AM: Patient was observed on floor lying on back. ROM was attempted . complained of slight pain in right hip pain. The investigation documentation included a single typed page which included: - 5/28/25 Interview with (Licensed Practical Nurse (LPN) L) . Guest was resting in the recliner during the nighttime hours and was toileted at 4:35 AM . continent at that time. (Resident #14) was transferred back into recliner by the nurses' station. At 5:09 AM, morning medication were given and continued to remain in the recliner. At 5:20 AM, during morning med pass, guest was observed on the floor lying on back next to recliner. Guest assessed for injury, did complain of slight right hip pain, not abnormalities noted lite hip rotation or shortening of the leg. Guest was transferred into wheelchair using two assist with gait belt. Guest has gripper socks on. Guest stated, 'I was trying to put by blanket back on the chair . 5/28/25 at 7:00 AM: (Acting DON) observed Resident #14) in wheelchair sitting next to nurse's med cart . was eating breakfast . 5/28/25 (no time) Based on incident report and initial complaints of pain in right hip, x-rays ordered to R/O (rule out) fracture. The typed sheet of paper was not signed by LPN L nor the Acting DON, did not have a time that LPN L's interview was completed, and did not specify who completed the interview. The DON was asked why Resident #14 had been sitting in the recliner at the nurses' station at approximately 4:20 AM and revealed Resident #14 had a rough night and the staff placed them in the recliner to keep an eye on them. The DON indicated LPN L told them they had sat by the Resident because Resident #14 was restless that night. When queried where the staff were when the Resident fell, the DON stated, They probably went to the med cart and indicated LPN L would have had other resident's medications to pass. When asked if staff would be able to see the Resident from the medication cart, the Acting DON responded they would not. When queried regarding the root cause of the fall, the DON stated, (Resident #14) tried to pull the blanket up. When asked where the blanket was and if the Resident had been covered with the blanket the last time they were observed by staff, the DON was unable to provide a response. When queried if the Resident had a call light and/or bell to contact staff while sitting in the recliner, the DON replied, No. The DON was asked why the Resident #14 was left alone and unsupervised by staff when they had been placed in a recliner at the nurses' station so staff could be directly supervised, a response was not provided. When asked about the increased risk of leaving Resident #14 alone and unattended with no method of contacting staff for assistance, the DON stated, Well better than to leave them alone in their room. When asked how it was better as the Resident fell and suffered a hip fracture, an explanation was not provided. The DON was asked why another staff member did not come sit with the Resident so LPN L could go and pass medications to other residents, an explanation was not provided. When queried how many staff were working that night and their location at the time of the fall, the DON responded that they did not know. The DON was asked if the facility had sufficient staffing levels on the date and time of the fall to provide adequate resident supervision and responded they were unaware of the facility being short staffed. The facility clock in sheets for the midnight shift on 5/27/25 to 5/28/25 were requested at this time. Review of facility provided Employee Assignment Sign -In Sheet for the midnight shift on 5/27/25 revealed the facility Census was 137 residents. There were six nurses, and seven CNA's scheduled. On Resident #14's unit, two nurses and three CNA's were scheduled but one CNA was identified as a NCNS (No Call No Show). An interview was completed with Scheduler O on 6/13/25 at 3:00 PM. When queried regarding staffing levels for midnight shift on Resident #14's unit, Scheduler O revealed that was the largest unit in the facility and stated, Three CNA's and 3 nurses.

Based on interview and record review, the facility failed to provide advanced written notification of a room change and obtain consent for one resident (Resident #70) of one resident reviewed, resulting in a cognitively intact resident not being informed of and/or provided the rationale for a room change prior to their room being moved. Findings include: Resident #70: On 6/10/25 at 1:13 PM, an interview was completed with Resident # 70 in their room. When queried if they had been in this room since they were admitted to the facility, Resident #70 verbalized they were in a different room before. Resident #70 was queried regarding the room change and stated, I just came back, and all my stuff was gone. I was mad. When queried if they were notified of the room change and the reason for the change prior to their personal items being moved to a different room, Resident #70 stated, No. When asked where they were when their personal items were relocated, Resident #70 revealed they thought they were in therapy. Resident #70 then stated, I asked the CNA's (Certified Nursing Assistants) and they didn't know why they were moved rooms. Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, depression, anxiety, and colostomy (surgically created opening in the abdomen allowing for the passage of stool into an external bag). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance to complete Activities of Daily Living (ADL) with the exception of set-up assistance for eating and oral hygiene. Review of Resident #70's Electronic Medical Record (EMR) revealed the Resident made their own medical and financial decisions. Review of Resident #70's EMR census documentation revealed the Resident was moved rooms on 3/12/25. Review of documentation in Resident #70's EMR revealed a Notice of Room Change assessment form dated 3/12/25. The assessment specified, 4. A copy of this notice has been reviewed with the resident/guest or responsible party and will be provided upon request . Yes . Name of person to whom this notice was reviewed with and provided to if requested: Left message for Son . The form was signed by Social Services Staff I on 3/14/25. An interview was conducted with CNA H on 6/11/25 at 3:46 PM. When queried if they were working when Resident #70 was moved room, CNA H replied, Yes. When asked if the Resident was upset about the move, CNA H responded, Yes. When it first happened, (Resident #70) was confused and didn't understand why it was happening. CNA H stated, (Resident #70) said no one told them (about moving rooms) or explained it. On 6/11/25 at 4:04 PM, an interview was completed with Social Services Staff I. When queried if Resident #70 is their own person and makes their own medical decisions, Staff I replied, Yeah. Resident #70's Notice of Room Change assessment was reviewed with Staff I at this time. When asked why the son was the only person listed as being contacted regarding the change on the assessment form, Staff I stated, I always contact whoever they list their next of kin so they know where they are when they come to visit. When queried why Resident #70 was not notified prior to the room change, Staff I stated, I am still kind of learning. Staff I was informed of Resident #70's verbalization of emotional distress related to not being made aware of the move and indicated they were unaware the Resident had been upset. When queried, Staff I confirmed understanding of the concern. An interview was completed with the Acting Director of Nursing (DON) on 06/12/25 at 9:12 AM. When queried if residents should be notified prior to room changes and if they have the right to refuse to move rooms, the DON responded that residents should be notified. The DON was informed of Resident #70's verbalization of emotional distress related to not being informed of moving rooms but did not provide further explanation. A policy/procedure related to notification of room change was requested from the facility Administrator on 6/11/25 at 4:39 PM but not received by the conclusion of the survey.

Based on observation, interview, and record review, the facility failed to ensure dignity by not having the call lights accessible, extended call light response times, and not treating residents in a respectful manner for five residents (Res. #15, Res. #50, Res.#187, Res. #289, & Res.#391) of five residents reviewed for dignity and respect and call light response times, resulting in fear of abandonment, isolation and decreased socialization and the potential for falls or accidents. Findings include: Resident #15 (R15) Dignity During the initial tour on 06/10/25 at 1:11 PM, Resident #15 was observed eating popcorn in bed in his room. During the initial interview, R15 revealed that he could not see any more since he was diagnosed with Glaucoma; he is now blind. When asked if he had access to his call light, he said he would often feel around his bed to find it but could not find the call light button. During an observation on 6/10/25 at 1:12 PM, Nurse M, assigned to R15, found the call light on the floor underneath his bed. Nurse M crawled under R15's bed and picked up the call button. She then clipped the call light cord on the bed and ensured R15 held the call button in his hand. The surveyor reviewed R15's Electronic Medical Records (EMR) on 6/11/25 at 11:00 AM. It revealed that R15 was admitted to the facility on [DATE]. He was admitted with a diagnosis of Senile Degeneration of the brain, Osteoporosis, History of Falling, and Blindness (both eyes) in addition to other diagnoses. His Brief Interview of Mental Status dated 4/10/2025 revealed a BIMS score of 07/15. A BIMS Score of 07 means moderately impaired cognitive status. His care plan for safety includes putting the call light within reach and encouraging him to use the call light for assistance as needed. Nurse M was interviewed on 6/10/25 at 1:15 PM. Nurse M admitted that the staff did not make the call light accessible. Nurse M stated that R15 was blind and picked up the call light from underneath the bed and acknowledged that the call light was not in a place where it was reachable. Resident #187 Dignity The surveyor reviewed R187's Electronic Medical Record (EMR) on 6/11/25 at 3:30 PM. R187 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Acute Chronic Diastolic Congestive Heart Failure, Metabolic Encephalopathy, Morbid Obesity, and Type 2 Diabetes Mellitus, in addition to other diagnoses. The Minimum Data Set (MDS) with an assessment date of 6/3/25, R187's Brief Interview of Mental Status (BIMS) Score was 15/15. A score of 15 means that the resident was cognitively intact. A review of R187's Plan of Care revealed that the facility initiated a safety care plan on 5/31/25. It specifically indicated that 1.) anticipate and meet needs PRN (as needed). 2.) Another was encouraging the resident to use a bell/call light for assistance . 7.) Put the call light within reach and encourage her to use it for assistance as needed. R187's care plan for toileting initiated on 5/30/25 indicated the following: .2.) Check the Resident frequently and PM for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN after incontinence episodes .3.) TOILET HYGIENE: Resident (R187) requires substantial/Maximal assist, with one helper. Assist with the bathroom frequently to avoid incontinence accidents. 4.) TOILET TRANSFER: Resident requires partial/moderate assistance with one helper . During the interview with R178 on (DATE/TIME, R187 reported leaving her alone in the hallway after lunch for a prolonged period. No one had brought her back to her room after lunch, and she stayed in the hallway for at least a couple of hours. No one took her to the bathroom, and she did not have the call light in the hallway. R187 stated, I had an accident and was soaked in urine for a long time. R187's son was interviewed on 6/10/25 at 4:04 PM. R187's son identified himself as the primary caregiver of R187 at home when discharged . He stated he had found R187's call light button on the floor at least twice, and when she needed assistance, it took a long time for them to respond to the call light. He described the response time as being from an hour to two hours. R187's son had indicated that R187 takes a water pill (Lasix) daily and that his mother has anxiety, especially with accidents if toileting assistance is delayed. R187's son stated, My mom feels embarrassed when she can't reach the bathroom in time.

Refer to Intake Numbers: MI00151742 Based on observation, interview, and record review, the facility failed to: 1.) provide services to prevent the development of new pressure ulcers consistent with professional standards, 2.) provide the appropriate skin care interventions to promote healing for two sampled residents (R304 and R306) of five residents reviewed with pressure ulcers, resulting in the development of avoidable pressure ulcer, delay in treatment and healing and potential for wound infection, pain, and complications. Findings include: Resident# 304 (R304) During the initial interview on 4/16/25 at 1:56 PM, R304 revealed he had recently developed a wound at the facility and stated he was not turned by staff as frequently as he should have been. According to the Record review conducted on 4/16/25 at 3:30 PM, R304 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of spinal stenosis at the lumbar region without neurogenic claudication and had surgical fusion of the spine (cervical region) procedure recently, anxiety disorder, neuromuscular dysfunction of the Bladder, and diabetes mellitus in addition to other diagnoses. R304 was admitted with an indwelling catheter for urinary retention upon discharge from the hospital. R304's Brief Interview for Mental Status (BIMS) score assessed on April 4, 2025, was 15/15. A score of 15 means R 304 is cognitively intact. R304 depended on staff for most Activities of Daily Living (ADL) tasks, especially toileting, hygiene, and showers. R304 had a urinary indwelling catheter but was always incontinent with a bowel elimination pattern. Minimum Data Set, dated dated dated [DATE] in Section M- (Skin Conditions) revealed R304 was at risk for developing Pressure ulcers and Injuries. Although R304 had a post-surgical wound from a recent spinal fusion procedure, there were no assessment upon admission that indicated skin injuries or alterations in skin integrity related to pressure ulcers or Moisture Associated Skin Damage (MASD) during admission and the initial skin assessment performed on April 4, 2025. A review of the facility's Admission Skin assessment dated [DATE] noted no new wounds. However, according to the nursing progress notes dated 4/14.2025 at 15:54 (3:54 PM), it revealed, Wounds on Buttocks. Present on Bilateral cheeks. Under notes, revealed: Guest with new pressure areas to B/L (bilateral) buttocks. Wound beds are beefy red, scant drainage present, no slough or necrosis or s/s (signs and symptoms of infection . The Education box specifically noted the : Importance of frequent turning and repositioning for pressure relief. Allow staff to provide incontinence care as needed. A follow-up neuro-surgical consultation report dated 4/10/25 was reviewed on 4/17/25 at 2:12 PM. Surgeon's Report indicated: . I also recommend the patient keep moving frequently at least every hour to prevent bed sores . No showers were recorded or documented from admitted d 3/31/25 until 4/7/25, a week after admission. R304 refused shower on 4/7/25, No record of skin assessment nor redness, discoloration or abnormality was noted until the Nurse's Wound assessment dated [DATE] described new wounds found on the bilateral buttocks. An interview with the wound nurse in the R304 unit was conducted on 3/17/25 at 1:00 PM. The Wound Nurse indicated that R304 was admitted to the facility on [DATE] without pressure wounds and developed them in-house. R304 had a hard time moving due to pain and does not get out of bed too often. The wound nurse recalled receiving a referral on 4/15/25 with the following wound measurements on the Sacrum: Area: 17.02 cm, 4.07 cm L (length), 8.22 cm W (width), 0.1 cm D (depth). According to the Wound Nurse, a treatment plan for R304 has started. The wound mattress and roho cushion on the wheelchair were ordered on 4/15/25 and added to R304's wound care plan. The pressure wound mattress was implemented on 4/15/25. R304 received encouragement and is turned more often. During wound care observation on 4/17/25 at 2:40 PM, the unit nurse manager and the unit wound nurse provided wound care to R304. R304's wife/POA was present at the bedside. R304 had an indwelling urinary catheter in place. After the wound dressing was applied, R304 denied pain and described the discomfort as stinging when the wound treatment was applied. The wound area was very red and tender. The wound measurements were consistent with the current wound measurement documented on 4/15/25: Area: 17.02 cm, 4.07 cm L (length), 8.22 cm W (width), 0.1 cm D (depth). A review of R304's Risk for Impaired Skin Integrity/ Pressure Injury Care Plan was created on 3/31/25; turning and repositioning, off-loading, and frequent skin assessment were not implemented as preventive measures upon admission. The wound nurse created the preventive measures and interventions to avoid the development of pressure ulcers, such as turning/repositioning the resident every 2 hours and PRN on 4/15/25 after a new pressure injury developed. The wound evaluation and treatment plan of care started on 4/15/25. Resident# 306 (R306) R306 was interviewed on 4/16/25 at 3:12 PM, R306's son was in the room with her. R306 revealed having issues with wound care. R306 had indicated that she started out with one small pressure area when she was first admitted ; now, there are two, and they have become bigger. She had other wounds on her bilateral legs that was infected and needed treatment and attention, however, her buttocks wound area expanded. R306's son had indicated that they had requested a pressure wound bed upon admission because it seemed to work at the hospital for all her wounds (both legs and her back), but the facility did not have them until they noted that the wound area became larger. The son indicated that R306 was not frequently checked by staff, and it took 6 days before they changed the dressing for her wounds on the legs. A record review of R306's Electronic Medical Record EMR revealed that R306 was admitted to the facility on [DATE] with the diagnosis of Diabetes Mellitus, Acute Kidney Failure, Cellulitis of the right and left lower limb, and Neuromuscular dysfunction of the Bladder. On 4/16/265 at 3:18 PM, R306 was observed with a patent urinary indwelling catheter in place on 4/16/25 at 3:12 PM. The Unit Wound Nurse was interviewed on 4/17/25 at 12:37 PM. She revealed that R306 received treatment for bilateral venous wounds on both lower extremities upon admission. R306 was admitted on [DATE]. She is a dialysis patient and has a compromised skin. She did not have anything when she was first admitted except for a shearing noted on the left buttocks. It was first pointed out on 4/6/25 with a baseline measurement of: Area 3.6 cm, 2.72 cm (L), 2.25 cm (W) with a depth of 0.1 cm. On 4/15/25, the left buttocks measurement revealed the following: Area: 4.09 cm, 4.64 cm (L), 1.88 cm (W). A new wound was found on the Right Buttocks, measured: Area: 2.6 cm, 2.4 cm (L), 1.7 cm (W). On 4/15, there are currently two wound areas being treated. During wound care observation was performed by the Wound Nurse and the Unit Nurse Manager on 4/17/25 at 11:53 AM; R306 had an indwelling urinary catheter noted in place. Redness was observed on the right and left gluteal wound, and skin irritation surrounding the perineal area. The Unit Nurse Manager explained that the irritated and reddened area was from a loose bowel movement. R306 was also observed with the swollen right big toe pressure ulcer with a black spot in the middle of the reddened, swollen area. No drainage nor open wound. When the wound nurse was queried, she stated that a dark discoloration on the tip of the right big toe was considered unstageable. It was just a recently developed house found on Tuesday, 4/15/25. The measurement was consistent with the recent wound description: Area=0.84 cm, .92 cm (L) with 1.25 cm (W). A review of R306 Risk for Impaired Skin Integrity/Pressure Injury Care Plan indicated that it was initiated/created on 4/5/25 with a revision date noted on 4/17/25. After reviewing the plan of care and interventions, no new interventions were put in place after newly developed wounds were discovered on 4/15/25. No specific revisions or added care interventions for staff were put in place to prevent the development or worsening of wounds. No new interventions were added for th right big toe new pressure area. The Facility Skin Management Policy with a revised date on 8/14 2024 was reviewed on 4/17/25 at 4:05 PM: Policy The facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Overview Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Practice Guidelines: .3. Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. 4. Residents admitted with any skin impairment will have: o Appropriate interventions implemented to promote healing, o A physician's order for treatment, and o Skin impairment location, measurements and characteristics documented 5. The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairment as follows: o In Electronic Health Record (EHR) facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. o Document weekly until the area is resolved. o Photos may be taken of pressure injury and vascular ulcers skin and wound evaluation for pressure injury and vascular ulcers. o Document weekly until the area is resolved. o Photos may be taken of pressure injury and vascular ulcers 6. The interdisciplinary team considers whether the resident exhibits conditions, or is receiving treatments, that may place the resident at higher risk of developing pressure injury or complicate their treatment. Such conditions may include: o Cognitive impairments o Drugs such as steroids that may affect wound healing o Impaired/decreased mobility and decreased functional ability o Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus o Impaired, diffuse or localized blood flow: for example, generalized atherosclerosis or lower extremity arterial or peripheral insufficiency o Bowel and/or bladder incontinence o Abnormal labs, malnutrition, hydration deficits o Resident refusal of some aspect of care and/or treatment o A history of a healed pressure injury 7. An initial care plan is developed upon admission/readmission if the resident is at risk or has a pressure injury and the comprehensive care plan may address: o Identifying the contributing risk factors for breakdown, including history of skin impairment or actual impairment o Hydration o Nutrition o Preventative devices, including recumbent and seated support surfaces o Preventative skin care o Pain o Physical activity o Positioning requirements o Proper body alignment o Education - when appropriate 8. The licensed nurse will document preventative measures on the care plan/kardex. 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record .

This Citation pertains to Intake Number MI 167. Based on interview, and record review, the facility 1) Failed to ensure or maintain the safety of one resident (Resident #111) out of 3 residents reviewed for safety/care and 2) Failed to follow Safety Interventions for a transfer with a Mechanical Lift (Hoyer) and 2-person assist, post fall, resulting in Resident #111 experiencing pain, suffering, and sent to an acute care setting with a closed fracture of the Right Tibial Tuberosity (knee area). Findings include: Resident #111: According to admission face sheet, Resident #111 was admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included: Non-Displaced Fracture of Right Tibial Tuberosity, Dementia, Acute Kidney Failure, Urinary Tract Infection, History of Covid, Alzheimer's, [CONDITION(S)], [CONDITION(S)], Seizures, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #111 was not scored on the Cognition Assessment, indicating severe cognition impairment. The MDS also documented that Resident #111 required extensive two person assist with Bed Mobility, Toileting, and coded a Total Dependence with Transfers (Mechanical Lift). According to Significant Change MDS, dated [DATE], Resident #111 was not score on the Cognition Assessment, indicating severe cognition impairment, and also coded as Extensive 2 person assistance with Bed Mobility, and Total dependence for Transfer with Mechanical Lift and 2 person assist. Resident #111's weight was documented in the clinical record as 128.6 pounds on 10/5/21. Review of Incident/Accident report completed by Licensed Practical Nurse C documented an incident that occurred on 10/26/21 at 12:50 PM, in Resident #111's room. According to the report, the listed Location: Resident's room. Type of A/I (accident/incident) : Observed on floor. Type of injury: was left blank. Location of Injury: Pain/swelling R (right) knee. Activity Before: was left blank. Under 'Describe the nature of the Accident/Incident and if injuries sustained, location of injuries' reflected: Observed in R side lying position on floor, w/c tipped on right side, c/o pain to R knee, R hip, swelling to R knee, abrasion to L medial ankle and R wrist. The report also documented Stat x-rays, R knee, pelvis, ice pack to knee, Tylenol PRN (as needed) for pain . Under Interventions Implemented Assisted to bed. Assist resident to common areas while out of bed, for frequent observations. Under Post Fall Evaluation, Fall Description Details: What was the guest saying they were trying to do before they fell : 'trying to stand up'. Also documented on the report as 'R side lying position, Resident holding R knee, w/c tipped to R side, unwitnessed fall', and for 'Other' as Kicking legs to the side of foot pedals. Under Guest's mental status prior to fall: Forgetful, confusion, alert. Under 'Were there any changes in the guest's normal routine': documented as 'No', but documented as Resident was observed putting legs over side of foot pedals and scooting down in her w/c. She was pulled up in w/c and fed lunch. Aid left room to take out lunch tray. Walked by room shortly after, observed resident on the floor. The report was signed as completed by LPN C and dated as 10/26/21. Review of Incident and Accident Investigation Form, completed by the Director of Nursing dated as reviewed 10/27/21, documented an Incident that occurred on 10/26/21 at 12:50 PM, in room 143-1. On the report, documented a description of an Incident that occurred with Resident #111. After being fed lunch, the CNA (certified nursing assistant) assigned to Resident's care (gave name of resident), left her in her room to return her tray to the food cart. The CNA also picked up other trays in other guests rooms. When passing by resident's room, the CNA observed her laying on the floor with her W/C (wheelchair) flipped over beside her. Resident was holding her right knee and verbalizing pain. She was lifted off the floor with 2 PA (two person assist) and placed into bed. She was medicated for pain, ice was applied, and a STAT x-ray of her knee and pelvis was ordered. Pain management continued. X-ray results revealed a fracture for which, initially, Resident was not sent out emergently as she is W/C bound at baseline. Appt. (appointment) for ortho was to be scheduled. Emergent transfer to ER later for [CONDITION(S)]. (slow heart rate less than 60 beats per minute). Under Physician Findings: On examination, she is guarding RLE (right lower extremity), right knee, crying. There is noted pain and [CONDITION(S)]. Worse to the RLE and right knee. No reported [CONDITION(S)] activity. Under Conclusion: Resident had slept later than normal, and once up, seemed to be very restless per CNA. CNA reports that resident was brought to common area for increased observation because she was attempting to drop her legs over the side of her W/C, rocking/sliding her pelvis. CNA took resident to her room for lunch to lessen stimuli. Resident ate well and upon finishing her lunch, the CNA left the room to take care of her food tray. As she passed Resident's room to assist another guest, she observe Resident on the floor. According to the report, Interviewee #1 was the CNA, dated as 10/27/21, as interviewed. Interviewee #2 was the Licensed Practical Nurse (LPN) dated as 10/26/21 as interviewed. At the bottom of the Investigation Form had the DON's name typed, but there was no date or signature of the person completing the report. Review of typed interviews completed by the DON, reflected an interview with LPN C done on 10/26/21. The interview was documented as: Nurse called to report that Resident had been observed on the floor in her room with her W/C tipped over beside her. Nurse verbalized resident had been out in common area for about an hour or so that morning and was returned to her room so her CNA could feed her lunch. Nurse reports that while the aid was returning residents tray to the cart and picking up other trays, she (CNA) walked past residents room and observed her on the floor. Nurse said she was immediately called to the room by the aid, and upon arrival, saw resident laying on her right side, holding her right knee. Nurse reports that she saw resident's W/C lying on its right side, beside her. Nurse reports that she and CNA (name) lifted resident into bed . Review of typed interview with CNA D on 10/27/21, documented CNA reported that she was responsible for caring for resident on 10/26/21, 1st shift, and that resident slept later than usual that day. She got resident washed and dressed and into her W/C and brought her out to common area. She reports that resident tossed her legs off the side of W/C a few times and was more active than she normally is. CNA reports that resident was moving her legs all over and saying she had places to go, and was rocking/sliding/thrusting her pelvis down in the W/C and had been repositioned several times with assistance. At lunch time, she took resident to her room, ate well, and was pretty calm during lunch. Once she finished, she took resident's tray and returned it to the cart, and continued to pick up other guest's food trays, near residents room. When passed by her room, she observed her on the floor. CNA verbalized she went in and picked up and moved the W/C that was on the floor beside resident. Resident was crying and holding her right knee. CNA called out for the nurse and the nurse came into the room. She reports that she and the nurse used a 2 PA (person assist) lift to get resident from the floor to the bed, once the nurse completed the assessment. CNA reports residents leg was swollen and had couple of scratches . Also on the typed report, with the interviews, was X-ray results: There is a fracture of the Tibial Tubercle. There is mild displacement of the distal fragment. There is no apparent callus formation . An interview was conducted with the DON on 3/22/22 at 3:30 PM, related to the fall with injury for Resident #111. The DON was asked if the resident could tell her what happened and verbalized 'No' she is rarely understood. The DON was asked if she had a room mate that could tell what happened, and indicated the room mate could not say what happened. The DON verbalized she did not suspect Abuse, based on her investigation, and that staff followed interventions. The DON verbalized that Resident #111 had fell out of her W/C and it (W/C)was tipped over, lying next to her, in her room. Resident was found on the floor, by her Aid, who was walking past the room, after picking up food trays. The DON indicated Resident #111 was restless, had been in a common area and taken to her room for lunch. The DON verbalized that the Power of Attorney was not able to be contacted so the Resident's son was called and informed of the incident. The DON verbalized a Nurse Practitioner was onsite and seen Resident #111. The DON indicated that the Aid left resident in a quiet area, in her room. The DON indicated Resident #111 was later transferred to the ER for [CONDITION(S)] and condition change. An interview was conducted on 3/23/22 at 9:15 AM, with CNA D related to the fall on 10/26/21. CNA D was asked if she remembered the fall and said she did. CNA D was asked what Resident #111 was like, and said that she is calm on some days, on the days she is not, she is hard to re-direct. She throws her legs over W/C foot pedals, (calf supports), and scoots her bottom on the seat, trying to get out of the W/C. CNA D was asked if Resident #111 was able to use the call light and said No, I don't think she can use it or knows what it is for. She is not able to walk either. CNA verbalized resident has fell out of bed before and will throw her legs over the side of the bed too. CNA D verbalized that Resident gets restless a lot on 3rd shift, and she will often come to work on 1st shift, get report that resident trying to get out of bed. CNA D verbalized that on the morning of 10/26/21, she fed resident her breakfast and was talking to her. CNA D said Resident #111 asked Have you talked to the Dog. CNA D indicated she answered 'No', but was trying to engage conversation with the resident, who does not make sense most of the time. CNA D said that resident ate really good that day. I sat on the side of the bed and fed her. She was not trying to get out of the bed at that time. I fed her breakfast. CNA D said she changed '[NAME]', (resident's room mate), who is not alert or oriented and could not tell her how Resident #111 got onto the floor. I washed my hands after changing [NAME] and seen Resident #111 throwing her legs over the side of the bed. This was around 10 AM. When I was trying to adjust Resident legs in the bed, she was pushing her legs against my hands and scooting her butt in the bed. I asked if she wanted to be changed. She did not answer, so I got her cleaned up, dressed, up in her w/c with the Hoyer Lift, with another Aide (gave name), who was my hall partner. I brought her out in the hallway to Foxhill Nurse Station. CNA D said that trays came late that day, and usually come around 11:30 AM, but did not arrive to the unit until after noon. CNA D indicated she had to adjust the feet/legs of Resident #111 at least 10 times or more during that time, every few minutes, while she was up in her chair at the nurse station. She was really hard to redirect. I took her to her room a little after noon to feed her. It took about 15 - 20 minutes to feed her. I asked her if she needed anything after she ate. She was not trying to get up at that time. I put her tray on the food cart. I also had rooms 41-45 (141-145), She is in room 143, which is close by. I picked up a couple of trays. I was gone maybe 10 minutes. While I was gone, her W/C was tipped on it's side, on the right side, by the right side of Resident #111. She was laying on her right side, on the floor, holding her right knee. She was crying. She had Capri's on. I seen the knee. It looked fine for a minute. I turned the call light on. I was yelling 'I need some help.' A Hospice Nurse (gave name) heard me yelling and came in. She looked at Resident #111's knee and felt around. She told the resident Were gonna get you up. She went and got the nurse. She came back with the nurse. The nurse tried to do some Range of Motion (ROM) and resident was crying harder and louder. The nurse was trying to lift her knee. I am not sure if it moved. The nurse got vital signs. We lifted her off the floor using 2 person assist. The nurse held her legs, and I grabbed her back. We lifted her onto the bed. We did not use the Hoyer Lift, we 2 person lifted her. CNA D was asked if a blanket or sheet was used to lift Resident #111 off the floor and said 'No'. CNA D said We should have used the Hoyer Lift. We did not though. Most falls, we use the Hoyer lift to get them off the floor. Her transfer status was with a Hoyer Lift at that time, and still is. Her knee was swollen. The nurse got ice packs. Thinking back, we should have used the Lift. I should have laid her back down in the bed before I picked up the trays. I found out later that her knee was broke and they sent her out. CNA D was asked why they did not use the lift, and said she took her guidance from the nurse who just wanted to get the resident off the floor. CNA D was asked about safety interventions for Resident #111 before the fall and said We keep Call light in reach. Frequent checks, bed in low position, and now she can't be left alone in her room. An interview was conducted with LPN C on 3/23/22 at 10:30 AM, related to the incident for Resident #111 on 10/26/21. LPN C was asked if she remember the fall and said she did. LPN C said Resident was non-ambulatory, non-weight bearing, and transfers with Hoyer Lift and 2 person assist. LPN C was asked what Resident #111 does when she becomes restless and verbalized she will throw her legs over the side of her w/c pedals, scoot her butt out of the chair, pulls on things, anything she can grab, reaches out for staff, try's to pull herself up. LPN C indicated Resident #111 can not use a call light. LPN C indicated she has walked by her room and seen her with her legs over the side of her bed and sideways in the bed. She fidgets. I get her back in the middle of the bed. Some days she is calm, She becomes restless mostly after she hears/talks from her daughter. She gets confused. LPN C was asked what is done for an unwitnessed fall and verbalized, the nurse gets vitals. Does an assessment and Neurological checks. We look at how they are laying, any items involved, get them back in the bed. LPN C was asked if there is a 'Fall Huddle' done for every fall, and said, No, not for every fall. Only the ones we can't determine how the fall happens. LPN C was asked about the fall on 10/26/21. LPN C verbalized what she recalled was that the CNA came and got her and said the resident is on the floor. LPN C then said Hospice nurse (named) came and got her and said the resident is on the floor. She and I went to the room. Resident was laying on the floor in between the bed and the wheelchair, on the right side of the bed, opposite of the wheelchair, which was tipped over. LPN C then verbalized that Resident #111 had her leg entangled in the wheelchair and could not recall if it was left or right, but thought it was the right leg. LPN C indicated that the Hospice nurse did not want to help or get involved because she is not one of our employees, and the resident was not on Hospice. LPN C verbalized the CNA was in another room answering call lights, and providing care. The Hospice nurse stayed with us until we got the resident back in bed, and then she left. The room mate was sitting up in a chair, behind the wall divider, and did not know anything. LPN C verbalized again, Hospice nurse came to the nurse station and got me and told me about the fall. We went into the room. The assigned aid was in another room. Then the assigned aid, me, and Hospice nurse was in the room all together. I think we all entered at the same time. I don't remember. I assessed her (resident) and she was holding her right knee. She had her foot entangled in the wheelchair. How I got the foot out was, I was holding her right leg near the bottom. I was stabilizing her leg. It was stuck where the wheel attaches to the chair. We had to guide the chair off the foot. Resident was yelling Oh my foot. Oh my leg. It hurts. She was holding her leg. The CNA or Hospice nurse had to lift the wheelchair up, and pull it backwards, while I held the leg. I don't remember who helped lift the chair. Maybe both of them. LPN C was asked how Resident #111 was placed into bed after the fall, and verbalized that her and the Aid picked her up off the floor. We did a 2 person lift. LPN C was asked if a Hoyer Lift was used to get Resident #111 off the floor, and said, No, We did not use a Hoyer Lift. Maybe We should have. I just wanted to get her off the floor. She was in so much pain. She was light. She only weighed 2 pounds. (Residents weight at that time was documented at 128.6 lbs on 10/5/21). LPN C indicated she applied ice and gave her Tylenol. I was able to see bruising starting. I got a STAT x-ray. This was the end of my shift. I called the DON and told her what happened. I don't know how she ended up on the floor. I told the Aid she should have laid her down before picking up food trays. I was mad. LPN C was asked about safety interventions before the fall and indicated she was supposed to be by the nurse station if she is anxious and not to be left alone. Review of Radiology Results Report, dated 10/26/21 at 18:36 (6:36 PM), for exam: 3V (three view) AP LAT (anterior/posterior/lateral) Oblique-Rt HIP w or wo (with or without) Pelvis 2-3 V-Rt. Under Procedure: Knee exam 3V AP LAT Oblique (Three view, anterior/posterior/lateral and oblique). Under Findings: There is a fracture of the tibial tubercle. There is mild displacement of the distal fragments. No apparent callous formation. There is no gross lytic or blastic [CONDITION(S)] in the bones. There is no dislocation. Bone demineralization is present. [CONDITION(S)] Join Disease in the right knee. This was electronically signed by MD on 10/26/21 at 6:35 PM. Review of Progress notes dated 10/26/21 at 15:34 (3:34 PM) documented by LPN C that Resident was observed on the floor in her room at 1:50 PM. She was last seen in her room approximately 15-20 minutes prior. Resident was positioned in right side laying position with her right leg pulled up and resident holding her right leg. Resident c/o pain to right knee with palpation and passive ROM. ROM remains at baseline to other extremities, abrasion noted to resident's left medial ankle and abrasion to left wrist. On call notified. Tylenol given for pain . Review of Progress notes dated 10/26/21 20:57 (8:57 PM) On call provider aware of x-ray results. Orders to keep non-weight bearing and continue with Tylenol for pain . Review of Interact SBAR (Summary to Providers) dated 10/26/21 at 22:10 (10:10 PM) documented a situation as: The Change in Conditions: Abnormal vital signs, Unresponsiveness, seems different from usual, At the time of the evaluation resident vital signs were: BP: 60/52 at 22:04 Pulse: 97 at 22:04 Temp: 97.6 at 22:04 Weight: 128.6 lbs on 10/5/21. Pulse Oximetry: O2 92 %. at 22:04 Blood Glucose: 165. at 22:04 Nursing observations, evaluation, and recommendations: Guest observed to be less responsive than normal. Sternal rub mildly effective. Diaphoretic. Will not open eyes-squeezes them shut when attempting to open and check PERRLA.(Neuro exam), Primary care provider responded with: Transfer to ER for eval and Tx (treat). Review of Resident #111 Safety Care Plan, with a creation date 5/31/19, documented Focus: Resident is at risk for fall related injury and falls R/T: [CONDITION(S)] disorder, [CONDITION(S)] (high blood pressure), weakness, decreased ROM, debility, incontinence, inability to ambulate-NWB (non weight bearing) right leg, Resident has been observed with her legs out of the bed, over the edge of her bed, Can become restless and wiggle down in her W/C. BIMS 0. Several Interventions documented as initiated prior to fall with fracture: Encourage resident to wear appropriate footwear as needed. Keep bed in lowest position. Keep environment safe as possible ., monitor feet out of bed and reposition, concave mattress, activities that minimize potential for falls. Put call light in reach and encourage resident to use it. Position in the middle of bed. Review of the safety care plan reflected interventions added post fall: assist to common area while out of bed .attempt change of position when known restless, move to quiet area in attempts to reduce restlessness (implemented post fall 11/01/21), Broda Chair . Review of CNA Care Guide (Kardex) documented for Transferring as: Resident requires total assistance using Hoyer Lift and 2 staff members. Review of 'Fall Management' Policy dated as revised 2019, documented The facility will identify hazards and guest resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Under Overview Each guest is assisted in attaining/maintaining his or her highest practical level of function by providing the guest adequate supervision, assistive devices, and/or functional programs . Fall Defined as The unintentional coming to rest on the ground, floor, or other lower level but not as a result of overwhelming external forces (guest pushing another guest). An episode where a guest lost his/her balance and would have fallen . When a Fall occurs, the licensed nurse will evaluate the guest for injury. -Do not move the individual until examined by the nurse. -The first responder will summon the nurse . -A Fall huddle will be help to determine the root cause of the fall . A second interview was conducted with the Director of Nursing on 3/23/22, related to the incident. The DON was asked if she was aware that the two staff performed a two person lift without using the Mechanical Hoyer Lift, post fall. The DON verbalized she was not sure if the resident was still a 2 person transfer at the time of the fall, and looked up Resident #111 transfer status in the electronic medical record. The DON was shown that before the fall, the Significant Change MDS, dated [DATE], reflected Total Dependence and 2 person assist with lift for Transfers. The DON was asked if she was aware that the foot/leg had been tangled up in the wheelchair, and verbalized she was not provided that information.

This Citation pertains to Intake Numbers MI 461 and MI 580. Based on interviews and record review, the facility failed to prevent falls for two residents (Resident #7 and Resident #3) out of four residents reviewed for falls, resulting in pain, injuries, and repeated falls. Findings include: Resident #7: According to the Admission Record, printed on 3/18/2021, Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included fractured femurs (broken bones) on the left and right legs, type 2 Diabetes Mellitus, [CONDITION(S)], heart failure, weakness, high blood pressure, rheumatiod arthritis, and a cardiac pacemaker. On 10/9/2020 an incident and accident investigation form was completed for Resident #7, at 2:30 PM, Resident #7 was rolled away from the Certified Nursing Assistant (CNA) I to perform care and Resident #7 stated that she was unable to stay in position and she rolled out of the bed onto the floor. According to the investigation report, Resident #7 had significant bruising to the left side of her face and her left arm. Resident #7 also had a large hematoma, a swollen bruise, to her right forehead and a laceration to her left eyelid, the eyelid is bleeding and her left eye is blood shot. There were also two skin tears, (lacerations) to her left lower arm. According to the progress note on 10/9/2020, Resident #7 rolled out of the bed while care was being performed. She usually is a two-person assist and only had one person. The patient hit her head and right arm on the floor, she was bleeding from her facial wound, was very shaken up and near tears. The facility wrapped her arm with gauze, applied ice to the forehead, applied Band-Aid to the skin tears and the laceration, and began neuro checks to monitor for head injury. The facility immediately suspended CNA I. Resident #7 was transferred to a facility for treatment for an active COVID infection as a result of a positive test. The Director of Nursing was interviewed on 3/18/2021 at 2:00 PM on 3/18/2021 and reported that the facility had terminated the nursing assistant as a result of the fall. The care plan for Resident #7 for activities of living, self care and required assistance with mobility, implemented on 9/29/2020, had an intervention for bed mobility as dependent and required the assistance of two staff. The Falls Management policy, dated as revised 10/2019, had a stated purpose to identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Resident #3: According to the Admission Record, printed on 3/18/2021, Resident #3 was a [AGE] year old man admitted on [DATE], with diagnoses of liver failure, obesity, dementia, anxiety, depression, Alzheimer's Disease, history of falls, Type 2 Diabetes, Mellitus, high blood pressure, and [CONDITION(S)]. The Admission Record indicated that Resident #3 had discharged on [DATE]. According to the incident and accident report, dated 11/20/2020, at 6:30 PM, Resident #3 was found on the floor on the right side of the bed after having the head of the bed elevated for him to eat. The intervention implemented was to get contour mattress and for now, use blankets placed under the sheet to keep guest in place. On 11/24/2020 at 5:00 AM, Resident #3 was found laying on the floor on his right side next to the bed, facing the bed. It had appeared as though he rolled right over. the intervention to be implemented was to put a concave mattress on the bed. Although, according to the incident report of 11/20/2020, this intervention had already been implemented and the blankets under the sheet were not mentioned in this report. On this date, Resident #3 sustained abrasions on both knees, which were cleansed with normal saline and covered with Band-Aid. Resident #3's care plan with a focus on the risk for fall related injury and falls had interventions, Positioning pillows in place to help identify bed parameters, dated 11/20/2020 and to have a contoured mattress to bari-bed to aid in identifying bed parameters as Resident leans to left side when in bed, dated 11/23/2020. No additional interventions had been added to the care plan after the fall on 11/24/2020. The facility policy on Fall Management, dated 10/2019, instructed The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. The policy also stated, when a fall occurs, the licensed nurse will complete: .Review and/or revise care plan and guest/resident Kardex . and that the interdisciplinary team would meet within 24 to 72 hours after the fall to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls. The Director of Nursing was interviewed on 3/18/2021 at 2:00 PM and stated that the fall for Resident #3 had happened on Thanksgiving and the interventions were done on Monday. However, the first fall on November 20, 2020 was the Friday before Thanksgiving, and the intervention of a contour mattress for the bed to define the bed parameters was implemented on the care plan three days after the fall on Monday, 11/23/2020; there were no additional interventions implemented after he sustained his second fall on 11/24/2020.

This Citation pertains to Intake Number MI 058. Based on interview and record review the facility failed to ensure that two residents (Resident #1 and Resident #2) of three residents reviewed for falls were assessed for complications after falling, resulting in one resident (Resident #1) of the two residents being hospitalized for [REDACTED]. Findings include: Resident #1: According to Admission Record, printed 1/27/2020, Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #1's Minimum Data Set (MDS) Resident Assessment Tool, dated 11/01/2019, her Brief Interview for Mental Status (BIMS) score was 03, indicating severe cognitive impairment. According to Section E of the MDS, Resident #1 did not exhibit any behaviors. According to Section G of the MDS, Resident #1 required extensive assistance (resident involved in activity; staff provide weight bearing support) of two people for bed mobility and dressing, limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) of one person for transfers and eating, and extensive assistance of one person for toileting and personal hygiene. According to Section H, Resident #1 was occasionally incontinent of urine. According to Section J, Resident #1 had a history of [REDACTED]. According to Section O, Resident #1 was receiving physical, occupational and speech therapies. According to Section P, Resident #1 did not use bed rails or any type of restraint. According to Resident #1's Fall Risk assessment, completed 10/29/2019 at 22:10, Resident #1 was not at risk for falls. The assessment answered yes to the following questions for Resident #1: 1. Does the resident have a history of falls, 2. Does the resident have fear of falling, muscle weakness, decreased lower extremity joint function, balance deficit, or gait deficit, 5. Does the resident take medications that may increase falls, 6. Does the resident have impaired vision, 7. Does the resident have impaired cognition, judgement, memory, safety awareness and/or decision making capacity. The Fall Risk assessment answered no to the following questions for Resident #1: 3. Does the resident have cardiac arrhythmias, [MEDICAL CONDITION], [MEDICAL CONDITION], TIA's, [MEDICAL CONDITION], dizziness, light headedness, stroke and/or orthostatic [MEDICAL CONDITION], 4. Does the resident have urinary urgency. According to Resident #1's care plan she was incontinent of bowel and bladder and was to be checked every two hours and as needed for incontinence (created 10/29/2019, initiated 11/4/2019, revised 12/5/2019). Resident #1 was at risk for cardiac complications related to multiple cardiovascular diseases including high blood pressure and was to have vital signs as ordered with the physician notified of abnormal readings (created 10/29/2019, initiated 11/4/2019, revised 12/5/2019). Resident #1 also had impaired visual function (created 10/29/2019, initiated 11/4/2019, revised 12/5/2019). Resident #1's care plan also said that she had activity of daily living (ADL) self-care deficit due to her weakness and decreased mobility which required staff assistance as intervention and encourage resident to use bell/call light to call for assistance (created 10/29/2019, initiated 11/4/2019, revised 12/5/2019). Resident #1 also had a care plan that said she was at risk for fall related injury and falls related to weakness and history of falls, attempts at independent transfers. Resident #1's interventions to prevent falls included encouraging activities, encouraging appropriate footwear, keeping the environment as safe as possible, physical and occupational therapy, call light in reach and encourage her to use it for assistance and to toilet before and after meals and upon awakening, before bed, check for toileting needs frequently throughout the night. All fall interventions were initiated 11/4/2019 and revised 12/5/2019. Review of Resident #1's Kardex the same safety interventions were noted. A Kardex is a tool that communicates the residents care planned interventions to the Certified Nursing Assistant (CNA) to direct the residents care. During an interview on 1/27/2020 at 3:00 PM, the Director of Nursing (DON) said that care planned interventions pull from any care plan to the Kardex immediately when they are created. When asked to clarify whether the interventions created on 10/29/2019 flowed to the Kardex before they were initiated on 11/4/2019, the DON stated, that it was weird that it was showing up like that. She reiterated that the day the care plan is created is the day they initiate them. The DON said she consulted with the electronic medical record provider and they said everything flows real time. There are no dates the interventions were started on the Kardex to determine if interventions were implemented/initiated on the day they were created (10/29/2019) or the day they were initiated (11/4/2019). According to facility policy titled, Care Planning, (revised 11/2017), said, Every resident in the facility will have a person-centered plan of care developed and implemented. The facility procedure included, A baseline care plan will be developed within 48 hours identifying any immediate needs, initial goals and interventions needed to provide effective and person-centered care. The procedure also said, the care plan and resident Kardex will be updated on admission .and with significant changes . Upon review of Incident and Accident Report, dated 10/31/2019 at 11:00 PM, it was noted that Resident #1 stood up as nurse walked in the room and sat on footrest to the wheelchair. The nurse was able to stabilize the wheelchair, so it did not flip over. At the time of the incident report, Resident #1's blood pressure was documented as 136/68. The nurse documented she implemented an intervention of educated resident that she needs to push call light when wanting to get out of chair, explained she needs assistance with transferring from chair to bed to reduce repetition of accident or incident. The nurse documented that Resident #1 did not respond when asked what she was trying to do just before she fell . The nurse documented that Resident #1's mental status prior to the falls was alert and oriented 1-2 with confusion. The nurse noted that Resident #1 was dry, had gripper socks on and was not using a position change alarm at the time of the fall. The CNA that assisted Resident #1 during the three hours leading up to the fall said that Resident #1 had been in bed but was getting where she was trying to get out of the bed so she was put back in wheelchair for a few minutes prior to nurse walking in room at the time the incident occurred. Upon review of Incident and Accident Report, dated 11/1/2019 at 05:35 AM, it was noted that Resident #1 fell in her room and acquired an injury (bump and bruise) to left side of temple. The documented nature of the accident stated, Resident was heard yelling and went into room to see resident laying face down on floor (with) feet tangled in (wheelchair). Resident was incontinent (at) time. (CNA) stated that she had been in to check on her less than hour before. At the time of the incident report, Resident #1's blood pressure was documented as 182/107. The report stated that Resident #1's physician was contacted at 06:45 AM and ordered neuro checks and to notify the physician of any changes. The nurse documented she implemented intervention of After assessment completed guest changed and brought to nurses station for close supervision to reduce repetition of accident or incident. The report stated Resident #1 would not answer question. Just moaned, when asked what she was trying to do before the fall. Resident #1's mental status prior to the fall was noted as alert and oriented X1 which was documented as Baseline per doctor. The report said that Resident #1 had gripper socks on, no alarm being used, and was wet at the time of the fall. The report also said, Yes to the question, Were temperature, pulse, respirations and/or O2 sat out of normal range for this resident. Resident #1's orthostatic blood pressures were documented as lying 184/107 and sitting refused and standing unable. The incident report read, the primary nursing assistant who observed and/or assisted the resident during the three hours prior to the fall was interviewed and described the life of the resident before the fall . The report stated that the CNA assisted getting resident back into bed. Fall was unwitnessed and nurse discovered resident on floor. The question of what the resident was doing in the three hours prior to the fall was not answered. The re-enactment of the fall section of the report said the nurse walked into resident room after hearing a thump and yell and walked into resident room and resident was laying on floor face down with pants down and wet and feet wrapped up in wheelchair as if trying to get up. Resident would not answer questions. Just kept moaning. The initial intervention to prevent future falls was documented on the report as toileting schedule before and after meals and upon awakening. Encourage out of room activities. According to the Assessments section of Resident #1's Electronic Medical Record (EMR), neurochecks were not documented for both falls (10/31/2019 and 11/1/2019). During an interview on 1/22/2020, the Director of Nursing stated the nurse must have completed a paper document to be uploaded into the Misc section of the EMR instead of the assessment form in the EMR. She stated she would look for the form. Upon review of the Misc section of her EMR no neurocheck documents were present. During a follow up interview on 1/27/2020 at 08:45 AM, the DON stated she was not able to locate any neurochecks for Resident #1's falls. According to Progress Notes in Resident #1's EMR, she admitted to the facility on [DATE] with noted confusion and was educated on how to use her call light to call for help transferring. According to physician progress notes [REDACTED].#1 came to the facility following hospitalization for a fall (negative CT scan noted), mild cognitive impairment and elevated blood pressures. The physician note also mentioned that Resident #1 was at risk for falls. According to activities progress note dated, 10/31/2019 at 11:44 AM, Resident #1 was able to tell the activities aide that she enjoyed church, being outside, country music, reading mystery novels and watching tv. According to social services note dated, 10/31/2019 at 15:07, Resident #1 was alert, verbal and able to make her needs known but had difficulty with short term and long term memory. According to physician progress notes [REDACTED].#1 was evaluated post fall. The physician note indicated neurochecks and fall protocol began. The note said that Resident #1 was more confused, grabbing her head and pain, slurred speech and neurological change noted per nursing assessment. The note continued that Resident #1 was urgently transferred to the emergency room for a CT scan of the head to rule out [MEDICAL CONDITION]. The physician note also documented that Resident #1 had a hematoma noted to her left forehead. According to nurses note dated 11/1/2019 at 00:09 AM, Resident #1 was witnessed trying to stand up without assistance and sat down on the footrest of her wheelchair. According to nurses note dated 11/1/2019 at 06:00 AM, Resident #1 was observed laying on the floor of her room facedown with pants and brief down. Both pants and brief were noted to be wet. The note said that Resident #1's feet were wrapped around the foot pedals of her wheelchair. The note stated that Resident #1 had a bruise on left temple. According to the note the physician was in house at the time of the fall and assessed Resident #1 and ordered neuro checks. According to physician assistant note dated, 11/1/2019 at 08:00, Resident #1 was evaluated at approximately 8AM at which time she was laying in bed, knees flexed, appeared uncomfortable, repeatedly touching forehead where there was note of large bruise. EMS (ambulance) quickly arrived and took pt (patient) to ER as she apparently had experienced a fall earlier this morning. According to Resident #1's blood pressure summary, printed on 1/27/2020, she had the following documented blood pressures: 10/29/2019 at 17:07: 160/83 (lying) 10/29/2019 at 17:08: 164/76 (sitting) 10/29/2019 at 17:10: 154/84 (standing) 10/30/2019 at 10:17 AM: 148/74 (lying) 10/30/2019 at 18:00: 164/80 (lying) 10/30/2019 at 21:00: 132/72 (lying) 10/30/2019 at 21:47: 142/72 (lying) 10/31/2019 at 08:44: 139/69 (lying) 10/31/2019 at 17:08: 165/73 10/31/2019 at 20:01: 142/72 (sitting) 10/31/2019 at 23:04: 137/68 11/1/2019 at 08:20: 188/77 (sitting, manual) Resident #1's last documented blood pressure one hour prior to hospitalization was significantly higher than her baseline. Resident had orders in place and was administered [MEDICATION NAME] 25mg by mouth twice a day related to high blood pressure upon admission until time of discharge. 0900 am dose on 11/1/2019 was not administered. The reason for the missed medication was documented as not given due to resident going to hospital. Upon review of Resident #1's hospital medical record it was noted that she was brought to the emergency roiagnom on [DATE] at 09:28 AM, where she was found to have a subdural hematoma. She was admitted to the intensive care unit .She is opening eyes, did not follow commands. Upon arrival to the emergency room her blood pressure was 227/121 and she had a bruise to her left forehead. According to emergency room Nursing Notes Resident #1 was yelling I can't see and did not respond to hand movement near her left eye. She required feeding tube placement due to difficulty swallowing. Resident #1's CT Scan was positive for Atypical appearance of blood along the left tentorium and into the left posterior cistern. She was diagnosed with [REDACTED]. She required a 17-day hospitalization . According to consultation report dated 11/2/2019, Resident #1 had fell 10 days ago, but did not have a head injury at that time (CT scan was negative). According to consultation report dated 11/3/2019 a palliative care approach was recommended to improve her quality of life and manage Resident #1's symptoms. During an interview with Speech Therapist (ST) A on 1/27/2020 at 12:36 PM she said she worked with Resident #1 during her short stay at the facility. ST A said Resident #1 had fairly good verbal expression of her needs and wants and was able to follow two step directives. ST A said Resident #1 had delayed processing but given ample time she was able to respond appropriately during her observations on 10/30/2019 and 10/31/2019. ST A said she picked Resident #1 up from the nurse's station on 11/1/2019 to take her to restorative dining to do diagnostic treatment. ST A said she knew something was right because Resident #1 wasn't able to say her name and she wasn't able to follow direction like she did on the 30th and 31st. ST A said she watches her residents clinical profiles very closely and Resident #1 had enough change that it alarmed her. ST A said she was really worried and notified the unit manager, who notified the physician. ST A said she brought Resident #1 back to the nurse's station and that is when she saw the nurse and physician assessing Resident #1. ST A did not recall Resident #1's nurse telling her that Resident #1 was being closely monitored at the nurses station post fall prior to her taking her to restorative dining. ST A said she called Resident #1's daughter to alert her to make sure they continue with the pureed diet at the hospital. During an interview with Doctor B on 1/27/2020 said she saw resident the morning of 11/1/2019 but I did not recall the details of the event. Doctor B reviewed her notes and said Resident #1 fell and developed altered mental status. When asked if she was made aware of Resident #1's elevated blood pressures post fall, Doctor B said sometime blood pressure will be elevated after a fall because the resident is agitated or stressed by what happened. Doctor B mentioned multiple times during the interview that she did not remember specifics and could only go off the documentation. Doctor B stated, I think If they would have told me I would have asked them to take a manual. Doctor B agreed it was hard to gauge the timing of everything based on the timestamps of the documentation being off. Doctor B said she did not see any neuro checks being done but that did not mean that they weren't done. Doctor B said If a blood pressure was reported as elevated, I would have mentioned that in my note. Doctor B stated, I did find that funny therapy was the one that notified of the change of condition. I vaguely remember that. Doctor B also stated, It's too bad you don't have neurochecks to review to see the timeline of the change of condition. During interview with Nurse C on 1/27/2020 at 1:15PM she said she was told in report that Resident #1 was confused, and it was her first night there so she made frequent checks on her. Nurse C said she was in the hallway when she heard a thump and a yell and found Resident #1 laying on the floor facedown. Nurse C said she noticed that Resident #1 had noticed a bruise on the side of Resident #1 face immediately. Nurse C said Doctor B was in the building and had her paged immediately to come and evaluate Resident #1 because she was concerned about the bump on Resident #1's head. Nurse C stated, The first thing that came to my mind was a bleed. Nurse C said she assessed resident #1 and her vital signs and said Doctor B saw Resident #1 within five minutes of the fall. Nurse C said Doctor B told her to start neurochecks. Nurse C was unsure if Doctor B was aware of Resident #1's elevated blood pressure. Nurse C said she did not remember what her blood pressure was but said blood pressure checks would have continued with the neurochecks. Nurse C said she would expect to see a high blood pressure right after a fall but would expect to see it come back down. When asked where she documented her neurochecks, Nurse C stated, I don't remember what happened to my neurochecks, I can't tell you what happened to the sheet. Nurse C explain they use the standardized sheet that says to do neurochecks every 15 minutes for the first one hour, every 30 minutes for the next two hours and then every four hours for the next eight hours. Nurse C said she told Nurse D in report at 07:00 AM on 11/1/2019 that Resident #1 was on every half hour neurochecks and passed the sheet to her. Nurse C said Resident #1 was at the nurse's station when she reported off to Nurse D. Nurse C said she stayed at the nurse's station after report to do some charting but was also keeping an eye on Resident #1. Nurse C said Resident #1 kept moaning and saying her head hurt. Nurse C said she noticed the bump was getting more and more black and blue. Nurse C stated, I've been a nurse for a long time, I was very concerned. Nurse C said she saw Doctor B before she left and told her the bruise was getting darker. When asked if she saw Nurse D do neurocheck on Resident #1 at the nurses station, Nurse C said I can't say that I saw her do any neurochecks while I was charting but I wasn't sitting there the whole time. Nurse C also said, That doesn't mean the CNA didn't do a neuro check. When asked if CNA's normally do neurochecks, Nurse C said she normally does hers because she likes to assess her patient herself, especially after a fall like that. Nurse C said sometimes the CNAs will get the resident's vital signs for the nurses. During an interview with Nurse D on 1/27/2020 at 1:37 PM she said she was the nurse that sent Resident #1 to the hospital on [DATE]. Nurse D recalled that Resident #1 was at the nurse's station so everyone could see her. Nurse D said she got report from Nurse C and then Resident #1 went down to restorative between 730 AM and 08:00 AM. Nurse D said nothing flagged her as abnormal at that time at the time she assessed Resident #1. When asked if she completed a neurocheck assessment on Resident #1 prior to her going to restorative dining with speech therapy, Nurse D stated, I'm pretty sure I got a set of vitals on her before she went to restorative but I'm not sure if I put them in the computer. Nurse D said she could not remember if Resident #1 was getting neurochecks but believed she was. Nurse D said she did a neurological assessment in restorative because the speech therapist came and got her and said that Resident #1's speech was more slurred than normal. Nurse D said she went and got Doctor B, and everything went so fast after that because she just wanted to get the resident to the hospital. Nurse D explained the facility has a neurological assessment they complete in the electronic medical record or they use a paper document. Nurse D said she did not remember completing the neurological assessment form in the electronic medical record and did not remember seeing or documenting on a paper form. Nurse D said Resident #1 left for the hospital about 08:30 AM. During an interview with CNA E on 1/27/2020 at 3:44 PM she said she was Resident #1's CNA the night of the fall. CNA E stated her recollection of that night was fuzzy because it was so long ago but believed she worked a half-shift that night because she had been working third shift into first shift. CNA E said she could not recall how often she checked on Resident #1 or if anyone communicated to her that Resident #1 was a fall risk or what her interventions were to prevent falls. CNA E said she remembered that Resident #1 had a bruise and knot on her head immediately after she fell , and they took her to the nurse's station after the fall. According to Neurological Assessment, Long-Term Care procedure provided by the facility, A focused neurologic assessment is necessary after a fall, if the resident may have sustained a head injury or is receiving anticoagulant therapy, which increases the risk of cerebral hemorrhage and subdural hematoma formation. In addition, the Centers for Disease Control and Prevention recommends computed tomography scanning of the head for older resident with a coagulopathy who sustain head trauma from a fall. The procedure explained that a neurologic assessment enhances the routine measurement of a resident's vital signs (temperature, heart rate, blood pressure, and respirations). Changes in vital signs coupled with changes in level of consciousness, pupil activity, motor response, orientation to time, place, and person can signify ominous neurologic compromise. According to facility policy titled, Fall Management, (revised 10/2019), The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . Guest/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. Practice Guidelines the facility outlined in their policy included, if a potential head injury is present, complete the Neurological Record. Resident #2: According to Admission Record printed 1/27/2020, Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] (initial admission date of [DATE]) with [DIAGNOSES REDACTED]. Upon review of incident and accident report dated 11/24/19 it was noted that Resident #2's bed was not appropriate height at time of incident. The report said her bed was too high and should have been low to floor. The report said the fall was unwitnessed. Upon review of Resident #2's electronic health record, no neurochecks were documented. Invention initiated post falls was Bed to be in lowest position at ALL times. Upon review of incident and accident report dated 12/25/19 it was noted that CNA providing care and left resident in bed while CNA left to grab something. When CNA came back Resident #2 was on the floor. The incident report noted that Resident #2's bed was not in its lowest position when the CNA left her unattended to grab something. Fall was unwitnessed. Upon review of Resident #2's electronic health record, no neurochecks were documented. Upon review of Resident #2's care plan the following intervention was noted, keep bed in lowest position when unattended and (Resident #2) is resting/sleeping (initiated 11/4/2019) and keep (Resident #2's) environment as safe as possible with: keep the bed in the appropriate position (initiated 5/31/2019). During an interview with the Director of Nursing (DON) on 1/27/2020 at 3:00 PM she agreed that Resident #2's care plan to prevent falls was not followed prior to her fall on 12/25/2019. The DON agree that the CNA that left Resident #2 unattended on 12/25/2019 should have lowered her bed before leaving to grab something. The DON said that if falls are unwitnessed, they do neurochecks. The DON said Resident #2 would not be able to say whether she hit her head so neurochecks should have been done. Upon review of Resident #2's electronic health record, the DON agreed no neurocheks were documented for the unwitnessed falls on 11/24/2019 and 12/25/2019.

This citation pertains to Intake Number MI 077 Past noncompliance was presented by facility, after survey team had identified and substantiated abuse by a facility nurse. Following discussions with management, past noncompliance was accepted. Based on interview and record review the facility failed to prevent abuse toward one resident (Resident #905), out of five residents reviewed for abuse, resulting in a facility nurse squirting one pump of Antibacterial Soap into Resident #905's mouth, after being called a derogatory name by the resident. Findings include: On 9/17/19 at 10:00 AM, a review was completed of Resident #905's medical records and it revealed the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS (Brief Interview for Mental Status) score indicated she was severely cognitively impaired. On 9/17/19 at 10:15 AM, review of the facility FRI (Facility Reported Incident) File and it revealed on (MONTH) 6, 2019 after Resident #905 called Nurse C a derogatory name, the nurse proceeded to grab the resident by her shirt in her chest area, get very close to her face and pointed at her with two fingers. Nurse C went to her treatment cart and retrieved a bottle of Antibacterial soap, put the pump in Resident #905's mouth and pushed down. Further review of the file is indicated below: FRI Investigative Summary - .(Nurse C) is noted to begin to walk away from (Resident #905) but then turns back toward her and is observed learning over her with her hands holding (Resident #905) [NAME]et. She is observed speaking with her face close to (Resident #905) face and both her hands holding her [NAME]et .She then released (Resident #905) [NAME]et and is seen walking towards the area where the Fox[NAME]treatment cart is kept. She is observed bending over and reaching into what appears to be the bottom drawer from which she removes a larger sized bottle with orange-ish substance in it. She walks back to (Resident #905). (Resident #905) is observed opening her mouth and (Nurse C) uses the pump on the bottle to squirt some of the orange-ish substance into her mouth. (Resident #905) immediately spits on the floor .The medication cart and treatment cart were gone through to determine id mouth wash was available. It appears that (Nurse C) took the mouthwash from the treatment cart but placed it in the cubby with her med card after she put the substance in (Resident #905's) mouth. No mouthwash was found but there was a bottle of Antibacterial hand soap that appeared to be in a similar bottle with similar color and a pump dispenser discovered in the bottom drawer of her treatment cart . Nurse C Training documents Review: - From 1/5/18-1/18 she attended the facility P[NAME] (Plan of Correction) training that included abuse. - On 8/28/18 Nurse C completed online Abuse and Neglect training. - On 10/31/18 Nurse C completed online [MEDICAL CONDITION] and Related Disorders: Behavior Management training. - On 8/2/16 Nurse C signed and dated a facility form entitled, Acknowledge of Abuse Policy. The form stated, I (Nurse C), acknowledge that I have been in-serviced on (company) Abuse Policy. I understand abusive situations can result in criminal charges and or civil sanctions. Disciplinary Action Record Work Rules: - .When asked what the resident (Guest) did to upset her (Nurse C) she replied she called me out my name ([***] ) .Upon completing the investigation (Nurse C) is terminated from employment at (the facility) effective 3/6/2019. On 9/17/19 at 11:51 AM, an interview was conducted with Unit Manager B who reported when they were informed Nurse C squirted hand sanitizer into Resident #905's mouth she contacted Poison Control regarding potential harmful effects. She was informed it could leave a bad taste in the resident's mouth and possible GI (gastrointestinal) upset. They recommended providing the resident with something to drink. On 9/17/19 at 11:57 AM, an interview was conducted with CNA (Certified Nursing Assistant) A regarding the incident on 3/6/19 with Resident #905. She reported she was behind the desk charting and Nurse C took Resident #905 to the bathroom and propelled her back to the nurse's station. CNA A stated she heard the resident call Nurse C a name but was not certain what the name was. CNA A heard Nurse C say to Resident #905, Don't call me out my name, I don't call you out of yours, I will wash your mouth out with soap. CNA A reported when she viewed the video footage of the incident, she was shocked and added She Resident #905 called staff derogatory names all the time. On 9/17/19 at 12:07 PM, an interview was conducted with Unit Manager D regarding the incident with Resident #905. She reported around 2:30 PM CNA [NAME] reported to her she overheard some talking at the nurse's station but was not sure what they were talking about. The conversation she overheard sat uneasy with her and she felt that she needed to report it. Manager D relayed the information to the DON (Director of Nursing) and they began watching the camera on that unit. Manager D reported she witnessed Nurse C being near Resident #905's face and pointing with her finger at the resident. She explained it's possible she had a hold of the resident's clothing, but she was not certain of this. Nurse C turned away to the treatment cart and picked up a bottle and took it back to where Resident #905 was sitting. Manager D reported she saw Resident #905 open her mouth and Nurse C squirt, 1 pump of the contents of the bottle into the resident's mouth. The resident immediately spit it out. Nurse C walked back to her cart and proceeded to hand Resident #905 tissue. Manager D stated after watching the video they pulled Nurse C off the floor and had her watch the video footage of the incident with them. She reported Nurse C was speechless, which was not normal for her. They suspended the nurse, counted her medications, confiscated her keys and walked her out of the building. Manager D explained Resident #905 was very confused and did not remember the incident. Law Enforcement was contacted, and they began their investigation. She reported in the past she has never had any concerns for the care that Nurse C provided to facility residents. On 9/17/19 at 12:20 PM, an interview was conducted with CNA [NAME] regarding her account of the incident with Resident #905 and Nurse C. CNA [NAME] explained she was coming back from lunch and there were a few staff at the desk, and they were whispering about something. CNA [NAME] reported she knew something was not right and she alerted Unit Manager D. She reported Resident #905 was her assigned patient on that day and she remembers the resident being at her baseline. On 9/17/19 at 12:30 PM, Social Worker F was queried regarding the incident with Resident #905. She reported Resident #905 was pleasantly confused, always worried about her son and looking for her parents. The Social Worker reported she was Informed of the incident by the DON and Unit Manager D. She completed a visit with the resident, and she had no recollection of the incident. Social Worker F reported viewing the incident on the camera and recalled Nurse C whispering in Resident #905's ear, going to her treatment cart and retrieving a bottle, using that same bottle bottle to squirt soap into Resident #905's mouth. The resident immediately spit out the substance. On 9/17/19 at 12:48 PM, CNA G was queried regarding her knowledge of the incident with Resident #905. CNA G reported she was coming out the Dining Room and observed Nurse C holding the sides of Resident #905's shirt. She heard Nurse C say, Don't do that to me, I don't do that to you, and the resident was making funny faces at the nurse. CNA G explained she had worked with Nurse C at other facilities and she did not believe in that moment she was causing any harm to the resident. CNA G reported after she observed that she continued into the nutrition room and when she emerged Nurse C was letting go of Resident #905 shirt. CNA G stated she did not witness Nurse C squirting soap into Resident #905's mouth. She reported the resident did not seem afraid or intimated. She reported Resident #905 is known to call staff explicit and racially charged names. On 9/17/19 at 12:58 PM, an interview was conducted with Activity Aide H regarding the incident on 3/6/19. She reported she was at the nurse's station completing progress notes and overhead Nurse C say to Resident #905, Do you know what I would do to you. Activity Aide H witnessed Nurse C standing over Resident #905 (who was in her wheelchair) and being close to the resident's face. Activity Aide #905 stated she thought this was normal behavior for Nurse C as she has witnessed her in resident's faces before. On 9/17/19 at 1:05 PM Volunteer I was interviewed about her account of the incident with Resident #905 and Nurse C. The volunteer reported she was sitting in the chair next to Resident #905 at the nurse's station. Resident #905 was on her right and there were two other residents to her left. After Nurse C placed Resident #905 next to her (and began to walk away), the resident turned to her and said, I hate that fat ass [***] . The volunteer told Resident #905, that is not nice, Resident #905 then stated, I don't care, I hate that [***] . Nurse C overheard the comments, approached Resident #905 and put her hands on either side of Resident #905 wheelchair (both hands were resting on the wheelchair armrests) and they (Resident #905 and Nurse C) began to glare at one another. Volunteer I reported the nurse was loud and said if you keep talking that way, I am going to wash your mouth out with soap. Resident #905 opened her mouth, indicating to Nurse C to try it. The nurse stepped to the side and retrieved a large bottle of some type of hand soap, with a finger pump on it. Nurse C stood to the side of Resident #905 and the resident opened her mouth and Nurse C proceeded to squirt ( 1 pump) of the hand soap into Resident #905 mouth. The resident turned to the side and spit it out the soap and the nurse stated, Don't spit on the floor. On 9/17/19 at 4:30 PM, phone call was placed to the Detective L and a return phone call was requested. At the time of this report no return phone call had been received. On 9/17/19 at 4:35 PM, a review was completed of the Police Report and it revealed the following, .On Wednesday (MONTH) 6, 2019 at approx 1557 hrs .were dispatched to (the nursing home), for a report of suspicious activity and possible vulnerable adult abuse . The video showed (Nurse C) pushing (Resident #905's) wheelchair down the hallway and parked her against the wall. (Nurse C) then grabbed (Resident #905) shirt, near her chest, got very close to her face. (Nurse C) then pointed at her with two fingers and walked around the corner. After she came back, she had an orange bottle with a pump, she put the pump in (Resident #905's) mouth and pushed down. (Nurse C) went out of frame for a few seconds, came back with a cup and a tissue and wiped (Resident #905's) face. (Officer K) spoke with two nurses (CNA A and CNA G) .(CNA A) said she heard (Nurse C) talked to (Resident #905) and heard her say, I've got my eye on you, (CNA A) thought nothing of it and left the area. (CNA G) said she saw (Nurse C) push (Resident #905) down the hallway and park her against the wall. She then heard (Resident #905) call (Nurse C') a [***] . (CNA G) said she saw (Nurse C') grab (Resident #905) by the shirt on the chest area and say, Don't speak to me like that. I don't speak to you like that .I'll wash your mouth out.(Officer J) and I conducted follow up at (Nurse C) residence .I knocked on the door and (Nurse C) answered, I then placed (Nurse C) in handcuffs .and advised her that she was under arrest for assault .(Nurse C) stated that (Resident #905) was fussing and cussing after she had taken her to the bathroom. She them put her hand on her shoulders and said I've got my eye on you and pointed at her with two fingers. (Nurse C) then said she was going going to wash her mouth out with soap and used mouthwash, not soap to do so. (Nurse C) said she keeps a personal bottle of mouthwash on her at all times and used that mouthwash on (Resident #905). (Officer J) asked her to describe the bottle and she said it was orange in color .On Thursday (MONTH) 7, 2019 .(Officer J) and I went to (the facility) to follow up .(the DON) took (Officer J) and I to the scene and showed us the cart that (Nurse C) had used the day before. She showed us the hand soap bottles which were kept in the same cart and were orange in color .which looked like the same bottle form the video . (the DON) then showed us the bottles of mouthwash they used and they were blue in color . On 9/17/19 at 4:40 PM, a review was completed of Genesee County 67th District Court Records for Nurse C. It revealed Nurse C was charged with assault and battery and plead not guilty on (MONTH) 1, 2019 and on 7/17/19 the criminal case against Nurse C was dismissed. Past Noncompliance was presented by the facility and was accepted by State Agency Management on 10/3/19. The facility confirmed the abuse of Resident #905 by Nurse C on (MONTH) 6, 2019 after a CNA reported to the DON an interaction that occurred between Nurse C and Resident #905. 1. Resident #305 did not remember the incident. The Nurse was immediately removed from providing resident care, suspended and escorted from the facility. The State Agency and Local Law Enforcement were immediately notified. Nurse C was arrested and subsequently criminally charged. The nurse's employment was terminated at the facility and her license reported to LAR[NAME] 2. Resident Council was held on 3/8/19 to discuss the incident. All residents were interviewed regarding abuse. All residents' family members that had contact with Nurse C were made aware of the incident and asked if they had any issue with the nurse. The interviews yielded no new reports of abuse. 3. The facility retrained all facility staff and volunteers on abuse and how to separate residents and reporting instances of alleged abuse. Training records were produced and examined. 4. The facility will continue to complete Quality Rounds, random audits will be completed, and abuse will be address at resident council meetings. 5. Date of compliance for the facility was (MONTH) 15, 2019. On 9/20/19 at 11:00 AM, a review was completed of the facility policy entitled, Abuse Prohibition Policy, revised 07/2018, the policy revealed, Each resident shall be free from abuse, neglect, mistreatment .It is the responsibility of all staff to provide a safe environment for the residents .

Based on observation, interview and record review, the facility failed to ensure that one (Resident # 705) of four Residents reviewed for pressure ulcers (wounds caused by pressure) out of a total sample of 24, received implementation and documentation of all planned interventions and failed to ensure adequate monitoring and re-evaluation of interventions to promote healing of a facility acquired pressure ulcer resulting in unnecessary pain, delayed healing, and the increased risk for infection. Findings include: Record review on 8/28/17 at 12:30 PM, revealed Resident #705 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 7/22/17 revealed the Resident was cognitively intact, required extensive assistance to perform Activities of Daily Living (ADL's), and had a stage three pressure ulcer (full-thickness loss of skin, in which fat is visible in the ulcer, undermining and tunneling may occur) on their coccyx. Record review of Resident #705's care plans on 8/28/17 at 1:47 PM, revealed the following care plans: (Resident #705) has skin breakdown/pressure ulcers r/t related to weakness, decreased mobility, B&B (Bowel and Bladder) incontinence/diarrhea, brief use, medication side effects . Resistant to repositioning/offload sacral area. BLE (Bilateral Lower Extremity) [MEDICAL CONDITION]. Open wound on sacrum . (Date Initiated: 6/21/16, Revised: 8/17/17). The following interventions were included in the care plan: -Encourage and assist (the Resident) to turn and reposition frequently. Explain the importance of turning and repositioning. Document refusals. (Initiated: 2/15/17, Revised: 6/13/17) -RoHo mattress to bed (Initiated: 8/3/16) -RoHo cushion to wheelchair (Initiated: 8/16/16, Revised: 2/8/17) -Turn/reposition Resident frequently throughout shift as tolerated by patient. (Initiated: 6/21/16, Revised: 6/23/16) -Wound care physician to eval and tx (treat) (Initiated: 8/9/16) -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -Administer treatments as ordered and observe effectiveness. Notify physicians of any changes (Initiated: 6/21/16, Revised: 9/30/16) -Assess/record/monitor wound healing. Measure length, width and depth when possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD as needed. (Initiated: 1/5/17, Revised: 1/6/17) -Observe and report to MD PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage. (Initiated: 9/30/16) -If Resident refuses treatment, confer with Resident IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods (Initiated: 1/5/17, Revised: 1/6/17) (Resident #705) is incontinent . When offered B&B Program (Resident) states, It won't do me any good, I don't feel when I have to go. (Date Initiated: 7/16/16, Revised 8/14/17). The following interventions were included in the care plan: -(Resident #705) is incontinent. Wash, rinse, and dry perineum,. Change clothing PRN after incontinence episodes. (Initiated: 7/16/16) -Resident uses disposable briefs. Change PRN. (Initiated: 9/27/16, Revised: 9/30/16) On 8/29/17 at 10:00 AM, Resident #705 was observed in their room lying in their bed. Nursing Assistant M was present in the room. When queried regarding Resident #705, Nursing Assistant M stated, I just got (the Resident) cleaned up. They are completely incontinent. Nursing Assistant M further stated, I am going to help (Resident #705) get up into their wheelchair. When queried regarding the last time that incontinence care had been provided to the Resident, Nursing Assistant M replied, I'm not sure. Resident #705 was then assisted into their wheelchair by Nursing Assistant M. When queried, Resident #705 indicated, I like to get into my chair every day. On 8/29/17 at 11:05 AM, a review of the facility provided Wound/Skin Documentation for Resident #705 revealed documentation on 8/3/16, 8/9/16, 8/16/16, 8/23/16, 8/30/16, and 9/7/16 that stated, (Resident #705) had a wound noted on 8/3/16 .See wound/skin healing record for further information . Wound measurements were not contained within any of the above documentation. Additional review revealed the following documentation pertaining to Resident #705's pressure ulcer: -9/13/16: at 3:08 PM: (Resident #705) had a wound noted on 8/3/16 .Right buttocks: Length = 1, Width = 0.6, Depth = 0.1, Stage II, undermining/tunneling . See wound/skin healing record for further information . -9/20/16 at 2:41 PM: (Resident #705) had a wound noted on 8/3/16 .Sacrum Length = 0.5, Width = 0.6, undermining/tunneling . See wound/skin healing record for further information . -9/27/16 at 3:50 PM: (Resident #705) had a wound noted on 9/20/16 .The wound's progress is healed . Continue treatment .See wound/skin healing record for further information . -10/4/16 at 1:00 PM: (Resident #705) had a wound noted on 8/30/16 .Sacrum Length = 1, Width = 1, undermining/tunneling . See wound/skin healing record for further information . -10/11/16 at 4:20 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 1, Width = 0.6, undermining/tunneling . See wound/skin healing record for further information . -10/18/16 at 6:18 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 1, Width = 0.6, undermining/tunneling . See wound/skin healing record for further information . Resident seen by wound care physician. There are two wounds that are 1 X 0.5 with a skin bridge. Will continue to encourage Resident to keep skin dry and alert staff when in need of incontinence care. -10/25/16 at 1:22 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 1, Width = 1, undermining/tunneling . See wound/skin healing record for further information . Sacrum has two wounds that are 1 X 1 with skin bridge . -11/1/16 at 4:07 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 1.2, Width = 1.2, Depth 0.1, undermining/tunneling . See wound/skin healing record for further information . -11/8/16 at 5:07 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 0.7, Width = 0.3, Depth = 0.2, undermining/tunneling . See wound/skin healing record for further information . -11/15/16 at 12:15 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 0.6, Width = 0.5, undermining/tunneling . See wound/skin healing record for further information . -11/22/16 at 3:07 PM: (Resident #705) had a wound noted on 9/20/16 . Coccyx Length = 1, Width = 1, undermining/tunneling . See wound/skin healing record for further information . -11/30/16 at 4:35 PM: (Resident #705) had a wound noted on 9/20/16 .Sacrum Length = 2, Width = 2.5, Depth = 0.1, undermining/tunneling . See wound/skin healing record for further information . -12/13/16 at 11:23 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.5, Width = 1, Depth = 0.3, undermining/tunneling . See wound/skin healing record for further information . -12/20/16 at 3:18 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.5, Width = 1, Depth = 0.3, undermining/tunneling . See wound/skin healing record for further information. -1/3/17 at 4:22 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 3, Width = 2, Depth = 0.3, undermining/tunneling . See wound/skin healing record for further information. -1/10/17 at 3:53 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.5, Width = 1.5, Depth = 0.4- State Unstageable, undermining/tunneling . See wound/skin healing record for further information. -1/17/17 at 3:11 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.6, undermining/tunneling . See wound/skin healing record for further information. -1/24/17 at 10:25 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2.5, Width = 2.5, Depth = 0.5- Stage Unstageable, undermining/tunneling . See wound/skin healing record for further information. -1/31/17 at 2:13 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2.5, Width = 2.5, Depth = 0.5- Stage Unstageable, undermining/tunneling . See wound/skin healing record for further information. -2/8/17 at 11:09 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2.5, Width = 2, Depth = 0.3 - Stage Unstageable, undermining/tunneling . See wound/skin healing record for further information. -2/14/17 at 2:56 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 3, Width = 3, Depth = 0.6 - Stage Unstageable, undermining/tunneling . See wound/skin healing record for further information. -2/21/17 at 11:09 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.5, Width = 1.5, Depth = 0.3 - Stage Unstageable, undermining/tunneling . See wound/skin healing record for further information. - 2/28/17 at 2:28 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.6, - Stage Unstageable, undermining/tunneling . See wound/skin healing record for further information. -3/7/17 at 11:03 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 2, Depth = 0.5 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -3/15/17 at 1:04 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.4 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -3/21/17 at 10:18 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.8, Depth = 0.3 -Stage III, undermining/tunneling . See wound/skin healing record for further information. -3/28/17 at 2:34 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.5, Width = 1.5, Depth = 0.3 -Stage III, undermining/tunneling . See wound/skin healing record for further information. -4/4/17 at 1:24 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 2, Depth = 0.4 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -4/11/17 at 11:08 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 2, Depth = 0.4, undermining/tunneling . See wound/skin healing record for further information. -4/18/17 at 12:10 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 2, Depth = 0.4 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -4/26/17 at 4:37 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.7, Width = 1.3, undermining/tunneling . See wound/skin healing record for further information. -5/2/17 at 1:47 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.4, Width = 1.3, Depth = 0.2, undermining/tunneling . See wound/skin healing record for further information. -5/9/17 at 7:24 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2.2, Width = 1, Depth = 0.2, undermining/tunneling . See wound/skin healing record for further information. -5/16/17 at 10:34 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.4, undermining/tunneling . See wound/skin healing record for further information. -5/23/17 at 2:30 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1, Depth = 0.5, undermining/tunneling . See wound/skin healing record for further information. -5/30/17 at 11:10 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.3, undermining/tunneling . See wound/skin healing record for further information. -6/6/17 at 11:43 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.5 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -6/12/17 at 2:09 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.3, Depth = 0.3, undermining/tunneling . See wound/skin healing record for further information. -6/20/17 at 12:45 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.9, Width = 1, Depth = 0.2, undermining/tunneling . See wound/skin healing record for further information. - 6/27/17 at 2:53 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.3, undermining/tunneling . See wound/skin healing record for further information. -7/5/17 at 2:53 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.5, Width = 1, Depth = 0.2 -Stage III, undermining/tunneling . See wound/skin healing record for further information. -7/11/17 at 10:34 AM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.4 -Stage III, undermining/tunneling . See wound/skin healing record for further information. -7/25/17 at 2:14 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 1.8, Width = 1.5, Depth = 0.2 -Stage III, undermining/tunneling . See wound/skin healing record for further information. -8/1/17 at 3:49 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 2, Depth = 0.3 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -8/8/17 at 4:32 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2.5, Width = 2, Depth = 0.4 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -8/15/17 at 4:32 PM: (Resident #705) had a wound noted on 12/7/16 .Sacrum Length = 2, Width = 1.5, Depth = 0.3 - Stage III, undermining/tunneling . See wound/skin healing record for further information. -8/22/17 at 3:08 PM: (Resident #705) had a wound noted on 12/7/16 . See wound/skin healing record for further information. Wound measurements were not contained within the documentation. On 8/30/17 at 8:30 AM, an interview was conducted with Resident #705. When queried regarding the pressure ulcer, Resident #705 stated, It started here. When queried regarding pain associated with the pressure ulcer, Resident #705 stated, I have quite a bit of pain with it. It comes and goes. Sometimes it's worse. When queried regarding their mattress, Resident #705 stated, They (staff) put that one (mattress) on after the sore (pressure ulcer) started. With inquiry regarding staff assisting the Resident to reposition while sitting in their wheelchair, Resident #705 stated, No. When asked if staff assist the Resident to be repositioned in bed, Resident #705 stated, Sometimes. On 8/30/17 at 9:35 AM, an interview was completed with Nurse Manager D. When queried regarding Resident #705's mattress, Nurse D stated, It's a pressure reduction mattress. On 8/30/17 at 2:10 PM, observation of Resident #705's pressure ulcer dressing change occurred with Nurse I and Nursing Assistant J. Upon removal of Resident #705's incontinence brief, a dressing was not observed on Resident #705's coccyx pressure ulcer. Nurse I stated, Oops, that happens sometimes. With further inquiry, Nurse I stated, Sometimes (Resident #705's) dressing comes off. The wound was irregularly shaped and the size of the wound was slightly larger than the approximate size of a quarter. The wound bed was red in color with white colored tissue, areas of tunneling/undermining were observed. The wound edges were unattached and white in color. The surrounding skin was red in color. On 8/30/17 at 2:30 PM, an interview was completed with Nurse Manager D. When queried regarding the onset date of Resident #705's pressure ulcer, Nurse D stated, I reviewed the documentation and on 7/25/16 there is documentation of blanchable redness. On 8/3/16, the first wound log was started so it (the pressure ulcer) was facility acquired. The onset date should be 8/3/16 not 12/7/16. (Resident #705) was readmitted on [DATE] but the pressure ulcer started here before that. With further inquiry Nurse D stated, On 8/4/17 it (pressure ulcer) was 1.1 (centimeter-cm) by 0.1 (cm). It has progressed since then. It (pressure ulcer) has even been debrided a couple of times. (Resident #705) does have pain (from the pressure ulcer). Documentation of facility wound logs were reviewed with Nurse D at this time. Review revealed Resident #705's coccyx pressure ulcer was acquired at the facility on 8/3/16. When queried regarding interventions and the Resident's care plan related to the pressure ulcer, Nurse D stated, (The Resident) has a pressure reduction mattress and a Roho (pressure reduction) cushion on their wheelchair. The dietician is involved and they are repositioned frequently. With further inquiry regarding frequent repositioning, Nurse D replied, Every couple of hours. Nurse D further stated, The problem is that (Resident #705) is incontinent and they are frequently wet. When asked about the Resident's coccyx pressure ulcer dressing not being in place, when wound care was completed, Nurse D replied, It probably came off when they (staff) cleaned (the Resident) up last. With additional inquiry regarding the Resident's incontinence and not having a dressing in place to their coccyx pressure ulcer, Nurse D stated, The CNA's (nursing assistants) are supposed to let the nurse know if the dressing comes off. No further explanation was provided. When queried regarding how often the Resident's hygiene is assessed, Nurse D replied, The staff change (the Resident) frequently. When queried regarding documentation of repositioning and hygiene/incontinence care in the Resident's medical record, Nurse D stated, They (staff) don't document every time unless a Resident refuses care. With further inquiry, Nurse D stated, No, there wouldn't be documentation. When queried regarding reevaluation of interventions for the pressure ulcer, Nurse D stated, The wound care doctor sees (the Resident) every week and changes the treatment if they feel it is appropriate. With further inquiry pertaining to reevaluation of interventions, other than the wound care treatment, to promote healing, Nurse D replied, What do you mean? When queried further regarding when the pressure reduction mattress was placed on the Residents bed, Nurse D replied, On 8/3/17. When asked if the mattress was effective and if other pressure reduction mattresses were available, Nurse D stated, I see what you mean. No we haven't done anything with those interventions. Maybe a different type of mattress and scheduled incontinence care would help. Nurse D then stated, We have relied on the treatments and have not updated any other interventions. We should have done that. Facility wound/skin healing record as indicated in documentation were requested at this time. On 8/30/17 at 3:05 PM, an interview was completed with the facility Administrator and the Director of Nursing (DON). When queried regarding Resident #705's pressure ulcer, the DON stated, We have interventions in place. When queried further regarding the length of time since the Resident developed the pressure ulcer at the facility, the effectiveness of current interventions, and the last time interventions were updated, the Administrator did not provide a response. Record review of the facility policy entitled Skin Management, (Revised 7/2016), on 8/30/17 at 4:35 PM revealed, The licensed nurse will initiate documentation in the electronic health record which includes a description of the pressure . injury as follows . document on the Wound/Skin Healing Record and The licensed nurse will document preventative measures on the care plan/kardex . Resident's with pressure injury will be assessed, measured and staged weekly in accordance with the practice guidelines until healed. Wound/skin healing records/logs for Resident #705 were requested but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to respond in a timely manner to a change in condition following a fall within the facility for one (#719) of seven Residents reviewed for assessment and monitoring following a fall, of a total sample of 24, resulting in a delay in medical treatment, unmet care needs, increased pain, and a deterioration in medical status. Findings include: Record review on 8/29/17 at 4:05 PM revealed Resident # 719 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had moderate cognitive impairment and required extensive to total assistance to perform Activities of Daily Living (ADL's). On 8/30/17 at 8:50 AM, an interview was conducted with Nurse N. When queried regarding Resident #719's fall within the facility on 3/11/17, Nurse N stated, (The Resident) fell in March and ended up going to the hospital. They broke their right hip. With additional inquiry, Nurse N stated, I wasn't working when it happened but (the Resident) got up to go to the bathroom and tripped. Nurse N further stated, (Resident #719) is A (alert) and O (orientated) times three (person, place, and time). On 8/30/17 at 8:50 AM, an interview was completed with Resident #719. Resident #719 observed sitting a recliner in their room. When queried regarding the fall that occurred within the facility, Resident #719 stated, I got up to use the bathroom and I didn't use the walker. Resident #719 further stated, When I fell , I screamed and one of the male aides came and picked me up and put me back in bed. With further inquiry, Resident #719 stated, They (facility staff) hemmed and hawed and I told them I couldn't take the pain, awful pain. They (facility staff) finally sent (to the hospital). The X-Rays at the hospital showed it (right hip) was broke. On 8/30/17 at 11:00 AM, record review of facility provided incident and accident report for Resident #719 revealed, (The Resident) found on floor near closets on back and butt. Walker near side standing up and pillow on floor. Was walking with pillow and walker to bathroom. On 8/30/17 at 11:05 AM, record review of Resident #719's medical record did not reveal any nursing note documentation pertaining to the fall that occurred on 3/11/17. On 8/30/17 at 11:15 AM, an interview was completed with the Director of Nursing (DON). When queried regarding nursing note documentation pertaining to Resident #719's fall in the medical record, the DON reviewed the medical record and stated, There are none. The DON then stated, There was an assessment completed after the fall. On 8/30/17 at 11:35 AM, an interview and record review was completed with the DON. When asked if Resident #719 was a fall risk prior to the fall that occurred on 3/11/17, the DON replied, They were able to get up independently. When queried regarding documentation of fall risk assessment, the DON stated, The fall assessment is done as part of the nursing assessment. When queried regarding the last fall risk assessment completed for Resident #719, the DON reviewed the medical record and provided documentation entitled Nursing Comprehensive Evaluation dated 1/12/17. This documentation was reviewed with the DON at the time. The provided Nursing Comprehensive Evaluation revealed the Resident was a risk for falls. When queried again, the DON stated, Oh yeah, (Resident #719) was a risk for falls. When queried regarding interventions that were in place, due to the Resident's fall risk, prior to the fall that occurred on 3/11/17, the DON stated, They were independent per PT (Physical Therapy). Record review of facility documentation entitled Nursing Home to Hospital Form was completed with the DON. Review revealed the following documentation, Resident had fall on 3/11/17 and continues to have uncontrolled pain with [MEDICATION NAME] (narcotic pain medication) PRN (as needed). Right hip x-ray negative. When queried, the DON stated, (Resident #719) had a mobile X-Ray on 3/11/17 that didn't show anything. Record review of documentation within Resident #719's medical record occurred on 8/30/17 at 12:00 PM. Review revealed the following documentation by Physician Assistant T on 3/15/17, Patient has been refusing to get out of bed, reports uncontrolled pain to therapy . Would not all assessment of RLE (Right Lower Extremity) strength. Pain to lateral right hip with PROM (Passive Range of Motion) RLE . Spoke with therapy, note patient is not WB (Weight Bearing) on that side and considering hoyer lift for patient who was previously independent. (Resident #719) is complaining of lateral right hip pain with ROM (Range of Motion) of right hip and at rest . Documentation on 3/16/17 by Physician Assistant T revealed Note previously ambulating with walker now therapy considering hoyer for transfer, patient resistant to movement of RLE, difficult with ambulation . Continued pain and difficulty with ambulation, resistant to bearing weight to RLE . recommending CT pelvis without contrast to investigate integrity of right hip prosthesis and surrounding structures . Documentation authored by Physician Assistant T on 3/20/17 revealed, The patient is seen today to review plan of care and . recommendations for post acute care management after fall with persistent right hip pain and difficulty with ambulation . Continued pain over the weekend, refusing to get out bed, participate with therapy . Plan for transfer to ER . Review of nursing documentation at this time revealed a note dated 3/17/17 which indicated, Resident CT of pelvis without contrast set up . on 3/28/17. Record review of Resident #719's care plans revealed the following care plans revealed the Resident had active care plans for falls and ADL self care deficits. The care plans were entitled: -(Resident #719) is at risk for falls r/t (related to) impaired mobility and generalized weakness. Incontinence. Talking medication that may increase risks for falls. Chronic pain. Hx (history) of falls. Right [MEDICAL CONDITION] with ORIF (Open Reduction and Internal Fixation- Surgical repair of fracture). (Date initiated: 10/22/13, Revised: 4/3/17). -(Resident #719) has an ADL Self Care Performance Deficit r/t generalized weakness. Dementia. (Resident #719) has a [DIAGNOSES REDACTED]. Depression. Chronic pain. (Resident #719) has a Hx for letting people do things for them that they can do themselves. Right hip fx (fracture). Arthritic changes noted to hands - able to perform full ROM (Range of Motion) to digits (Created: 10/22/16, Initiated: 3/24/17, Revised: 6/22/17) was also noted. The interventions for the care plan had multiple dates including dates prior to the date that the care plan was created. On 8/30/17 at 1:00 PM, an interview was completed with the facility Administrator and the DON. When queried regarding Resident #719's ADL care plan including the multiple creation, initiation, and revision dates, the Administrator stated, This is really hard to follow. The DON stated, The computer system does not make it easy. When queried regarding ADL care interventions at the time of the Resident's fall, the DON stated, They were independent. At this time, the facility Administrator indicated a discontinued intervention (Initiated: 9/24/15, Revised: 3/8/17) that indicated the Resident was independent with transfers. When queried why the Resident was not sent to the hospital for treatment of [REDACTED]. We didn't have a reason to send (Resident #719) to the hospital then. When queried regarding pain, the DON replied, There was not increased pain documented by nursing staff. On 8/30/17 at 2:00 PM, an interview was conducted with Physical Therapy Staff S. When queried regarding Resident #719, Staff S stated, (The Resident) was in extreme pain after the fall. It was completely opposite of what they had been before. (The Resident) went from being able to get up in their room independently to having to have a Hoyer (mechanical lift). When queried why the Resident was not sent to the hospital until 3/20/17 when the fall occurred on 3/11/17 when there was such a significant change in the Resident's pain level, Staff S stated, I can't answer that but what I can answer is that this really knocked (Resident #719 down) and (the Resident) had so much pain. Record review of Physical Therapy documentation for Resident #719 revealed documentation dated 3/14/17 that, indicated, Significant decline in right LE (Lower Extremity) strength d/t (due to) recent call at 3:00 AM on 3/11/17. X-Rays negative for fx (fracture). Pelvis appears anteriorly rotated, however, patient unable to tolerate muscle energy technique to correct . has severe right hip pain at increases with minimal left LE (Lower Extremity) movement. Additional Physical Therapy documentation dated 3/15/17 revealed, Patient was making consistent progress towards reaching ST (Short Term) and LT (Long Term) goals until recent fall; significant decline in all functional mobility d/t (due to) significant right hip pain . Additional Physical Therapy documentation dated 3/14/17 revealed, Significant decline in right LE (Lower Extremity) strength d/t (due to) recent call at 3:00 AM on 3/11/17. X-Rays negative for fx (fracture). Pelvis appears anteriorly rotated, however, patient unable to tolerate muscle energy technique to correct . has severe right hip pain at increases with minimal left LE (Lower Extremity) movement. On 8/30/17 at 3:00 PM, an interview was completed with Nurse D. When queried regarding why Resident #719 was not sent to the hospital earlier following the fall, decline in condition, and pain, Nurse D stated, Typically, if we can treat them (Residents) here, they stay here. When asked about the Resident's decline in abilities and pain levels, Nurse D did not provide further explanation. On 8/30/17 at 3:45 PM, an interview was completed with the facility Administrator. When queried regarding the length of time between the fall with injury and when the Resident was transferred to the hospital including Resident #719's change in condition and decreased level of functioning, the Administrator stated, There was no indication to transfer the Resident. They were not experiencing increased pain. With additional inquiry regarding Resident #719's lack of participation in therapy, lack of mobility, and Physician Assistant documentation of Resident assessment and refusals related increased levels of pain, the Administrator replied, I see what you are saying, moving makes the pain worse so (the Resident) didn't move. When queried if decreased mobility and increased pain would be a reason to send a Resident to the hospital, the Administrator replied, Yes. The Administrator further stated, We did have a CT scan scheduled for the twenty-eighth. Record review on 8/30/17 at 4:10 PM of facility policy entitled Significant Change (Revised 11/2016) revealed, Facilities have an ongoing responsibility to assess the Resident's status and intervene to assist the Resident to meet his or her highest practicable level of physical, mental and psychosocial well-being. Review of facility policy entitled Pain management(Revised 8/2016) on 8/30/17 at 4:15 PM revealed, Residents will be monitored for the presence of pain and be evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected.

Based on interview and record review the facility failed to provide appropriate care, based on assessed needs, to prevent falls with serious injury for two (#706 and 715) residents, out of seven reviewed for falls, from a total sample of 24, resulting in Resident #706 falling 8 times, because 1 person assistance was not provided with ambulation per the care plan and Resident #715 rolled out of bed onto the floor, during Activities of Daily Living (ADL) care, because care was provided by 1 Certified Nursing Assistant, instead of 2, as indicated in the care plan, causing a left femur fracture and unnecessary pain and suffering. Findings include: On 8/29/17 at 3:00 pm, a review of Resident #715's electronic medical records, revealed the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with the following Diagnoses: [REDACTED]. Based on the Minimum Data Set (MDS) assessment dated [DATE], Resident #715 is a two plus person assist for toileting, dressing, transferring and bathing. The Resident's care plan denotes the Resident requires the assistance of two staff when providing care. It specifically stated, (Resident #715) requires total assistance to use bedpan, total assist for cleansing and clothing change. 2 person assist. On 8/30/17 at 8:20 am, an interview was conducted with Resident #715 in regards to their fall with fracture at the facility on 8/12/17. The Resident explained the bed was raised to the Certified Nursing Assistant's (CNA's) waist as incontinence care was being provided. Resident #715 reported they had a blowout. The Resident stated there was only one CNA providing incontinence care, which was normal. Resident #715 added they now know that there should be three person's to assist the resident, but was not aware of this prior to the fall, as it was normally 1 person providing care. Resident #715 explained they were turned on the left side towards the night stand and the CNA was on the right side of the bed. The CNA was cleaning the resident's bottom and the resident rolled out of the bed and hit their head and chin on the nightstand. The Resident informed the facility the pain they were experiencing after the fall, was increased from their baseline level of pain. On 8/30/17 at 9:40 am, a record review was completed of the document entitled, Incident and Accident Report, dated: 8/12/17. The CNA was changing (Resident #715), resident was on their side, being cleaned up, she leaned too far and rolled off bed. She hit her head on end table, landing on her right left hip and has a laceration on left lower leg . Not assisted per care plan, needed two person assist. On 8/30/17 at 9:50 am, a review was completed of Resident #715's progress notes, it revealed the following; on 8/12/17 a progress note stated, X-ray of left knee and left hip were completed, the tech was only able to obtain one view due to the patient size, several attempts were made. Resident stated pain was still present since fall. On 8/30/17 at 10:00 am, a review was completed of the Radiology results for the X-ray completed for Resident #715 and it showed there was no fracture or dislocation found. On 8/30/17 at 10:15 am, a review was completed of Nursing Progress Notes for Resident #715, the following was noted in regards to the Resident's pain following the fall on 8/12/17: 8/13/17 at 12:10 am: Resident complains of hip pain at times. 8/14/17 at 3:07 am: Resident had complaints of knee pain. 8/15/17 at 10:49 am: Resident had complaints of pain in hips. 8/16/17 at 2:41 pm: Resident with complaints of increased pain to the left hip. Stated it hurts when rolled from side to side or elevated in bed. Ice, biofreeze, and diversion were not successful. 8/17/17 at 1:20 pm: Left hip and knee X-ray ordered due to increased complaints of increased pain. X-rays showed fracture of distal left femur and the exam was limited by underexposed technique (image is too light). Orders were provided to transfer Resident #715 to hospital. On 8/30/17 at 11:00 am, Nurse F was queried about the fall with fracture Resident #715 sustained at the facility. Nurse F stated she was being provided with report from the 1st shift nurse, when CNA L came to the doorway of Resident #715's room and reported the Resident had fallen. Nurse F explained that several of the staff responded to the Resident's room to assist. Resident #715 had fallen to the left side of the bed, their legs were out in front of them and the top part of the Resident's shoulders were leaning against the dresser. There was a laceration visible on the Resident's leg and pressure was applied. Nurse F reported many nurses assisted with placing the Hoyer pad underneath the Resident and transferring her to the bed. X-rays were completed and were negative but it was reported it was difficult for the X-ray Technician to get a clear picture due to Resident #715's size. Nurse F was queried as to the staff needed to provide incontinence care to this Resident and she responded, Two person assist. Nurse F stated Resident #715 was getting turned and kept rolling and ended up on the floor. The Nurse added the Resident would request an additional CNA if she was not comfortable with the one staff providing care. Nurse F agreed the CNA did not follow the Resident's care plan for a two person assist which resulted in Resident #715 fracturing their femur. On 8/30/17 at 11:30 am, a review of the Radiology report for Resident #715 was reviewed from 8/17/17. It revealed Resident #715 had a fracture of the distal left femur. There was an addendum added to the results that stated, The distal femoral fracture was present on the prior exam of 8/12/17, but not as well seen. On 8/30/17 at 2:10 pm, the Director of Nursing (DON) was queried about the lapse in time from the initial X-ray until the 2nd X-ray. The DON explained the first X-ray was completed by the mobile X-ray Company and the results came back as negative. It was noted the X-ray Technician had to work hard to get the film, due to the size of the patient. The DON was asked would this would effect the results of the X-ray, the DON stated, No. The DON further explained the 2nd X-ray was completed by the same company and it was determined Resident #715 did have a femur fracture. The femur fracture was present on the initial X-ray and whomever read the report did not see the fracture. The DON reported Resident #715's pain was already being managed prior to the fall and her pain level after the fall was not increased past the Resident's baseline. The DON added on 8/17/17 the Resident had complaints of increased pain and that prompted the 2nd X-ray to be ordered. The DON explained Resident #715 is able to make her needs known to staff. The DON reported due to the contradicting reports the decision was made to send the Resident to the emergency room for further evaluation. On 8/31/17 at 10:00 am, a review was completed of the progress note completed by Physician Assistant R on 8/17/17 at 5:52 am. It stated, Patient was having her ADL's (activities of daily living) done and rolled over too far on the bed and gravity took over and the patient fell to the floor. Pain in the left hip, both legs, original X-ray's were negative. Patient complaining of more pain in the left knee, states pain has become worse in the past 24 hours. On 8/31/17 at 10:30 am, the pain assessment levels were reviewed for Resident #715 for the prescribed medication of Norco, that is ordered every 4 hours for pain, on the Medication Administration Record (MAR). It revealed the following: August 12, 2017- 5:00 pm: 8 (on a 0-10 scale, with 0 being no pain and 10 being the worst pain) 9:00 pm: Pain level not assessed, but pain medication administered. August 13, 2017- 1:00 am: 6 5:00 am: 6 9:00 am: 8 1:00 pm: 10 5:00 pm: Pain level not assessed, but pain medication administered. 9:00 pm: Pain level not assessed, but pain medication administered. August 14, 2017, August 15, 2017, August 16, 2017 Pain level not assessed for the entire day but pain medications were administered. August 17, 2017- 1:00 am: Pain level not assessed, but pain medication administered. 5:00 am: Pain level not assessed, but pain medication administered. 9:00 am: Pain level not assessed, but pain medication administered. 1:00 pm: Pain level not assessed, but pain medication administered. On 8/17/17 at 11:00 am, a review was completed of the document entitled, Bed Mobility and Transfers. It states, Always check Kardex (electronic system where care needs of residents are located for CNA's) prior to providing care. Care Plan interventions are linked to the Kardex to ensure appropriate care is provided to each guest. It does not matter what the guest says is ok or what other people do .always roll guest towards you if you are alone- only roll away of there is another person present at that side of the bed . Resident #706 On 8/28/17 at 9:00 AM, during the initial tour, Resident #706 was observed shaky, walking in the hallway without assistance, in a fast motion, with a front wheeled walker (FWW). On 8/28/17 at 12:00 PM, a record review of Resident #706's face sheet, revealed an original admitted d 2/24/17 with a recent re-admission on 8/9/17. The resident's [DIAGNOSES REDACTED]. The MDS (Minimum Data Set assessment), dated, 6/13/17, revealed the resident needed assistance with all ADL's (activities of daily living) which included limited assist of one person with eating, and extensive assistance of one person with dressing and walking. On 8/28/17 at 1:00 PM, a review of Resident #706's Fall Care Plan, created on 12/6/16 and updated on 5/31/17 and 8/27/17, revealed the following (The resident) is at risk for falls r/t (related to) weakness, gait/balance deficit, tremors, impulsiveness, Parkinson's (a disease causing tremor of muscles, impaired balance and shuffled walking). Resident #706s ADL Care Plan, dated created on 12/6/17 and updated on 5/31/17 and 8/26/17, revealed, (The resident) has an ADL self-care performance deficit and requires assistance with ADL's and mobility r/t generalized weakness, unsteady gait (walking)/balance deficit. On 8/28/17 at 3:00 PM, a review of Resident #706's Incident and Accident Reports (from 2/27/17 to 6/5/17) revealed the resident had 8 falls. See the following: 2/27/17 at 10:45 PM, - Patient walked down hall with walker and side stepped two steps and threw self to floor on right side. Intervention - Reassurance, visit with staff. 3/23/17 at 5:50 AM, - Found patient to be lying on back halfway in bathroom and halfway in (the resident) room. (The resident) had no response as to why (the resident) was walking by self. Intervention - encouraged resident to leave bedroom door open to allow light from hallway to brighten (the resident) room a little. 4/5/17 at 8:52 AM, Observed guest on top of box. Stated (the resident) was -looking for (the resident's) glasses and tripped over (the resident's) socks. Intervention - explained to guest the importance of wearing the correct size socks. Call light use and waiting for assistance. IDT review - assess for proper size gripper socks, assess environment for clutter and remove items as guest allows. 4/14/17 at 9:45 AM, - Guest walking in hallway with walker, guest carrying a cup of cheerios. Guest states tripped on (the resident) gown and fell forward landing on (the resident) hands and knees. Guest then rolled onto (the resident's) back and was found by staff. - Intervention implemented was talked to guest about not carrying any items when using (the resident) walker. IDT review instructed guest not to wear long gowns during day while attempting to walk. 4/18/17 at 6:00 AM, - Observed res (resident) fall/sit into cardboard box next to dresser. Foley (catheter draining urine from bladder) intact, attached to bed. 2PA (person assist) to stand, ROM (range of motion) WNL (within normal limits) . The intervention implemented was request to remove clutter from room. IDT review - evaluate room for clutter and assist guest in packing and storing clothes to assist with clutter and safety. 5/20/17 at 10:12 PM, - Resident said (the resident) was trying to get out of bed to go to bathroom. (The resident) was discovered halfway out of the bed (head first). Call light was on. The intervention implemented was offer toileting upon waking, before, after meals and at hs (bedtime). IDT review - cont. prev. interventions. reddened skin was marked with rt (right) shoulder red. 6/4/17 at 5:40 PM, - Guest stated (the resident) was trying to use restroom, and fell while transferring. The intervention implemented was call light placed in reach, door open, bed lowered to lowest level, rounds by CNA (certified nurse assistant) every hour, by nurse every 2 hours and during med pass. IDT review - pt (patient) educated on use of call light. Auto locking W/C (wheelchair) brakes. 6/5/17 at 10:33 AM, revealed patient observed sitting at the end of bed on floor. Patient stated (the resident) slid from bed to the floor. Intervention - encouraged (the resident) to avoid sitting on edge of bed. On 8/29/17 at 6:20 AM, a record review of the progress note dated 8/25/17, by nurse D revealed, Patient continues to receive therapy services with focus on improving strength for transfers, balance, and mobility. On 8/29/17 at 11:30 AM, observed Resident #706 walking in the hallway around the nurses' station, with FWW without any staff assistance. There were 2 staff members sitting at the nurses' station who did not offer assistance to the resident. While the Resident was walking, staff member C walked up to the resident for a brief moment and then walked away. Staff member C was queried if Resident #706 can walk alone, staff member C responded, I will walk with (the resident) if they are shaky but sometimes (the resident) walks by themself. On 8/29/17 at 12:00 PM, further review of Resident #706's care plans revealed that the ADL care plan had been updated on 8/29/17, during the survey to indicate the resident required Supervision assist x 1 as needed with rolling walker in facility and room, Prior to 8/29/17 the ADL care plan and the MDS assessment both indicated the resident required one person extensive assistance with ambulation in room and in hall. On 8/29/17 at 12:30 PM, a record review of Resident #706's Physical Therapy progress report, dated 8/25/17, by Physical Therapist K, revealed Reason for skilled services: patient requires skilled PT (physical therapy) to increase LE (lower extremity) ROM and strength, minimize falls, improve dynamic balance, promote safety awareness, facilitate (I) independence with all functional mobility, increase independence with gait Upon further review of physical therapy progress notes, a PT Plan Of Treatment note signed on 8/10/17, for a certification period of 8/10/17 - 9/6/17, by Physical Therapist K, revealed Resident #706 will safely ambulate on level surfaces 86 to 119 feet using FWW with contact guard assist (to have one or two hands on the body to help steady the body or help with balance). On 8/29/17 at 3:10 PM, observed Resident #706 walking in the hallway with FWW without any staff assistance. The resident was wearing a long dress with the bottom of her dress touching the tops of her slippers. On 8/30/17 at 12:00 PM, an observation was made of Resident #706 walking in the room without a walker unassisted. The resident walked from the bathroom to the corner of the room, approximately 15 feet, almost tripping into the lounge chair that was in the corner of the room. The resident had health care gloves on both hands and stated they were in the bathroom cleaning clothes. Resident #706 stated, I fill the sink half way up with water and use 2 pumps of the soap on the wall. I scrub them, rinse them, and then hang them on the hangers. There were 3 blouses hanging in the shower. At 12:15 PM Nurse O walked into the room and gave no indication that the resident required assistance. On 8/30/17 at 2:30 PM, a review of the physician progress notes [REDACTED]. Upon further review, a Physician note, dated 8/28/17, written by Physician B, revealed patient is at risk for falls due to weakness, Parkinson disease, cancer .history of recent hospitalization . On 8/30/17 at 3:00 PM, the Director of Nursing (DON) was queried on Resident #706 walking in the hallway without staff assistance and her response was (The resident) fluctuates but right now is independent with walking. On 8/30/17 at 4:30 PM, the Administrator was queried on why Resident #706, who had 8 falls from 2/17 through 6/17, had multiple discrepencies documented in the medical record concerning the resident's need for one person assistance with ambulation and that the resident was observed walkig on multiple occasions unassisted, and no explanation was received. On 8/30/17 at 4:40 PM, a record review of the Fall Management policy, dated 8/2016, revealed The facility will identify hazards and resident risk factors and implement interventions to minimize falls .the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls.

This citation pertains to MI 735. Based on observation, interview, and record review, the facility failed to provide the assistance one resident needed to get off of the toilet (Resident #104) out of five residents reviewed for abuse and neglect in a sample of five residents resulting in a fall that caused a laceration and bruising requiring a visit to an emergency room when Resident #104 attempted to transfer herself unassisted by facility staff. Findings include: On 10/16/2015 at 9:45 am, Resident #104 was observed sitting in her wheel chair beside her bed in her room. Resident #104 had a cast on her right arm and green-yellow-purplish bruising under her right eye and covering a large portion of the right side of her face. There were steri-strip bandaides over and on Resident #104's right eyebrow. Resident #104 was asked, What happened to you? Resident #104 replied, They left me on the toilet too long and I fell . If you sit there too long it hurts. I got hemorrhoids since I came here. I never had them before. They didn't come back. Resident #104 was asked if she had used her call light to summon assistance and said Yes I put the light on. They left me on too long, it hurt. According to the Admission Record, dated 10/16/2015, Resident #104 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Care Plan, dated 9/9/2015, Resident #104 was alert, verbal and able to make her own decisions and needs known and although she had some decline in cognition and some difficulty with short term recall, the physician had deemed her competent to make her own medical decisions. A facility Incident and Accident Report, dated 9/22/2015, revealed that Resident #104 had been found laying on her right side with her glasses dug into her right eyebrow and the right side of her face on the ground under the sink on the floor of her bathroom at 9:15 pm on 9/22/2015. The description of the accident included the statement that Resident #104 was on the toilet for too long, got impatient, got off the toilet on her own and fell . The intervention implemented listed on the accident report was Resident has fallen before when getting impatient and I explained to her that she needs to wait for help when ambulating for her safety (sic). The section of the accident report where the nursing assistant was to be interviewed and her description of the accident was recorded stated that she helped her to the bathroom and had 3 other residents that were tolieting (sic) at the same time she said that she was waiting for her to come back, patient got impatient and tried transferring self off toliet(sic). The accident report identified the root cause of this fall to be the amount of assistance in effect and toileting status. According to the accident report, Resident #104 was sent to the hospital for evaluation. A typewritten page with a summary of an interview with the Certified Nursing assistant dated 9/23/2015 indicated that the nursing assistant acknowledged that Resident #104's call light was activated and on when she returned to Resident #104 at the time of the accident. The hospital Patient Education Summary for Resident #104 had a discharge date of [DATE] at 3:37 am and indicated discharge instruction sheets for facial or scalp contusion and an adult head injury had been provided. A progress note recorded by a Physician's Assistant on 9/23/2015 indicated that Resident #104 had been seen because of a fall last night and sustained a right upper eyebrow laceration, and knee pain. The progress note revealed that Resident #104 had gone to the emergency room and had a CT scan of the brain at the hospital. Upon examination the Physician's Assistant recorded on 9/23/2015 that Resident #104 had a right upper eyebrow with a large ecymotic (bruised) area, a laceration with a scab and steristrips on, some tenderness in her ribs, and right knee pain with arthritic changes. The care plan for Resident #104 for activities of daily living, dated 9/6/2015 indicted that she needed the assistance of one staff person to stand and transfer. The care plan for Resident #104 that addressed a risk of falls, dated 9/6/2015, indicated that Resident #104 attempted to transfer unassisted. During an interview with Staff C, the Physical Therapy Assistant (PTA) who had been providing therapy to Resident #104, on 10/16/2015 beginning at 11:35 am, she stated that Resident #104 was extremely cooperative with her therapy treatments. PTA Staff C stated that at times Resident #104 forgot things and repeated herself and needed minimal verbal cuing for safety awareness for using a cane and her foot placement when she walked. PTA Staff C stated that Resident #104, to her knowledge, was not impulsive or unpredictable for transferring herself. During an interview with the Director of Nursing (DON), Staff B on 10/16/2015 that began at 2:45 pm, she was asked how long Resident #104's call light had been on in her bathroom on the evening of 9/22/2015 when Resident #104 had attempted a self transfer and had fallen injuring herself. The DON Staff B replied that according to the computerized record, Resident #104's bathroom call light had been on for longer than 10 minutes. The DON Staff B stated that it was her rule that call lights were to be answered in 10 minutes but the facility had no policy related to the length of time in which call lights were to be answered. The DON was asked specifically how long the bathroom call light had been on, and she answered 25 minutes. The DON stated that Resident #104's plan of care now indicated that Resident #104 was to be given privacy in the bathroom but was not to be left alone. The DON also stated that the facility management was now monitoring call light times. The DON was asked for the print out of the computerized record of the call length time for Resident #104 for 9/22/2015 and the DON stated that she did not have a copy of the call light records and was unable to provide a printout from the computer. ( )