Every finding on record at Riverside Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure labeling and dating of perishable food products stored in the kitchen walk-in cooler, in the refrigerator in the Nutrition Room and failed to ensure a resident refrigerator was maintained in accordance with facility policy. Findings include:On 4/20/2026 at 7:49 AM a review of the facility walk-in cooler was conducted. Within the cooler an opened and undated container of peach yogurt was found. Also, in a large stainless-steel bowl covered with clear plastic film was prepared potato salad that was undated when prepared and did not display a discard date. A zip-lock bag of hard-boiled eggs that was unlabeled and undated. An opened 2-gallon container of shredded cheese with a preparation date of 4/16 but no use by date.On 4/20/26 at 8:03 AM a review was conducted of the locked Nutrition Room. Review of the refrigerator in this room revealed a cottage cheese container with the first name of a resident but no dating documentation on the container. An opened container of Vanilla med plus 2.0 dated 4/14/26 but no use by date was identified. Also, a bag with a resident's first name with a door dash receipt attached dated 4/18/26.On 4/20/2026 at 2:37 PM an interview was conducted with Dietary Manager (DM) F. DM F reported food products are to be labeled with the date received (delivered) and then when the product is opened, and a use-by date. DM F reported at the very least the product is date marked when it was opened and a use-by date.On 4/22/2026 at 8:39 AM a review of the walk-in-cooler revealed an opened container of cottage cheese with a received date of 4/21/2026 but was not dated when it had been opened or a use-by:-date.The policy provided by the facility titled Date Marking for Food Safety implemented 11/1/2022 was reviewed. The policy reflected Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. And Policy Explanation and Compliance Guidelines for Staffing.2 The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing the food shall be responsible for date marking the food at the time the food is opened or prepared.On 4/20/2026 at 2:50 PM an additional review was conducted of the Nutrition Room with DM F who noted a tamale wrapped in tin foil that was undated. DM F reported if the tamale was not gone by the end of the day it will be tossed.The policy provided by the facility titled Use and Storage of Food Brought in by Family or Visitors implemented 11/1/2011 was reviewed. The policy reflected foods must be labeled and dated and consumed by the resident within 3 days.On 4/20/2026 at 3:01 PM a review of the personal refrigerator was conducted in the room of Resident (R) 24 with the Resident and DM F present. The review revealed the refrigerator contained undated and uncovered pizza slices on a paper plate. The refrigerator was noted to have a freezer compartment with frost build-up that extended beyond the borders of the freezer door into the refrigerator. R24 reported the facility had maintained the defrosting of the freezer. The Resident reported that he is the one who monitored the refrigerator temperature and that there were two thermometers in the refrigerator. R24 provided a temperature log in a plastic sleeve that was dated Jan and was blank.The policy titled Resident Refrigerators implemented 11/1/2022 and provided by the facility was reviewed. The policy reflected 2. Maintenance staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. And 4.b. Leftovers shall be dated upon receipt and discarded in three days .e. Food shall be in covered containers or securely wrapped.On 4/22/2026 at 1:03 PM the Maintenance Director I reported he did not monitor the temperature of the refrigerator in the room of R24.

Based on observation, interview and record review the facility failed to provide medication according to professional standards of practice for 1 resident (R31) of 7 residents reviewed. Findings include: Review of an admission Record revealed R31 admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes with chronic kidney disease. Review of R31's Physician Orders on 4/21/2026 revealed active orders for Insulin Fiasp 35 units subcutaneously three times a day for diabetes and Insulin Lantus 70 units subcutaneous two times a day for diabetes. During a medication administration observation on 4/21/2026 at 8:33 AM, LPN Q was observed preparing to administer Insulin Fiasp and Insulin Lantus to R31. LPN Q attached a new pen needle to the insulin pen for Insulin Fiasp and Insulin Lantus, dialed the ordered insulin amount and administered the insulins to R31. LPN Q did not dial a priming dose or expel insulin into the either of the needles to ensure patency of the needle. In an interview on 4/21/2026 at 8:35 AM, LPN Q reported she only primed the new insulin pen when they were opened and had not primed any new needle that was applied when the insulin pen was used. LPN Q reported she had not been taught that procedure. In an interview on 4/21/2026 at 10:00 AM, the Nursing Home Administrator/Director of Nursing (NHA/DON) reported that the standard of practice is to prime an insulin pen needle prior to dialing the ordered amount of insulin during administration. Review of a Manufactures Guidelines for Insulin Lantus revealed to always perform the safety test before each injection and indicated after a new needle is applied to select a dose of 2 units by turning the dosage selector and tap the reservoir so that any air bubbles rise up toward the needle and then to check if insulin comes out of the needle tip. Guidelines indicated that the safety check may have to be performed several times before insulin is seen in the needle. Review of facility policy/procedure Insulin Pen, implemented on 11/1/2022 revealed .Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir.

Based on observation, interview, and record review, the facility failed to ensure beverages were served to residents at a palatable temperature. Findings include:On 4/22/2026at 8:15 AM an observation was conducted in the kitchen during breakfast service. Next to the steam table several carts were observed with trays that held cups and glasses of milk and juices awaiting the addition of plated food to be dispensed to residents. A glass of milk was selected at random from a cart and the temperature was obtained using a thermometer provided by Dietary Staff (DS) E. The thermometer displayed the temperature of the milk was 62.8 degrees Fahrenheit (F). DS E reported that the milk should be served at 35 degrees F. DS E reported the beverages had been prepared about a half hour prior to breakfast and remained on the trays by the steam table since. It was observed that the beverages that had been prepared earlier continued to be dispensed to the residents being served breakfast although it was identified that these beverages exceeded a palatable serving temperature.Review of the Kitchen food temperature log, identified by DS E, reflected a documented temperature of the milk as 35 degrees F for the breakfast service on 4/22/26.On 4/22/2026 at 8:28 AM an interview was conducted with Dietary Manager (DM) F. DM F was informed of the temperature of the milk at breakfast service. DM F reported it is a difficult time of the year when the kitchen is warm but indicated she may consider ways to keep beverages at a more desirable temperature.

Based on observation, interview, and record review, the facility failed to 1) ensure hand hygiene prior to resident care, 2) ensure proper Personal Protective Equipment (PPE) usage for Enhanced Barrier Precautions (EBP), 3) prevent contamination of supplies during dressing change and resident care for 2 residents (R7 and R5) of 12 residents reviewed for Infection Control.Findings Include:R5Review of the Medical Record reflected R5 admitted to the facility with diagnoses that included Dementia and Seizure Disorder. The Minimum Data Set (MDS- a tool used to assess a resident's care needs) dated 2/2/2026 was reviewed. Section H of this MDS that pertained to Bowel and Bladder revealed R5 was always incontinent of urine. Section GG – Functional Abilities, reflected R5 was dependent for toileting hygiene. On 4/20/2026 at 9:30 AM an observation was conducted of personal (incontinence) care provided to R5 in her room. After R5 was transferred to her bed using a Hoyer lift Certified Nurse Aide (CNA) J was observed walking to the bathroom with two cloths to wet at the sink to clean R5 during personal care. CNA J was observed to drop one cloth onto the floor, pick it up, then proceed to the sink to wet this cloth and another cloth and used both wetted cloths to clean the personal area of R5. R7 Review of an admission Record revealed R7 admitted originally to the facility on [DATE] with pertinent diagnoses which included Alzheimer's Disease, arthritis, and legal blindness. Review of a Physician Order dated 1/25/2026, revealed an active order for Enhanced Barrier Precautions (infection control precautions include wearing a gown and gloves for close contact care) related to wounds. During an observation on 4/20/2026 at 9:06 AM in R7's room, Hospice Registered Nurse (HRN) U and Hospice Certified Nursing Assistant (HCNA) V were transferring R7 from his chair to his bed. HRN U and HCNA V did not apply gloves to their hands before, during, or after the transfer. HCNA V applied gloves and proceeded to complete a bed bath for R7. HCNA V did not change gloves or apply a gown throughout the bed bath. HRN U applied gloves and assessed R7's skin and assisted with bed bath. HCNA V and HRN U did not wear a gown during the transfer or bed bath for R7. During an observation on 4/21/2026 at 10:42 AM, Licensed Practical Nurse (LPN) Q had prepped for a treatment for R7's coccyx. LPN Q acquired treatment supplies from the treatment cart and proceeded to place the supplies onto the overbed table that had not been sanitized prior. LPN Q placed the supplies that were on the overbed stand onto a clean barrier. LPN Q required supplies from R7's dresser drawer and reached into the drawer with gloved hands to obtain the needed supply touching the handle of the dresser drawer when she opened and closed it. LPN Q did not change her gloves and continued with treatment. Review of facility policy/procedure Enhanced Barrier Precautions, revised 2/26/2025 revealed .Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.High-contact resident care activities include.dressing, bathing, transferring, providing hygiene.wound care. Dining observation: During an observation on 4/20/2026 at 8:29 AM in the dining hall, Certified Nursing Assistant (CNA) D finished setting up one resident's breakfast tray and without performing hand hygiene moved another resident (R7) chair closer to the dining table and began to feed him breakfast. During an interview on 4/20/2026 at 11:02 AM, CNA D reported she forgot to perform hand hygiene prior to feeding R7. Review of facility policy/procedure Hand Hygiene, implemented 11/1/2022 revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Further review revealed hand hygiene should be performed between resident contacts and prior to providing care.

Based on interview and record review the facility failed to meet requirements for the medical director's quarterly attendance of the quality assessment and assurance committee meetings. Findings include:During an interview and record review on 4/22/2026 at 1:30 PM, the Nursing Home Administrator/Director of Nursing (NHA/DON) revealed that the medical director had not attended the required quality assurance committee meetings quarterly. NHA/DON revealed signature pages for the QAA meetings, and the last attendance recorded for the medical director was in June of 2025. Review of facility policy/procedure Quality Assurance and Performance Improvement (QAPI), revised 3/5/2025 revealed .The Quality Assessment and Assurance (QAA) Committee shall be interdisciplinary and shall consist at a minimum of.the medical director or his/her designee.Meet at least quarterly and as needed.

Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 2 (R5 and R32) of the 7 residents observed during the medication administration task. This resulted in a facility medication error rate of 12.2% (5 errors out of 41 opportunities). Findings include:R5 Review of a admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, anxiety disorder, schizoaffective disorder, and cognitive communication deficit. Review of a Medication Administration Record (MAR) revealed medications administered to R5 on 4/21/2026 included constulose (used to treat constipation) 20 milliliters (ml), carbamazepine (used to treat schizoaffective disorder) 7.5 ml, risperidone (used to treat schizoaffective disorder) 1 milligram (mg), and valproic acid (used to treat schizoaffective disorder) 5 ml. In an observation and interview on 4/21/2026 at 7:30 AM, Licensed Practical Nurse (LPN) Q reported that she had preset R5's medications so she could add them to the resident's chocolate milk (240 milliliters (ml) cup). The medications were observed to be orange in color and in a clear cup in the top drawer of the medication cart with R5's name on the cup. LPN Q reported she did this routinely. During a medication administration observation on 4/21/2026 at 7:43 AM, LPN Q entered R5's room and placed the chocolate milk which contained the medications with a straw into R5's hand. R5 began drinking the liquid and LPN Q proceeded to leave the room and continued her medication pass. In an observation and interview on 4/21/2026 at 9:20 AM, Activities Director (AD) T verified in the dining room that R5's breakfast tray contained approximately 1 inch remaining of the 3 inches of the medicated chocolate milk that was handed to R5. R5's breakfast tray contained the cup with medicated chocolate milk and had been placed on the meal cart for disposal. R5 was not in the dining room. R32 Review of a admission Record revealed R32 admitted to the facility on [DATE] with pertinent diagnoses which included hypertension, type II diabetes, and depression. During a medication administration observation on 4/21/2026 at 8:17 AM, LPN Q removed aspirin 81 mg tablet, atorvastatin 80 mg tablet, furosemide 20 mg tablet, two gabapentin 100 mg capsules, glipizide 10 mg tablet, hydrochlorothiazide 12.5 mg tablet, Januvia 100 mg tablet, Jardiance 10 mg tablet, lisinopril 20 mg tablet, ibuprofen 600 mg tablet and two senna 8.6-50 mg tablets and two acetaminophen 500 mg tablets and placed medications in a clear medication cup. LPN Q did not remove a 10 mg tablet of amlodipine besylate (used to treat high blood pressure). Review of a Order Summary dated 4/21/2026 at 10:00 AM during reconciliation revealed an active order for amlodipine besylate 10 mg was not administered during the 8:17 AM medication administration to R32. Further review of the MAR revealed amlodipine besylate was signed as administered by LPN Q. In an interview on 4/21/2026 at 11:19 AM, LPN Q reported that the amlodipine besylate 10 mg was signed out in the MAR. When asked how it was missed, LPN Q stated I don't know how I missed that one. Review of facility policy/procedure Medication Administration, revised on 6/12/2024 revealed .Nurse should ensure that the six rights of medication administration are followed.right resident, right drug, right dosage, right route, right time, and right documentation.Nurse should review MAR to identify medication to be administered.Observe resident consumption of medication .To correct any discrepancies and report to the nurse manager.

Based on observation, interview, and record review, the facility failed to consistently supervise residents requiring supervision with smoking potentially affecting all residents who currently smoke.Findings include:Review of an admission Record revealed R1 admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia and anxiety.Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R1, with a reference date of 3/19/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R1 was cognitively intact. Review of a current tobacco use Care Plan intervention for R1, initiated 3/17/2026, directed staff that resident required supervision with all smoking.Review of R1's Smoking and Safety Assessment, dated 3/10/2026, revealed .Resident is a supervised smoker, Resident is safe without the use of an apron.In an observation and interview on 4/21/2026 at 1:03 PM in the courtyard, four residents were smoking in the designated smoking area under the supervision of Housekeeping staff C. Housekeeping staff C reported currently all residents in the facility who smoke require the supervision of staff while smoking. When R1 was finished smoking, she asked Housekeeping staff C to take her to her room. Housekeeping staff C told R1 that he could not leave the other residents unsupervised while they were smoking. R1 stated You don't any other time. Housekeeping staff C then admitted that he often leaves residents requiring supervision with smoking alone for a few minutes at a time while he escorts R1 to her room. In an interview on 4/21/2026 at 1:47 PM, the Nursing Home Administrator/DON (NHA/DON) reported that all facility residents who currently smoke require supervision of staff while smoking. The NHA/DON reported these residents should not be left alone while smoking.Review of facility policy/procedure Resident Smoking, Vaping & Smokeless Tobacco, revised 4/1/2026, revealed .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Supervision will be provided as indicated on each resident's care plan.

This citation pertains to intake #2704144.Based on interview and record review the facility failed to ensure one resident's (R1) grievance was addressed of two residents reviewed for concern/grievance resolution.Findings include:Review of an admission Record revealed R1 admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia and anxiety.Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R1, with a reference date of 3/19/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R1 was cognitively intact. During an interview on 4/21/2026 at 10:45 AM, R1 reported staff cleaned and organized her room without her permission while she was out of the facility and when she returned, she was missing personal items including blankets, a doll, a stuffed rabbit, and several pieces of clothing. R1 reported she had discussed her concern with multiple staff members, and nothing was done to resolve her complaint. R1 reported she did not feel the Nursing Home Administrator/Director of Nursing (NHA/DON) cared about her concern.During an interview on 4/21/2026 at 11:00 AM, the Nursing Home Administrator/Director of Nursing (NHA/DON) acknowledged she was aware of R1's concern regarding missing items. The NHA/DON reported staff cleaned and organized R1's room when she was out of the facility and R1 complained that items were missing when she returned to the facility. The NHA/DON reported she had discussions with the ombudsman and guardian about R1's missing items, but she did not fill out a resident concern form or document R1's concerns in the Electronic Medical Record (EMR). The NHA/DON could not verify that she had followed up with R1 regarding her missing items and stated that in hindsight should have documented these concerns on a grievance form and documented a progress note in the EMR.Review of facility policy/procedure Resident and Family Grievances, revised 2/24/2024, revealed .Grievances may be voiced in the following forums. Verbal complaint to a staff member or Grievance Official. Procedure. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation.

Based on observation, interview, and record review, the facility failed to provide accommodation of needs and ensure call lights were left in reach of dependent residents for two residents (R4 and R19) of two residents reviewed for call light accessibility.Findings include:R4Review of an admission Record revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included depression and dementia.Review of a current impaired vision Care Plan intervention for R4, with a revision date of 3/17/2026, directed staff to be sure the resident's call light was in reach at all times.In an observation on 4/20/2026 at 9:12 AM in R4's room, R4 was resting in bed, and his call light was coiled up on the floor at the foot of his bed and out of reach. R4 reported he did not know where his call light was located.In an observation on 4/20/2026 at 2:36 PM in R4's room, R4 was resting in bed, and his call light was coiled up on the floor at the foot of his bed and out of reach. In an observation on 4/22/2026 at 8:37 AM in R4's room, R4 was resting in bed, and his call light was curled up under his feet and blanket and at the foot of his bed, out of reach. R19Review of an admission Record revealed R19 admitted to the facility on [DATE] with pertinent diagnoses which included anxiety and dementia.Review of a current fall Care Plan intervention for R19, initiated 3/20/2026, directed staff to ensure resident's call light was in reach and encourage him to use it to request assistance as needed.In an observation and interview on 4/20/2026 in R19's room, R19 was up in his geriatric chair in the center of his room yelling Nurse, Nurse! every 30 seconds. His call light was located approximately 10 feet away on his bed and out of reach. R19 was unable to move himself in his chair to locate the call light. After a few minutes, Certified Nursing Assistant (CNA) N responded to his yelling, moved his chair closer to the television at his request, and then left the room with the call light still on his bed and out of reach. R19 reported staff frequently left his call light out of his reach.Review of facility policy/procedure Call Lights: Accessibility and Timely Response, implemented 11/1/2022, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to properly assess 2 residents (R5 and R38) out of 2 residents reviewed for self-administration of medications. Findings include:R5 Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, anxiety disorder and cognitive communication deficit. In an observation and interview on 4/21/2026 at 7:30 AM, Licensed Practical Nurse (LPN) Q reported that she had preset R5's medications so she could add them to the resident's chocolate milk (240 milliliter (ml) cup). The medications were observed to be a liquid orange in color and in a clear cup in the top drawer of the medication cart with R5's name on the cup. LPN Q reported she did this routinely. In an observation on 4/21/2026 at 7:43 AM, LPN Q entered R5's room and placed the chocolate milk containing the medications with a straw into R5's hand. R5 began drinking the liquid and LPN Q proceeded to leave the room and continued her medication pass. R38 Review of an admission Record revealed R38 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, depression, hypertension, and delusional disorder. In an observation and interview on 4/21/2026 at 7:30 AM, LPN Q reported that she had preset R38's medications so she could add them to the resident's coffee mug (240 ml cup). Crushed medications were observed in a clear cup with R38's name on them in the top drawer of the medication cart. LPN Q reported she did this routinely. In an observation on 4/21/2026 at 7:40 AM, LPN Q entered R38's room and placed the coffee cup containing the medications on the overbed stand. R38 was in bed with his eyes closed. LPN Q reported to R38 his coffee was ready. R38 responded that he would get to it. LPN Q proceeded to leave the room and continued with her medication pass. When asked how she would know if R38 would have disposed of the coffee down the sink drain in his room, LPN Q stated I don't. In an observation and interview on 4/22/2026 at 7:50 AM, R38 had a covered coffee mug on his overbed stand. R38 was in his bed with his eyes closed. LPN Q was located on a different hallway and reported she had put R38's medications into his coffee and placed the coffee on the overbed stand in his room. In an interview on 4/22/2026 at 11:25 AM, the Nursing Home Administrator/Director of Nursing (NHA/DON) reported that there were no medication self-administration assessments for R5 or R38 to self-administer medications. Review of a facility policy/procedure Resident Self-Administration of Medication, revised on 7/24/2024 revealed .When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider if the medications are appropriate and safe for self-administration along with the resident's cognitive status including their ability to correctly name their medications and know what conditions they are taken for and the resident's comprehension of instructions for the medications they are taking, the resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs.

Based on interview and record review, the facility failed to notify the guardian and responsible party of Care Conferences for two residents (R9 and R5) of two residents reviewed for Care Conferences. Findings includeR9Review of the Electronic Medical Record (EMR) admission Record reflected R9 originally admitted to the facility 5/20/2005 with pertinent diagnosis that included Anoxic Brain Damage (damage to the brain caused by a lack of oxygen to the brain cells) and Acute and Chronic Respiratory Failure. Review of the admission Record reflected that Responsible Party (RP) S was also the Care Conference Person for R9.The EMR document titled Multidisciplinary Care Conference dated 3/31/2026 at 10:41 AM was reviewed. The document reflected a Care Conference was conducted for R9 with the Attendance of a Registered Nurse, Dietary, Social Worker and Nursing Administration. The documentation of the Care conference did not reflect RP S had been notified of the Care Conference.On 4/20/2026 at 10:46 AM a telephone interview was conducted with RP S. RP S reported he had not been notified of care conferences in a while. RP S offered that perhaps the facility was no longer conducting care conferences.R5Review of the EMR admission Record Reflected R5 admitted to the facility 11/10/2022 with pertinent diagnoses that included Schizoaffective Disorder, Dementia, and Cognitive Communication Deficit. The admission Record reflected that Guardian (G) R was the Resident's Responsible Party.The EMR for R5 revealed a document titled Multidisciplinary Care Conference dated 2/24/2026 at 8:12 AM. Review of the document reflected documentation of a Care Conference for R5 with the Attendance of a Registered Nurse, Dietary, Social Worker, and Nursing Administration. The documentation did not reflect that G R was invited or contacted to take part in the Care Conference for R5.On 4/20/26 at 10:56 AM a telephone interview was conducted with G R. G R reported she thought maybe the regulation had changed as notifications of upcoming Care Conferences had fallen off.On 3/22/2026 at 9:23 AM an interview was conducted with Social Worker (SW) A in her office. SW A reported she was the one that had scheduled Care Conferences and notified responsible parties of upcoming Care conferences. After review of emails and other documentation SW A reported she did not have any documentation the RP S had been notified or invited to the Care Conference conducted on behalf of R9 on 3/31/2026. SW A also reported that she did not notify G R of the Care Conference conducted 2/24/2026 for R6 stating the oversight was totally me.

This citation pertains to intake #2704144.Based on interview and record review, the facility failed to ensure one resident (R1) was provided dignified care of one resident reviewed for dignity.Findings include:Review of an admission Record revealed R1 admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia and anxiety.Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R1, with a reference date of 3/19/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R1 was cognitively intact. During an interview on 4/21/2026 at 10:45 AM, R1 reported staff cleaned and organized her room without her permission while she was out of the facility and that this bothered her.During an interview on 4/21/2026 at 11:00 AM, the Nursing Home Administrator/Director of Nursing (NHA/DON) reported staff cleaned and organized R1's room when she was out of the facility because it was a mess and there were wet and dirty boxes. The NHA/DON reported she had permission from R1's guardian prior to cleaning R1's room.During a telephone interview on 4/21/2026 at 11:25 AM, R1's Guardian R reported she had not given permission for the facility to clean R1's room and the facility had not discussed this with her. Guardian R reported because of R1's delusions and paranoia it did not make sense for staff to clean her room when R1 was gone from the facility. Guardian R reported she would be happy to clean R1's room during her quarterly visits. During an interview on 4/22/2026 at 9:34 AM, the NHA/DON reported she had reviewed the Electronic Medical Record and was unable to find documentation regarding the facility's rationale for cleaning R1's room without her permission, and she could not find any documentation that this had been discussed with Guardian R prior.Review of facility policy/procedure Promoting/Maintaining Resident Dignity, implemented 11/1/2022 revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines. explain care or procedures to the resident before initiating the activity. Respect the resident's living space and personal possessions. At no time will staff search a resident's body or personal possessions without consent from the resident, or if applicable, the resident's representative.

This citation pertains to intake #1322431. Based on observation, interview, and record review the facility failed to implement care planned interventions and ordered treatments for pressure ulcer prevention for 1 resident (R102) of 3 residents reviewed for pressure ulcers. Findings include:Review of a Face Sheet revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke) and hemiplegia (muscle weakness or partial paralysis on one side of the body). Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R102, with a reference date of 8/5/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6, out of a total possible score of 15, which indicated R102 was severely cognitively impaired. Further review of the same MDS assessment revealed R102 was dependent on staff for toileting hygiene, always incontinent of bowel, and at risk for developing pressure ulcers. Review of a current skin risk Care Plan interventions for R102, initiated 2/5/2025, directed staff to keep skin clean and dry as possible, minimize skin exposure to moisture, provide incontinence care after each incontinence episode, and use moisture barrier product to perineal area as needed. Further review of activities of daily living (ADL) interventions revealed R102 was incontinent of bowel and bladder and required extensive assistance with personal hygiene. Review of R102's Physician's Orders, active 9/3/2025, revealed and order for Calmoseptine ointment (a topical medicated ointment used to prevent skin irritation from incontinence) to be applied to buttocks after each episode of incontinence. In an observation on 9/3/2025 at 9:20 AM in R102's room, R102 was assisted back to bed by mechanical lift by Licensed Practical Nurse (LPN) C and Certified Nursing Assistant (CNA) D and was provided incontinence care. R102's brief was soaked, and urine had soaked through the brief and saturated his pants. R102 also had a bowel movement. Observation of buttocks revealed no evidence of barrier cream or ointment residue, and no barrier cream or Calmoseptine ointment were applied by staff at the time. In an interview on 9/3/2025 at 9:39 AM, CNA D reported that the previous shift got R102 up and into his chair at approximately 5:00 AM. CNA D reported she had not checked or changed R102 from when he was placed into his chair by the previous shift at approximately 5:00 AM until she assisted him back into his bed at 9:20 AM because she did not have time. CNA D reported incontinent residents should be checked and changed every two hours. Review of R102's Medication Administration Record (MAR) on 9/3/2025 at 2:00 PM revealed Registered Nurse (RN) F documented that she administered Calmoseptine ointment to R102's buttocks that morning. In an interview on 9/3/2025 at 2:15 PM, RN F reported that she had not administered Calmoseptine ointment to R102 that morning as documented. RN F stated The CNAs do this. In an interview on 9/3/2025 at 2:18 PM, CNA D reported she did not normally apply Calmoseptine ointment to residents. CNA D reported Calmoseptine ointment was stored in the treatment cart and nurses usually applied this. In an observation on 9/4/2025 at 9:05 AM in R102's room, R102 was assisted back to bed by mechanical lift by CNA E and CNA G and was provided incontinence care. R102's brief was soaked, and urine had soaked through the brief and saturated his pants. R102 also had a bowel movement. Observation of buttocks revealed no evidence of barrier cream or ointment residue, and no barrier cream or Calmoseptine ointment were applied by staff at the time. In an interview on 9/4/2025 at 9:20 AM, CNA E reported the previous shift got R102 up to his chair at approximately 5:30 AM. CNA E reported residents with incontinence should be checked and changed every 2 hours. CNA E reported she should have checked R102 for incontinence before breakfast, but he was escorted to breakfast by another staff member before she was able to do this. CNA E reported she did not believe R102 had an order for any kind of barrier cream. CNA E reported CNAs use barrier cream if it is in the room, but if it is in the treatment cart the nurse will administer the cream. In an interview on 9/4/2025 at 12:52 PM, RN F reported she was not aware R102 had a bowel movement that morning. RN F reported she was sure R102 had Calmoseptine ointment placed by the previous shift when they got him up that morning because that is the process. RN F reported CNAs have been getting the Calmoseptine ointment from the treatment cart to apply, but they should not because it is medicated and should be applied by a nurse. RN F reported she was not aware the Calmoseptine order for R102 was to be applied as needed for episodes of incontinence. In an interview on 9/4/2025 at 1:15 PM, the Director of Nursing (DON) reported Calmoseptine ointment was medicated and must be stored in the treatment cart and administered by a nurse. The DON confirmed the expectation that staff check and change incontinent residents every two hours. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Usually MASD is mainly caused by moisture from incontinence, so preventing incontinence or having a good management plan when a patient is incontinent is imperative. The do's for effective management include identification and treatment, use of skin risk assessment tools, use of appropriate barrier products, and ensuring adequate hydration ([NAME] and Justice, 2019). Keep the patient's sheets clean and dry, and do not double pad the bed. Also remember that incontinence is not an expected or normal finding in most adults. Thus, do not assume that incontinence is inevitable, especially in older adults ([NAME], 2018). [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1253). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to effectively clean and maintain food service equipment affecting 38 residents. Findings Included: On 03/24/2025 at 08:32 a.m. an initial tour of food services was conduced with Dietary [NAME] I. The following items were observed: Cardboard box, containing dinex cup lids, was observed to be on the floor in the dry storage room. The base boards, on the wall that the door swung into, was observed to have black substance on it the entire length of the wall. The door jam of the dry storage room was observed to be rusted along the floor. Observation of the freezer, which staff called the vegetable freezer, revealed soiled bottom shelf that appear to be dried liquid film. Observation of 7 pots and pans contained dark colored substance on the inside of the pains. The substance appeared to be backed on food substance that could not be removed. Observation of toaster grill appeared to have backed on substances on the grates of the toaster device and what appeared to be burnt on toast crumbs. Observation of the grill, oven, and gas grills appeared to be soiled. The upper porting of the grill revealed dark black substance. The oven door handle appeared to be covered with grease. The oven racks were observed to be discolored with food substances. The bottom of the oven appeared to be covered with burnt grease and food substances. The side of the oven door appeared to have old yellow dark grease covering it. During an interview on 03/24/2025 at 09:27 a.m. Dietary Manager (DM) J was shown concerned items above. DM J explained that items are cleaned daily and demonstrated a document entitled Dietary Aide Daily Cleaning Chart with initials present for cleaning equipment task. Review of the preceding document demonstrated absent charting for 03/22/2025 and 03/23/2025. DM J explained that cleaning of the equipment should have been completed. DM J agreed that the items listed above were not clean as observed during observation. DM J explained that the soiled pots and pans could not be cleaned, and they would be discarded, and new items would be ordered.

Based on observation, interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for two residents (R7 and R39) of 38 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings include: Resident #7 (R7) Review of the medical record reflected R7 was an initial admission to the facility on [DATE] with a readmission on 03/07/25. Diagnoses of Psychosis not due to a substance or known Physiological condition, Diabetes 2, Post Traumatic Stress Disorder, Obesity, Generalized anxiety, Depression, Chronic Pain, Chronic Pulmonary Disease and muscle wasting. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R7 requires set up for meals and assistance with all care. Record review revealed of R7's Advanced Directives had a signature from the guardian and dated 09/24/24. Witnesses were Social Worker (SW) F dated for 09/30/24 and Business office Manager (BOM) M signed as a witness for 10/01/24. During an interview on 03/24/25 at 4:47 PM, SW F stated the last Advanced Directives for R7 was dated 09/24/24, stated her process was, when she received it back from the guardian, she put it in the doctor's box to sign, once he signed it, then she signs it. Writer asked SW F why the delay in signing and dating after the guardian signed? Writer asked SW F whose signature was she witnessing? SW F read through the instructions on completing this document above her signature line. SW F stated she was to witness the Guardian or residents' signature. Writer asked SW F why she signed the document after the guardian/resident signed it and after the doctor signs it. SW F stated that was how she was taught to do it when she started working here. SW F asked writer what way should she follow? Writer encouraged her to discuss this with her Administrator. Resident #39 (R39) Review of the medical record reflected R39 was an initial admission to the facility on [DATE] with a readmission on 03/07/25. Diagnoses of Cerebral Infarction, Hemiplegia, affecting the left nondominated side, General Anxiety, Adjustment Disorder, Dysphagia, Cognitive Communication deficit and Dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2025, revealed R39 had a Brief Interview of Mental Status (BIMS) of 09 (cognitively impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R39 dependent of all care. Record review revealed R39 signed his advanced directive on 01/28/25. Provider signed the advanced directives on 01/28/25, 2 witnessed signatures dated 01/29/25, not at the time the R39 signed his advanced directions/ DNR to witness his signature. During an interview on 03/24/25 at 4:47 PM, SW F stated the last Advanced Directives for R7 was dated 09/24/24, stated her process was, when she received it back from the guardian, she put it in the doctor's box to sign, once he signed it, then she signs it. Writer asked SW F why the delay in signing and dating after the guardian signed? Writer asked SW F whose signature was she witnessing? SW F read through the instructions on completing this document above her signature line. SW F stated she was to witness the Guardian or residents' signature. Writer asked SW F why she signed the document after the guardian/resident signed it and after the doctor signs it. SW F stated that was how she was taught to do it when she started working here.

Based on interview and record review the facility failed to ensure that an accurate and timely Notice of Medicare Non-Coverage (NOMNC) was provided for three Residents (#5, #8, #35) and an accurate Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided for two Residents (#8 #35) out of three residents reviewed for Beneficiary Notification. Findings Included: Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility 09/23/2019 with diagnoses that included subarachnoid hemorrhage (stroke), bipolar disorder, hypertension, anxiety, depression, peripheral venous insufficiency, lymphedema (swelling caused by lymphatic system blockage), dysphagia (difficulty swallowing), type 2 diabetes, hyperlipidemia (high fat in blood), chronic obstructive pulmonary disease (COPD), chronic pain, seizures, gout (increase in uric acid in bone joints), and gain and mobility abnormalities. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/05/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During review of the SNF (Skilled Nursing Facility) Beneficiary Notification Review (completed by the facility) revealed that the facility failed to provide R5 with an Notice of Medicare Non-Coverage (NOMNC) that notified R5 of when his services will end. Review of the same NOMNC demonstrated that it was signed by the representative on 08/09/2024. Review of R5's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) revealed that his last covered day of services was to be 08/11/2024. Resident #8 (R8) Review of the medical record revealed R8 was admitted to the facility 02/22/2025 with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease, sleep apnea, obesity, hypoxemia (low blood oxygen levels), type 2 diabetes, hypertension, anemia (low red blood cells), hyperlipidemia (high fat in blood), aortic valve stenosis, atrial fibrillation, and heart failure. The most recent Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/28/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. R8 discharged home 03/06/2025. During review of the SNF (Skilled Nursing Facility) Beneficiary Notification Review (completed by the facility) revealed that the facility failed to notify R8 with a Notice of Medicare Non-Coverage (NOMNC) that notified R8 48 hours prior to the end of skilled services on 03/05/2025. R8's NOMNC was not signed until 03/04/2025. Review of R8's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), provided to R8 on 03/04/2025, did list the reason that Medicare may not pay for her inpatient skilled services starting 03/06/2025 and did not show the estimated cost that services will cost per day/item or services. Resident #35 (R35) Review of the medical record revealed R35 was admitted to the facility 08/09/2024 with diagnoses that included type 2 diabetes, cerebral infarct (stroke), adjustment disorder with depressed mood, hypokalemia (low potassium levels), hypertension, dysphagia (difficulty swallowing), cognitive communication deficient, muscle weakness, hyperlipidemia (high fat content in blood) and breast cancer. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/15/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During review of the SNF (Skilled Nursing Facility) Beneficiary Notification Review (completed by the facility) revealed that the facility failed to provide R35 with an Notice of Medicare Non-Coverage (NOMNC) that notified R35 of when her services will end. Review of the same NOMNC demonstrated that it was signed by the resident 10/29/2024. Review of R35's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), provided to R35 on 10/29/2024, did list the reason that Medicare may not pay for her inpatient skilled services starting 11/02/2024 and did not show the estimated cost that services will cost per day/item or services. During an interview on 03/26/2025 at 10:16 a.m. Business Office Manager (BOM) M explained that she was the person that provided residents with the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) once resident no longer qualified for Medicare Skilled Services. BOM M reviewed 5's (NOMNC) and confirmed that he had not been notified of the date that services would no longer be provided. BOMM could not explain why the date had not been include on the NOMNC. BOM M reviewed R8's NOMNC and confirmed that it had not been signed within 48 hours of services not provided. BOM M also confirmed that R8's SNFABN did not include the reason that services were no longer provided or listed the estimated cost that services will cost per day/item or services. BOM M could not explain why the information was not completed on the SNFABN or why the NOMNC had not been completed prior to 48 hours before the end of services. BOM M confirmed that R35's NOMNC did not include the information that listed when her services would end. BOM M confirmed that R35's SNFABN did not include the reason that services were no longer provide or listed the estimated cost that services will cost per day/item or services. BOM M could not explained whey the information was not completed on the SNFABN or why the NOMNC did not list when the dates of services would end.

Based on interview and record review, the facility failed to ensure recommended laboratory monitoring was in place for one (R15) of five reviewed. Findings include: Review of the medical record reflected R15 admitted to the facility on [DATE], with diagnoses that included diabetes, constipation and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided weakness) following nontraumatic intracranial hemorrhage (brain bleed) affecting the left side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/24, reflected R15 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R15's medical record reflected Physician's Orders for 65 units of Basaglar insulin (used to treat diabetes) to be administered twice daily, 500 milligrams (mg) of Metformin (medication used to treat diabetes) by mouth twice daily and four units of Novolin R FlexPen 100 units per milliliter (u/mL) insulin (used to treat diabetes) to be administered three times daily. R15's medical record reflected they were to have a fasting blood sugar check daily, every Monday, Wednesday and Friday. A Note to Attending Physician/Prescriber, for a Pharmacy Medication Regimen Review dated 6/13/24, reflected to consider ordering current labs, which included A1C levels (blood test that measures the average amount of sugar in the blood over the past three months) and Lipid Panel (blood test that measures the amount of fats and cholesterol in the blood). The Physician agreed with the recommendation on 6/18/24. A laboratory report for 6/20/24 reflected R15 refused to have their A1C and Lipid Panel blood tests collected. R15's medical record reflected laboratory test results for 10/28/24, which included but was not limited to fasting lipids and fasting glucose (sugar). An A1C was not included in the laboratory results for 10/28/24. In an interview on 03/25/25 at 11:10 AM, Registered Nurse (RN) B reported A1C was generally checked every three months for diabetic residents. RN B reported R15 refused to have their A1C drawn in June 2024. RN B reviewed R15's laboratory results, dating back to February 2024, and acknowledged they did not see any A1C results.

Based on observation, interview, and record review, the facility failed to ensure a safe environment and provide adequate supervision of smoking or screening them with form named PHCM Smoking risk to determine if they can smoke independently for two of two sampled residents (Resident #5 and Resident #2) reviewed for accidents and safety. Resident #2 (R2) During an interview and observation on 03/26/25 at 4:23 PM, R2 stated he had to turn in his lighter and cigarettes to nursing staff every time he goes inside, and he can get them back whenever he wants to go back outside. R2 also stated he can go outside anytime he wants to smoke. Did not respond to writer asking him if he had a lighter and marijuana hide outside from everyone. R2 stated he is independent with smoking, so he can come and go as he pleases. Observation of burn marks on his hoodie sweatshirt. During an interview on 03/27/25 at 10:39 AM, LNA/DON A stated the document PHCM Smoking risk, was under the assessments found under observations. Record review did not reveal that a smoking risk assessment was completed on admitted d 05/31/24. 45038 Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility 09/23/2019 with diagnoses that included subarachnoid hemorrhage (stroke), bipolar disorder, hypertension, anxiety, depression, peripheral venous insufficiency, lymphedema (swelling caused by lymphatic system blockage), dysphagia (difficulty swallowing), type 2 diabetes, hyperlipidemia (high fat in blood), chronic obstructive pulmonary disease (COPD), chronic pain, seizures, gout (increase in uric acid in bone joints), and gain and mobility abnormalities. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/05/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 03/24/2025 at 10:00 a.m. R5 was observed sitting up in his wheelchair at the side of his bed. R5's left side of his bed was observed to be against the wall and the right side of his bed a half bedrail was observed. When R5 was asked why he had a bedrail on the right side of his bed, he explained that it was placed there to keep him from falling out of bed. Review of R5's medical record did not demonstrate a physician order for the use of a bedside rail. Review of R5's plan of care did not demonstrate that R5 currently used a bedside rail for assistance of mobility or as a means of restraint to prevent falls. R5's medical record did not demonstrate that R5's bedrail and bed had been measured for possible entrapment at the time the bedrail was applied or on a quarterly basis. Review of R5's medical record did not demonstrate that any alternative interventions were attempted prior to the placement of a bedrail on R5's bed. Review of R5's medical record did not demonstrate that an evaluation had been completed evaluating the independent use by R5 for lowering or raising the bedrail. In an interview on 03/24/2025 at 04:15 p.m. Director of Nursing (DON) A explained that the facility does have residents that use bedrails. DON A explained that if bedrails were used, the resident would be evaluated for independence of use, a physician order would be written, and the bed rail would be care planned for use. DON A also explained that the bed and bedrail would be measured (for possible entrapment) when initiated, quarterly, and when the resident's condition would change. DON A reviewed R5's medical record and confirmed that no physician order was present for the use of a bedrail, no plan of care was present for the use of a bedrail, no assessment for the use of the bedrail was in the medical record. During an interview on 03/25/2025 Director of Nursing (DON) B explained that the facility had not completed measurements of R5's bedrail or bed on implementation of the bedrails for possible entrapment. DON B explained that the facility had not completed quarterly measurements of R5's bedrail or bed for possible entrapment. DON B explained that she could not determine when R5's bedrails were applied to his bed.

Based on observation, interview and record review, the facility failed to prevent constipation and ensure medication orders specified dosing and route instructions for one (Resident #15) of one reviewed. Findings include: Review of the medical record reflected R15 admitted to the facility on [DATE], with diagnoses that included diabetes, constipation and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided weakness) following nontraumatic intracranial hemorrhage (brain bleed) affecting the left side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/24, reflected R15 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was always incontinent of bowel and bladder. On 03/24/25 at 9:57 AM, R15 was observed in their room, watching TV. R15 reported issues with constipation since their admission to the facility, which they felt staff was doing very little about. R15's medical record reflected Physician's Orders for one 0.52 gram Metamucil capsule (medication used to treat constipation) by mouth twice daily and two tablets of Senna Plus (medication used to treat constipation) 8.6-50 milligrams (mg) by mouth twice daily. In addition, R15's medical record included the following Physician's Orders for constipation: -Senna 8.6 mg by mouth every 12 hours as needed (PRN) -If no bowel movement within 72 hours, give Milk of Magnesia PRN (medication dose and route not specified in the order) -10 mg bisacodyl suppository, every three days, PRN, if Milk of Magnesia was not effective (medication route not specified in the order) -10 mg bisacodyl rectal suppository As Needed (specified frequency not noted in the order) -Fleets enema to be given PRN, every third day, if the bisacodyl suppository was not effective -Dulcolax rectal suppository (dose not specified in the order), PRN, if there were no bowel movement results within approximately 12 hours of Milk of Magnesia administration -Fleets enema rectally, PRN, if results of the suppository were not satisfactory within two hours Documentation of R15's bowel movements for 2/25/25 to 3/25/25 reflected R15 did not have a recorded bowel movement for the dates of 3/7/25, 3/8/25, 3/9/25, 3/10/25, 3/11/25, 3/12/25, 3/13/25 and 3/14/25. In an interview on 03/25/25 at 11:10 AM, Registered Nurse (RN) B reported the night shift nurses pulled bowel movement reports and looked for any resident that had not had a bowel movement in three days. The report was then provided to the day shift nurse. If constipation needed to be addressed, they obtained orders, if needed. RN B acknowledged that it did not appear that R15 had a bowel movement from 3/6/25 to 3/15/25. On 3/25/25, review of R15's March 2025 Medication Administration Record (MAR) did not reflect that any as needed medications had been provided to them for constipation.

Based on observation, interview and record review, the facility failed to develop a Baseline Care Plan with necessary healthcare information for one (R37) of 14 reviewed. Findings include: Review of the medical record reflected R37 admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis of both arms and legs) and neuromuscular dysfunction of the bladder. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/24, reflected R37 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had an indwelling urinary catheter. On 03/24/25 at 11:30 AM, R37 was observed seated in a wheelchair, in their room. R37 reported having a Foley catheter (indwelling urinary catheter). On 03/26/25 at 9:46 AM, R37 was observed in bed, watching TV. A urinary catheter drainage bag was observed hanging on the right side of the bed frame. R37's Baseline Care Plan, which was initiated on 12/23/24, did not reflect the presence of a Foley catheter. R37's Care Plan reflected, .I am on Enhanced Barrier Precautions relate [sic] to wounds and indwelling catheter . The start date of each Approach (intervention) was 12/23/24, however, the approaches/interventions were created on 1/13/25. In an interview on 03/26/25 at 3:43 PM, Certified Nurse Aide (CNA) O reported they used the Care Plan to identify the care needs of a resident. If a resident had a Foley catheter, it would be included in the Care Plan, according to CNA O. In an interview with Registered Nurse (RN) B and Nursing Home Administrator/Director of Nursing (NHA/DON) A on 03/26/25 at 11:58 AM, it was reported that Baseline Care Plans were initiated upon admission. NHA/DON A reported R37's Foley catheter was not on their Baseline Care Plan. It was reported that Foley catheter care was ordered upon admission, so the CNAs would have been able to chart on catheter care.

This citation pertains to intake 0 Based on observation, interview and record review, the facility failed to provide appropriate and adequate [CONDITION(S)] care for 2 residents (Resident #1 and Resident #2) reviewed for [CONDITION(S)] care, resulting in an immediate jeopardy when (1) Resident #1 was admitted to the facility on [DATE] with a [CONDITION(S)] and no physician orders were in place for [CONDITION(S)] care or suctioning, (2) staff lacked knowledge regarding aseptic technique for suctioning and [CONDITION(S)] care increasing Resident #1's and Resident #2's chance for an infection, (3) staff lacked knowledge regarding emergency procedures in the event Resident #1 or Resident #2 decannulated, and (4) emergency supplies were not readily available in the facility in the event Resident #1 decannulated. This deficient practice placed residents receiving [CONDITION(S)] care at risk for serious harm, injury and/or death. Findings include: Resident #1 (R1) Review of a facility Face Sheet and Minimum Data Set (MDS) Admission assessment dated [DATE] reflected R1 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment reflected that R1 was severely cognitively impaired and required total assistance from two people for bed mobility, transfers, dressing and toilet use. Review of a Care Plan initiated on 6/7/22 reflected R1 had Potential for complications related to [CONDITION(S)] with a goal of Resident will not exhibit signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, [CONDITION(S)], cyanosis, decreased breath sounds) through the next review date. Approaches to meet the goal of the care plan included: Monitor and report signs of [CONDITION(S)], monitor and report signs of respiratory distress, monitor respiratory status, position resident in upright/sitting position (as tolerated) for optimal breathing, provide a calm environment free of stimuli to reduce/prevent anxiety, provide oxygen per physician order, provide [CONDITION(S)] care as ordered and PRN (as needed), change [CONDITION(S)] ties as ordered and PRN. The care plan did not reflect any instruction for emergency situations. Review of R1's clinical record revealed there were no physician orders pertaining to R1's [CONDITION(S)], [CONDITION(S)] care or endotracheal suctioning. Medication Administration Records (MARs) and Treatment Administration Records (TAR) were reviewed and no evidence of [CONDITION(S)] orders of any kind were identified. Progress Notes were reviewed and did not show nurses were regularly documenting pre and post procedure respiratory assessments and [CONDITION(S)] care or suction. Review of the facility policies [CONDITION(S)] Care revised 4/27/2018, Changing the [CONDITION(S)] Tube last revised 4/27/2018 and Managing [CONDITION(S)] Emergencies last revised 4/27/2018 reflected acceptable professional standards were used to formulate the procedures. During an observation and interview on 7/19/2022 beginning at 10:48 AM, Licensed Practical Nurse (LPN) C was asked to assess R1's room and identify standard and emergency supplies that would be required to manage R1's [CONDITION(S)]. LPN C was not able to locate a spare [CONDITION(S)] and there was not a resuscitation bag in the room. LPN C said she was not sure what she would do in the event R1 had a [CONDITION(S)] emergency. During an interview and observation on 7/19/22 beginning at 12:15 PM, the Director of Nursing (DON) evaluated the supplies in R1's room and it was identified there was not a spare sterile [CONDITION(S)] in the size needed by R1. The top drawer of a dresser in the room contained an open tube of santyl, a tube of petroleum jelly, wound cleanser, a tube of [MEDICATION(S)] (wound treatment) ointment, 2 plastic containers of normal saline that had been opened and used, an open package of hydrofoam dressing, an uncovered roll of gauze, a visibly soiled and open package of 4x4 gauze dressings, a leaking bottle of [MEDICATION(S)], clear fluid was pooled in the drawer, a size 16 Fr straight catheter and an open and unsterile spare [CONDITION(S)] tube. The DON threw the contaminated supplies into the garbage and confirmed there were no spare tracheostomies in the room. The DON obtained keys to the supply room situated on the other side of the building and confirmed along with Human Resources/Supply Clerk (HR) G (the employee responsible for ordering and organizing the supply room) that there were no tracheostomies in the sizes required by R1 in the building. The DON reported she was aware of a resident (R2) extubating twice in the past. Resident #2 (R2) Review of a Face Sheet reflected R2 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 7/19/22 at 1:13 PM, LPN B said if R2 decannulated she would replace the inner cannula but was not sure what she would do if R2 extubated completely. LPN B said she was never trained on emergency [CONDITION(S)] procedures. LPN B said she had not done R2 [CONDITION(S)] care that day and proceeded to don gloves without first performing hand hygiene and did not don a gown or face shield as would be standard during a procedure with the high likelihood for droplet production, LPN B did not assess or provide suction to R2 who had sputum accumulated and draining on and around the [CONDITION(S)]. LPN B then removed and discarded the disposable inner cannula and replaced the inner cannula without changing her gloves and performing hand hygiene in between steps. LPN B removed the soiled split dressing from under the base of the [CONDITION(S)] and used a clean washcloth moistened with tap water to clean around the base of the [CONDITION(S)] and in the skin folds around R2's neck, then dried the areas with another dry towel. LPN B then began to replace the [CONDITION(S)] tie and reported she was not familiar with the process, incorrectly believing there were two separate ties. LPN B then tucked a split dressing under the base of the [CONDITION(S)]. LPN B was not observed assessing R2 after the process and did not document the procedure in the clinical record. During a follow-up interview on 7/19/22 at 1:45 PM, LPN C reported that she never went through the entire nurse orientation skills checklist when she was most recently hired in 2021 and was never educated about [CONDITION(S)] care or emergency [CONDITION(S)] care. LPN C said when she worked at the facility previously, R2 extubated and she did not know what to do, instead she called the former DON and then called emergency medical services. On 7/19/2022 at 4:36 PM, the facility Administrator and Director of Nursing were notified of the Immediate Jeopardy that was identified on, and began on, 7/19/2022. On 7/21/22 the State Agency attempted to verify the facility completed the following to remove the immediacy: 1. On 7/19/22 Back up [CONDITION(S)] Shiley 6XLT was placed in R1's room to replace the residents opened un-sanitized back up [CONDITION(S)]. 2. On 7/19/22 Policies for [CONDITION(S)]; Management of [CONDITION(S)] Emergencies NP 146 and Changing the [CONDITION(S)] tube NP 000 were verbally reviewed and understood by nurses currently working the floor by DON and LPN D. 3. Beginning on 7/19/22 [CONDITION(S)] care competency was verbally reviewed and understood by nurses currently working the floor by DON and LPN D understanding that in the event of an emergency they call 911. There are 3 RNs, 9 LPNs. No employee will be allowed to work without receiving education 4. On 7/19/22 policies for [CONDITION(S)]; Management of [CONDITION(S)] Emergencies NP 146 and changing the [CONDITION(S)] tube NP 000 were reviewed by Regional Director of Clinical Registered Nurse?Masters of Nursing Science (RN/MSN) T and deemed appropriate. 5. On 7/19/22 Emergency cart set up, to include: -a one sized smaller [CONDITION(S)] -suction kit -[CONDITION(S)] care kit -Water soluble lubricant -[CONDITION(S)] holder -Sterile gloves -Pulse Oximeter was placed in R1's room to mirror R2's room to ensure that staff felt familiar with same set up in both rooms and knew where items were located regardless of which room they were in. 6. On 7/19/22 R1 and R2 were assessed by nurse for respiratory distress and no concerns were noted. 7. On 7/19/22 R1 and R2's care plans were reviewed and updated to identify current [CONDITION(S)] size and one size smaller to utilize in the event of an emergency. 8. On 7/19/22 orders were added to the MAR for the nurse to validated that the emergency backup supplies are present and functioning. 9. Beginning on 7/19/2022 all new hire nurses will complete [CONDITION(S)] care competency as part of orientation check off. 10. Beginning on 7/19/22 attempts to find an instructor specializing in [CONDITION(S)] care to complete hands on return demonstration with nurses was initiated. 11. On 7/20/22 the facility Medical Director and the DON from a sister facility began hands on return demonstration with nurses prior to them working. 12. On 7/20/22 R1's orders for [CONDITION(S)] care were entered into the medical record to reflect appropriate plan of care. 13. On 7/21/22 the DON continued with hands on return demonstration with nurses prior to them working. Nurses signed documentation stating that they understood [CONDITION(S)] care and emergency situations as well as completed hands on return demonstration. On 7/21/22 the state agency was not able to validate the removal plan had been effective as evidenced by the following observations and interviews: On 7/21/22 beginning at 9:47 AM, LPN O reported the Director of Nursing (DON) only verbalized [CONDITION(S)] care and procedures with her. LPN O signed a form indicating she did perform a hands on return demonstration to establish competency but reported she did not demonstrate the procedures to the DON. LPN O did not demonstrate competency or familiarity with standard procedures during an observation of [CONDITION(S)] care for R2 beginning at 10:20 AM on 7/21/22. On 7/21/22 at 10:43 AM, LPN D (involved in the removal plan noted above) reported that she never performed hands on return demonstration pertaining to [CONDITION(S)] care and only verbally reviewed the policies and procedure with the DON that morning before assuming care of R1. LPN D was unable to identify the emergency back up [CONDITION(S)] for R1 upon request and did not demonstrate competency with [CONDITION(S)] procedures during the observation on 7/21/22, including failing to assess or reassess R1 before and after the attempted [CONDITION(S)] care. LPN D reported that she signed a form indicating she had received hands on education and completed a return demonstration despite not being shown or demonstrating competency related to [CONDITION(S)] care that morning. During an interview on 7/21/22 at 11:05 AM, the DON was asked how she educated LPN D and LPN O prior to their shift. The DON reported that she conducted a review of the [CONDITION(S)] care policies and had the LPN D and LPN O do hands on return demonstration for [CONDITION(S)] care. The DON provided signed copies of forms [CONDITION(S)] Care Competency signed by LPN O and the DON on 7/21/22 and LPN D and DON signed on 7/21/22. The DON's report conflicted with the observations and interviews conducted with LPN O and LPN D on 7/21/22. On 7/21/22 at 11:10 AM, the DON, Nursing Home Administrator (NHA) and Regional Director of Operations (RDO) F were informed the Immediate Jeopardy (IJ) was not removed. The facility amended the removal plan to include the following: 14. On 7/22/22 at 11:30 AM a Respiratory Therapist (RT) conducted hands on training with return demonstration to nurses on duty. On 7/25/22 the State Agency validated the removal of Immediate Jeopardy as of 7/22/22. Although the immediate jeopardy was removed on 07/22/2022, the facility remained out of compliance at a scope of isolated and severity of no harm that is not immediate jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed.

This citation pertains to intake 0 Based on observation, interview, and record review, the facility failed to ensure catheter tubing was secured to prevent pulling/trauma for 1 resident (Resident #1), resulting in urethral damage, pain/discomfort and in the potential for dislodgement of the catheter tubing. Findings include: Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, Secure catheter with catheter securement device at catheter bifurcation (see manufacturer directions). Allow enough slack to allow leg movement and avoid any traction on catheter .Securing indwelling catheters reduces risk of urethral trauma, urethral erosion, CAUTI (Catheter Associated Urinary Tract Infection), or accidental removal . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #1 (R1) Review of a facility Face Sheet and Minimum Data Set (MDS) Admission assessment dated [DATE] reflected R1 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment reflected that R1 was severely cognitively impaired and required total assistance from two people for bed mobility, transfers, dressing and toilet use. Review of a Care Plan dated 6/7/22 (date of admission to the facility) reflected R1 required an indwelling urinary catheter related to brain injury and pressure ulcers, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: Observe urinary output with daily care; notify nurse of abnormal findings; provide catheter care every shift. Review of R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions: Indwelling catheter for protection of stage 4 wounds to bil (bilateral) hips and coccyx; Record foley output every 12 hours twice a day was started on 6/12/22 (5 days after admission). No additional foley catheter orders were noted. During an observation on 7/20/22 at 4:15 PM, The Director of Nursing (DON) assisted Licensed Practical Nurse (LPN) C with wound care for R1. Upon completion of wound care and measurements, R1's foley catheter was viewed and it was noted that there was not an anchor/securement device in place to stabilize the catheter tubing (reduces risk of pulling on the catheter which can cause pain and trauma). R1 had significant urethral erosion (urethral catheter had cut through the glans penis). The DON said she would let the doctor know about the observation. During an observation on 7/21/22 at 9:00 AM, LPN D completed wound care for R1 after being incontinent of bowel necessitating replacement of a dressing to the coccyx. Certified Nurse Aide (CNA) N assisted with incontinence care and also provided catheter care. R1's catheter was not anchored/secured and the glans penis was again observed to be split and the catheter tubing was pulling on the distal aspect of the erosion and onto the shaft of the penis. A significant accumulation of smegma was noted at the base of the glans penis and under part of the foreskin. The tubing of the catheter visible at the base of the urethra was noted to have blood/mucous on the catheter tubing. LPN D said she would let the physician know about the observation. Review of R1's progress notes from 6/7/22-7/21/22 did not reflect any mention of R1's glans penis injury or documented assessment of the finding, including notification to the physician. Review of R1's pre-admission to the facility hospital documentation reflected hat R1 had a chronic indwelling foley catheter due to his wounds. No evidence R1 had sustained injury to his glans penis was noted.

This citation pertains to intake 0 Based on observation, interview and record review, the facility failed to implement adequate pressure ulcer prevention and treatment protocols according to professional standards for 2 residents (Resident #1 and Resident #3), resulting in the worsening of a facility acquired pressure ulcer for Resident #3 and the potential for unrecognized deterioration and serious complications from unmonitored, untreated and worsening pressure ulcers for Resident #1. Findings include: Review of the Fundamentals of Nursing revealed, Continually assess a patient's skin for breakdown and color changes such as pallor or redness. Consistently use a standardized assessment tool such as the Braden Scale. The screening tool identifies patients with a high risk for impaired skin integrity or early changes in the condition of patients' skin. Early identification allows for early intervention. Observe the skin often during routine care (e.g., when the patient is turned, during hygiene measures, and when providing for elimination needs). Frequent skin assessment, which can be as often as every hour and is based on patients' mobility, hydration, and physiological status, is essential to promptly identify changes in their skin and underlying tissues. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 833). Elsevier Health Sciences. Kindle Edition Review of a policy Pressure Ulcer Treatment Level III revised on 3/17/22 reflected the purpose of the procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. In addition to outlining Pressure Ulcer Interventions/Care Strategies the policy specified required equipment and supplies and detailed steps for completing wound care including the appropriate use of Personal Protective Equipment (PPE), hand hygiene and glove use, documentation of the procedure to include all assessment data (i.e., color, size, pain, drainage, etc.) and any change in the resident status along with the requirement to report pertinent findings. During an interview on 7/19/2022 at 11:30 AM, the Director of Nursing (DON) reported that she and the Infection Control Nurse, Licensed Practical Nurse (LPN) D take weekly wound measurements, usually on Mondays. The DON said they do not have a wound care nurse but do consult with a wound care physician as ordered. Resident #1 (R1) Review of a facility Face Sheet and Minimum Data Set (MDS) Admission assessment dated [DATE] reflected R1 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment reflected that R1 was severely cognitively impaired and required total assistance from two people for bed mobility, transfers, dressing and toilet use. Review of extensive hospital referral information sent to the facility on [DATE] prior to his admission on 6/7/22 reflected an order to have R1 follow up with a wound clinic within 2 weeks of discharge from the hospital. Review of hospital Wound Team Notes dated 5/26/22 (the most recent measurements prior to R1's admission to the facility on [DATE]) reflected the following: -Left Hip/Trochanter: healing stage 4 pressure injury. Serous drainage now measures 5 x 6 x 1.5 cm's, undermining 1.5 cm 5 to 11 o'clock. -Right Hip/Trochanter: healing stage 4 pressure injury. Serous drainage. Now measures 2 x 5 x 1 cm. wound base is red granulation tissue healing edges in -Sacrum/Coccyx: Healing stage 4 pressure injury that measures 7.5x5x0.5 cm. Red granulation tissue. -Right heel: Unstageable Pressure Injury that measures 2.5 x 2.5 x 0.2 cm's. Tissues yellow/tan slough. -Right medial great toe 1.75 x 1.0 cm purple/dark red nonblanchable suspected deep tissue injury. Left heel remains red and pink clean and healed. Review of the Admission Nursing Comprehensive Evaluation dated 6/7/22 and completed by the DON included the following assessment of R1's wounds: Resident had wounds x 4 evaluated, L (left) heel 1x1 cm diameter open area with no depth treated with hydrogel and allevyn R (right) heel skin prepped. L hip 6cmX5cm with 5cm tunneling bottom left corner. Coccyx 8cm x 4.5 cm with 2.4 depth packed with calcium alginate covered with bordered gauze. R hip 5.6 cm X 4.2 cm with 1.8 cm tunneling to right side. The DON's assessment was significantly different from the hospital records as evidenced by the findings at the left and right heels (left heel now open, right heel without a wound at all). The left hip reflected worsening of the wound as compared to the hospital record in depth; the coccyx wound had deteriorated as did the right hip. Review of a Care Plan initiated 6/7/2022 reflected Resident (R1) has multiple pressure ulcers due to underlying medical conditions, wounds may not heal and formation of more wounds may be unavoidable. The goal of the care plan is for the pressure ulcers to improve without any signs or symptoms of infection. Interventions to meet the goal of the plan of care included: treatment per orders, wound care services to evaluate and treat. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes for R1 for did not reflect detailed skin and wound assessments were being documented per the facility policy and professional standards. Review of Weekly Skin Assessments dated 6/21/22, 6/28/22, 7/5/22 and 7/12/22 did not reflect measurements or wound characteristics were being completed to track R1's wound progression or healing. An Admission Body Observation dated 6/7/2022 indicated R1 had pressure sores described as 4 in depth, no additional description or measurements were documented. Review of the Admission Nursing Comprehensive Evaluation dated 6/7/22 did include measurements of R1's wounds but follow-up measurements and descriptions were not documented in the clinical record again until 7/19/22 and on 7/20/22 and were incomplete and inaccurate as evidenced by not all wounds were reflected in each of the progress notes and a description of the characteristics and drainage were not recorded. No evidence in the clinical record reflected a wound care consultation was obtained for R1's extensive pressure ulcers. Review of a Progress Note written by LPN D on 7/19/22 at 8:18 PM reflected Wounds measured as follows R (right) hip 3cm x 4 cm L (left) hip 5.5 cm x 3 cm with 3 cm tunneling. L (left) heel 3 cm in diameter. No additional pertinent wound assessment findings were recorded and did not include evaluation of R1's coccyx wound. During an observation and interview on 7/20/22 at 4:15 PM, The Director of Nursing (DON) assisted Licensed Practical Nurse (LPN) C with wound care for R1. The following observations/assessments/measurements were obtained and verbalized by the DON and LPN C: A) R1's right heel was covered with an undated dressing. Upon removal of the dressing the DON reported the nurse who applied it did not use the ½ normal saline, ½ [MEDICATION(S)] solution per physician order. The right heel wound measured 2.5 cm x 2.5 cm with a depth of 0.5 cm, the wound bed covered in tan slough making the wound unstageable. The wound was cleaned with wound cleanser and packed with a solution of ½ normal saline and ½ [MEDICATION(S)] soaked gauze that LPN C cut to size with a rusty scissor that was not cleaned prior to use. The wound was covered with boarder foam dressing. B) R1's left heel was intact. C) R1's Right hip dressing was not dated. The right hip wound measured 5.5 cm long x 2.5 cm wide with 0.5 cm depth at 12 o'clock, 0.75 cm depth at 9 o'clock and 11 o'clock and 0.4 cm depth at 6 o'clock. The wound was cleaned with wound cleanser and packed with the ½ normal saline and ½ [MEDICATION(S)] soaked gauze and covered with a border foam dressing. LPN C removed her gloves and donned a clean pair without performing hand hygiene. D) R1's Left hip wound measured 3.5 cm x 5.5 cm with 1.0 cm undermining at 12 o'clock, 1.5 cm at 6 o'clock. Slough obscured a portion of the wound bed and bone was visible. A darkened area at the edge of the wound at 2 o'clock was suspicious for necrosis and the DON texted the doctor and obtained a new order to change the dressing from ½ normal saline and ½ [MEDICATION(S)] wet to dry dressing to an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's wound was cleaned with wound cleanser and the new dressing was implemented. E) R1's coccyx dressing and gauze packing was removed, the wound was cleansed and measured 7.0 cm x 5.0 cm with 0.5 cm tunneling at 12 o'clock and 0.2 cm tunneling at 6 o'clock. The wound bed was covered with calcium alginate and a boarder foam dressing. The DON said she would enter the new order into the medical record. When asked, the DON reported R1 had not been seen by the wound doctor since he admitted to the facility. The preceding observations reflected inaccuracies and incomplete documentation and worsening of wounds when compared to the progress note documentation on 7/19/22 Review of a Progress Note authored by the DON on 7/20/21 at 6:00 PM reflected L (left) heel 1.5 x 1 cm x 0.2, Coccyx 7x4x0.5 (at12o'clock) X 0.2 at 6 o'clock. The measurements were not consistent with the observation of R1 made on 7/20/22 at 4:15 PM and did not reflect the wound on R1's left hip, right heel and related treatment order changes or any other pertinent assessment findings. Review of the most current physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Once a day every other day; 05:00 AM-05:00 PM started on 6/22/2022 and ended on 7/20/2022. The order is unclear as to frequency of dressing changes (every day versus every other day). Review of the June and July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 (R3) Review of a Face Sheet reflected R3 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Resident Matrix form CMS-802 dated 7/19/22 reflected R3 had a stage 2 facility acquired pressure ulcer. Review of a Care Plan initiated on 4/30/22 reflected R3 was at risk for skin breakdown related to impaired mobility, diabetes and [CONDITION(S)]. The goal of the plan was that R3 would be free of skin breakdown unless clinically unavoidable. Interventions to meet the goal included Float heels when in bed using using pillows or soft heel boots; observe skin daily with care; document a weekly skin assessment. During an observation and interview on 7/20/22 at 9:45 AM, R3 reported that he developed wounds on his heels while at the facility. R3's heels were resting on the bed and an undated dressing covered R3's right heel, R3's left heel was observed without a dressing covering an open wound with depth. R3 agreed to an observation of wound care and measurement with the nurse on duty. During an observation on 7/20/22 at 10:18 AM, The DON assisted LPN C with wound care for R3. R3 was lying on a bare mattress for the procedure, a clean barrier was not in place. The DON assisting with positioning and observation of the wound while LPN C measured the left heel wound and reported it was 1.5 cm x 1.2 cm with a depth of 0.4 cm. The DON said the observation was consistent with a stage 3 pressure ulcer. LPN C cleaned and dressed the wound by placing calcium alginate in the wound bed and covering it with boarder foam. The undated dressing was removed from R3's right heel and revealed no skin impairment. The DON reported that that area had healed and they would apply skin prep to the area instead of covering it. Review of Progress Notes dated 5/18/22 at 4:59 AM reflected the first observation of R3's left heel as follows: Left heel, 1.2 x 1.1 open area. Tx (treatment) written for calcium alginate with foam dressing q (every) 48 hours, and prn until healed. Keep heels up off bed at all times. The progress note does not describe depth or drainage or other pertinent assessment findings. Further review of progress notes from 5/18/22-7/20/22 do not reflect wound monitoring or assessment findings or an attempt to review the current treatment plan for efficacy. The progress notes and skin assessments never reflected R3 had a wound on his right heel. Review of a newer Care Plan focus area initiated 6/14/2022 (nearly 4 weeks after the development of a facility acquired pressure ulcer) reflected Resident (R3) has a pressure ulcer due to multiple underlying medical conditions, wounds may not heal and formation of more wounds may be unavoidable. The goal of the care plan is for the pressure ulcers to improve without any signs or symptoms of infection. Interventions to meet the goal of the plan of care included: treatment per orders, wound care services to evaluate and treat; utilize pressure reduction devices. Review of Weekly Skin Assessment reports dated 5/2/22, 5/3/22, 5/17/22, 5/23/22, 6/6/22 and 7/18/22 did not reflect an assessment of R3's left heel pressure ulcer.

Based on observation, interview, and record review, the facility failed to follow CDC (Center Disease Control) and CMS (Centers for Medicare and Medicaid Services) guidelines and recommendations to contain and prevent the spread of COVID-19, resulting in an Immediate Jeopardy (IJ) when the facility staff did not appropriately utilize PPE (personal protective equipment) and follow basic infection control practices, resulting in 1 resident (R12) contracting COVID-19 and the continued risk for infectious disease spread in the facility. This deficient practice placed all residents and staff at risk for serious harm, injury, and or death from COVID-19 and other infections. On 1/31/22 at 8:49 AM, the Director of Nursing (DON) was passing medications. The DON reported she was passing medication because the Licensed Practical Nurse (LPN) E that was scheduled tested positive for COVID-19 at the end of her shift on 1/26/22. The DON was asked for the records of all staff that have tested positive for COVID-19 in the last month, family and notification of positive COVID-19 staff and COVID-19 test results for all residents. The DON found an employee binder for COVID-19 testing. LPN E's name was not on the employee's list, and she was not able to find any documentation that she tested positive. The DON said they did not have an infection preventionist on staff at this time but the former infection preventionist had set up the binder and managed all the COVID-19 testing and notification. The DON said she assigned LPN K to test the residents for COVID-19 on 1/26/22. LPN K was also assigned to resident care that night. The DON could not find any records that indicted the residents were tested for COVID-19 and when she checks with LPN K, LPN K did not test the residents for COVID-19. As of 1/31/22 at 9:00 AM, none of the residents were tested for COVID-19 that were exposed to COVID-19 on 1/26/22 when the facility was aware that LPN E tested positive for COVID-19 at the end of her shift. Review of the facility COVID-19 binder revealed it only had 31 of 36 staff currently employed staff listed. The staff person that tested positive for COVID-19 on 1/26/22 was not listed anywhere in the binder. 11 staff were highlighted in yellow, and the DON said they were the staff that had recently tested positive for COVID-19. The DON was not able to locate an accurate record of staff testing. The DON was not able to locate the dates that the 11 staff had tested positive. The DON said the former infection control nurse had managed all of the COVID testing information and she was not aware the process and paperwork. On 1/31/22 at 9:30 AM, the DON and NHA were asked how the residents and families were notified of positive COVID-19 staff and residents in the building. They both indicated that the residents were verbally notified, and families were called. They were asked for the documentation of this notification, and they reported it was not documented anywhere and they did not have anyway of verifying that notification was done on 1/26/22 when a staff member tested positive for COVID-19. Resident medical records were reviewed, and notes were located for other dates of COVID-19 notification, however none of the records documented notification of staff testing positive on 1/26/22. Resident #12 (R12) Review of R12's face sheet, no date, revealed he was a [AGE] year old male that was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R12's progress noted dated 1/31/22 at 6:09 PM revealed, Resident tested positive of Covid, DON (Director of Nursing) sent resident to ER via Ambulance cart to (name of hospital). On 2/1/22 at 3:35 PM, the State Agency served to the facility NHA a notice of Immediate Jeopardy (IJ) that was identified on 1/31/22 and began on 1/26/22 for failing to develop and utilize and infection control program and practice infection control standards of practice to prevent a COVID-19 outbreak. The facility provided the following IJ Removal Plan: Issue Cited: Riverside Manor Nursing center the facility failed to develop and utilize an infection control program and practice infection control standard of practice to prevent a covid-19 outbreak. 1. Identification of Residents Affected or Likely to be Affected: While all residents have the potential to be affected, the affected area is throughout the facility. Beginning 2/2/22 - Emar will be updated daily for s/s of Covid BID and any COVID-19 test results. The staff member that tested positive was immediately sent home. 2. Actions to Prevent Occurrence/Recurrence: Upon receiving notice of F 880 The facility needs to immediately get assistance from a qualified infection preventionist to institute an infection control program who policies and procedures, education for staff and enough staff to ensure assessing, screening, and testing of all residents and staff for Covid-19, per CDC recommendation and infection control standard of practice. Beginning 2/2/22 - Registered Nurse (RN) G is a certified infection control prevention was hired back at Riverside Healthcare center. Beginning 2/2/22 - All residents and staff were tested for covid on 2/1/22 by the Don and Charge Nurse and none tested positive. Staff with a positive covid-19 will be immediately sent home and instructed not to report to work to avoid additional exposure to others. Staff will be directed on when to return to work based on asymptomatic and symptomatic status per facility policy and CDC Guidelines. Contact tracing will be initiated. Residents that test positive will be immediately place in isolation and transferred out to the hospital and/or a covid hub for medical care and readmitted after clearance with initiation of notification and documentation. Beginning 2/2/22- All staff, residents and legal guardians were notified of the past positive cases and will be documented in the medical records of each patient chart by the DON. Contact tracing and monitoring with documentation in the medical record of testing notification. Testing of residents and staff will be performed weekly and/or more according to the positivity rate. Covid-19 screening Results will documented in the resident's electronic medical record. Beginning 2/2/22- The Infection Control nurse has made tracking logs to track all residents and staff covid testing with results. Beginning 2/2/22- The Gratiot County health department was notified of the positive covid case and any positive case of covid 19 test and contact tracing, monitoring and documentation. Beginning 2/2/22 - An audit was done by DON to see if any residents/staff were showing s/s of covid, and none noted on 2/2/22. Beginning 2/2/22- All residents who are not fully vaccinated was offered the vaccine by the DON. All staff are fully vaccinated except the ones who have an approved exemption. Beginning 2/2/22- Physicians was notified of the positive covid case on 2/2/22. Beginning 2/2/22- The policy on infection control/covid testing was reviewed and deemed appropriate. The Administrator and DON have been re-educated by the Regional Nurse on Covid 19 prevention, screening/testing, monitoring and education for staff and enough staff to ensure testing for both residents and staff. The policy addresses the implementation of COVID -19 screening, testing and/or PPE use? Beginning 2/2/22- The entire facility will be placed in observation for 5 days per CDC/CMS guidelines. All staff will be required to wear N-95 mask. Beginning 2/2/22- The facility added another screening tool for residents that includes monitoring s/s of covid BID and the facility added another screening tool for staff which will be done for s/s of covid 19 at the start of the shift and the end of the shift. Beginning 2/2/22- All residents covid results will be documented in the Electronic Medical Record (EMR) whenever the test is done immediately. Date the Facility Asserts Likelihood for Serious Harm No Longer Exists: 2/4/2022 On 2/6/22 the State Agency verified the facility had initiated there IJ removal plan. Although the Immediate Jeopardy was removed on 2/2/22, the facility remained out of compliance with a scope of widespread and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency. On 1/31/22 at 8:59 AM, Medical Records (MR) L was observed performing housekeeping duties and wearing a surgical mask rather than the N95 mask. On 1/31/22 at 9:24 AM, Activity Aide (AA) M was observed wearing a surgical mask as she was pushing a resident in her w/c that did not have foot pedals in place. AA M reported she started working at the facility 1/11/22 and that she had not been tested for COVID 19 since she started at the facility. On 2/7/22 at 8:53 AM, a large sharps container was observed sitting unsupported on the top of the East medication cart. Also noted was the sharps container that was affixed to the side of the cart remained over-filled with needles and syringes extending above the fill line. Review of the Employee and Visitor COVID 19 screening log did not reveal that the Medical Director had been in the building. On 2/9/22 at 11:43 AM, a telephone interview was conducted with Medical Director (MD) I. MD I reported a review of the facility Employee and Visitor COVID 19 screening log would not reveal his name. MD I reported that he screens himself before he enters the building.

This citation contains two deficient practice statements. DPS #1 Based on observation, interview, and record review, the facility failed to properly monitor and maintain safe water temperatures, resulting in the high likelihood of scalding, resulting in an immediate jeopardy for all 38 residents in the facility. The Administrator was notified of the Immediate Jeopardy: [DATE] at 2:46 PM of the Immediate Jeopardy that was identified on [DATE] at 8:45 AM of the Immediate Jeopary that began on [DATE] when the facility stopped logging temps. The Facility was requested for a written plan of correction for abatement: [DATE] at 2:46 PM Facts Supporting Immediate Jeopardy: On [DATE] at 8:45 AM, the hand sink for room 30 was measured using a Thermapen digital probe thermometer and found to be at 120.8 degrees Fahrenheit. On [DATE] at 8:50 AM, the hand sink for room 31 was measured using a Thermapen digital probe thermometer and found to be at 135.0 degrees Fahrenheit. During an interview on [DATE] at 8:55 AM, Maintenance Director Y was informed of the high water temperatures at the tested hand sinks and stated they will see what is wrong with the water. On [DATE] at 8:56 AM, the hand sink for room 32 was measured using a Thermapen digital probe thermometer and found to be at 134.8 degrees Fahrenheit. On [DATE] at 8:58 AM, the hand sink for room 37 was measured using a Thermapen digital probe thermometer and found to be at 130.5 degrees Fahrenheit. During an interview on [DATE] at 9:30 AM, Maintenance Director Y stated that they turned down the water temperature at the mixing valve. At this time, water temperature monitoring logs were requested and Maintenance Director Y stated that they were recently hired, and they only have one day of water temperature monitoring for [DATE]. On [DATE] at 9:50 AM, the hand sink for room 32 was measured using a Thermapen digital probe thermometer and found to be at 134 degrees Fahrenheit. During an interview on [DATE] at 9:52 AM, Maintenance Director Y was queried on why the water temperature was still high and stated the mixing valve was lowered but the hot water still needs to be flushed out, but was called away to another task. On [DATE] at 10:37 AM, assisted with the Administrator, the hand sink for room 32 was measured using a Thermapen digital probe thermometer and found to be at 108 degrees Fahrenheit. During an interview on [DATE] at 2:12 PM, Maintenance Director Y confirmed the water heater providing excessive hot water affected rooms 30 through 39. On [DATE] at 3:02 PM, the hand sink for room 23 was measured using a Thermapen digital probe thermometer and was found to be at 123 degrees. Fahrenheit. At this time, Maintenance Director Y was informed other areas of the building were affected by hot water. During an interview at [DATE] at 3:50 PM, Maintenance Director Y stated that he turned the mixing valve down for the newly observed high water temperatures affecting the remainder of the rooms. During an interview on [DATE] at approximately 1:45 PM, the Director of Nursing provided the Surveyor with the specific information of the resident records showing the following residents demonstrated low cognition level as evidenced by BIMs scores, and are independently ambulatory or can independently propel, resulting in a high likelihood of accidental exposure to excessive water temperatures: Resident 29; BIMS - 04 Resident 10; BIMS - 08 Resident 25; BIMS - 09 Resident 17; BIMS - 03 Resident 28; BIMS - 99 According to the facility's water temperature monitoring logs, the facility has monitored water temperatures on [DATE], [DATE], [DATE], and [DATE]. According to the facility's, ROOM WATER TEMPERATURE, log, dated [DATE], bathrooms for rooms #'s 1, 2, 5, 6, 22, 24, and 25 were monitored. According to the facility's policy, Water Temperatures, Safety of, revised [DATE], it notes, Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 F, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. 5. Direct-care staff will be informed of risk factors for scalding/[CONDITION(S)] that are more common in the elderly, such as: a. Decreased skin thickness; b. Decreased skin sensitivity; c. Peripheral [CONDITION(S)]; d. Reduced reaction time; e. Decreased cognition; f. Decreased mobility; and g. Decreased communication. Facility Removal Plan [Facility] submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility's failure to maintain water temperatures at a safe level. [Facility] believes that as of [DATE], the measures it has implemented are sufficient to demonstrate that residents are receiving adequate prevention measures. 1. Identification of Residents Affected or Likely to be Affected: While all residents have the potential to be affected, the affected area was identified in all residents' rooms. Beginning [DATE] - Completed water checks of all affected areas to ensure water temperatures were below 120 [degrees] F. No deficits were found. Beginning [DATE] - NHA conducted a review of all incident reports confirming that there have been no incidents of resident [CONDITION(S)] since [DATE]. Beginning [DATE] - NHA conducted a review of Resident Council minutes confirming that there have been no complaints at this meeting about water temperatures [DATE]. Beginning [DATE] - NHA confirmed with DON that there have been no resident complaints/grievances filed regarding water temperatures since [DATE] 2. Actions to Prevent Occurrence/Recurrence: Upon receiving notice of elevated tap water temperature, the facility took the following actions: Beginning [DATE] - Maintenance staff made adjustments to mixing valves to lower water temperatures below 120 [degrees] F. Beginning [DATE] - A review with the Maintenance director revealed temperatures were above 120 [degrees] F. Maintenance director reported that upon discovery of elevated temps he adjusted water mixing valves and retakes the water temp, he acknowledged that he did not document any corrective action, and notified the NHA. We identified ways to improve the tool used for documentation and updated this form with explanation of changes noted below. Beginning [DATE] - Implemented a revised Maintenance Radom Weekly Test Report Log which includes checking of water temps to include the following: o Clear instruction that read as follows: Complete random weekly checks listing the room number and documenting temperatures of tap water. Temperatures shall be no more than 120 [degrees] F. Discrepant findings will be remedied immediately. o Added signature lines for the Director of Maintenance or designee and Administrator to review. Beginning [DATE] - Maintenance staff completed a water temp audit of all resident rooms finding no temps above 120 [degrees] F. Beginning [DATE] - Maintenance to increase monitoring of all residents rooms to twice daily until such time that QAPI committee determines the issue to be resolved and safe to return to weekly checks. Beginning [DATE] - The NHA provides mandatory face-to-face education with competency testing to the Maintenance Staff regarding safe temperature requirements and updated log. 3. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] On [DATE], the State Agency verified the facility had initiated their IJ removal plan. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance with a scope of widespread and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency. This citation pertains to MI 5429 DPS #2 Based on observation, interview, and record review the facility failed to provide a safe route/area for independent residents to smoke, to keep one resident's oxygen tank full when up in her wheelchair, respond timely to an emergency alarm, provide safety equipment for residents when smoking and provide a safe smoking environment when multiple residents were smoking together resulting in the potential for serious harm or death. Findings include: Review of R4's face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: acute respiratory failure with [CONDITION(S)], muscle weakness, difficulty in walking, unsteady on feet, diabetes mellitus II, and obesity. R4 was her own responsible party. On [DATE] at 11:15 AM, R4 was wheeled into the main dining room for the resident council meeting with the State. R4 was in a wheelchair with a portable oxygen tank on the back. After 10 to 15 minutes of being in the meeting R4 said she was short of breath and thought her oxygen tank had run out. The Surveyor asked the kitchen staff to get help for R4 and report it was an emergency as her oxygen tank was empty. When staff did not immediately respond to the request the Surveyor pulled the emergency cord in the main dining room. After one minute when staff did not respond the Surveyor went into the hall and yell to the Certified Nurse Aides that R4 needed oxygen and it was an emergency. A certified nurse aide came to the main dining room with a new oxygen tank, but she was not able to connect the regulator to the new tank as when she attempted to tighten the connection the tank made a loud hissing noise. A licensed nurse came to the main dining room to assess R4 but she was unable to get her pulse oxygen reading as the meter had a dead battery. R4 had to be transported back to her room and placed back on her electric oxygen concentrator. Once R4 was back on oxygen in her room she returned to her baseline breathing and calmed down. On [DATE] at 12:00 noon the Surveyor reported the oxygen emergency and lack of response to verbal request for medical assistance and no response to the emergency call alarm to the Director of Nursing (DON) and Nursing Home Administrator (NHA). The CNA's reported they did not respond to the alarm because they had never heard the alarm before. The DON and NHA said they would investigate the situation and start education. On [DATE] at 1:00 PM the DON said she started education on the portable oxygen tanks. The DON said she met with the oxygen supplier, and they told her some tanks need o rings. The company provided them with additional o rings. The DON took the Surveyor to the supply room and new o rings were in the room. After going to the supply room, the DON went to R4's room. R4's oxygen tank on her chair was empty and R4 said it was the same tank she had yesterday. The DON attempted to put a new tank on R4's wheelchair but it leaked air out just like the one had done in the meeting on [DATE]. The DON had to go to the supply room to get an o ring before she could connect R4's regulator to her tank. R4 let the DON know that she always wanted a functional tank so in an emergency she could safely get out of her room. Resident #6 Review of R6's face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: hemorrhagic disorder due to extrinsic circulating anticoagulants (blood thinners), acquired absence of left leg above the knee, diabetes mellitus, anxiety disorder, post-traumatic stress disorder, chronic pain, peripheral vascular disease, and localized [CONDITION(S)]-RLE (right lower extremity). Review of R6's Resident Safe Smoking Agreement dated [DATE] revealed, 6. I understand that if I am an independent smoker that I MUST completely exit the property for all unsupervised smoking. 9. I understand that if I violate or do not comply with the smoking policy and/or smoking agreement, I will b subject to suspension and or loss of smoking privileges and/or involuntary discharge. 13. Violation will be considered a threat to resident health and safety and will be grounds for involuntary discharge from the facility in accordance with State and Federal rules and regulations. During an interview with the Nursing Home Administrator (NHA) on [DATE] at 2:00 PM the Surveyor explained that Residents that were their own responsible party had express frustration that staff could smoke in the visitor parking lot, and they had to go in their wheelchair out to the main road about ¼ mile on the icy driveway (no sidewalk) to smoke. The NHA confirmed staff were able to smoke on the facility property, but residents had to leave the property to smoke if they did not go out at the supervised times with the other residents. The NHA confirmed they do not assist any residents outside to smoke if it is below 32 degrees outside. They only assist resident smoke 3 times a day. The NHA said there was nothing he could do about it as he had checked with his supervisor, and this was the corporate policy. I asked if his supervisor and the corporation was aware that the route residents had to take in their wheelchair was not safe and was a great distance. The NHA assured me his supervisor and the corporation were aware of the hazards and again told me he was not able to change company policy. On [DATE] at 2:00 PM the staff smoking area was observed to be clear of snow/ice and salted. The area had a cigarette receptacle for disposal. The area was sheltered as it was surrounded on 3 sides by the facility building. On [DATE] at 1:00 PM R6 was observed outside in her wheelchair headed to the main road to smoke. The Surveyor had just returned to the facility and the ¼ route R6 had to maneuver in her wheelchair was covered with snow and ice. R6 said the facility was not assisting residents to smoke today because it was colder than 32 degrees. R6 said smoking helps her clear her head and she did not want to get kicked out, so she had to go to the main road to smoke. On [DATE] at 10:00 AM R6 said over the weekend she was allowed to smoke in the resident smoking area but today they changed the code to the door going to the smoking area so she would have to go out to the main road again to smoke. R6 said it makes her feel like a second-class citizen when she is not able to smoke when she needs to in a safe area. During a facility scheduled assisted smoking time on [DATE] at 9:10 AM the following safety concerns were observed. 10 Residents were assisted to an area outside the that had 3 sides covered with traps and a covered top. All residents except one were in wheelchairs. There was one employee helping, Activity Aide (AA) M. AA pushed one resident in her wheelchair without foot pedals over 20' to get her into the sheltered area. The space in the shelter did not allow for more than an inch or 2 of space between each resident. All the residents smoked at the same time. Several of the residents struggled to flick off the hot ashes to the ground and held the hot ashes over their flammable clothing and/or close to another resident's flammable clothing. R15 was brought out to the shelter in her wheelchair after all the other residents had been assisted with a cigarette. AA said to the residents she did not know what kind of assistance R15 needed. R15 did not speak or give AA any communication for her needs. Several residents spoke up and said you need to put a smoking apron on R15 and hold her cigarette because she will try to put it all the way in her mouth. AA put a smoking apron on R15 and handed her a lit cigarette. R15 put the cigarette in her mouth past the filter and smoked it until the ashes reached her fingers. R15 did not flick her ashes. AA took the cigarette from R15 when it was smoked ½ way as the ashes had reached her finger. AA put R15's cigarette out and gave R15 a new cigarette and did the same thing. AA lit all the residents' cigarettes but only did not help any resident hold their cigarette. R15 was the only resident that used a smoking apron. While the residents all smoked AA used a vape cigarette to smoke. R7 Review of R7's face sheet, no date, revealed, she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Multiple [CONDITION(S)], [CONDITION(S)], anxiety disorder, chronic pain, neuromuscular dysfunction of the bladder, [CONDITION(S)], idiopathic peripheral autonomic [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), and [CONDITION(S)] (severe chronic pain in a facial nerve that starts on the brain). R7 had a legal guardian. During the smoking observation on [DATE] at 9:10 AM, R 7 did not use a smoking apron. R7 hand poor hand control of the cigarette and held the hot ashes over a fussy blanket that was over her legs. R7 did not have a smoking apron on when she was smoking. Review of R7's smoking care plan dated [DATE] revealed, Some difficulty holding cigarette and occasionally drops ashes on lap. Smoking may be determined by the assessment and medical needs of the resident deemed by the physician and medical staff. Under approach dated [DATE] revealed, must wear smoking apron. Review of R7s Smoking Risk assessment dated [DATE] the assessment rated her at 1 (minimal problem) for Drops cigarette/cigar butts or matches on floor, furniture, self or others; [CONDITION(S)] fingertips; smokes near oxygen. The assessment did not assess for the ability to flick hot ashes, light a cigarette, or put out the cigarette. R15 Review of R15's smoker care plan dated [DATE] revealed, unable to smoke safely smoke cigarettes due to history of burning her own fingers. Uses an electronic vape. Resident shows no interest in going outside to smoke at this time but is still an option for her. [DATE] Resident has started to smoke safely, she is to be watched assisted by staff when smoking and is to wear smoking apron when handling smoking materials. Review of R15 s Smoking Risk assessment dated [DATE] the assessment rated her at 0 (no problem) for Drops cigarette/cigar butts or matches on floor, furniture, self or others; [CONDITION(S)] fingertips; smokes near oxygen. The assessment did not assess for the ability to flick hot ashes, light a cigarette, or put out the cigarette. There was no indication R15 was not able to determine how far to safely put a cigarette in her mouth and did not change finger placement when the ashes reached her fingers. During an interview with the Director of Nursing (DON) on [DATE] at 11:00 AM the DON said she was not aware R15 still smoked, she was not aware AA was not providing the smoking aprons or assisting the residents smoke as directed in the resident's care plans, she was not aware AA was vaping while the residents smoked, she was not aware of the lack of space between residents when all residents smoked at the same time. The DON said she would start education immediately and AA would be providing smoking aprons and safety when residents smoked.

Based on observation, interview, and record review, the facility failed to assess and provide care and services to prevent the loss of range of motion for one resident (Resident #8 (R8)) and ensure no further loss of range of motion, resulting in R8 having severe range of motion loss and severe restriction of all mobility with the potential for further loss of ROM. Findings include: R8 Review of the medical record reflected R8 was originally admitted to the facility 5/20/05 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record also revealed R8 had a [CONDITION(S)]. The Minimum Data Set (MDS) dated [DATE] revealed R8 was in a vegetative state and displayed total dependence on staff for all care. On 1/25/22 at 10:06 AM, audible rattling breath sounds were heard in the hall coming from the room of R8. Upon entry R8 was observed lying on her back with the head of the bed raised. R8 had slid down with just her shoulders and head elevated. The Director of Nursing (DON) was summoned who entered the room with LPN E. While repositioning R8 bilateral foot drop was observed. While staff performed incontinence care on R8 it was observed that both legs were extended and stiff with the right leg crossed over the left leg. It was observed that two staff were required to separate the Residents stiff legs to remove the wet brief. It was noted that, with difficulty and by bending the legs of the resident at the knees, that the two staff were able to apply a clean brief to the Resident. Review of the Care plan for R8 reflected a Care Plan and Problem of Resident has contractures to bilateral hands/elbows related to chronic comatose condition .with a goal of the resident will be clean and well groomed. The Care Plan reflected interventions to include Provide gently (Range of Motion (ROM)) daily with Care and Provide PT/OT or restorative program as needed. This Care Plan did not reveal any ROM to be conducted with the arms or legs of the R8. The Care Plan for (Activities of Daily Living (ADL)) Functional/Rehabilitation Potential initiated 1/13/21 reflected a goal of The resident will achieve maximum functional ability through the next review date of 4/14/2022. An intervention documented as implemented on 1/13/21 reflected Locomotion Wheelchair use with 1 person. No other Care Plan problem or focus was found related to improving, maintaining, or protecting the range of motion of the other joints to include the lower extremities for R8. During the Recertification Survey conducted from 1/23/22 through 2/10/22, R8 was never observed to be in her wheelchair. The Resident's wheelchair remained stored in her room on the far wall across from her bed. On 2/9/22 at 8:23 AM, an interview was conducted with the DON. The DON was asked when was the last time R8 was out of her bed. The DON reported she believed R8 was last out of bed when she had a shower on the past Saturday (4 days prior on 2/5/22). Review of the shower sheet for R8 reflected that, before the shower on 2/5/22. Prior to this the Resident had last received a shower on 1/11/22. On 2/7/22 at 2:54 PM, an interview was conducted with Therapy Director (TD) U. TD U reported Therapy has not performed any recent evaluations of R8. TD U reported R8 uses anti-contracture devices called carrots for her hands. TD U reported the facility does not have a Restorative Program stating, they don't have the staff for that. TD U reported she not seen R8 up in her wheelchair and indicated that staff do not get R8 or other residents out of bed as in the past.

This citation pertains to MI 5429 Based on observation, interview, and record review the facility failed to provide sufficient number of staff to consistently meet the physical and psychosocial needs of the residents, resulting in pressure ulcers, lack of showers/basic activities of daily living, pain and frustration. Findings: The Facility Assessment that was provided by the facility reflected handwritten signatures of facility administration at the bottom of the front page and dated 11/10/21. Review of the Facility Assessment reflected Page 3 Part 1 Our Resident Profile. 1.2 reflected an average daily census of 37 - 39 residents. Page 9 Staffing Plan 3.2 reflected a table that indicated Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. The table reflected the facility required Licensed nurses providing direct care- 4 - 6, Nurse aides - 2 - 4. Further review of the Facility Assessment did not reveal documented numbers of staff required to meet the needs of the residents for each shift. The Facility Assessment revealed methods and factors to consider when determining facility staffing without any documentation of what the needs of the facility were determined to be. Review of the facility Resident Census and Condition of Residents report (form 672) dated 1/23/22 reflected the facility had 38 residents of who 22 were occasionally or frequently incontinent of bladder, 32 were in a chair most or all the time and 3 residents could ambulate independently. The 672 also reflected that 8 residents were dependent on staff for eating and that an additional 3 residents required assistance with meals for a total of 11 residents the facility identified as needing assistance during meal times. On 1/23/22 at 9:25 AM, on entrance to the facility it was observed that the facility was staffed with two nurses and three CNAs. On 1/23/22 at 10:50 AM, no current Nurse Staff Posting was located. On 1/23/22 at 12:20 PM, Certified Nurse Aide (CNA) T reported the facility had been short staffed for about two months and that she was routinely finding residents wet in the morning. On 1/23/22 at 2:40 PM, CNA EE reported that the facility is short bariatric sheets and, due to a shortage of laundry staff, the CNAs have to wash the sheets or use two flat sheets in place of a bariatric sheet. CNA EE reported that sometimes the night shift has just one nurse and one CNA. CNA EE reported she and others receives texts asking them to come to work, Please come, we have no one. Review of the facility staffing schedule reflected the facility was commonly staffed with two floor nurses and two Certified Aides during the day shift. Subsequent staffing reflected that the Director of Nursing (DON) was often one of the two floor nurses. On 1/23/322 at 3:32 PM, an interview was conducted with the NHA and the DON. It was reported that about a month prior a number of facility staff left for higher pay at a sister facility leaving the facility in need of additional staff. The DON reported the facility currently had two Agency nurses but at times the night shift will have four hour blocks of only one nurse and one Certified Nurse Aide in the facility. The NHA reported that the facility had an active recruitment program but did not have any likely current candidates. The NHA was asked if he had initiated an emergency staffing plan based on the Facility Assessment. The NHA stated I need to go through it and activate it. Then the NHA reported he hadn't determined if staffing was at a critical stage. However, the NHA reported that the corporate office was aware the facility had a staffing issue but did not indicate that a plan was in progress other than an advertisement on the internet. Review of the Staffing Sheets provided by the facility reflected: 1/9/22, 1/12/22 and 1/18/22 there was one nurse and one CNA for the night shift, on 1/10/22 there was one nurse for day shift, afternoon shift, and night shift, and on 1/14/22 there was one nurse on the day and night shift, but the Staffing Sheet did not reveal a nurse for the afternoon shift. On 1/24/22 the facility schedule board was reviewed for staffing. The board reflected one nurse and two CNA's until 2:00 PM when a third CNA would arrive. The DON reported she was working as a staff nurse in addition to her DON duties. On 1/31/22 the facility schedule board reflected two nurses and two CNAs for the day shift with the DON working as a staff nurse in addition to her DON duties. The schedule board reflected one nurse was scheduled to work the night shift. On 2/2/22 at 9:13 AM, the facility schedule board was reviewed for staffing. The board reflected two nurses and two CNAs with one CNA being the facility Social Worker (SW) A. The schedule board reflected no nurses were scheduled for the night shift at the time of this review. On 1/24/22 at 11:22 AM, CNA P reported the facility tries to have three Certified Nurse Aides (CNA) on the day shift but that it is usually two CNA's. On 1/26/22 at 8:47 AM, the staff schedule board was reviewed. The schedule board reflected two nurses were working the day shift with the DON as one of the floor nurses. The schedule board reflected that the facility would be staffed with just one CNA from 7:00 PM until 10:00 PM. On 2/10/22 at 12:26 PM, Licensed Practical Nurse (LPN) B reported prior to this survey she worked the night shift and worked many nights with just one CNA. LPN B reported she went to contingency status because of the workload she just couldn't do it anymore. R21 R21 was admitted to the facility 10/8/19. The Minimum Data Set (MDS) dated [DATE] reflected R21 was severely cognitively impaired, was totally dependent on staff for bed mobility, and was at risk for developing pressure sores. The MDS reflected no pressure sores or skin issues at that time. On 1/25/22 the DON reported that R21 had developed a Stage Three pressure sore. The MDS dated [DATE] reflected R21 had a Stage Four pressure sore The Electronic Medical Record (EMR) reflected that on 1/31/22 this pressure sore measured 6.8 centimeters (cm) by 5 cm with slough. R23 R23 was admitted to the facility 11/6/20. The MDS dated [DATE] reflected R23 was totally dependent on staff for bed mobility, did not have any pressure sores at the time of this MDS but was at risk for developing pressure sores. On 1/24/22 at approximately 4:00 PM an observation of a skin assessment of R23 revealed eight measurable open areas on the buttocks not previously identified. The DON reported she did not know how long R23 had these areas. In an interview conducted 1/25/22 at approximately 2:00 PM, R23 reported he did not like to be in his wheelchair because his bottom Feels like Shredded meat and they leave me up for over two hours because they don't have time to help me. R5 R5 was admitted to the facility 12/22/20 and, due to a history of a stroke, had [CONDITION(S)] (paralyzed or weakness to one side of the body). Review of the MDS dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 14 which indicated the Resident was cognitively intact. On 1/24/22 at 10:34 AM, an interview was conducted with R5 in his room. R5 reported he had not had a shower in three weeks due to the facility being grossly understaffed. R5 presented as unshaven and with unkept, greasy hair. On 2/7/22 at 1:21 PM a request was made for the shower sheets of R5. Review of the shower sheets provided by the DON reflected R5 had showers on 8/30/21, 9/6/21, and 9/23/21. The next shower documented was a refusal by the R5 on 12/16/21. Documentation of a shower on 1/27/22 was noted. On 2/3/22 at 4:14 PM, R5 reported was supposed to get a shower today at 2:00 PM but no one came to get him. No other documentation of showers or refusals was provided by the facility. R32 R32 was admitted to the facility 9/23/19, The MDS dated [DATE] reflected R32 was cognitively impaired. This survey began on 1/23/22 with an exit date of 2/10/22. R32 was never observed dressed and out of bed until the day of exit. R32 was observed in bed, with the room always darkened, undressed without a shirt, and unshaven. Multiple observations were documented of R32 in bed as described above. On 2/7/22 at 1:21 PM a request was made to the DON for shower sheets of R32 from October 1, 2021, to present. The shower sheets provided by the DON for R32 reflected the Resident had a shower 12/3/21 and 12/20/21. No further documentation that R32 was provided of showers given either before or after these dates. On 2/7/22 at 2:54 PM, an interview was conducted with Therapy Director (TD)U. TD U reported that R32 used to be very social and would sit at his doorway and talk to everyone. TD U reported that following an alleged incident with a staff member R32 rarely gets out of bed. In an interview conducted 2/9/22 at 1:19 PM with Social Worker (SW) A. SW A who works also as the Activities Director and as a Certified Nurse Aide (CNA) reported she did not know of an incident and that she did not know why R32 doesn't get out of bed. R8 Review of the medical record reflected R8 was originally admitted to the facility 5/20/05 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ., The (MDS) dated [DATE] revealed R8 was in a vegetative state and displayed total dependence on staff for all care. On 1/25/22 at 10:06 AM, the DON was summoned to the room of R8 due to audible rattling breath sounds. While repositioning R8 with Licensed Practical Nurse (LPN) E bilateral foot drop was observed. R8 was observed to have both legs, stiff, and with the right leg crossed over the left leg. Two staff were required to separate the Residents stiff legs to remove the wet brief. The Care Plan for R8 reflected interventions to include Provide PT/OT or restorative program as needed. The Care Plan for (Activities of Daily Living (ADL)) Functional/Rehabilitation Potential initiated 1/13/21 reflected a goal of The resident will achieve maximum functional ability with an intervention of Locomotion Wheelchair use with 1 person. During the Recertification Survey conducted from 1/23/22 through 2/10/22 R8 was never observed to be in her wheelchair. On 2/9/22 at 8:23 AM during an interview the DON reported she believed R8 was last out of bed when she had a shower on the past Saturday (4 days prior on 2/5/22). Review of the shower sheet for R8 reflected that, before the shower on 2/5/22, the Resident received a shower on 1/11/22. On 2/7/22 at 2:54 PM, an interview was conducted with Therapy Director (TD) U. TD U reported the facility doesn't have a restorative program as they (the facility) don't have the staff for that. TD U reported she not seen R8 up in her wheelchair and indicated that staff do not get R8 or other residents out of bed as in the past. R4 Review of R4's face sheet, no date, revealed R4 was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Diabetes mellitus II, and obesity. R 4 was her own responsible party. On 1/23/22 at 2:25 PM, an interview was conducted with R4 in her room R4 reported staff do not get her out of bed when she wants to sit in her recliner. R4 said that she missed a visit with her mother before Christmas because there wasn't a lift sling available to get her out of bed. R4 said that during the time when her mother attempted to visit visitors were not allowed to resident rooms and met, instead, in a designated area in the facility due to COVID 19 restrictions. R4 said the facility did not have a mechanical lift sling for her, so she ordered her own sling online. R4 said the sling she ordered on her own arrived after Christmas of 2021. A bright blue sling was noted on the recliner chair nearby. R4 said when staff don't want to get her up, she is told the battery for the mechanical lift is not charged. On 1/24/22 at 9:01 AM, R4 said that she cannot tell when she voids. R4 said that staff will check and change her only twice a day with the first time in the afternoon then again about 11:00 PM. R4 said she was not changed at 11:00 PM last night and was wet now. It was observed that R4 was wet at this time. R4 indicated this is frustrating for her. On 1/25/22 at 2:52 PM, R4 said last night she wanted to get out of bed. R4 said that staff told her they will get her up if they have time. R4 stated I guess they didn't have time as R4 remained in bed. On 1/31/22 at 10:51 AM, R4 was observed in her recliner chair. R4 said she had not been changed yet today. R4 said she used her call light about an hour ago and that an office staff member responded. R4 said that the staff member told her the CNA was on break and that she would let the CNA know R4 needed care. It was noted that the call light was not on during this observation. R4 indicated the light had been turned off and she Feels forgotten. During the resident council task on 2/1/22 at 11:00 AM, 7 of 7 residents shared that the facility was not addressing their concerns. They all voiced care concerns and frustration with the facility not responding to their concerns. Residents were not aware of a formal process to address their concerns and said in the meeting concerns are not addressed or resolved. Concerns that they all shared were not enough staff which was causing them to go for more than a week without a shower, rooms not mopped or cleaned, and long waiting times to get their needs met. During the resident council task on 2/1/22 at 11:00 AM, 7 of 7 residents shared that the facility was not addressing their concerns. They all voiced care concerns and frustration with the facility not responding to their concerns. Residents were not aware of a formal process to address their concerns and said in the meeting concerns are not addressed or resolved. Concerns that they all shared were not enough staff which was causing them to go for more than a week without a shower, rooms not mopped or cleaned, and long waiting times to get their needs met.

Based on interview, and record review, the facility failed to have a physician supervise and follow up a medical recommendation to treat pain effectively for one Resident R7, resulting in R7 having excruciating pain daily. Findings include: Review of R7's face sheet, no date, revealed, she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 had a legal guardian. During medication pass on 1/25/22 at 3:20 PM, R7 reported that she had pain in her face at a 10 on a 1-10 scale. R7 said she had [CONDITION(S)] and the medication [MEDICATION(S)] was not able to control her pain anymore. R7 said she had surgery years ago and the pain had come back. She said Doctor I said he could not give her a higher dose of [MEDICATION(S)], and this was very upsetting. R7 waited until the last minute to take her [MEDICATION(S)] as she can only take it 3 times a day and as it gets time for the next dose the pain gets out of control 3 times day. R7 told the surveyor about her past suicide attempts and reported this pain makes her want to end it. Review of R7's electronic medical records revealed a Neurology note dated 5/26/21 that revealed the neurologist recommended Gamma Knife consultation related to R7's [CONDITION(S)] pain. During an interview with the facility Social Worker (SW) A on 1/26/22 at 3:37 PM, SW A reviewed R7's neurology notes in the medical record. A Neurology note dated 5/26/21 was located that recommended Gamma Knife consult related to [CONDITION(S)] pain. SW A said she was not the SW in the facility in May and was not aware of how the SW at the time followed up with medical consultation recommendations. SW A was not able to locate any notes in R7's medical record that indicated anyone including R7's Physician I had followed up with the May 26th, 2021, Neurologist recommendations. SW A said she had been taking R7 to her outside appointments since October 2021. SW A was able to find some handwritten notes that she had made after R7 went out to doctors since October 2021. SW A did not scan these notes in the medical record or document the recommendations in R7's medical record. SW A did not document informing R7's guardian O or physician I about the recommendations. SW A said she drives the residents to appointments, works as a Certified Nurse Aide (CNA) when the facility is short staffed and was not provided any training of expectations for follow-up or documentation when residents have outside appointments. During a telephone interview with R7's legal guardian BB, BB expressed frustration with R7's Physician I not being able to control R7's [CONDITION(S)] pain. The guardian was aware that the [MEDICATION(S)] was affecting R7's blood sodium levels but BB was not aware of what the Neurologist recommendations were or what else could be done to control the [CONDITION(S)] pain. BB said no one had ever discussed a medical procedure called Gamma Knife with her to control the pain. BB said the facility does not share the neurology recommendations with her and they have not had enough staff for someone to sit down with her to review R7's medical records. During a telephone interview with R7's Physician I on 1/26/22 at 10:00 AM, Physician I said he was not aware that R7's [CONDITION(S)] pain was out of control. Physician I said he had R7 on the highest dose of [MEDICATION(S)] he could. Physician I had a pharmacist conference call into the telephone conversation, and he confirmed that Physician I was giving a higher dose of [MEDICATION(S)] than was recommended for [CONDITION(S)]. Physician I denied any knowledge of R7's neurologist recommending a procedure called Gamma Knife. Physician I said the facility contacted him about the Gamma Knife procedure today and he would do the referral today. Review of R7's Neurology consult note dated 9/27/21 at 4:13 PM revealed, The patient has also continued to have right facial pain. She was on a much higher dose of [MEDICATION(S)] but it was decreased and currently is on [MEDICATION(S)] 200 mg, 1 and ½ tablet bid (twice a day). Her sodium has drifted down from 135 to 124 today. She is quite upset that her [MEDICATION(S)] was decreased. She repeated said that she would never go off of it as that is the only medication which helped her [CONDITION(S)] pain. Her [MEDICATION(S)] level was 15.2 on 6/7/21. Review of R7's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note dated 6/20/21 (about 3 weeks after the Neurologist recommended a Gamma Knife consultation related to R7's [CONDITION(S)] pain) revealed no indication Physician I had reviewed the Neurologist recommendations or was aware that a referral was need for R7 to receive a Gamma Knife consultation. Under Plan revealed, 8. [CONDITION(S)]. We will treat with her current medication's and follow symptomatically and follow with neurology as well as need. Physician I's notes date 7/17/21, 8/14/21, 10/10/21, documented the same thing as the note 6/20/21. Review of R7's. Physician I's note dated 11/8/21 item 8 was changed slightly to read, [CONDITION(S)], intermittently symptomatically and follow up with neurology for further suggestions, might have to increase her analgesics if need. Physician I's note 12/5/21 revealed, 8. [CONDITION(S)], still symptomatic, continue [MEDICATION(S)], follow symptomatically and neurology follow up. Physician I's note dated 1/16/22 revealed, 8. [CONDITION(S)], still symptomatic, awaiting further recommendations from Neurology. We will treat with her current analgesics, including [MEDICATION(S)], follow her level biochemically, and follow symptomatically and follow with further neurology recommendations as well. Review of R7's Psychiatric Evaluation dated 3/10/21 revealed under history of present illness, The patient is a [AGE] year old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to monitor blood sugars for 1 Resident (R36) of 5 residents reviewed for medication regimen, resulting in R36 having an excessively high blood sugar when it was discovered and potential for serious harm or death related to prolonged high blood sugars. Findings include: Review of R36's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Acute [CONDITION(S)] ([CONDITION(S)]), Morbid (severe) obesity, acute [CONDITION(S)], [CONDITION(S)] due to streptococcus pneumoniae, neuromuscular dysfunction of bladder (neurological condition of the bladder), difficulty walking, anxiety disorder, sleep apnea and [CONDITION(S)]. During record review on 2/9/22 at 4:00 PM, the Surveyor notified the Nursing Home administrator (NHA) that blood sugars and laboratory results were not located in R36 medical record. Review of R36's Medication Administration Record (MAR) for February 2022 revealed R36 had a blood sugar taken on 2/9/22 at 11:00 PM that read 430 (high, normal is 70-110) and a blood sugar was taken on 2/10/22 at 7:00 AM that read 317 (high, normal is 70-110). On 2/10/22 at 8:40 AM, the Director of Nursing (DON) verified R36 had not had any finger stick blood sugar readings since last November as the nurse writing orders only ordered blood sugars for 7 days and no one caught the error. The DON said R36 did not have an A1C (laboratory test for blood sugar monitoring) in the last year. The DON said she took R36 blood sugar when she became aware last night, notified the physician, ordered an A1C and verified all other residents that were diabetic were getting blood sugar readings. The DON was not aware R36's blood sugar was 430 at 11:00 PM on 2/9/22 and was not aware that there was no record of the nurse calling the physician at 11:00 PM when R36's blood sugar was 430. The DON was asked to provide the laboratory findings and any information on physician notification of the 430 blood sugar on 2/9/22 at 11:00 PM. Upon exit no laboratory findings or physician notification were provided. Review of R36's progress note dated 2/9/22 at 6:20 PM revealed a note electronically signed by the DON, Blood sugar check 347, New order recd. (received) Review of R36's Medication Regimen Review dated 2/1/22 at 12:00 PM revealed the note was signed by Pharmacist N that documented, The resident's medication regimen contained no new irregularities. Review of R36's Medication Regimen Review dated 1/4/22 at 10:03 AM that documented, The resident's medication regimen contained no new irregularities. Review of R36's Medication Regimen Review for December 2021 was not located in R36's medical record. Review of R36's Medication Regimen Review dated 11/02/21 at 1:50 PM that documented, The resident's medication regimen contained no new irregularities. During a telephone interview with Pharmacist N on 2/10/22 at 9:30 AM, he confirmed that he did R36's pharmacy review on 2/1/22 and he should have verified nursing was monitoring R36's blood sugar, the readings and the Resident's A1C. The Pharmacist also verified nursing and the physician should have been monitoring R36's blood sugars and A1C. Pharmacist N did not offer any reason for this error.

This citation pertains to intake number MI 5541 and MI 5429 Based on interview and record review, the facility failed to prevent the abuse of 1 Resident (R137) of 2 Residents reviewed for abuse, resulting in R137 needing emergency room treatment when R22 hit R137 in the eye. Findings include: R22 Review of R22's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 22 was not his own responsible party. Review of R22's Psychiatric Hospital history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff reports that the patient became physically aggressive (throwing, kicking, and attempting to punch a nurse) for asking him to lower his music. The patient continuously raises volume, causing disruption to other residents. The patient tore a metal decoration off the wall and was throwing chips in his room. He has been refusing hygiene care, is restless, and continues to be physically aggressive, per facility, on 11/01/21. Patient is calm and cooperative during examination. Patient is seen within 24 hours of admission. After Past Psychiatric History revealed, As mentioned above, patient has a history of [CONDITION(S)] with 4 previous admissions starting at age 25. Details of these admission are unknown. After Personal history revealed, Patient has resided at his current facility for approximately 2-1/2 weeks. Prior to that, he was placed at (name of sister facility) but was sent to the emergency room due to violent behavior and not returned to that facility. Review of R22's Medical Progress Note dated 12/5/21 revealed under history, This is a [AGE] year-old Afro-American gentleman with a past medical history significant for chronic dementia with recurrent behavioral disturbances, chronic [CONDITION(S)], initial Psychiatric hospitalization at [AGE] years old, hypertension, chronic obstructive pulmonary disease, mild chronic [CONDITION(S)], Type 2 diabetes mellitus, [CONDITION(S)] difficulty ambulation, predominantly wheelchair bound, chronic anxiety, who was in 2 previous sister facilities, although because of behavioral disturbances was frequently sent to the hospital and most recently last month after being treated pharmacologically and seems to be doing fairly good. Review of R22's psychiatric consult note dated 12/17/21 revealed, 12/13/21 at 10:00 AM, R 22 was 'slamming his drawer shut in his room at 0800 which irritated his roommate. The roommate went to R22's side of the room and was witnessed being hit on the left forehead area the roommate's closed fist (right hand). R22 had a hold of the roommates left hand. Under assessment and plan revealed, Recommend changing [MEDICATION(S)] 1 mg (anxiety medication) every 8 hour PRN (as needed) TID (three times a day) to [MEDICATION(S)]).5 mg (medication for sedation, and anxiety) every 8 hours PRN x 14 days, as resident is already taking [MEDICATION(S)] and would not need two different benzo's (Benzodiazepines, a class of psychoactive medications) ordered. Would recommend having documentation every time PRN dosage is given with behavior note to consider whether or not this medication PRN should be continued, increased scheduled dosage or DC PRN dosage. Review of R22's Medical Progress Note dated 12/26/21 revealed under history, This is a [AGE] year-old Afro-American gentleman with a past medical history significant for chronic dementia with recurrent behavioral disturbances, chronic [CONDITION(S)], chronic obstructive pulmonary disease, mild chronic [CONDITION(S)], Type 2 diabetes mellitus, [CONDITION(S)] difficulty ambulation, predominantly wheelchair bound, chronic anxiety, previously residing in different facilities and homeless shelters, although because of behavioral disturbances has had recurrent hospitalization s with aggressive and violent behavior towards staff and residents. He was sent to the hospital yesterday with again violent, assaultive behavior with another resident and has returned very cooperative and seems to be doing OK currently. Review of R22's event report dated 12/25/21 at 7:25 AM revealed, resident was observed at 0725 hitting another resident in the face and grabbing onto a gown. Writer immediately separated both residents. (Name of police department) notified and were in at 0735 to speak with both residents and writer Full body skin assessment completed. Small scratch to forehead. Resident denies any pain/discomfort. Md notified and guardian notified via phone and aware of incident. New order to send resident to (name of hospital) ER for eval and treatment. Resident transferred via gurney (name of company) 0845 to (name of hospital) for eval and treat. Administrator notified immediately. Review of R22's progress note dated 12/25/21 at 12:06 PM revealed, Resident returned via ambulance cart to room A, EMT staff reported to this Nurse that resident was very compliant and pleasant with no behaviors. No apparent distress noted, oriented to staff, room and call bell. Review of R22's medical record revealed no behavior tracking documentation in relation to [MEDICATION(S)] PRN medication usage as directed in R22 psychiatric consultation dated 12/17/21. Review of R22's care plan revealed he had a care plan for Behavioral Symptoms dated 1/3/22 (10 day after he assaulted R137). Approaches included: keep distance between residents and other during hallucinations. See history listed above as resident had a long history of aggressive behavior prior to the assault on 12/25/21. No interventions were in R22's care plan prior to 1/3/22 to protect other residents from his aggressive behaviors. The facility was not able to locate any documentation that showed they were supervising or had implemented interventions to protect other residents from R22's known aggressive and physical behaviors. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 2/8/22 at 2:40 PM, the Surveyor followed up on her request for R22's behavior tracking, care plan and any increase in supervision notes. The DON and NHA were not able to locate any behavior tracking notes or notes that R22 was being supervised when he assaulted R137. The DON said behavior tracking notes are kept on the unit in a book. The DON found the behavior tracking book, but she could not locate any notes for R22 or R137. The Surveyor reviewed R22's care plan with the DON and NHA. There was no indication of when R22 needed close supervision or how the facility was going to supervise him when his behaviors escalated. There was no indication what interventions were placed for R22 before he hit R137 or when he returned to the facility after physically assaulting a resident. Upon exit no additional information was provided. Resident #137 Review of R137's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R137 was his own responsible party. Review of R137's progress note dated 12/25/21 at 7:25 AM revealed, Writer observed another resident hitting this resident in the face and grabbing onto his gown. Writer immediately separated both residents. Full body sin assessment completed with purple bruise to left lower eye areas, scattered scratches to right chest area and resident with c/o pain to right pinky finger, no swelling or redness noted to finger, pink in color. Resident became verbally aggressive with staff after writer assessed resident while stating, its Christmas and I have no family. Staff left resident to calm himself down and called 911 for report of altercation. Cleanse scattered scratches to right chest with soap and water, rinse and lota (unknown) till resolved q (every) shift. Writer asked resident what happened, and resident stated I was coming out of my room to get coffee and as I was propelling through the hallway resident grabbed at me and started hitting me. Review of R137's progress note dated 12/25/21 at 10:42 am revealed, R137 returned from ER at 10:30. Assessment shows bruising/very superficial abrased are to right chest (sp). Area cleansed. No dressing needed. He also shows 0.5 cm bruise under left eye. He states he will ask us for assist to move people-he states he was gently moving the other resident out of his way when the other resident started hitting him. He did have an [MEDICATION(S)] 10 mg (narcotic pain medication) at the ER.

This citation pertains to intake number MI 5541 and MI 5429 Based on interview and record review the facility failed to implement abuse policies to prevent the abuse of 1 Resident R137 of 2 Residents reviewed for abuse, resulting in R137 needing emergency room treatment when R22 hit R137 in the eye. Findings include: R22 Review of R22's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 22 was not his own responsible party. Review of R22's Psychiatric Hospital history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff reports that the patient became physically aggressive (throwing, kicking, and attempting to punch a nurse) for asking him to lower his music. The patient continuously raises volume, causing disruption to other residents. The patient tore a metal decoration off the wall and was throwing chips in his room. He has been refusing hygiene care, is restless, and continues to be physically aggressive, per facility, on 11/01/21. Patient is calm and cooperative during examination. Patient is seen within 24 hours of admission. After Past Psychiatric History revealed, As mentioned above, patient has a history of [CONDITION(S)] with 4 previous admissions starting at age 25. Details of these admission are unknown. After Personal history revealed, Patient has resided at his current facility for approximately 2-1/2 weeks. Prior to that, he was placed at (name of sister facility) but was sent to the emergency room due to violent behavior and not returned to that facility. Review of R22's Medical Progress Note dated 12/5/21 revealed under history, This is a [AGE] year-old Afro-American gentleman with a past medical history significant for chronic dementia with recurrent behavioral disturbances, chronic [CONDITION(S)], initial Psychiatric hospitalization at [AGE] years old, hypertension, chronic obstructive pulmonary disease, mild chronic [CONDITION(S)], Type 2 diabetes mellitus, [CONDITION(S)] difficulty ambulation, predominantly wheelchair bound, chronic anxiety, who was in 2 previous sister facilities, although because of behavioral disturbances was frequently sent to the hospital and most recently last month after being treated pharmacologically and seems to be doing fairly good. Review of R22's psychiatric consult note dated 12/17/21 revealed, 12/13/21 at 10:00 AM R22 was 'slamming his drawer shut in his room at 0800 which irritated his roommate. The roommate went to R22's side of the room and was witnessed being hit on the left forehead area the roommate's closed fist (right hand). R22 had a hold of the roommates left hand. Under assessment and plan revealed, Recommend changing [MEDICATION(S)] 1 mg (anxiety medication) every 8 hour PRN (as needed) TID (three times a day) to [MEDICATION(S)]).5 mg (medication for sedation, and anxiety) every 8 hours PRN x 14 days, as resident is already taking [MEDICATION(S)] and would not need two different benzo's ordered. Would recommend having documentation every time PRN dosage is given with behavior note to consider whether or not this medication PRN should be continued, increased scheduled dosage or DC PRN dosage. Review of R22's Medical Progress Note dated 12/26/21 revealed under history, This is a [AGE] year-old Afro-American gentleman with a past medical history significant for chronic dementia with recurrent behavioral disturbances, chronic [CONDITION(S)], chronic obstructive pulmonary disease, mild chronic [CONDITION(S)], Type 2 diabetes mellitus, [CONDITION(S)] difficulty ambulation, predominantly wheelchair bound, chronic anxiety, previously residing in different facilities and homeless shelters, although because of behavioral disturbances has had recurrent hospitalization s with aggressive and violent behavior towards staff and residents. He was sent to the hospital yesterday with again violent, assaultive behavior with another resident and has returned very cooperative and seems to be doing OK currently. Review of R22's event report dated 12/25/21 at 7:25 AM revealed, resident was observed at 0725 hitting another resident in the face and grabbing onto a gown. Writer immediately separated both residents. (Name of police department) notified and were in at 0735 to speak with both residents and writer Full body skin assessment completed. Small scratch to forehead. Resident denies any pain/discomfort. Md notified and guardian notified via phone and aware of incident. New order to send resident to (name of hospital) ER for eval and treatment. Resident transferred via gurney (name of company) 0845 to (name of hospital) for eval and treat. Administrator notified immediately. Review of R22's progress note dated 12/25/21 at 12:06 PM revealed, Resident returned via ambulance cart to room A, EMT staff reported to this Nurse that resident was very compliant and pleasant with no behaviors. No apparent distress noted, oriented to staff, room and call bell. Review of R22's medical record revealed no behavior tracking documentation in relation to [MEDICATION(S)] PRN medication usage as directed in R22 psychiatric consultation dated 12/17/21. Review of R22's care plan revealed he had a care plan for Behavioral Symptoms dated 1/3/22 (10 day after he assaulted R137). Approaches included: keep distance between residents and other during hallucinations. See history listed above as resident had a long history of aggressive behavior prior to the assault on 12/25/21. No interventions were located in R22's care plan prior to 1/3/22 to protect other residents from his aggressive behaviors. The facility was not able to locate any documentation that showed they were supervising or had implemented interventions to protect other residents from R22's known aggressive and physical behaviors. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 2/8/22 at 2:40 PM the Surveyor followed up on her request for R22's behavior tracking, care plan and any increase in supervision notes. The DON and NHA were not able to locate any behavior tracking notes or notes that R22 was being supervised when he assaulted R137. The DON said behavior tracking note are kept on the unit in a book. The DON found the behavior tracking book, but she could not locate any notes for R22 or R137. The Surveyor reviewed R22 care plan with the DON and NHA. There was no indication of when R22 needed close supervision or how the facility was going to supervise him when his behaviors escalated. There was no indication what interventions were placed for R22 before he hit R137 or when he returned to the facility after physically assaulting a resident. Upon exit no additional information was provided. Resident #137 Review of R137's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R137 was his own responsible party. Review of R137's progress note dated 12/25/21 at 7:25 AM revealed, Writer observed another resident hitting this resident in the face and grabbing onto his gown. Writer immediately separated both residents. Full body sin assessment completed with purple bruise to left lower eye areas, scattered scratches to right chest area and resident with c/o pain to right pinky finger, no swelling or redness noted to finger, pink in color. Resident became verbally aggressive with staff after writer assessed resident while stating, its Christmas and I have no family. Staff left resident to calm himself down and called 911 for report of altercation. Cleanse scattered scratches to right chest with soap and water, rinse and lota (unknown) till resolved q (every) shift. Writer asked resident what happened, and resident stated I was coming out of my room to get coffee and as I was propelling through the hallway resident grabbed at me and started hitting me. Review of R137's progress note dated 12/25/21 at 10:42 am revealed, R137 returned from ER at 10:30. Assessment shows bruising/very superficial abrased are to right chest (sp). Area cleansed. No dressing needed. He also shows 0.5 cm bruise under left eye. He states he will ask us for assist to move people-he states he was gently moving the other resident out of his way when the other resident started hitting him. He did have an [MEDICATION(S)] 10 mg (narcotic pain medication) at the ER.

This citation pertains to intake number 1 This citation has 2 Deficiency statements. DPS #1 Based on interview and record review, the facility failed to implement a care plan to prevent abuse of 1 Resident R137 of 2 Residents reviewed for abuse, resulting in R137 needing emergency room treatment when R22 hit R137 in the eye. Findings include: R22 Review of R22's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 was not his own responsible party. Review of R22's Psychiatric Hospital history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff reports that the patient became physically aggressive (throwing, kicking, and attempting to punch a nurse) for asking him to lower his music. The patient continuously raises volume, causing disruption to other residents. The patient tore a metal decoration off the wall and was throwing chips in his room. He has been refusing hygiene care, is restless, and continues to be physically aggressive, per facility, on 11/01/21. Patient is calm and cooperative during examination. Patient is seen within 24 hours of admission. After Past Psychiatric History revealed, As mentioned above, patient has a history of [CONDITION(S)] with 4 previous admissions starting at age 25. Details of these admission are unknown. After Personal history revealed, Patient has resided at his current facility for approximately 2-1/2 weeks. Prior to that, he was placed at (name of sister facility) but was sent to the emergency room due to violent behavior and not returned to that facility. Review of R22's Medical Progress Note dated 12/5/21 revealed under history, This is a [AGE] year-old Afro-American gentleman with a past medical history significant for chronic dementia with recurrent behavioral disturbances, chronic [CONDITION(S)], initial Psychiatric hospitalization at [AGE] years old, hypertension, chronic obstructive pulmonary disease, mild chronic [CONDITION(S)], Type 2 diabetes mellitus, [CONDITION(S)] difficulty ambulation, predominantly wheelchair bound, chronic anxiety, who was in 2 previous sister facilities, although because of behavioral disturbances was frequently sent to the hospital and most recently last month after being treated pharmacologically and seems to be doing fairly good. Review of R22's psychiatric consult note dated 12/17/21 revealed, 12/13/21 at 10:00 AM R 22 was 'slamming his drawer shut in his room at 0800 which irritated his roommate. The roommate went to R22's side of the room and was witnessed being hit on the left forehead area the roommate's closed fist (right hand). R22 had a hold of the roommates left hand. Under assessment and plan revealed, Recommend changing [MEDICATION(S)] 1 mg (anxiety medication) every 8 hour PRN (as needed) TID (three times a day) to [MEDICATION(S)]).5 mg (medication for sedation, and anxiety) every 8 hours PRN x 14 days, as resident is already taking [MEDICATION(S)] and would not need two different benzo's ordered. Would recommend having documentation every time PRN dosage is given with behavior note to consider whether or not this medication PRN should be continued, increased scheduled dosage or DC PRN dosage. Review of R22's Medical Progress Note dated 12/26/21 revealed under history, This is a [AGE] year-old Afro-American gentleman with a past medical history significant for chronic dementia with recurrent behavioral disturbances, chronic [CONDITION(S)], chronic obstructive pulmonary disease, mild chronic [CONDITION(S)], Type 2 diabetes mellitus, [CONDITION(S)] difficulty ambulation, predominantly wheelchair bound, chronic anxiety, previously residing in different facilities and homeless shelters, although because of behavioral disturbances has had recurrent hospitalization s with aggressive and violent behavior towards staff and residents. He was sent to the hospital yesterday with again violent, assaultive behavior with another resident and has returned very cooperative and seems to be doing OK currently. Review of R22's event report dated 12/25/21 at 7:25 AM revealed, resident was observed at 0725 hitting another resident in the face and grabbing onto a gown. Writer immediately separated both residents. (Name of police department) notified and were in at 0735 to speak with both residents and writer Full body skin assessment completed. Small scratch to forehead. Resident denies any pain/discomfort. Md notified and guardian notified via phone and aware of incident. New order to send resident to (name of hospital) ER for eval and treatment. Resident transferred via gurney (name of company) 0845 to (name of hospital) for eval and treat. Administrator notified immediately. Review of R22's progress note dated 12/25/21 at 12:06 PM revealed, Resident returned via ambulance cart to room A, EMT staff reported to this Nurse that resident was very compliant and pleasant with no behaviors. No apparent distress noted, oriented to staff, room and call bell. Review of R22's medical record revealed no behavior tracking documentation in relation to [MEDICATION(S)] PRN medication usage as directed in R22 psychiatric consultation dated 12/17/21. Review of R22's care plan revealed he had a care plan for Behavioral Symptoms dated 1/3/22 (10 day after he assaulted R137). Approaches included: keep distance between residents and other during hallucinations. See history listed above as resident had a long history of aggressive behavior prior to the assault on 12/25/21. No interventions were located in R22's care plan prior to 1/3/22 to protect other residents from his aggressive behaviors. The facility was not able to locate any documentation that showed they were supervising or had implemented interventions to protect other residents from R22's known aggressive and physical behaviors. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 2/8/22 at 2:40 PM the Surveyor followed up on her request for R22's behavior tracking, care plan and any increase in supervision notes. The DON and NHA were not able to locate any behavior tracking notes or notes that R22 was being supervised when he assaulted R137. The DON said behavior tracking note are kept on the unit in a book. The DON found the behavior tracking book, but she could not locate any notes for R22 or R137. The Surveyor reviewed R22 care plan with the DON and NHA. There was no indication of when R22 needed close supervision or how the facility was going to supervise him when his behaviors escalated. There was no indication what interventions were placed for R22 before he hit R137 or when he returned to the facility after physically assaulting a resident. Upon exit no additional information was provided. Resident #137 Review of R137's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R137 was his own responsible party. Review of R137's progress note dated 12/25/21 at 7:25 AM revealed, Writer observed another resident hitting this resident in the face and grabbing onto his gown. Writer immediately separated both residents. Full body sin assessment completed with purple bruise to left lower eye areas, scattered scratches to right chest area and resident with c/o pain to right pinky finger, no swelling or redness noted to finger, pink in color. Resident became verbally aggressive with staff after writer assessed resident while stating, its Christmas and I have no family. Staff left resident to calm himself down and called 911 for report of altercation. Cleanse scattered scratches to right chest with soap and water, rinse and lota (unknown) till resolved q (every) shift. Writer asked resident what happened, and resident stated I was coming out of my room to get coffee and as I was propelling through the hallway resident grabbed at me and started hitting me. Review of R137's progress note dated 12/25/21 at 10:42 am revealed, R137 returned from ER at 10:30. Assessment shows bruising/very superficial abrased are to right chest (sp). Area cleansed. No dressing needed. He also shows 0.5 cm bruise under left eye. He states he will ask us for assist to move people-he states he was gently moving the other resident out of his way when the other resident started hitting him. He did have an [MEDICATION(S)] 10 mg (narcotic pain medication) at the ER.

Based on interview and record review, the facility failed to meet professional standards and provide quality care related to diabetic care of 3 Residents ( R18, R36, R5 ) of 5 diabetic residents reviewed, resulting in poor blood sugar control and potential for serious medical complications. Findings include: R18 Resident #18 (R18) was admitted to the facility 11/12/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review the Minimum Data Set (MDS) assessments for 5/21/21 and 8/21/21 did not reflect a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS also reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the Resident was cognitively intact. The medical record reflects R18 can make her own medical decisions. Review of the Care Plan for R18 did not reveal a Care Plan for Diabetes Mellitus. The Care Plan did reflect a Nutrition Status Care Plan (page 8). However, this Care Plan did not reflect the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Goal and Approach (interventions) reflected a focus of weight management, meal assistance and swallowing. One intervention implemented 8/17/21 reflected Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of the Doctor's Orders reflected on 7/21/21 an order was entered for HGBA1C (every) three months. Review of the laboratory results for R18 reflected an HGBA1C result on 9/13/21. This indicated that the next HGBA1C was to be drawn on or about 12/13/21. However, review of the medical record did not reveal that an HGBA1C had been completed since 9/13/21. On 2/10/22 at 8:54 AM, the Director of Nursing (DON) acknowledged that the HGBA1C was not, and still has not been obtained as ordered. On 2/8/21 at 10:37 AM, an interview and record review were conducted with R18 in her room. R18 reported she does not receive a diabetic meal. R18 reported if it is on the printed menu she receives it. R18 reported she gets sweets, such as brownies with her meals. R18 provided a copy of her meal ticket that she reported came with her meal the morning of 2/8/22. This meal ticket was reviewed and reflected it was a breakfast ticket and indicated LCS (Low Concentrated Sweets) and No Sweets. R18 reported for a nighttime snack she is provided ice cream and chocolate milk. R18 reported she has never talked to a Dietician and that she has questions and concerns. On 2/9/22 at 11:11 AM, a telephone interview was conducted with Registered Dietician (RD) AA. RD AA reported she started at the facility as the Registered Dietician in August of 2021. RD AA reported she has never physically been in the facility or seen any facility residents face to face. RD AA was asked, from a professional standards perspective, if it was acceptable to assess and document on residents without seeing the residents face to face. RD AA reported she was told by her corporate superior it was ok. RD AA reported that the RD is responsible for the high risk residents to include diabetics and residents that receive nutrition by tube feedings. RD AA reported she doesn't think she has to be in-house for this. RD AA reported she is in contact with the Certified Dietary Manager (CDM) and is supposed to oversee the CDM eight hours a month but did not give an explanation how this was accomplished remotely. AD AA indicated that R18 is non-complainant with maintaining a diabetic lifestyle. RD AA indicated she was not aware that R18 was overdue on her labs. RD AA reported diabetic residents will be provided the same meals offered other residents just in smaller portions. On 2/9/22 at 1:05 PM, an interview was conducted in the facility kitchen with Cook/ Dietary Aide (CDA) Z. CDA Z was asked if diabetic residents receive the same size portions as other residents. CDA Z reported residents will only get different size portions If their healthcare professional orders like half portions. Review of the Doctor's Orders for R18 revealed an order entered 11/23/21 for (Low Concentrated Sugar) regular texture thin liquids diet. The order did not specify smaller or half portions. Review of the Electronic Medical Record (EMR) Progress Notes reflected a Quarterly Assessment documented by RD AA on 8/17/21 which acknowledged R18 was a new diabetic, had diabetic education from the CDM (7/28/21) and that Pre (sic) documentation resident is non-compliant of diet restriction; orders out 1-2x /wk; pizza, burgers and other fast food. The next Dietary documentation in the Progress Notes reflected a (remote) Annual Assessment entered by RD AA on 11/23/21 which indicated the Resident had no skin breakdown and no [CONDITION(S)] noted. This Annual Assessment included the same line from 8/17/21 of, Pre (sic) documentation resident is non-compliant of diet restriction; orders out 1-2x /wk; pizza, burgers and other fast food. The Progress Notes from the time of the remote Quarterly Assessment on 8/17/21 to the remote Annual Assessment by RD AA on 11/23/21 were reviewed. The review revealed two entries. The first entry on 8/24/21 at 9:07 PM reflected that R18 Was working hard to adjust diet to maintain (blood sugar) readings. A second Progress Note entry reflected on 10/20/21 at 8:52 PM that R18 was non-complainant with food and drink. This entry did not specify if this was food ordered from outside the facility by R18 or if this was from the offered evening snack. No other documentation was found in the Progress Notes that reflected R18 was non-complaint or had received further dietary education during that time. Neither the Quarterly or Annual Assessment documentation completed by RD AA reflected a review to ensure a Care Plan was in place that addressed generic or personalized interventions for a new diabetic Resident. Review of the EMR for R18 did not reveal any Physician documentation since 8/14/21. An EMR Nursing Progress Note of 9/12/21 at 10:38 PM revealed a Physician encounter with R18 when the Resident asked about weight loss. The nursing documentation reflected the Physician instructed the Resident speak with the Dietician. However, no order for a Dietary consult was found or is a Dietician encounter documented except for the remote Annual Assessment completed by RD AA on 11/23/21. No further Dietary documentation is noted as of 2/10/22. On 2/9/22 at 11:43 AM, a telephone interview was conducted Medical Director (MD) I MD I reported he had evaluated R18 five or six times since August of 2021. MD I was informed no documentation was found the EMR of these encounters. MD I reported he did not know that the lab test for the HGBA1C had not been completed and indicated he would have addressed an abnormal value if the result had been provided to him. Review of the history of the Doctors Orders for R18 from 7/19/21 to 2/10/22 reflect 83 DO changes and administrations of insulin apart from the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . These adjustments and administrations were implemented in response to continued and successive elevated blood sugar test results. No documentation was found in the Progress Notes that staff had informed or discussed with the Resident the change in types of insulin or the frequent ordered dose adjustments. The laboratory result for the HGBA1C of 9/13/21 was 10.1 with a normal range considered by the lab to be 4.3 to 6.0. The HGBA1C lab ordered by the Dr. that was to be repeated in three months was not obtained despite alleged monitoring by the Physician, Nursing and Dietary. The Physician alleged encounters and evaluations of the Resident since 8/14/21 but no documentation of these encounters were provided by survey exit. The EMR reflects one face to face by the CDM of Dietary when the Resident was first diagnosed with diabetes in July 2021. RD AA reported she did not assess R18 in-person. RD AA documented a Quarterly and Annual assessments remotely documenting persistent non-compliance of the Resident without basis found in the EMR Progress Notes. Furthermore, no Plan of Care by any discipline had been established to address treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R36 Review of R36's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During record review on 2/9/22 at 4:00 PM, the Surveyor notified the Nursing Home administrator (NHA) that blood sugars and laboratory results were not located in R36's medical record. Review of R36's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/22 at 8:40 AM, the Director of Nursing (DON) verified R36 had not had any finger stick blood sugar readings since last November as the nurse writing orders only ordered blood sugars for 7 days and no one caught the error. The DON said R36 did not have an A1C (laboratory test for blood sugar monitoring) in the last year. The DON said she took R36 blood sugar when she became aware last night, notified the physician, ordered an A1C and verified all other residents that were diabetic were getting blood sugar readings. The DON was not aware R36's blood sugar was 430 at 11:00 PM on 2/9/22 and was not aware that there was no record of the nurse call the physician at 11:00 PM when R36's blood sugar was 430. The DON was asked to provide the laboratory findings and any information on physician notification of the 430 blood sugar on 2/9/22 at 11:00 PM. Upon exit no laboratory findings or physician notification were provided. Review of R36's progress note dated 2/9/22 at 6:20 PM revealed a note electronically signed by the DON, Blood sugar check 347, New order recd. (received) Review of R36's Medication Regimen Review dated 2/1/22 at 12:00 PM revealed the note was signed by Pharmacist N that documented, The resident's medication regimen contained no new irregularities. Review of R36's Medication Regimen Review dated 1/4/22 at 10:03 that documented, The resident's medication regimen contained no new irregularities. Review of R36's Medication Regimen Review for December 2021 was not located in R36's medical record. Review of R36's Medication Regimen Review dated 11/02/21 at 1:50 PM that documented, The resident's medication regimen contained no new irregularities. During a telephone interview with Pharmacist N on 2/10/22 at 9:30 AM, he confirmed that he did R36 pharmacy review on 2/1/22 and he should have verified nursing was monitoring R36's blood sugar, the readings and his A1C. The Pharmacist also verified nursing and the physician should have been monitoring R36's blood sugars and A1C. Pharmacist N did not offer any reason for this error. Review of the facility job description titled Registered Dietitian dated 7/1/17, revealed under, Responsibilities and Duties: Reviews menus meeting requirements for variety and rotation of menu items. Completes consults for at risk residents including but not limited to tube feeders, TPN, [CONDITION(S)], diabetics, complex wounds, and develops plan of care. Monitors resident weights and participates in resident weight committee at each facility quarterly or more frequently. Participates in QAPI Committee at each facility quarterly or more frequently. Monitors and reviews MDS (Minimum Date Set) assessments and care plans for at risk residents completed by facility staff. Monitors facility compliance with food safety and sanitation practices monthly and provides feedback to NHA (Nursing Home Administrator) and Kitchen Manager. R5 Review of R5's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the dietary note for R5 entered by Registered Dietician (RD) AA on 1/25/22 at 1:26 PM. The entry reflected it was an Annual nutritional status. The entry reflected a current body weight of 116 .6 ponds (lbs.) and that the Resident's weight was trending downward. The documentation reflected that R5 will refuse meals (related to) outside side and items in room. The entry reflected that R5 denied any chewing or swallowing problems and that no skin breakdown or [CONDITION(S)] were noted. It was noted that the following text appeared exactly was entered on 8/17/21, and unknown UBW, POC goal for weight within 115-130# Diet is NASP is being tolerated. Feeds self with tray set up in room, Current intakes are variable of 0 -100% mostly 76 -10% of meals pre (sic) nursing, Denies any chewing /swallowing issues, Resident has natural teeth. Skin with no breakdowns (sic), no n/v/c/d, no [CONDITION(S)] noted. These statements indicate that RD AA had discussed nutrition with R5 and did not observe any skin issues or [CONDITION(S)]. On 2/3/22 at 4:14 PM, R5 reported he has not talked to an RD. R5 reported he doesn't know of an RD or met anyone with the name of the RD. On 2/9/22 at 11:11 AM, a telephone interview was conducted with Registered Dietician (RD) AA. RD AA reported she started at the facility as the Registered Dietician in August of 2021. RD AA reported she has never physically been in the facility or seen any facility residents face to face. RD AA was asked, from a professional standards perspective, if it was acceptable to assess and document on residents without seeing the residents face to face. RD AA reported she was told by her corporate superior it was ok.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent, assess and treat 2 Residents (R21 and R23) wounds, resulting in R21 developing a stage 4 pressure ulcer and R23 developing multiple areas of skin breakdown and experience pain related to skin break down. Findings include: R21 R21 was originally admitted to the facility 10/8/19. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected R21 was severely cognitively impaired, was at risk for the development of pressure sores but did not have any pressure sores or other skin conditions at the time of this MDS assessment. The MDS reflected R21 was totally dependent on staff for bed mobility, eating, and toileting. On 1/25/22 at 9:27 AM, the Director of Nursing (DON) reported that R21 has a Stage Three pressure sore that appeared around a month ago. The DON reported this pressure sore was not reflected on the facility 802 or the 672 forms provided to the survey team on 1/23/22. Review of the MDS dated [DATE] reflected R21 has a Stage Four pressure sore. Review of the Electronic Medical Record (EMR) for R21 revealed a Admission Body assessment dated [DATE] at 11:23 PM that reflected R21 had returned from the hospital. The document reflected R21 did not have any pressure sores, rashes, or bruises. The document reflected No skin issues noted. The EMR Weekly Skin Assessment for R21 dated 12/4/21 at 2:28 AM reflected an Induration - coccyx and that this area was Non-Blanchable. A Care Plan was initiated on 12/4/21 that reflected the Problem of a Pressure Sore and Resident has a pressure ulcer to right buttock. Review of the EMR Progress Notes did not reflect measurements were obtained and documented. Review of the EMR for measurements of the pressure sore revealed an entry on 12/22/21 at 7:53 AM that R21 noted to have large open wound area to buttocks but no measurements were documented. On 1/1/22 at 7:25 AM an entry reflected a measurement of 6.5 x 2.5 (assume centimeters (cm)). The next wound measurement documentation located was an entry dated 1/31/22 at 4:49 PM with a notation of Recorded as Late Entry on 2/1/22 at 4:51 AM. The entry reflected that the wound measured I (length)- 6.8 cm x W (width) - 5.0cm with slough . no depth recorded. The measurement entered on 2/1/22 reflected an increase of 0.3 cm in length and a doubling of the width measurement. Review of the EMR Progress Notes for R21 reflected an entry from Registered Dietician (RD) AA dated 12/7/21 at 10:51 AM that revealed Skin with no breakdowns which indicated RD AA was not aware that a pressure sore had been identified on 12/4/21. The entry reflected a weight loss concern for R21 but that there would be no change of the nutritional plan. On 2/9/22 at 11:11 AM, a telephone interview was conducted with RD AA. RD AA reported she started at the facility as the Registered Dietician in August of 2021. RD AA reported she has never physically been in the facility or seen any facility residents face to face. RD AA reported that the RD is responsible for the high risk residents. R23 R23 was originally admitted to the facility 11/6/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected R23 was totally dependent on staff for bed mobility and transfers. Section M of the MDS reflected R23 was at risk for the development of pressure sores but did not have any pressure sores or healed pressure sores at the time of this MDS assessment. Review of the Electronic Medical Record (EMR) of R23 revealed each Weekly Skin Assessment from 11/25/21 to 1/20/22 reflected Reddened - buttocks- (treatment) in place. No further findings are documented. Review of the Prescription Order for R23 dated 11/29/21 revealed Triple Antibiotic ointment with instructions of cleanse excoriated areas to upper back and buttocks with soap and water, rinse and pat dry and apply (Triple Antibiotic Ointment twice a day) until resolved. Review of the General Order for R23 dated 12/30/21 reflected Magic Butt Cream with the special instructions to apply Magic Butt cream (twice a day and as needed). The shower and bath sheets provided by the facility with dates 11/11/21, 12/9/21, 12/16/21, 12/23/21, and 1/6/21 were reviewed. The format of the shower and bath sheets were divided into quarters for four separate dates. Each quarter depicts a human figure front and back. Below the figure is written Skin condition: None: Or Explain with blank lines to add any pertinent findings if the staff providing the care observes any skin conditions. Review of the shower and bath sheets for the above dates did not reflect any skin conditions were documented. The last shower and bath sheet was completed on 1/13/22 reflected a bed bath was given noting many small sores on body. On 1/24/22 at approximately 4:00 PM, an observation was conducted in the room of R23 for review of the Resident's skin. Staff present were Registered Nurse (RN) K and the DON. R23 appeared unkempt with greasy hair. R23 was not wearing a brief. R23 had a catheter and tubing that was not anchored to the bed. Noted yellow urine and white sediment in the tubing of the catheter. The R23 was turned with assistance onto his right side. The left buttocks presented with five open areas and surrounding excoriation and moisture associate skin damage (MASD). The right buttocks appeared red and noted several open areas. In total there were eight open areas of various sizes. RN K washed the buttocks with soap and water using a washcloth. Blood was noted on the washcloth with wiping. The large wound near the lower inner buttocks appeared to have slough that was removed with the wiping of the entire buttocks. This wound began to actively bleed prompting RN K to hold pressure to the area. Subsequently the wounds were measured beginning on the left upper lateral buttocks to the inner lower right buttocks and measured as follows: Wound #1) 1 centimeter (cm) x 1.3 cm, Wound #2) 0.8 cm x 1.2 cm, Wound #3) 0.6 cm x 1.4 cm, Wound #4) 1.5 cm x 2.7 cm, Wound #5) 1.7 cm x 2.7 cm, #6) 2.3 cm x 2.6 cm x 0.2 cm deep. This wound was located peri-rectal and appeared to be characteristic of a Stage II pressure sore. On the right buttocks across from wound #6 was the open wound that had been actively bleeding. This wound, #7), measured 2.4 cm x 2.8 cm x 0.3 cm deep and appeared as a Stage II pressure sore. Wound #8) on the right side measured 1cm x 1 cm. The wounds were addressed, and RN K assisted in rolling R21 to his other side. However, this was done without changing her gloves and hand sanitizing. On 1/25/22 at approximately 2:00 PM, an interview was conducted with R23 in his room. R23 reported he cannot remember the last time he was up in a wheelchair. R23 reported that there was no point in it as his bottom feels like shredded meat. R23 reported he cannot self-propel the wheelchair and usually just sits next to the bed. R23 reported he doesn't like to sit in his wheelchair because they leave me up for over two hours because they don't have time to help me. R23 reported when he is in bed staff prop him up on his side to keep pressure off his backside.

Based on observation, interview, and record review, the facility failed to administer resources effectively and efficiently to maintain the residents highest practicable physical, mental, and psychosocial well-being, resulting in a repeat immediate jeopardy for water temperatures, and immediate jeopardy for infection control, most deficiencies that were on the last annual survey were repeated and no active quality assurance program in place to resolve facility issues. Findings include: During the quality assurance review on 2/7/22 at 2:36 PM, the Nursing Home Administrator (NHA) said he has been the administrator since September 2021. The NHA said the former Director of Nursing (DON) ran the Quality Assurance (QA) meetings. The NHA found the QA book but could not locate records that showed all key personnel (NHA, DON and Medical Director) had attended the meetings since he was the administrator. The NHA could not speak to the process or what the facility had put in place after the immediate Jeopardy for hot water temperatures after the last annual survey. The NHA could not speak to a process improvement plan of any of the concerns that had been identified during this survey. See the 2567 dated 2/10/22 for the immediate jeopardy at 689 for water temperature too high and the immediate jeopardy at 880 for infection control related to COVID-19 concerns. The survey team identified 7 regulatory concerns at the harm level and two immediate jeopardy concerns. The team identified multiple concern that were systematic and led to care concerns for multiple residents. See the 2567 dated 2/10/22 for the details of all concerns. The NHA did not have any quality assurance program in place to identify or fix facility concerns.

Based on interview and record review, the facility failed to implement resident care policies related to diabetic care, wound care, activities of daily living, physician services, medical consultation, dental care, pharmacy reviews and medial coordination of care, resulting in multiple harm level deficiencies. Findings include: During the quality assurance (QA) review on 2/7/22 at 2:36 PM, the Nursing Home Administrator could not locate a QA plan that indicated the medical director was involved in coordination of care for the residents. QA meeting minutes did not indicate the Medical Director attended all quarterly QA meetings. See the 2567 dated 2/10/22 for care deficiencies related to lack of blood sugar/laboratory monitoring of diabetic patients. Lack of complete and accurate pharmacy reviews, lack of dental care, lack of wound care, and lack of activities of daily living all resulting in harm or the potential for serious harm.

Based on interview and record review, the facility failed to test residents that were exposed to COVID-19 when they became aware an employee tested positive for at the end of there shift on 1/26/22, resulting in delayed testing results for one resident R12 and the potential for other residents to have a delay in identification of the onset of COVID-19 which can lead to serious health problems and/or death. Findings include: During an interview with the Director of Nursing (DON) on 1/31/22 at 8:49 AM the DON said Licensed Practical Nurse (LPN) E tested positive for COVID-19 on 1/26/22 after her shift was over. The DON was asked for verification resident COVID-19 testing. The DON had assigned Licensed Practical Nurse (LPN) K to test residents for COVID-19 when LPN K was working on 1/26/22 along with her normal nursing duties. The morning of 1/31/22 the DON contacted LPN K and discovered resident COVID-19 testing was not done on 1/31/22. The facility began testing residents for COVID-19 on 1/31/22 when it was discovered testing was not done as required on 1/26/22. On 1/31/22 R12 tested positive for COVID-19 (5 days after standard testing was to begin) and was admitted to the hospital. R12 did not return to the facility prior to survey exit.

Based on observation, interview, and record review, the facility failed to effectively treat 1 Resident's pain (R7), resulting in R7 experiencing excruciating pain daily. Findings include: Review of R7's face sheet, no date, revealed, she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 had a legal guardian. During medication pass on 1/25/22 at 3:20 PM, R7 reported that she had pain in her face at a 10 on a 1-10 scale. R7 said she had [CONDITION(S)] and the medication [MEDICATION(S)] was not able to control her pain anymore. R7 said she had surgery years ago and the pain had come back. She said Doctor I said he could not give her a higher dose of [MEDICATION(S)], and this was very upsetting. R7 waited until the last minute to take her [MEDICATION(S)] as she can only take it 3 times a day and as it gets time for the next dose the pain gets out of control 3 times day. R7 told the surveyor about her past suicide attempts and reported this pain makes her want to end it. During a telephone interview with R7's legal guardian BB, BB expressed frustration with R7's Physician I not being able to control R7's [CONDITION(S)] pain. The guardian was aware that the [MEDICATION(S)] was affecting R7's blood sodium levels but BB was not aware of what the Neurologist recommendations were or what else could be done to control the [CONDITION(S)] pain. BB said no one had ever discussed a medical procedure called Gamma Knife with her to control the pain. BB said the facility does not share the neurology recommendations with her and they have not had enough staff for someone to sit down with her to review R7's medical records. During a telephone interview with R7's Physician I on 1/26/22 at 10:00 AM, Physician I said he was not aware that R7's [CONDITION(S)] pain was out of control. Physician I said he had R7 on the highest dose of [MEDICATION(S)] he could. Physician I had a pharmacist conference call into the telephone conversation, and he confirmed that Physician I was giving a higher dose of [MEDICATION(S)] than was recommended for [CONDITION(S)]. Physician I denied any knowledge of R7's neurologist recommending a procedure called Gamma Knife. Physician I said the facility contacted him about the Gamma Knife procedure today and he would do the referral today. Review of R7's electronic medical records revealed a Neurology note dated 5/26/21 that revealed the neurologist recommended Gamma Knife consultation related to R7's [CONDITION(S)] pain. During an interview with the facility Social Worker (SW) A on 1/26/22 at 3:37 PM, SW A reviewed R7's neurology notes in the medical record. A Neurology note dated 5/26/21 was located that recommended Gamma Knife consult related to [CONDITION(S)] pain. SW A said she was not the SW in the facility in May and was not aware of how the SW at the time followed up with medical consultation recommendations. SW A was not able to locate any notes in R7's medical record that indicated anyone including R7's Physician I had followed up with the May 26th, 2021, Neurologist recommendations. SW A said she had been taking R7 to her outside appointments since October 2021. SW A was able to find some handwritten notes that she had made after R7 went out to doctors since October 2021. SW A did not scan these notes in the medical record or document the recommendations in R7's medical record. SW A did not document informing R7's guardian O or physician I about the recommendations. SW A said she drives the residents to appointments, works as a Certified Nurse Aide (CNA) when the facility is short staffed and was not provided any training of expectations for follow-up or documentation when residents have outside appointments. SW A said she started the referral for R7 to have the Gamma Knife consultation today. Review of R7's Neurology consult note dated 9/27/21 at 4:13 PM revealed, The patient has also continued to have right facial pain. She was on a much higher dose of [MEDICATION(S)] but it was decreased and currently is on [MEDICATION(S)] 200 mg, 1 and ½ tablet bid (twice a day). Her sodium has drifted down from 135 to 124 today. She is quite upset that her [MEDICATION(S)] was decreased. She repeated said that she would never go off of it as that is the only medication which helped her [CONDITION(S)] pain. Her [MEDICATION(S)] level was 15.2 on 6/7/21. Review of R7's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note dated 6/20/21 (about 3 weeks after the Neurologist recommended a Gamma Knife consultation related to R7's [CONDITION(S)] pain) revealed no indication Physician I had reviewed the Neurologist recommendations or was aware that a referral was need for R7 to receive a Gamma Knife consultation. Under Plan revealed, 8. [CONDITION(S)]. We will treat with her current medication's and follow symptomatically and follow with neurology as well as need. Physician I's notes date 7/17/21, 8/14/21, 10/10/21, documented the same thing as the note 6/20/21. Review of R7's. Physician I's note dated 11/8/21 item 8 was changed slightly to read, [CONDITION(S)], intermittently symptomatically and follow up with neurology for further suggestions, might have to increase her analgesics if need. Physician I's note 12/5/21 revealed, 8. [CONDITION(S)], still symptomatic, continue [MEDICATION(S)], follow symptomatically and neurology follow up. Physician I's note dated 1/16/22 revealed, 8. [CONDITION(S)], still symptomatic, awaiting further recommendations from Neurology. We will treat with her current analgesics, including [MEDICATION(S)], follow her level biochemically, and follow symptomatically and follow with further neurology recommendations as well. Review of R7's Psychiatric Evaluation dated 3/10/21 revealed under history of present illness, The patient is a [AGE] year old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation pertains to intake numbers MI 762 and MI 050. Based on interview and record review, the facility failed to prevent misappropriation by a staff member for Resident #1, reviewed for misappropriation. This deficient practice resulted in an immediate jeopardy when a staff member misappropriated funds from Resident #1 who then owed a large outstanding balance to the facility, sustaining mental anguish, and the risk for involuntary discharge; and failed to report the embezzlement to the State Agency, law enforcement, conduct an investigation and audit to ascertain whether the staff member embezzled from other residents. Findings include: Resident #1 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #1 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 8 out of 15 which represents Resident #1 had moderate cognitive impairment. According to the Face Sheet Resident #1 was his own responsible party. A review of the Resident Statement dated 9/30/21 reflected a total balance due of $11,475 to the facility. The Notes reflected, Your account is three months PAST DUE and must be brought current to avoid involuntary discharge. The Statement with a print date of 11/10/21 provided by the facility reflected the patient pay amount of $2,297 each month for February and March 2021 and $2,337 each month for April through November 2021. The statement reflected a full payment was made for January 2021 and only partial payments made from February to September 2021 and no payments made from October and November 2021 leaving a balance of $11,475 owing. During an interview on 11/2/21 at 1:30 PM, this surveyor attempted to interview Resident #1 about his outstanding bill at the facility but Resident #1 was not able to answer specific questions pertaining to the outstanding balance only to say that (name of Former business office manager (BOM) J) had stolen money from him and the police know about it. Review of the progress noted dated 9/9/21 at 7:47 AM authored by Social Worker (SW) S reflected, The family is concerned about (name of Resident #1) having his debit card, I did a mini mental health assessment and afterwards talked to his (name of family member) about the need to have guardianship established. Review of the Mini-Mental State Examination dated 9/9/2021 assessed by SW S revealed a score of 13 out of 30 which represents moderate dementia. Review of the MDS dated [DATE], assessed by SW J, revealed Resident #1 had a BIMS of 8 out of 15 which represents Resident #1 had moderate cognitive impairment. Review of the Report of Physician or Mental Health Professional dated 11/2/21 (over 7 weeks after the Mini-Mental Exam on 9/9/21) reflected, 6. I believe the individual, due to these described conditions, is not presently able to make informed decisions in the following areas: check all that apply, determining where to live, consenting to supportive services, handling personal financial affairs, and authorizing or refusing medical treatment. During a telephone interview on 11/5/21 at 9:10 AM, Former BOM J stated that she was a distant family member to Resident #1. The Former BOM J stated, The deal was if I spend his money just make the payment .I never denied I owed him some money. I've been suspended. I didn't steal his money, but I used it. When asked what Resident #1's money was used for, the Former BOM J stated, I would buy him pop, food, cigarettes, and snacks. I used the debit card to withdraw cash from the ATM to pay his bill (patient pay amount). He'd complain about paying by checkbook because he'd say I just paid it. He was confused. When asked if Former BOM J ever used it for personal use, the Former BOM J stated, Yes, I never denied that I did. During a telephone interview on 11/3/21 at 10:44 AM, Resident #1's family member K stated that he called the facility on 10/11/21 and discovered Resident #1 owed over $10,000 on the patient pay account. In addition to that Resident #1's family member K was having a difficulty getting Resident #1's checkbook and debit card back from the Former BOM J. Resident #1's family member K stated that on 10/12/21 he called the police and met them at the facility to discuss this complaint. Resident #1's family member K said the facility eventually retrieved the checkbook from Former BOM J but was unable to get the debit card back, so he had the bank cancel the card. Resident #1's family member K stated the Former BOM J was a distant relative of Resident #1's and assisted him with paying his bills. Resident #1's family member K stated that Former BOM J would call each month to tell him that Resident #1's bill was paid and had $60 left over for the month. Resident #1's family member K stated he (Resident #1) kept telling us She's (Former BOM J) taking my money. Record review of an outside psychological assessment dated [DATE] done by Nurse Practitioner (NP) O reflected, Resident states that he has it very bad. Resident states he is upset because he has had thousands of dollars stolen from him by one of the workers in the facility. Resident states that his money has been stolen over the last 17-18 months and the Police are involved. Resident states he is very upset about this .Resident states he is upset that he had money stolen from him, reviewed with DON (Director of Nursing) who states that this is factual information (not a delusion). Resident's case is being investigated and Police are involved . During an interview on 11/5/21 at approximately 3:15 PM, Nurse D stated that recently Resident #1 has been upset and verbal about it. Nurse D states that Resident #1 complains daily that the Former BOM J owes him $18,000. Nurse D stated Resident #1 also complains that he no longer has his debit card because the Former BOM J cut it up so now he can't use it to get his money. During an interview on 11/5/21 at approximately 3:20 PM, CNA E stated that Resident #1 is upset daily. CNA E stated that Resident #1 told her that Former BOM J took his money and his debit card and he can't use it now. During an interview on 11/3/21 at 3:40 PM, the Nursing Home Administrator (NHA) stated Resident #1's family member K came to the facility on [DATE] and said that he did not think (name of the Former BOM J) has been paying Resident #1's whole bill. When asked if the allegation of the Former BOM J not paying the full patient pay amount for Resident #1 was reported to the State Agency, police, and investigated at the facility level, the NHA stated, No, I thought it was a family issue. The NHA stated he assumed that Resident #1's family member K had reported it to the police. During a record review and interview on 11/10/21 at approximately 2:45 PM with the Regional BOM M and the NHA, the Regional BOM M reviewed the patient pay collection notes with this surveyor. Except for one the initial note all of the documentation was entered by the Former BOM J. The Former BOM J documented from 4/7/21 - 7/8/21 and left her position in August of 2021 and went to another position within the company. When asked why the notes dropped off after 7/8/21 when there continued to be an outstanding balance to collect, the Regional BOM M stated that the Former BOM J should have made a note at least weekly until the balance was caught up but didn't. The patient pay amount records reflected the payments were received and documented by the Former BOM J. The Regional BOM M confirmed that it appears that the Former BOM J was bringing in payments in check and cash and applying them herself to the patient pay account for Resident #1. The NHA stated the facility does not have a policy or procedure for conflicts of interest with staff managing resident finances but in the future the facility would have another process for relatives to ensure there are no further conflicts. The facility was notified of Immediate Jeopardy (IJ) at F-602 on 11/5/21 at 12:50 PM was identified on 11/5/21 and began on 10/12/21, due to the facility's failure to report embezzlement and misappropriation of resident funds to the State of Michigan, and law enforcement, and failed to start an investigation. This deficient practice resulted in the Former BOM J systematically and continuously embezzling funds from Resident #1's bank account and not applying the full payment to the patient pay account since February 2021, along with Resident #1 verbalizing he is very upset that he has had thousands of dollars stolen from him. This deficient practice placed all residents at serious risk for the likelihood of ongoing abuse and misappropriation when the facility failed to investigate the reason that Resident #1 was suddenly going into arrears on his account and when made aware on 10/12/21, failed to report the embezzlement to the State Agency, law enforcement, conduct an investigation and audit to ascertain whether the Former BOM J embezzled from other residents. Immediacy was removed on 11/9/21 when the facility had the following in place: Removal Plan Tag Cited: F 602 Issue cited: Facility failed to report embezzlement or misappropriation of resident funds to the State of Michigan and law enforcement agency as well as the administrator failed to start an investigation. Identification of Resident affected or likely to be affected: While all residents have the potential to be affected, the affected area was identified to be isolated to one patient (Resident #1). Beginning 11/5-The Administrator Completed rounds in the facility/ checking to ensure no other residents were affected by this deficient practice. Beginning 11/5- The Nursing Home Administrator made a report to the State of Michigan and local law enforcement agency. Beginning 11/5- All staff were re-educated on Abuse including misappropriation of resident funds. Beginning 11/5-Resident #1 balance of $11,475 was written off by the Vice President of Operations. Beginning 11/5- The social worker will meet and follow up with Resident #1 to ensure that the resident has not suffered ill effects as well as the nursing staff document each shift of how Resident #1 is doing. The resident was referred to psychiatrist service as patient gave consent. Actions to Prevent Occurrence/Reoccurrence Upon receiving notice of resident misappropriation of funds, the facility took the following action: Beginning 11/5- Resident #1 was assessed by the charge nurse and physician VIA tele-health and noted no other concerns. Beginning 11/5-The Facility reviewed the Abuse policy including misappropriation of resident funds was reviewed and deemed appropriate Beginning 11/5- The social worker and Administrator interviewed all alert residents asking if they were abused or had any misappropriation of resident funds all alert residents stated no on 11/5. Beginning 11/5- The Social worker called the legal guardian or emergency contact for each resident who is not alert and asked if any patient was abused or had any misappropriation of resident funds no new concerns were identified. Beginning 11/5 the regional director of operations gave the nursing home administrator a 1:1 education reviewing the abuse policy and procedures as well as reporting all allegations of abuse to the State of Michigan as well as reporting it to the local law enforcement as well as investigating all allegations of abuse. Beginning 11/5 after the nursing home administrator spoke with the patient and family the root cause analysis revealed patient is the friend of the former business office manager who was supposed to be paying the patient pay amount monthly per the resident request. Beginning 11/5 the corporate business office manager/designee will ensure any patients with a Patient pay amount is paid directly to the corporate business office manager or Administrator and will be provided a receipt of each transaction. Beginning 11/5 the facility Revised the process on how patient funds will be received and given out with the new business office manager handles the first step as when receiving funds or giving funds from patient trust will be verified by the Nursing home administrator/designee day to day. This process will reduce any embezzlement and will have a check and balance. Beginning 11/5 The Administrator/designee will audit 10% of the current resident population twice a week for four weeks than monthly/prn to ensure that no residents were abused which will include misappropriation of resident funds. Residents who are not alert the administrator/designee will contact the legal guardian or emergency contact. Findings will be reviewed and discussed in QA. Beginning 11/5 the regional director of operations will audit the center 10% of the current resident population twice a week for 4 weeks than monthly/prn to ensure any allegation of abuse is investigated and reported to the State of Michigan as well as the local law enforcement. Results will be reviewed and discussed in QA. Beginning 11/5 (Name of Former BOM J) was terminated and no longer works for the company at all. (Name of Former BOM J) was initially suspended on 10/12 due to prior investigation from the company. Beginning 11/5 administrator called the police to make a formal report. Beginning 11/5 it was determined (name of Former BOM J) only possessed a certificate of completion for actives professional, she was never certified per the National Certification Council for Activities Professionals. She also never possessed a social worker tech license per [NAME] search. Beginning on 11/9 education was provided to the new interim BOM with addendums made to the plan. During an interview and record review on 11/10/21 at 8:15 PM, the NHA provided an addendum with staff education to the removal plan with the date initiated of 11/9/21 related to the Resident Trust Fund Policy and handling of resident funds and confirmed the last removal plan item was started on 11/9/21 instead of 11/8/21. Although the IJ was removed on 11/9/21, the facility remained out of compliance at a scope of isolated and severity of Actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

Based on observation, interview, and record review, the facility failed to properly monitor and maintain safe water temperatures, and remove snow and ice from emergency exits, resulting in the high likelihood of scalding and slipping hazards, resulting in an immediate jeopardy for all 26 residents in the facility. Immediate Jeopardy was identified: 02/10/20 at 1:37 PM. It began on 01/08/20. The Administrator was notified of the Immediate Jeopardy: 02/10/20 at 4:01 PM The Facility was requested for a written plan of correction for abatement: 02/10/20 at 4:01 PM Facts Supporting Immediate Jeopardy: On 02/10/20 at 9:20 AM, Certified Dietary Manager T stated that the facility currently only has a part time Maintenance worker. On 02/10/20 at 1:37 PM, the shared bathroom hand sink for rooms [ROOM NUMBERS] was measured using a Thermapen digital probe thermometer and found to be at 125 degrees Fahrenheit. On 02/10/20 at 1:41 PM, the shared bathroom hand sink for rooms [ROOM NUMBERS] was measured using a Thermapen digital probe thermometer and found to be at 122 degrees Fahrenheit. During an interview on 02/10/20 at 1:47 PM, Previous Maintenance Employee (PME) S was queried on the hot water in the facility and stated that the water heater was replaced a couple of weeks prior. At this time, during an inspection of the water heater, PME S was observed to adjust the water heater to 120 degrees at the digital control module. PME S stated that it was set at 140 degrees Fahrenheit. On 02/10/20 at 1:49 PM, PME S stated that the newly installed water heater provides hot water for the two main halls (rooms 1-6 and 22-29). According to an invoice provided by (HVAC Contractor), the new water heater was installed on 01/06/2020. The following temperatures were measured on 02/10/20: At 1:55 PM, room [ROOM NUMBER] hand sink was measured at 126 degrees Fahrenheit, At 1:58 PM, room [ROOM NUMBER] hand sink was measured at 124.5 degrees Fahrenheit, At 2:00 PM, room [ROOM NUMBER] hand sink was measured at 129 degrees Fahrenheit, At 2:01 PM, room [ROOM NUMBER] hand sink was measured at 130.5 degrees Fahrenheit, At 2:09 PM, room [ROOM NUMBER] hand sink was measured at 128.6 degrees Fahrenheit, During an interview on 02/10/20 at 3:05 PM, Human Resources Staff (HR) R stated that she was responsible for measuring and documenting the water temperatures. HR R was asked by the surveyor if she knew the maximum allowable temperature for the water and she stated 120 degrees Fahrenheit. HR R was notified that some of the temperature logs were recorded above 120 degrees (121 and 122 degrees), and was queried if the high water temperatures were reported to anyone, and HR R stated, There is no one to report it to. HR R was queried on the procedure for taking the water temperature and stated that the water is let run for 3-5 minutes and then the temperature is taken with a dial thermometer. HR R was asked by the surveyor if she ever calibrates the thermometer and stated, No I don't. According to the facilities water temperature log, dated 1-22-2020, the temperature reflected 121 degrees for the bathroom of room [ROOM NUMBER] & 8. According to the facilities water temperature log, dated 1-8-2020, the temperature reflected 122 degrees for the bathroom of room [ROOM NUMBER] &6. During an interview on 02/10/20 at 3:30 PM, the Nursing Home Administrator (NHA) was queried on if any residents were harmed by the high-water temperatures and he stated no. On 2/10/2020 at 4:34 PM, PME S stated that he had flushed the hot water distribution system and the water temperature was averaging around 115 degrees. During an interview on 2/11/20 at approximately 1:30 PM, the Director of Nursing (DON) provided the Surveyor with the specific information of the resident records showing the following residents demonstrated low cognition level as evidenced by BIMs scores, and are independently ambulatory, resulting in a high likelihood of accidental exposure to excessive water temperatures: Resident 1; BIMS - 4 Resident 10; BIMS - 6 Resident 12; BIMS - 0 Resident 22; BIMS - 0 Resident 25; BIMS - 0 During an interview on 2/11/20 at 3:33 PM, PME S was queried on the East hall water temperatures, which are not supplied water by the newly installed water heater, and stated that the temperature of those dedicated water heaters that serve the East hall (rooms 30-39) had to be turned down in addition to the newly installed water heater, after the facility was notified of the high water temperatures on 2/10/20. According to the facilities policy titled, Water Temperatures, Safety of, dated, 7-1-2016, it noted, Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 F, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Facility Removal Plan (Facility) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility's failure to maintain water temperatures at a safe level. (Facility) believes that as of 2/10/2020, the measures it has implemented are sufficient to demonstrate that residents are receiving adequate prevention measures. 1. Resident identified to be affected by the alleged deficient practice. 0 Residents with the potential to be affected by the alleged deficient practice: Residents who reside on East and West unit are at risk. We have initiated a building wide audit of all water temperatures; including resident shower areas and public restrooms to assure water temperatures fall below 120 degrees F. We have corrected and adjusted the temperature and the water temperature is all within compliance, currently, 2. Systemic Measures 1. Implementing new water monitoring form for the maintenance director to use to log temperatures which is part of our policy (Maintenance director and Central supply manager have been in serviced and educated on the use of new form) 2. 8 faucets areas every day, twice a day, for 14 days 3. Daily thereafter of 8 faucets a day for 30 days 4. 8 faucets weekly thereafter In an event of non compliance at a certain faucet or area the water that is being supplied to that area of faucet will be shut off and the staff member will notify their immediate supervisor and maintenance Director will be notified to resolve the issue. QAPI 1. The Maintenance Supervisor will conduct random rounds on water temps 2. QAPI committee will review findings at least quarterly to review data on water temperatures and assure benchmarks are being met. This information will be used to drive policy changes, staff education, and training. On 02/10/20 at 9:06 AM, upon walking into the facility, one small path (the width of a snow shovel) was observed to be cleared of snow on the sidewalk to the entrance of the building. No salt was observed to be applied on the sidewalk. On 02/10/20 at 9:35 AM, the following doors were observed to have snow on the sidewalk/concrete path exiting the building: Exit door D Exit Door I was observed to be shoveled but not salted, leaving a thin layer of compressed snow. Exit door J Exit door H On 02/10/20 at 9:44 AM, a staff member was observed to begin shoveling the back entrance where residents exit to smoke. On 02/10/20 at 11:15 AM, exit door D and J were observed to still not be shoveled or salted During an interview on 02/11/20 at 2:18 PM, HR R was queried on who was responsible for snow removal and stated, We all are. On 02/11/20 at 3:02 PM, NHA stated in an email that the facility does not have a snow removal policy. During an interview on 2/10/2020 at 3:09 PM, Human Resource Director (HRD) R stated that she had monitored water temperatures in resident rooms. She was aware that the temperature logs revealed temperatures in resident room sinks exceeded 120 degrees, HRD R replied that she had no one to report to, that she did not know how to fix the temperatures, and that she was aware that the water temperatures should not exceed 120 degrees. During an interview on 2/11/2020 at 12:04 PM, Certified Nursing Assistant (CNA) Q stated that when something is broken or supplies are needed, that item is written on the Clipboard. The Clipboard was observed on a wall in the nurses station, and the items written included paper clips, paper, and no documentation of hot water concerns. When asked CNA Q stated that she had noticed the water was warm but did not write it down or tell anyone. During an interview on 2/12/2020 at 9:45 AM, the Director of Nursing (DON) stated that staff will just tell management staff that something needs to be fixed, and that she had started a log (Clipboard) for staff to write things they needed or items that have to be fixed. The DON was not aware of water in resident rooms being hot. Although the immediate jeopardy was removed on 2/10/2020, the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that has the potential to affect a large portion or all the facility's residents due to the inability to verify staff education, all policy updates, system changes, and sustained compliance. DPS B Based on observation, interview and record review, the facility failed to develop a resident appropriate intervention after a fall to prevent another fall for one resident (Resident #1) out of 4 residents reviewed for falls resulting in on going falls with the most recent fall being a fall with injury requiring emergency room intervention. Findings include: Resident #1 According to a facility face sheet no date noted reflected Resident #1 was an [AGE] year-old readmitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Resident #1's Brief Interview for Mental Status (BIMS) was 6 out of 15 indicating he was severely cognitively impaired. Resident #1 had been deemed incompetent to make his own decisions and had a family member making decisions for him. On 2/10/20 at 9:33 AM, Resident #1 was observed in a reclining chair, feet were up. Resident #1's posture was relaxed, and eyes were closed. on 2/10/20 at 12:12 PM, Resident #1 walked into the dining room with a wheeled walker. It was observed resident had a cut to the top right of his forehead with steri strips (medical grade tape) over the cut. On 2/10/20 at 1:43 PM, Resident #1 was observed in his room in his recliner. His right eye was observed to have reddish mood shaped bruising under it. Resident #1 was asleep. His feet were up in the recliner. During an interview on 2/10/20 at 1:49 PM, Registered Nurse (RN) H, she revealed that Resident #1 did fall recently and had a cut on his forehead. Review of a Physician order [REDACTED]. Sent to ER (emergency room ) for evaluation. On 2/10/20 at 4:00 PM, Resident #1 was observed walking alone in the hall near his room. Resident did not have his walker and was walking next to the wall, holding the wall. On 2/11/20 at 1:47 PM, review of incident accident (I/A) reports and investigations submitted by the Director of Nursing (DON) the I/A reports and investigations reflected: 1) On 8/23/19 at 2:30 PM in Resident #1's room, Resident was found on his side, laying on the floor. He stated he was trying to sit in his recliner, slid down. He received a skin tear. Intervention: redirect resident to ask for help when trying to transfer. Fall risk score reassessed on 8/23/19 and was 28 (above 10 is at risk for a fall). 2) On 12/24/19 at 10:35 PM resident was found in his room. Resident #1 stated he slipped out of bed and landed on his bottom. It was an unwitnessed fall. Intervention: make sure residents' mattress is pushed in and not hanging off the bed more to the left. Hospice also removed the mattress with the higher sides so he could get out of bed easier. 3) On 2/1/20 at 6:00 AM, Resident #1 was found in his room and was not sure what he was doing or what happened. This fall resulted in in injury to right eyebrow and top of his right wrist. This fall was unwitnessed. Interventions: 15 min checks for 24 hours. Family and physician notified. Statements reviewed. 2/3/2020 at 10:00 IDT review, .Hospice to supply a new bed that is adjustable height. Will keep at optimal level at this time. On 2/12/20 at 10:06 AM, during an interview with the DON regarding Resident #1's fall she revealed 8/23/19 at 2:30 PM in Resident #1's room, Resident was found on his side, laying on the floor. Trying to sit in his recliner, slid down. Resident #1 got a skin tear. This fall was unwitnessed she confirmed that neurological checks needed to be done. The DON confirmed that the new intervention to prevent another fall was to redirect resident to ask for help when trying to transfer. The DON agreed she doesn't feel Resident #1 was cognitively intact enough for instructions to ask for help to be retained. According to a facility policy titled, Falls - Clinical Protocol dated 6/1/16 reflected, .Cause Identification: For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .after a first fall, the staff (and physician, if possible) should watch the individual risk from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur .The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or management of falling and fall risk. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risk of serious consequences of falling .Monitoring and follow up: The staff and physician will monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls .If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention .has resolved. In the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions .

Based on Observation, interview and record review, the facility failed to prevent the development of pressure sores in 2 residents (Resident #2 and Resident #4) of 6 residents, from a total sample of 15 residents, resulting in development of pressure ulcers and open abrasion areas. Findings include: Record review of facility 'Pressure Ulcer Record' policy and procedure, dated 1/30/15, to document the presence of skin impairment/new skin impairment related to Pressure when first observed and weekly thereafter until the site is healed. One site will be recorded per page. Resident #2: Record review of Resident #2's 'Pressure Ulcer Record' dated 5/19/16 revealed a right buttocks pressure ulcer that was not present upon admission and was staged II, measurements 2.0 cm X 0.4 cm with a mushy/boggy periwound area noted. Record review of facility survey readiness book presented to surveyor on 5/24/16 at the beginning of the on-site survey revealed a list of pressure ulcers, which neither Resident #2 or Resident #4 where identified on the list as avoidable or unavoidable. Record review of facility 'Pressure Ulcer Protocol At-A-Glance' form (undated) revealed Stage II- Partial thickness skin loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. The pressure ulcer may also present as an intact or open/ruptured serum filled blister. If the blister is blood filled then it is a deep tissue injury. Stage III- Full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. The ulcer may include undermining or tunneling. Observation on 5/25/16 at 1:45 PM of Resident #2's right inner buttocks open area with Licensed Practical Nurse (LPN) N revealed a quarter size open area covered in barrier cream. LPN N had to clean the barrier cream off to observe the area and the Resident #2 cried out when the open area was touched. When cleansing the open area scant drainage was noted on cloth and the Resident #2 screamed out with discomfort when touching of area. Observation of the left inner buttocks revealed there to be a skinned over smaller red area. Record review of resident #2's 'Nurse Tech Information Kardex' revealed under the heading skin protection: Up for meals only. Record review of physician order dated 4/17/16 revealed up in chair for meals only. Record review of skin care plan dated 4/17/16 up for meals only. In an interview on 5/26/16 at 8:00 AM with Registered Nurse (RN) LL who stated she was nurse for the East Hall that day, revealed that she changed the treatment to Resident #2's right buttocks open area to a Derma Levin foam dressing. RN LL stated that she had already applied the dressing change and that she has used the Derma Levin on stage III and IV pressure ulcers before and that they heal nicely. RN KK stated that she changed the treatment from a barrier cream because it (open area) was not healing, and Certified Nurse Assistant (CNA) had told her that it was getting worse. Resident #4: Record review of Resident #4's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with severe cognitive impairment that required assistance with ADL's (Activity of Daily Living) and ambulatory. There were no pressure or skin issues noted on the MDS assessment. Medical [DIAGNOSES REDACTED]. Record review of Resident #4's nurse notes dated 5/14/16 at 10:00 PM revealed, 'N.O. (New Order) draw CBC 5/15/16 R/T (related to) increased temperature, drainage from wound, serous and greenish drainage. Temperature 101.3 before Tylenol given. 99.8 After Tylenol. (Location of wound not identified and no measurements noted) Record review of Resident #4's nurse notes dated 5/15/16 at 1:20 PM revealed 'Resident continued on neuros r/t fall, WNL (With in Normal Limits) for resident. No s/s of pain. Dressing to coccyx changed, moderate amount sanguinous drainage noted greenish/yellow exudate. (No measurements noted and no physician order noted for dressing) Record review of Resident #4's nurse notes dated 5/17/16 at 3:00 PM revealed '2 cm X 4 cm unstageable open area noted to coccyx, yellow slough noted. Doctor notified and treatment order written. Record review of Resident #4's 'Pressure Ulcer Record' dated 5/17/16 revealed that initial identification of pressure ulcer was not present upon admission. Pressure ulcer location identified as coccyx, unstageable with measurements of length 4 cm X width 2 cm (no depth measured) with yellow slough, edges with redness, purulent drainage with odor present. Record review of Resident #4's 'Pressure Ulcer Record' dated 5/18/16 by the wound care nurse Licensed Practical Nurse (LPN) H revealed staging UTD (per LPN H Unable To Determine) measurements of length 4 cm X width 2 cm (no depth measured) with yellow slough, edges with redness, moderate purulent drainage with odor present. Observation on 5/24/16 at 2:15 PM with Licensed Practical Nurse (LPN) H during Resident #4's wound dressing change revealed the LPN H to gather his supplies from the treatment cart proceed to the dementia unit to Resident #4's bathroom turned the faucet water on, applied gloves (no hand washing noted) and removed the old dressing from Resident #4's coccyx area. With the same gloves the LPN H performed a soap and water cleansing with wash cloth and rinsed with a water and pat dry. LPN H then removed the gloves and applied new gloves and applied skin prep around the edges of the pressure ulcer. LPN H then produced scissors from his pocket and cut a piece of Silasorb treatment material from an already opened package of Silasorb, cut a piece to fit the wound bed with the scissors from his pocket. There was no observation of the scissors being cleaned prior to the cutting the treatment material. the state surveyor observed the coccyx pressure ulcer and had the LPN H measure the wound at 1.2 cm X 3.2 cm. LPN H stated I would say it's a stage III, looking at it today. LPN H did not measure any depth although he did say that there was depth but no bone showing. LPN H placed the cut piece of Silasorb into the bed of the wound and placed an [MEDICATION NAME] sacral dressing over the treatment. # During the review of resident #2's medical record, a physician's order dated 4/17/2016 documented that he was to be up in his chair for meals only, peril guard to coccyx twice a day, and measure right inner coccyx weekly on Monday evenings for his skin issue. On May 25, 2016, resident #2 was observed on his reclining chair inside his room from 10:00 a.m. until 12:25 p.m. when he was observed transferred to his bed by facility staff. On May 26, 2016 at 9:05 a.m., resident #2 was observed from the hallway in his room on his reclining chair. He was by himself, and no meal tray was observed in his room. He remained in his recliner chair until the lunch meal. During an interview with facility staff Certified Nursing Aide (JJ) on May 26, 2016 at 12:58 p.m. in the East Hallway near the nursing station, she stated that she was taking care of resident #2 that shift, and he was showered at 7:30 a.m., then went to his room for breakfast as she fed him on his chair, repositioned him around 10 a.m., then he stayed in his chair until lunch at noon where he was fed by her and then put to bed after lunch. This did not follow the physician's order for his care. ( )

Based on interview and record review the facility failed to monitor and assess 1 (# 104) sampled resident for [MEDICAL CONDITION] activity and pain from a total sample of 4 residents reviewed resulting in resident being hospitalized for [REDACTED]. Findings Include: According to Resident #104's quarterly Minimum Data Set Assessment ((MDS) dated [DATE], Resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #104's SBAR Situation, Background, Appearance Review dated 3/22/16 revealed resident had a [MEDICAL CONDITION], unresponsive, rash with BP with vital signs of blood pressure of 170/110, pulse of 89, respiratory rate of 22, temperature of 97.1 Farenheit, pulse oximetry of 94% on room air and a blood sugar of 91. There was no other description of the [MEDICAL CONDITION] activity noted on the form. Review of Resident #104's Nurse Progress Notes dated 3/20/16 was the last entry until Resident's return from the hospital on [DATE]. There was no entry on 3/22/16 that resident had a [MEDICAL CONDITION] on 3/22/16 or was transported to the hospital on [DATE]. Review of Resident #104's Nursing Home to Hospital Transfer form, dated 3/22/16 at 5:22 AM, revealed Reason for transfer was for unresponsive, [MEDICAL CONDITION], rash and increased BP (blood pressure). On 3/30 /16 at 3:19 PM, Certified Nurse Aide (CNA) O reported she had notified RN H that Resident #104 was having a [MEDICAL CONDITION]. RN H was reported to have immediately left the room during the [MEDICAL CONDITION] activity to get the resident's nurse leaving CNA O alone with Resident #104. On 3/30/16 at 3:21 PM, LPN H reported CNA O reported to her Resident was having a [MEDICAL CONDITION] and as she entered Resident's room Resident's entire body was rigid he was shaking so I left and got the nurse that was taking care of him. LPN H was asked, You left the resident during a [MEDICAL CONDITION]? and responded, Yes, I am a unit over and not the one taking care of him. CNA O stayed with him. LPN H was asked, would a nurse normally stay with a resident having a [MEDICAL CONDITION]? and responded, I normally do not know. I have not been with him during it. LPN H was asked, As an RN have you been with residents with [MEDICAL CONDITION] before? RN H responded, Yes. LPN H was asked what the protocol for [MEDICAL CONDITION] was at the facility was and responded. I do not know. LPN H was asked does the facility have a policy and responded, I would have to look it up. LPN H was asked, Did you document any information about the [MEDICAL CONDITION] and responded, No, I did not. On 3/31/16 at 12:10 PM, Director of Nursing B was asked what was expected from nursing staff when a resident is having a [MEDICAL CONDITION] and responded, I expect the nurse to stay with the resident. On 3/31/16 at 12:20 PM, LPN D, with Director of Nursing B, was asked if she had given report to either CNA I or CNA J upon resident's return from the hospital around 9:30 AM on 3/22/16 and reported I believe so but I can not be sure. Someone else took the paperwork (physician orders) from the hospital. So you never reviewed those physician orders? No someone said there was no change in orders I don't know who said it. DON B asked is it common practice to take some else's word when you assume care for a resident? LPN D responded No it is out of my character. Review of Resident #104's Nurse Progress Note dated 3/22/16, at 9:30 AM, stated returned from ER no orders. In bed resting. no [MEDICAL CONDITION] activity observed. The next documentation was at 4:00 PM, no [MEDICAL CONDITION] activity noted, consumed all of lunch and fluids with out difficult. Incontinence care give. Moves all extremities. There was no documentation of an assessment completed upon return to the facility. Review of Resident #104's Nurse Progress Note on 3/22/16 revealed there was no documentation noted of any [MEDICAL CONDITION] activity monitoring on the afternoon or midnight shift. Review of Resident #104's Right Hip X Ray dated 3-23-26 at 11:48 AM, faxed to the facility on [DATE] at 11:49 AM and at 16:02 PM for Pain in right hip. Results: There is a new [MEDICAL CONDITION] compared to 1/12/16. there is narrowing of the hip compartment consistent with [MEDICAL CONDITION]. There is an acute or sub acute subcapital fracture with superior displacement of the distal fracture fragment. There are [MEDICAL CONDITION] changes at the lower lumber spine. Conclusion: [MEDICAL CONDITION]. According to Hospital physician progress notes [REDACTED]. On 3/23/16 at 10:00 AM, Nurse Progress Note at 8:00 AM, temp 100.2 CNA reported not bearing wt (weight) on (R) leg (pulls up) NP (nurse practitioner) notified STAT X-rays of R hip/ leg ordered. Resting in bed Temp 99.2 consumed fluids for writer. Resting in bed with eyes closed. Review of Resident #104's Medication Administration Record dated March 2016 revealed [MEDICATION NAME] 500 mg (milligram) caplet Give 1 tablet by mouth twice daily as needed (pain) on 3/29/16 a copy of Resident's MAR was reviewed with documentation of a dose administered on 3/23/16 at 8:00 AM. on 3/30/16 a review of the MAR and clinical record revealed a second dose was added to the MAR dated 3/24/16. Resident was discharged on [DATE] at 8:00 AM. There was no [MEDICATION NAME] documented as given on 3/22/16 for a fever. On 3/30/16 at 12:08 PM, LPN D reviewed statement (no date) and reported she came in to work on 3/22/16, was informed by LPN E resident had just had a [MEDICAL CONDITION], assisted with calling the Nurse practitioner and was instructed to send Resident out to hospital, gathered paperwork and sent. LPN D reported Resident returned back at 9:30 AM, but did not see him returned to his bed, not really awake but did respond, rubbed thigh, fed lunch in bed, and ran a low grade temp of 100.2. did not appear in pain when changing. LPN D was asked, Did you assess him then? No answer. LPN D was asked,You had no reports by staff of Resident #140 having any of pain, No. Did staff tell you Resident was in pain? CNA J came and told me on Wed 3/23/16 in the am a little after 7:00 AM when he got up for breakfast during med pass. LPN D stated, when they tried to stand Resident #104 up he put his leg up like a stork. Resident #104 was reported to normally lay frog leg so did not see any abnormal observation of aligment. On 3/23/16 at 7:30 AM, LPN D reported had obtained an order for [REDACTED]. LPN D reported to have given the results to Director of Nursing B and they were received at 4:02 PM. LPN D reported Resident #104 was known to get out of bed, walk, not sit still, not make needs known to what he wants. LPN D was asked, Were the staff instructed to get Resident up? and responded, They had him up, they were getting him up, and were going to walk him to the dining room but he would not put weight on his foot so they put him back to bed. LPN D was asked, So he stayed in bed until he was x-rayed. No answer then stated 'No he was in the wheel chair. So you knew he was in a wheel chair? 'Yes. Normally he played with his hands and made noises, he did not do any of that. How do you know? I went in at 7:10 AM after I gave crushed medication to another resident. The staff did not say anything more when they changed him the rest of the shift. LPN D was asked, Did you give him anything for Pain I gave him Tylenol he ran a low grade fever. He does not normally take pain medication. The fever went down and did not go back up. Gave report to LPN H and per LPN H the fever did not go back up. On 3/30/16 at 3:17 PM, CNA J reviewed statement (no date) and reported had worked both 3/22/16 and 3/23/16 and on 3/22/16 CNA I had requested assistance with repositioning resident to remove blankets approximately 1:30 PM, that were under resident from when he was returned from the hospital and when resident #104 was rolled over it seemed like something was hurting. CNAI went out and told LPN D and was told OK. The following day on 3/23/16 about 7:00 AM, CNA J reported went down to assist and CNA I again reported Resident #104 was having facial expressions, was lethargic and when we tried to roll him he grabbed at his right hip. CNA J reported CNA I went to report the concern to LPN D and LPN D was reported to have waved her off. CNA J reported he could not walk to eat so we put him in the wheel chair and went to the dining room he was there for about 45 minutes but he did not eat anything. CNA J reported between herself and CNA I had reported to LPN D Resident #104 was having pain a minimum of 5 times over the 2 day period and had not seen LPN D do an assessment on Resident #104. On 3/31/16 at 12:00 PM, CNA I reviewed statement dated 3/25/16 and reported she had worked both 3/22/16 and 3/23/16, had assisted with changing Resident #104 prior to lunch on 3/22/16 at around 11:30 AM with CNA J. CNA I reported resident grabbed his right hip, screaming in pain, requested LPN D and was told by LPN D she was to busy. He was probably tired, leave him in bed and feed him his lunch there. CNA I reported a second time was at approximately 1:30 PM went to change Resident #104 and pull the gurney sheet out from under him and he once again yelled out in pain, LPN D was again notified. CNA I reported at change of shift the CNA and Nurse were both informed of Resident #104 having pain with repositioning, and on 3/23/16 at approximately 7:10 AM, (for the third time) with CNA J Resident #104 was dressed and when when they went to stand him up he would not bear weight, LPN D was requested to come and assess Resident #104, stated she was too busy to come down to the room, informed CNA Jit is probably his muscles from the [MEDICAL CONDITION] and so we decided to take him down in a wheel chair instead of walking him down to the dining room. CNA I stated, SW R overheard our concern and addressed it with LPN D. CNA I was asked during the 2 days you worked, did you ever see LPN D assess Resident #104 and responded, No. On 3/30/16 at 1:35 PM, Social Worker (SW) R reviewed statement dated 3/24/16 and reported on 3/23/16 she was in the dining room passing trays for breakfast and met CNA J propelling Resident #104 in to the dining room at approximately 7:10 AM, and noted Resident was sitting odd and asked CNA #104 about the situation. CNA J reported to SW R that Resident #104 had not wanted to get up or place weight on the leg since his return from the hospital with the [MEDICAL CONDITION]. CNA J had informed SW R that LPN D had been informed but had refused to assess Resident #104. SW R reported CNA Jand CNA I had both reported to her they had informed LPN D on 3/22/16 that Resident #104 was having pain. SW R reported she went directly to LPN D to report the concern and asked if she had assessed Resident #104 and LPN D snapped back that she knew and was notifying the PCP. 3/30/16 at 1:55 PM, CNA Lreviewed statement dated 3/23/16 and reported she had received report from CNA I and J that resident #104 was having pain. CNA L reported On 3/22/16 at approximately 4:45 PM, Resident was laying in bed, went to roll him over and change brief and resident grabbed at his hip. CNA L reported LPN D was informed of Resident #104's pain, was instructed to take Resident #104 down to dinner anyway. CNA L was asked if LPN D was observed to have assessed Resident #104 or give him anything for Pain? CNA L responded, No. CNA L reported she had requested Registered Nurse (RN) S to assess Resident #104, CNA L reported following the assessment was instructed by RN S not to take resident down to the dining room and to feed resident #104 in his bed. CNA L reported had informed night shift CNA N and LPN H about Resident's pain. CNA L was asked, did you document any where in Resident #104's clinical record about resident's pain. No I was not aware of the 24 hour book for reporting Resident's symptoms. When did you receive training on this? CNA L responded, this last week CNA L was asked, Have you have previous concerns with LPN D not listening to resident concerns? Yes. I still go to her and tell her but then go to the other nurse. What happens when you do that does she get mad? CNA L responded, I don't think she cares. CNA L was asked, How does she respond when you tell her things? and responded, When I told her about Resident #104 she said, Well, you still need to get him up. When you tell her about another resident she just blows it off. Sometimes she ignores you, with Resident #104 she did not even walk in the room. 3/30/16 at 4:28 PM, CNA K reviewed statement dated 3/22/16 and reported on Tuesday 3/22/16 was assisted by CNA L Resident #104 was gotten up for dinner between 4:45 PM and 5:00 PM. CNA K reported Resident #104 was not moving at all. CNA K reported she had tried to stand Resident #104 up, he was trying to hold on to his right leg, was grimacing and would not put pressure on feet. CNA K reported Resident #104 was grimacing with the brief change. CNA Khad reported that CNA L had gone to inform LPN D who was passing medication and had been instructed to get Resident up any ways. CNA K reported, We decided to leave Resident in bed then we saw RN S and requested for her to go look at Resident #104. RN S assessed him and instructed us to leave him in bed. On 3/31/16 at 6:45 AM, RN S reviewed statement (not dated), and reported had worked on 3/22/16 and stated, early in the afternoon shift prior to supper on 3/22/16 CNA K and CNA L came to me and requested help to stand Resident #104 up. So, I thought that was unusual but sometimes he is like standing up a tree so I agreed. RN S was asked, What did you find? Resident was laid on his back in bed, no discomfort at that point. We went to swing his legs over the side of the bed and he grabbed legs/hip and grimaced, I tried to some ROM on his legs, and he grabbed at his hip and made a not good face. Then went to talk to nurse responsible (LPN D) reported he had already had something for pain and was going to report to NP. RN S was asked, Did you document any of the assessment? RN S responded, No had reported to his nurse. Did you put any of it on the 24 hour report? RN S responded, No reported to LPN D and assumed she would follow up on it. On 3/31/16 at 12:31 PM, LPN D was interviewed a second time, with DON B present, and was asked if any staff had informed her of resident having pain on 3/22/16 or 3/23/16 and stated do not recall. Later in the interview stated, I had already given him something for pain, [MEDICATION NAME] (used for [MEDICAL CONDITION]) and stated CNA J had notified her of resident having pain around 7:00 AM on 3/23/16 while doing med pass and preparing crushed medications for another resident. LPN D was asked if Staff were instructed not to get resident up until he was assessed and LPN D stated, CNA J walked out of the room before I could instruct her to not get resident up LPN D then stated, Resident was already up in the wheel chair. then stated I had assessed the resident. LPN D was asked what time Resident #104 was assessed, and LPN D could not answer. CNA I, CNA J and SW R all report resident was in the dining room from approximately 7:00 AM through 7:45 AM. LPN D was asked if 3 staff reported Resident was in the dining room at that time how did you assess the resident? LPN D had no answer. LPN D reviewed the pain assessment dated [DATE] in resident's record LPN D was asked when the pain assessment was completed. LPN D Could not recall when the pain assessment dated [DATE] was completed. LPN D Reviewed Resident #104's MAR and was asked Resident was given one Tylenol on 3/23/16 at 8:00 am? LPN D responded, It was for a Temperature of 100.2 that morning on 3/23/16. LPN D was asked, Did he get anything on 3/22/16 for pain? LPN D responded, I do not remember. Resident did not have any pain on 3/22/16? LPN D refused to answer. So why did you do a pain assessment? LPN D refused to answer. LPN D was asked, Did RN S talk to you about an assessment she had completed on Resident #104 on 3/22/16 and a pain concern? and LPN D responded, She said something, she had looked at Resident when she walked in to the med room LPN D was asked did SW R inform you of any concerns with Resident on 3/23/16 at 7:10 AM? LPND responded Did any one tell you Resident was in pain LPN D was asked, so you were aware he was having pain? LPN D refused to answer. How many CNA's notified you Resident was having pain, LPN D refused to answer. LPN D was asked Did CNA I, J, K or L inform you of Resident having pain? LPN D refused to answer. On 3/31/16 at 4:20 PM, Attending Physician T reported Resident #104 had a fall the previous week with no injuries or pain that had been observed or reported by staff, had discussed with the surgeon the possibilities of the fracture was related to Resident being at risk due to his height, lankiness, severe [MEDICAL CONDITION], atusim and had been informed it was rare but possible. Attending physician stated, he had not been notified of Resident #104 being in pain prior to 3/23/16, when he was admitted to the hospital and stated he was available at any time and They should have called me. According to the facility policy [MEDICAL CONDITION] Precautions during [MEDICAL CONDITION], dated 11/20/14, revealed For residents that have active [MEDICAL CONDITION] consider an MD order for padding side rails if side rails are ordered. Use lowest level of bed if no side rails ordered. Support the resident during an active [MEDICAL CONDITION]. If resident is standing or siting, guide to the floor while protecting the head. Keep resident in a side lying position. Never force anything in resident's mouth, including fingers Someone must remain with the resident during the [MEDICAL CONDITION] activity. Provide privacy to the extent possible. Protect the head to prevent head injury. Remove pillows if resident is in bed to prevent airway occlusion. As resident regains consciousness, assess vital signs and reorient and reassure resident. Check resident frequently during the postictal phase. Evaluate resident for injuries from the [MEDICAL CONDITION] including oral cavity and extremities. Notify health care providers as soon as possible. During [MEDICAL CONDITION] observe and record the progression of symptoms. Document as appropriate using the following guidelines: Precipitating Factors: Did resident have some type of emotional upset. Was [MEDICAL CONDITION] started by some type of environmental stimulus, e.g. unusual light pattern, noise? Did resident receive ordered medications? Aura: If and how did resident knew of attack. Did resident have any unusual taste, smell or visual change before [MEDICAL CONDITION] occurred. Point of Origin: Was there a clonic phase, with twitching and jerking of one part of body. Involvement was [MEDICAL CONDITION] localized or generalized . Deviation of Eyes .Incontinence .Respiratory Pattern.: Was there any apnea or dyspnea? Loss of Consciousness: Could resident be roused to point of response .What was length of time of unconsciousness? .Frequency and Duration: How often has resident had [MEDICAL CONDITION]? How long did [MEDICAL CONDITION] occur? . According to facility policy Change in Condition, dated 11/30/16, The Primary Clinical Nurse will communitate to the nurse manager/supervisor any change in resident conditin as it occurs. This will also be communitated in the 24 hour report as well. The Physician/Family Responsibilie Party will be notified as soon as possible include but not limited to significant change, accident/incident, change in treatment, transfer/D/C. All physician-ordered interventions will be immediately carried ot by the Clinical Nurse overseen by nurse manager/supervisor . With the change of resident status, the Clinical Nurse will gather all subjective and objective asessment information, the Nurse is responsible to complete and assessment of the resident's condition to nclude vital signs, level of consciousness and any other symptoms related to the conditon and make any judgement calls regarding the course of action to be taken, the need to contact the agent/sarrogate/contact person and or physician and must document the date, time, party's notified, findings and details of the notification in the Nurses Notes. Notfication of the physician and agent/ surrogate/contact person of significant change in status shall routinely occur in the shift in which it occurs. According to the Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article. ) ( )

Based on observation, interview and record review the facility failed to prevent a significant weight loss for 1 sampled resident (#101) from a total sample of 6 residents reviewed for food palatability and preferences resulting in the potential of a 20 pound weight loss for Resident #101. Findings include: According t0 Resident #101's admission 5 day Minimum Data Set MDS assessment, dated 2/8/16, with [DIAGNOSES REDACTED]. Residents weight was 198 pounds, with the CAT worksheet problem area: 12 Nutritional Status revealed the following concerns identified: inability to sit up, recent change of cognition, requires frequent cueing, indicators of [MEDICAL CONDITION], wandering, throwing food, poor memory, anxiety, difficulty making self understood and understanding others. IncludeCre (creatinine) was high, Hgb/Hct, (hemoglobin/hematocrit) [MEDICATION NAME] and (Glomerular Filtration Rate) GFR were low on (2/2). Resident has good po (oral) intake. No weight history noted. No major skin issues noted. Will Follow labs, weight and po intake. According to Resident #101's admission 14 day MDS assessment, dated 2/15/16, Resident #101's weight was documented as 184 pounds. Weight loss was documented as a no. This should have indicated a weight loss from 198 pounds on 2/8/16, to 184 pounds and was a loss of 14 pounds. According to Resident #101's Admission / Readmission Data Collection, Resident #101 weight was documented as 198 pounds. Review of Resident #101's physician progress notes [REDACTED]. revealed Resident had been hospitalized at a inpatient psych unit for increased aggression and agitation, had refused meds at times and spit them out. There was not documentation that resident had refused meals or of recent weight loss. Review of Resident #101's nurse progress notes revealed no notification to the physician of a recent weight loss concern. According to Resident #101's Vital sign weight log, revealed a weight on 2/2/16, at 198 pounds. The next weight was on 2/8/16, and on 2/15/16, (13 days later) at 184 pounds with a loss of 14 pounds. On 2/22/16, revealed a weight of 180 pounds with a loss of 4 more pounds for a total loss of 18 pounds in 20 days. There were no reweighs documented. According to Resident 101's weight documented on 3/2/16, recorded it was at 178 pounds for a total loss of 20 pounds in 29 days. According to Resident #101's food acceptance record, dated for the month of February 2016, revealed Food intake on 2/2/16, was 100 % following that date, intake was refused and extremely varied. Out of 90 possible meals, 18 meals were documented above 75 %. 47 meals were below 25 - 50 %, and 25 meals were refused. Out of 29 bed time snacks, resident refused 15, accepted 13 and was sleeping for 1. On 3/3/16 at 10:50 AM, DON B reviewed the food acceptance record, dated 2/16, documentation for Resident #101's Food intake on 2/2/16, revealed his intake was 100 %. Food intake following that date revealed resident had refused and was extremely varied. and the MDS dated [DATE] documentation stated, 2/2). Resident has good po (oral) intake. DON B stated an assessment should not be based on one day of a resident's intake and stated, I agree completely. According to the Care plan Altered Nutritional status r/t dx Alzheimer's, mood disorder' dated 2/8/16, revealed resident can eat independently with assistance on set up, Obtain food likes and dislikes, Weight every month and weekly PRN, Allow time to complete meal, According to the Care Plan, there were no interventions for when resident refused meals. No intervention to offer meals when resident was alert and not in a sleeping mode and no interventions to offer alternative selections on the menu when refused what was offered. On 2/29/16 Resident #101 was observed to have slept through lunch. On 3/1/16 at 8:30 AM, Resident was observed for breakfast in the dining room. Resident was sitting up in his wheel chair with his eyes closed. CNA J reported had attempted a couple of times to assist Resident. Resident was heard to yell, Come on when Resident was asked if he wanted a drink of the chocolate milk. Resident breakfast tray was untouched except for 50% of the orange juice. No staff offered any other alternatives and the tray was removed without any further attempts. According to the Food Acceptance Record Resident was not documented to have dinner on 3/1/16 (it was blank). On 3/1/16 at 2:55 PM, Director or Nursing reported she had been informed by the MDS Nurse that Resident #101's MDS assessment had been triggered for a significant weight loss during the 14 day assessment and a conversation had been held with RD C due to the significant weight loss. On 3/1/13 at 1:30 PM, Registered Nurse (RN) K reported Resident usually got up early in the morning between 5:30 and 6:00 AM, and was more alert at that time of the morning, took meds, would take supplement at that time and would hold a conversation at that time of day. RN K reported Resident #101 usually did not refuse care, medications, or fluids offered at that time of day. RN K was asked if Resident was ever offered a meal at that time and responded, No, just the supplements. On 3/2/16 at 10:05 AM, MDS Nurse G reported had recognized resident had a weight loss and completed the appropriate correction with the MDS with a significant weight loss. MDS Nurse G was asked during the prior assessment did you review the food acceptance log? and responded no I did not. On 3/1/16 at 2:10 PM, Dietary Manager L was asked if a food preference was done with the family and responded the RD completed the assessment with the familyand reported resident's only preference was chocolate milk and there were no dislikes. He refuses meals. Dietary Manager was asked if Resident refuses meals are there any interventions on the care plan due to the refusals? Dietary Manager L stated, we put stuff in the refrigerator, pudding, sandwiches, magic cups, cookies. Dietary Manager L was asked if Resident got up at 6:00 AM, and was alert could he have a tray at that time? and responded Staff are here at 5:30 AM, staff can request a tray and get it ready. According to the Care Plan there were no interventions for when resident refused meals. On 3/2/16 at 8:35 AM, Resident #101 was observed for breakfast in the dining room. Resident was sitting up in his wheel chair. Resident #101 had eaten his egg, and 50 % of the oatmeal and a few sips of the chocolate milk. CNA I was asked why a second egg was not offered and responded, I did not think about it after he refused the oatmeal and toast. Director of Nursing B at 8:40 AM, was observed to have assisted Resident #101 with his some of the oatmeal and 100 % of the chocolate milk. At 8:50 AM, Resident #101 was observed to have requested CNA I to hold the thickened water so he could take a drink. CNA I was asked for the food acceptance record for Resident #101. Resident #101 was not listed on the on the food acceptance record form in the dining room. On 3/2/16 at 10:30 AM, Registered Dietician C reported Resident #101 admission weight was documented on the vital sign form and the nursing admission form at 198 pounds and verified reviewed both forms, and assumed after the second weight that was not observed to have been documented in the clinical record on 2/8/16, that the records were incorrect. RD Creported a week later a re-weight was requested and Resident had lost 14 lbs. Resident's weight was reported by RD C at 184 pounds on the reweigh. RD C stated, even if he is not eating that is a lot of weight. It was assumed it was incorrect on admission. RD C reported med pass was added to Resident # 101's daily diet on 2/12/16 three times a day (4 days later). RD C was asked if the family had been contacted for any food preferences and stated, Chocolate was the preference. Did you go back following the identified weight loss and ask again if there were any other food preferences when you saw he was losing weight? No. did his wife say anything about liking fluids ice cold? Not that I am aware of. RD C reported Resident #101's weight on 3/3/16 was reported at 178 pounds a decrease of 2 pounds from previous weight of 180 pounds and a total of 20 pounds in 29 days. There was no reweight available. Even considering the possibility of an admission weight at 189 pounds, Resident #101 had still lost 11 pounds. According to the Nutrition Care Plan, there were no interventions for when resident refused meals, no preferred snacks while awake, and no accommodations for resident's sleep schedule and feeding meals for resident while he was awake and alert other than supplements and snacks, to prevent further weight loss. According to the facility weight policy Weighing the Resident, dated 11/30/14, stated, At a minimum, all residents of the facility shall be weighed upon admission and monthly unless ordered otherwise by the physician or as directed by the weight committee, or if contraindicated by the residents' condition. On 3/3/16 at 1:55 PM, DON B stated, there is no policy for weights or re-weights available with perimeters. The regional staff were not able to find one either. DON B stated she had contacted the hospital and the discharge weight was 189 pounds. Considering the possibility of an admission weight at 189 pounds, a 5% weight loss in 29 days would be 9.45 pounds, 7% at 13.23 pounds, and 10 % would be 18.9 pounds. Considering Resident's documented admission weight at 198 pounds, a 5% weight loss would be 9.9 pounds, 7% at 13.8 pounds and 10% at 19.8 pounds. Resident #101 has lost a minimum of 11 pounds to a potential of 20 pounds to date. ( )

This citation pertains to MI# 170 and MI# 394 Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devise (seat belt) to prevent the falls in 2 (#101, #102) 4 sampled residents, from a total sample of 4 residents, resulting in Resident #101 who is quadriplegic, sustaining a fall from his wheelchair while being transported into the facility transport van resulting in left leg fracture and Resident #102, who had experienced a decline in health, sustained a fall from her wheelchair resulting in fracture and laceration to the nose. Findings include: Resident #101: Record review of facility reported incident dated 5/10/12 reflected that Resident #101 who was noted to be a quadriplegia, brain injury, seizure disorder and cervical spine stenosis was taken to the local wound clinic by the facility van driver. Resident #101 received his treatment and the driver returned to the wound clinic to retrieve the resident. At 4:30 PM upon arrival Resident #101 was noted to be in his wheelchair and ready for transport. The driver was noted to wheel Resident #101 out to the van and place Resident #101 onto the lift gate, raised the lift and as he started to push him into the van, Resident #101 fell forward out of his wheelchair on to the van floor. The van driver left Resident #101 and went back into the wound clinic to ask for help. EMS (emergency medical services) was called. Resident #101 was taken to the hospital for x-rays which were positive for non-displaced fracture of the left distal fibula and tibia. The conclusion of the facility investigation revealed that the facility identified that Resident #101 was at the wound clinic for peri-anal (rectal area) wound treatment and not positioned correctly by the clinic. In an interview on 6/5/12 at 3:18 PM, Administrator #1 stated, "I investigated the incident when (Resident #101) fell in the van. The wound clinic did his treatment in his wheelchair tilted back. I got into his wheelchair and to work on the wound in his bottom (Administrator #1 demonstrated by lifting her right leg knee to chest to show peri-anal area) the wound clinic had to have moved him over in the chair to work on the wound......" Record review of Resident #101's minimum data set ((MDS) dated [DATE] revealed Resident #101 was a [AGE] year old male with cognitive skills for daily decision making as severely impaired never or rarely making decisions, he had total dependence and two people assist for transfers, and total dependence with ADL's (activities of daily living) with limitations in range of motion to upper and lower extremities on both sides. Record review of the wound clinic records dated 5/10/12 reflected that Resident #101 was at the clinic to have his outer right foot wound treated. Not the right peri-anal area. Record review of the wound clinic physician note dated 5/10/12 reflected that Resident #101 was being seen for chronic right foot ulcer thought to be secondary to pressure ulcer stage 3. The documented indicated that with Resident #101 in the sitting position, the ulcer was cleansed and treated. In an interview on 6/5/12 at 8:43 AM, Driver #6, who stated that he was not certified nurse assistant or medical person, but just the driver, revealed that he took Resident #101 to the wound clinic and unloaded him and pushed him into the wound clinic. Driver #6 stated that the clinic usually takes Resident #101 from his wheelchair with a Hoyer (mechanical lift device). Driver #6 described how Resident #101 is transported with two Hoyer lift pads because the facility used a strap style Hoyer and the wound clinic used a plastic slot style Hoyer and that both are nylon type of material and tend to be slippery. Driver #6 stated that he waited in the lobby area and after the treatment, Resident #101 was brought back to him. Driver #6 stated Resident #101 was sitting fine in the wheelchair and that he wheeled him out the door, (over the door threshold) and out to the van. Driver #6 stated he lowered the lift, wheeled Resident #101 onto the lift, raised the lift, got up on the bumper and climbed onto the lift, was behind Resident #101 and started to push forward with the wheelchair, when Resident #101 slid/fell out of the wheelchair. Driver #6 stated Resident #101 landed with his shoulders on the wheelchair foot pedals, and went right onto the van floor. Driver #6 stated that he left Resident #101 in the van on the floor while he went back into the wound clinic to get help. After the wound clinic staff and Driver #6 reviewed the situation, a call was placed to 911 for emergency services. Driver #6 stated that it took 3 emergency service men and a male wound clinic staff person to put Resident #101 on a back board to remove him from the van. During the interview on 6/5/12 at 8:43 AM, Driver #6, the state surveyor asked what was different with this transport? Driver #6 stated, "that's when he's (resident #101) in the wheelchair there are two Hoyer pads with pillows on the sides for positioning". Driver #6 could not say if the pillows blocked his vision of Resident #101's actual seating position, but that he assumed that when they (wound clinic) put him in his chair that he wasn't all the way in the chair and he wasn't all the way back in the chair. Driver #6 reported that the nylon Hoyer pads are slippery, with one pad against the other it just slips and that the resident is a quadriplegic and has no feeling to know if he's in the chair. Record review of the emergency room record and x-rays dated 5/10/12 revealed that Resident #101 sustained a non-displaced fracture of the fibula and tibia. Observation and interview on 6/5/12 at 2:55 PM of Resident #101 revealed he had contractures of the lower legs and feet bilateral. Observation of Resident #101's left leg revealed an ace wrap/compression dressing to left lower leg and ankle/foot area. Resident #101 stated that he remembered the fall in the van and that he went boom on the floor. Record review of the fall care plan dated 8/22/11 reflected Resident #101 had the potential for fall related to immobility, quadriplegia, impaired cognitive skills. Facility approaches did not include information that Resident #101 used or at what angle to position Resident #101 in when in use of the tilt in space wheelchair. Record review of the mobility care plan dated 8/22/11 reflected that Resident #101 was a Marissa (mechanical) lift and unable to bear own weight, with a gel cushion in wheelchair when up. Facility approaches did not include information that Resident #101 used or at what angle to position the resident in when in use of the tilt in space wheelchair. In an interview on 6/5/12 at 1:57 PM with the manager of physical and occupational therapy revealed that Resident #101 had a tilt in space style wheelchair that let the staff tilt the wheelchair for positioning. The manager of physical and occupational therapy stated that Resident #101's wheelchair had a dial (level style with a bubble indicator) on the side of his wheelchair that shows the angle of the tilt so that staff would know how far Resident #101 was tilted. Observation on 6/6/12 at 10:10 AM, restorative certified nurse assistant (CNA) #5, of Resident #101's tilt in space wheelchair revealed that the wheelchair had level device attached to the tilt portion of the chair so that the resident could be placed at different angles of position. CNA #5 was able to tilt the wheelchair to demonstrate how the level worked but could not identify which positioning angle was appropriate for the resident for safety. There was no seat belt noted. Record review of Resident #101's 'Resident Information Sheet' (undated) revealed that the resident was a wheelchair user and that 'Chair Safety' heading, there was nothing marked or to indicate at what angle to tilt the 'tilt in space wheelchair' for the staff to place the wheelchair so that the resident to be safely positioned. On 6/6/12 at 12:10 PM the state surveyor requested tilt in space wheelchair education in-service for the staff on the use and proper tilt positions that each resident requires when using. The MDS (minimum data set) licensed practical nurse #3 and the therapy program manager #4 both looked for and stated that there was no tilt in space wheelchair in-services that they knew of or could find within the facility. Observation on 6/5/12 at 9:20 AM of the van driver #6 and sampled Resident #103 revealed that the van driver went into the resident's room and transferred the resident from his bed to his wheelchair with no gate belt. Record review of resident #103's Nurse Tech Information Kardex (undated) revealed that the Resident #103 was a two person assist transfer. Observation on 6/5/12 at 9:20 AM of the van driver #6 during the transport van gate lift of Resident #103, revealed that when a resident is pushed onto the lowered lift and then is raised to the level of the van floor and then the driver climbed on to the back bumper of the van to get on to the lift and then push the resident forward into the van. The resident when on the moving lift has the wheelchair brakes locked but has no way to remain secured in the wheelchair when the lift is in motion. Record review of the van driver #6 employee file and education records for the past year reflected that driver #6 did not have a signed job description and the last 'developmental Feedback' (evaluation) was dated 7/26/2010 as a driver. Resident #102: Record review of facility reported incident dated 5/20/12 at 8:20 PM revealed that Resident #102 was in her wheelchair and while wheeling herself down the hall she fell forward out of her chair, hitting her face on the floor. Resident #102 was noted to sustain a laceration to the bridge of nose, 0.5 X 1.0 centimeters and bleeding from both nares. Resident #102 was sent to emergency room for evaluation and treatment where a C/T scan of the maxillofacial showed nasal bone fracture. Record review of Resident #102's re-admission assessment dated [DATE] at 2:50 PM revealed that Resident #102 [DIAGNOSES REDACTED]. Functional status revealed that Resident #102 was a total assist with transfers and able to self-propel wheelchair. Fall risk assessment revealed Resident #102 to be intermittent confusion, to have 3 or more falls in past 3 months, chair bound, balance problems while standing, takes 3-4 medications, and have 1-2 predisposing diseases for a total score of 17. The assessment stated that a total score of 10 or above deems resident at risk. Record review of Resident #102's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old female with [DIAGNOSES REDACTED]. Resident #102 was assessed to have an increased dependence in activates of daily living (ADL's), assessed for impaired balance during transition. Record review of Resident #102's accident/Incident reports revealed Resident #102 had a history of [REDACTED]. Ina an interview on 6/5/12 at 2:25 PM, certified nurse assistant (CNA) #11 revealed that Resident #102 was her assigned resident on 5/20/12. CNA #11 stated that Resident #102 had a behavior of scooting down in her wheelchair and tipping her head back over the back of the wheelchair and self-propelling while looking up at the ceiling. Record review of Resident #102's physical therapy initial evaluation dated 5/18/12 reflected reason for referral: Resident exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, decreased coordination and decreased judgment indicating the need for physical therapy to improve dynamic balance, increase coordination, increased range of motion and strength, promote safety awareness. Sitting static and dynamic balance was assessed as poor. Summary note: Currently the Resident #102 is very confused and not able to follow commands well. As of evaluation day, resident is non-ambulatory. In an interview on 6/6/12 at 9:10 AM with the therapies manager #4 revealed that Resident #102 was in and out of the facility for cognitive changes and that she used a standard bariatric wheelchair. The therapies manager #4 reviewed the therapy notes with the state surveyor and during the 3/19/12 to 5/2/12, Resident #102 was seen by therapy for decreased cognition and increased confusion. The therapy manager #4 revealed that Resident #102 did recline in wheelchair per her preference and had a decline in self-propelling of wheelchair, requiring more rest brakes during propelling with increased confusion and delusions. The therapy manager #4 stated that Resident #102 would recline/slouch with body curvature extended neck back over the back of the wheelchair. Review of the therapy evaluation dated 5/18/12 with the therapy manage #4 revealed that Resident #102 was fatigued, confused, didn't follow directions and was a maximum assist of 2 people to stand and a Hoyer transfer. Resident #102 did not receive therapy on 5/19/12 or 5/20/12. The therapy evaluation did not recommend additional safety devices such as a releasing seat belt or shoulder/positioning devices to assist the resident in wheelchair stability In an interview on 6/5/12 at 10:45 AM with CNA #7 revealed Resident #102 was in the TV room with her family when the family left and did not return Resident #102 to her room. CNA #7 stated that Resident #102 was not her resident and that she had never been Resident #102's actual CNA and that she was on a different part of the hall. CNA #7 stated that Resident #102's CNA #11 asked her to get Resident #102. CNA #7 stated that Resident #102 was in her wheelchair and that she said "come on (resident)" CNA #7 stated that Resident #102 had a wide wheelchair and that she did not have any foot pedals on, but had on gripper socks. Resident #102 self-propelled and started going down the hall, moving herself. CNA #7 stated that she was behind the wheelchair encouraging the resident to move. CNA #7 stated that Resident #102 would stop, lay her head back, lounge in the chair, she would adjust herself in the chair and then lean forward and use her feet to move again. CNA #7 stated that Resident #102 did this 5-6 times before she fell , each time she would adjust herself slouch and lay her head back and then continue. CNA #7 stated that all of a sudden Resident #102 stopped, leaned forward, CNA thought Resident #102 was going to adjust in the chair, but that she kept going forward onto her face on the floor. CNA #7 stated that she was behind the resident's wheelchair and that Resident #102 didn't try to break the fall. CNA #7 stated that she ran around the wheelchair to see to Resident #102 and that there was blood from her nose. In an interview on 6/6/12 at 10:26 AM with nurse licensed practical nurse (LPN) #12 revealed that CNA #7 came and got her while she was back in the dementia unit to assist with Resident #102. LPN #12 stated that as she approached Resident #102 lying on the floor with blood on the floor from the nose. LPN #12 stated that Resident #102 stated to her that she was trying to stand up. LPN #12 stated that CNA #7 told her that Resident #102 was trying to either stand up or adjust in the wheelchair and fell out. In an interview on 6/6/12 at 10:00 AM, Resident #102 revealed that she remembered falling from her wheelchair and that the fall. Resident #102 stated "I just fell like a big blob on to my face from the wheelchair. I fell in the hallway; I just went right over forward, right out of the wheelchair". Resident #102 stated that the injury to her face "hurt, extremely hurt, and never felt anything like that, even my eyes hurt". Record review of Resident #102's fall care plan dated 5/18/12 revealed approaches of: Evaluate for unsteady gait, Instruct resident on appropriate safety measures. Assess cognitive status as ability to ask for assistance, Alarms to bed and chair. On 5/22/12 it was noted the facility added a seat belt alarm and dycem to wheelchair. #

THIS CITATION PERTAINS TO INTAKE MI 488. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY SUPERVISE 1 (RESIDENT #501) OF 12 SAMPLED RESIDENTS, FROM A TOTAL SAMPLE OF 12 RESIDENTS, WHO HAD PREVIOUSLY FALLEN AND HAD A KNOWN HISTORY OF DISRUPTIVE AND AGGRESSIVE BEHAVIORS, RESULTING IN A FRACTURE, PAIN AND hospitalization , AND 1 SAMPLED RESIDENT (RESIDENT #504) AND 3 NON-SAMPLED RESIDENTS WHO WERE AT HIGH RISK FOR FALLS, NOT HAVING THEIR SAFETY EQUIPMENT IN PLACE AND/OR FUNCTIONING PER THEIR NURSING ASSISTANT CARE INFORMATION SHEETS, RESULTING IN A HIGH POTENTIAL FOR FALLS WITH SERIOUS INJURIES AND hospitalization S. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED 11/3/11, physician progress notes [REDACTED].#501 WAS admitted to the facility on [DATE], HAD SHORT AND LONG TERM MEMORY LOSS, REQUIRED ASSIST AND CUEING FROM STAFF WITH ALL OF HER ACTIVITIES OF DAILY LIVING (ADL'S), WAS AT RISK OF FALLS AND HAD A WELL DOCUMENTED HISTORY OF AGGRESSIVE AND DISRUPTIVE BEHAVIORS. THE RESIDENTS [DIAGNOSES REDACTED]. RESIDENT #501 fell AT THE FACILITY ON 10/22/11, WHICH RESULTED IN A FRACTURE WITH hospitalization . REVIEW OF RESIDENT #501'S CARE REVIEW OF RESIDENT #501'S CARE PLANS, ALTERATION IN THOUGHT PROCESS (DATED 8/4/11), SELF CARE DEFICIT (DATED 8/5/11), ELOPEMENT (DATED 8/5/11) AND ALTERATION IN COMMUNICATION (DATED 8/5//11), REVEALED RESIDENT #501 had a history of [REDACTED]. REVIEW OF THE FALLS CARE PLAN DATED 8/5/11, REVEALED THE resident had a history of [REDACTED]. REVIEW OF THE NURSING ASSISTANT (CNA/CENA) RESIDENT INFORMATION SHEET (UN-DATED) REVEALED RESIDENT #501'S BEHAVIORS INCLUDED "MED (MEDICATION) REFUSALS, ADL REFUSALS, VERBAL AGGRESSION, PHYSICAL AGGRESSION" AND "SEXUAL INAPPROPRIATENESS". OBSERVATION OF RESIDENT # 501 WAS DONE DURING THE TOUR ON 1/18/12 (BETWEEN 8:00 A.M. AND 9:15 A.M.). RESIDENT #501 WAS IN HER ROOM (ON THE LOCKED DEMENTIA UNIT) IN BED WITH HER EYES CLOSED. SHE WAS NOTED TO BE CLEAN, APPROPRIATELY DRESSED AND HER SAFETY PRECAUTIONS WERE IN PLACE PER HER FALL/SAFETY CARE PLAN AND RESIDENT INFORMATION SHEET (RIS, NURSING ASSISTANT/CNA RESIDENT CARE INSTRUCTIONS). THE SURVEYOR WAS UNABLE TO INTERVIEW THE RESIDENT DUE TO DECREASED COGNITIVE STATUS. REVIEW OF THE FACILITY INCIDENT REPORT DATED 10/22/11, REVEALED ON 10/22/11 AT 0345 (3:45 A.M.), RESIDENT #501 WAS OBSERVED ON THE FLOOR IN THE DINING ROOM ON THE LOCKED UNIT. THE INCIDENT REPORT STATED "THE RESIDENT WAS IN THE DINING ROOM AT THE TABLE WHEN IT IS SUSPECTED THAT SHE STOOD UP TO REACH FOR A POTATO CHIP AND fell on HER BUTTOCKS". REVIEW OF THE FACILITY INVESTIGATION REPORT (UN-DATED), REVEALED "SHE (RESIDENT #501) IS ALWAYS UNDER SUPERVISION BY STAFF AND LIVES IN THE SECURED UNIT, KNOWN TO BECOME AGITATED, BELLIGERENT AND VERY DIFFICULT TO REDIRECT. JUDGMENT IS POOR. (THE RESIDENT #501) HAD SAT ON THE FLOOR OF HALLWAY AND DINING ROOM SEVERAL TIMES THROUGHOUT DAY AND DURING THE NIGHT (10/21/11 THROUGH 10/22/11). AT 0345 (3:45 A.M.) CENA REPORTED TO NURSE (THE RESIDENT #501) WAS SITTING ON BUTTOCKS ON THE FLOOR IN DINING ROOM. DX (DIAGNOSES) FRACTURE OF L (LEFT) PUBIC RAMUS (PELVIS), admitted for PAIN CONTROL (TO THE hospital on [DATE])". REVIEW OF THE FACILITY INCIDENT/ACCIDENT LISTING REVEALED RESIDENT #501 HAD FALLEN PRIOR TO HER FALL ON 10/22/11 (ON 7/30/11) AND AFTER (ON 12/4/11). REVIEW OF THE FACILITY RESIDENTS HOSPITAL TRANSFER FORM DATED 10/22/11, STATED "INCREASED AGITATION, fell AT 0430 (4:30 A.M.), C/O (COMPLAINT) OF L (LEFT) HIP, INNER THIGH, LEG PAIN". REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL DATED 10/23/11, REVEALED RESIDENT #501 WAS EVALUATED ON 10/22/11, AFTER A FALL WHICH RESULTED IN A FRACTURE OF THE LEFT SIDE OF PELVIS AND WAS admitted TO THE HOSPITAL FOR PAIN CONTROL. REVIEW OF THE HOSPITAL X-RAY DATED 10/22/11, REFLECTED "THERE IS A FRACTURE OF THE SUPERIOR PUBIC RAMUS ON THE LEFT (THE LEFT SIDE OF THE PELVIS). THERE IS A QUESTIONABLE FRACTURE INVOLVING THE INFERIOR PUBIC RAMUS ON THE LEFT". REVIEW OF THE WRITTEN STATEMENT DATED 1/18/12 AND PER INTERVIEW DONE ON 1/18/12 AT 1:35 P.M., WITH CNA #1 (ON 10/21/11-10/22/11 THIRD SHIFT). CNA #1 REVEALED NURSE #1 TOLD HER AND CNA #2 TO "CLOSELY MONITOR" RESIDENT #501 BECAUSE SHE HAD BEEN HAVING AGGRESSIVE BEHAVIORS DURING THE DAY SHIFT. CNA #1 SAID SHE WAS SITTING IN A CHAIR IN THE HALLWAY WERE SHE COULD SEE THE RESIDENT IN THE DINING ROOM, WHERE SHE WAS WALKING AROUND, CLEANING OFF THE TABLES, TALKING TO HERSELF AND STANDING ON THE FURNITURE. CNA #1 SAID ANOTHER RESIDENT'S BED ALARM WAS GOING OFF SEVERAL TIMES DURING THE NIGHT AND AT APPROXIMATELY 4:00 A.M., SHE HAD GONE TO SHUT THE ALARM OFF WHEN SHE HEARD RESIDENT #501'S CHAIR FALL. WHEN CNA #1 CAME INTO THE DINING ROOM, SHE SAW THE RESIDENT SITTING ON THE FLOOR IN FRONT OF HER CHAIR. CNA #1 SAID SHE HAD ASKED CNA #2 TO WATCH THE RESIDENT WHILE SHE WENT TO TURN OFF THE OTHER RESIDENTS ALARM, OR TO GO TURN OFF THE ALARM AND CNA #2 SAID "NO, YOU CAN DO BOTH BECAUSE THEY ARE ACROSS THE HALL FROM EACH OTHER". CNA #1 SAID WHEN SHE WENT TO TURN OFF THE OTHER RESIDENTS LIGHT IS WHEN RESIDENT #501 fell . CNA #1 SAID SHE DID NOT SEE THE RESIDENT FALL, SHE HEARD THE CHAIR SHE WAS IN FALL. CNA #1 STATED "THIS COULD HAVE BEEN PREVENTED". REVIEW OF CNA #1'S WRITTEN STATEMENT DATED 10/23/11, STATED "( NURSE #1) GAVE (RESIDENT #501) SOME MEDS, (NURSE #1) SAID IT SHOULD CALM HER DOWN IN ABOUT 1 HR (HOUR). (RESIDENT #501) WAS GOING IN OTHER CLIENTS ROOMS AND WAS GETTING HARD TO REDIRECT. (RESIDENT #501) THEN BECAME AGGRESSIVE AND COMBATIVE TO THE CNA'S. (A SECOND RESIDENT'S) BED ALARM WENT OFF, WENT IN TO SHUT IT OFF, ALARM WAS GOING OFF QUIETLY FOR 4 OR 5 TIMES. (RESIDENT #501) SAID "THAT HURT". I WENT TO CHECK ON HER, (RESIDENT #501) WAS ON THE FLOOR SITTING ON HER BUTT". AN INTERVIEW WAS DONE ON 1/23/12 AT 6:20 A.M., WITH CNA #2 (ON 10/21/11-10/22/11 THIRD SHIFT, ASSIGNED TO THE UNIT THE RESIDENT WAS ON). CNA #2 REVEALED ON 10/21/11, AT THE BEGINNING OF HER SHIFT, SHE WAS TOLD BY NURSE #1 "TO WATCH HER (RESIDENT #501)". CNA #2 REVEALED CHARGE NURSE #1 TOLD CNA #1 AND HER TO WATCH RESIDENT #501 "CLOSELY" BECAUSE SHE WAS NOT ACTING LIKE HERSELF; SHE HAD BEEN ACTING AGGRESSIVE WITH STAFF EARLIER THAT DAY ON FIRST AND SECOND SHIFTS. CNA #2 SAID "IF (CNA #1) WOULD HAVE BEEN WATCHING HER RESIDENT BETTER, THE FALL COULD HAVE BEEN PREVENTED". AN INTERVIEW WAS DONE ON 1/19/12 AT 8:45 A.M., WITH CNA #3 (ON 10/21/11 FIRST SHIFT, ASSIGNED TO THE UNIT RESIDENT #501 WAS ON). CNA #3 STATED "WHEN SHE (RESIDENT #501) IS UP-SET, I TELL THE OTHER AIDE (CNA) TO HELP OUT WITH HER. WHEN SHE IS IN THAT MOOD YOU NEED TO KEEP YOUR EYES ON HER, WE ARE EXPECTED TO HELP EACH OTHER AND BE RESPONSIBLE FOR ALL RESIDENTS". AN INTERVIEW WAS DONE ON 1/19/12 AT 1:55 P.M., WITH CNA #4 (ON 10/21/11 SECOND SHIFT, ASSIGNED TO THE UNIT RESIDENT #501 WAS ON). CNA #4 STATED "I WORKED THE SHIFT PRIOR TO HER (RESIDENT #501) FALL, WE WERE DOING ONE-ON-ONE WITH HER THAT DAY, SHE WAS GOING AFTER OTHER RESIDENTS AND WANTING TO GO OUTSIDE". AN INTERVIEW WAS DONE ON 1/19/12 AT 10:10 A.M., WITH NURSE #1 (ON 10/21/11 THROUGH 10/22/11, ASSIGNED TO THE UNIT RESIDENT #501 WAS ON). NURSE #1 REVEALED ON 10/21/11 AT THE BEGINNING OF THE SHIFT, SHE HAD INFORMED CNA #1 AND CNA #2 THAT RESIDENT #501 WAS "HAVING BEHAVIORS AND I TOLD THEM TO MONITOR HER CLOSELY. AT 3:45 A.M., (CNA #1) CAME OUT AND TOLD ME SHE fell . THEY (THE CNA'S) SAID THEY WERE IN THE HALLWAY AND DID NOT SEE HER FALL, THEY NEED TO WORK AS A TEAM". REVIEW OF THE CONFIDENTIAL INFORMATION SHEET DATED 10/22/11, FILLED OUT BY NURSE #1, REVEALED AT 3:45 A.M., RESIDENT #501 WAS FOUND BY STAFF SITTING ON THE FLOOR OF THE DINING ROOM. THE FACILITY POST INCIDENT INFORMATION SHEET ASKED THE QUESTION WHAT DO YOU FEEL COULD HAVE PREVENTED THIS INCIDENT AND NURSE #1 HAD DOCUMENTED "DOING 1:1 (ONE-ON-ONE) LIKE ASKED, CARE MIDNIGHT INTERACTION CONSTANT THROUGHOUT NIGHT". REVIEW OF NURSE'S NOTES DATED 10/21/11 AT 6:00 A.M. TO 6:00 P.M., STATED "RES (RESIDENT #501) TALKING NON-STOP, BECOMING AGGRESSIVE AND UPSET ROOMMATES. RES BECOMING VERBAL AGGRESSIVE WITH OTHER RES AND STAFF, RES MOVED TO (ANOTHER ROOM). RES BECOMING SEXUALLY AGGRESSIVE AT TIMES ATTEMPTING TO KISS OTHER RES". REVIEW OF NURSE'S NOTES DATED 10/21/11 AT 10:40 P.M., STATED "RES VERY ANXIOUS AND AGITATED. RES VERY VERBALLY AGGRESSIVE AND ATTEMPTING TO BE PHYSICALLY AGGRESSIVE TOWARDS STAFF. CONSTANT REDIRECTION, WILL CONTINUE TO MONITOR CLOSELY". REVIEW OF NURSES NOTES DATED 10/22/11 AT 4:35 A.M., STATED "AT 0345 (3:45 A.M.) CENA (CNA) ALERTED RES WAS ON BUTTOCKS ON FLOOR IN DINING ROOM". REVIEW OF THE MEDICATION ADMINISTRATION RECORD DATED 10/11; REVEALED RESIDENT #501 WAS GIVEN " ATIVAN (ANTI-ANXIETY MEDICATION) ON 10/21/11 AT 11:00 P.M. AN INTERVIEW WAS DONE ON 1/23/12 AT 8:10 A.M., WITH THE IN-SERVICE NURSE (RN). THE IN-SERVICE NURSE REVEALED THAT ALL CNA'S ARE EDUCATED ON FALL PRECAUTIONS AND RESIDENT BEHAVIORS DURING ORIENTATION, ANNUALLY AND AS NEEDED. THE IN-SERVICE NURSE ALSO REVEALED ALL CNA'S ARE INSTRUCTED TO CHECK ALL RESIDENT ALARMS FOR BEING IN PLACE AND IN WORKING ORDER AT THE START OF AND THROUGHOUT THEIR SHIFT. REVIEW OF RESIDENT #501'S BEHAVIOR/MOOD SYMPTOM TRACKING TOOL DATED 7/27/11 THROUGH 10/21/11, REVEALED DOCUMENTATION DATED 10/21/11, SAYING THE RESIDENT WAS IN THE HALLWAY, HER ROOM AND DINING ROOM EXHIBITING "VERBAL AGGRESSION, REFUSING CARE" AND BEING "SEXUALLY INAPPROPRIATE". REVIEW OF THE THERAPY PLAN OF CARE DATED 10/27/11, REVEALED WHEN THE RESIDENT RETURNED TO THE FACILITY AFTER HER hospitalization DUE TO A FRACTURE, SHE EXHIBITED DIFFICULTY WITH AMBULATION AND WITH BED MOBILITY. REVIEW OF THE PAIN INTERVENTION FLOW SHEET DATED 10/11, REVEALED THE RESIDENT COMPLAINED OF PAIN IN HER LEFT LEG AND HIP RELATED TO HER FRACTURE ON 10/22/11, 10/26/11, 10/27/11 AND 10/28/11. OBSERVATION MADE ON 1/19/12 AT 1:15 P.M., REVEALED A NON-SAMPLED RESIDENT IN THE ACTIVITY ROOM SITTING IN A CHAIR, WITHOUT HER SEAT ALARM IN PLACE. THE RESIDENTS CNA RESIDENT INFORMATION SHEET (UN-DATED) AND FALLS CARE PLAN REVEALED DOCUMENTATION THAT SHE WAS TO HAVE A SEAT ALARM ON. THE STAFF INFORMED THE SURVEYOR THE RESIDENTS ALARM HAD BEEN LEFT ON THE RESIDENTS UNIT. OBSERVATIONS MADE ON 1/23/12 (AT 7:25 A.M., 7:35 A.M. AND 7:36 A.M.), BY THE SURVEYOR AND MDS COORDINATOR REVEALED 1 SAMPLED RESIDENT (#504) AND 2 NON-SAMPLED RESIDENTS SITTING IN THE DINING ROOM IN THEIR WHEELCHAIRS, WITH THEIR ALARMS (1 SEAT BELT AND 2 SEAT ALARMS), NOT IN FUNCTIONING ORDER (UN-PLUGGED), PER THEIR CNA RESIDENT INFORMATION SHEETS AND FALLS CARE PLANS. REVIEW OF THE FACILITY FALL RISK REDUCTION AND MANAGEMENT PROGRAM/POLICY DATED 8/02 (REVISED 9/07), REVEALED A COMPONENT TO THE FALL REDUCTION PROGRAM WAS THE "IMPLEMENTATION OF INDIVIDUALIZED INTERVENTIONS TO MINIMIZE RISK FACTORS FOR FALLS AND INJURIES". THE FACILITY DEFINED AVOIDABLE ACCIDENT AS "AN ACCIDENT OCCURRED BECAUSE THE FACILITY FAILED TO: IMPLEMENT INTERVENTIONS, INCLUDING ADEQUATE SUPERVISION, CONSISTENT WITH A RESIDENTS NEEDS, GOALS, PLAN OF CARE, AND CURRENT STANDARDS OF PRACTICE IN ORDER TO REDUCE THE RISK OF AN ACCIDENT". THE FACILITY DEFINED SUPERVISION AS "AN INTERVENTION AND MEANS OF MITIGATING THE RISK OF AN ACCIDENT. FACILITIES ARE OBLIGATED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS, BASED ON THE INDIVIDUAL RESIDENTS ASSESSED NEEDS AND IDENTIFIED HAZARDS IN THE RESIDENT ENVIRONMENT". REVIEW OF THE FACILITY INCIDENT REPORT DATED 10/22/11 AND THE FALL INCIDENT LISTING SHEET REVEALED RESIDENT #501'S FALL WAS "UN-WITNESSED". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUCTIONING FOR 1 OF 3 RESIDENTS (#3) WITH A [MEDICAL CONDITION] FROM A TOTAL 14 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #3 WHO WAS HAVING ACUTE RESPIRATORY DISTRESS EVIDENCED BY PERSISTENT COUGHING, COPIOUS AMOUNT OF TRACHEAL SECRETIONS, STRUGGLE TO BREATHE AND THE POTENTIAL FOR INCREASED RISK OF RESPIRATORY COMPROMISE AND POTENTIAL DEATH. THE IMMEDIATE JEOPARDY WAS DISCOVERED ON 8/31/11 AT 1:15 P.M., WHEN RESIDENT #3 WAS OBSERVED COUGHING UP COPIOUS AMOUNT OF SECRETIONS WHICH REQUIRED URGENT TRACHEAL SUCTIONING. IT TOOK OVER 15 MINUTES FOR A FACILITY STAFF TO RESPOND TO THE SITUATION WHERE THE RESIDENT BECAME INCREASINGLY HARDER TO BREATHE AND ANXIOUS. IT TOOK ANOTHER 2 MINUTES TO GATHER SUPPLIES AND SUCTION MACHINE TO BE FUNCTIONAL. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 9/1/11 AT 10:00 A.M. THE IMMEDIATE JEOPARDY WAS REMOVED BUT NOT CORRECTED ON 9/1/11 AT 2:45 P.M. WHEN THE FACILITY'S REMOVAL PLAN WAS ACCEPTED. THE REMOVAL PLAN CONSISTED OF THE FOLLOWING: EVERY 15 MINUTE CHECKS FOR 4 HOURS OF THE RESIDENT'S RESPIRATORY STATUS, COMPLETION OF TRAINING AND COMPETENCY TESTING FOR TRACHEAL SUCTIONING FOR ALL LICENSED STAFF, ENSURING ALL SUCTIONING SUPPLIES AND POSTING OF SUPPLY LIST AT BEDSIDE. ALSO THE TRAINING OF NURSE AIDES TO ASSESS SIGNS AND SYMPTOMS OF RESIDENTS WITH SECRETION WAS TO BE ADDED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, NON-COMPLIANCE WITH THE REGULATORY REQUIREMENTS REMAINED AT POTENTIAL FOR MORE THAN MINIMAL HARM FOR RESIDENT #3 AND 2 OTHER RESIDENTS WITH [MEDICAL CONDITION]. FINDINGS INCLUDE: RESIDENT #3 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #3'S NURSING CARE PLAN RELATED TO THE [MEDICAL CONDITION] CARE DATED 3/28/11 INCLUDED TO "SUCTION RESIDENT'S [MEDICAL CONDITION] AS NEEDED PER POLICY, MAINTAIN HUMIDIFIED AIR [MEDICAL CONDITION] 70 % AT ALL TIMES, SHUT OFF T-MIST (TRACHEAL MIST) AS NEEDED FOR INCREASED SECRETIONS,[MEDICAL CONDITION] DAILY AND PRN (AS NEEDED), NEB (NEBULIZER) TREATMENTS AS ORDERED, CLEAN INNER CANNULA EVERY OTHER DAY AND PRN, [MEDICAL CONDITION] COME OUT SEND TO HOSPITAL." ON 8/31/11 AT 1:15 P.M., RESIDENT #3 WAS OBSERVED IN HER ROOM, COUGHING VIGOROUSLY, MAKING LOUD GURGLING SOUNDS DUE TO LARGE AMOUNT OF TRACHEAL SECRETIONS. THE RESIDENT ALREADY HAD COPIOUS AMOUNT OF THICK PALE YELLOW SECRETIONS RUNNING DOWN THE LEFT SIDE OF THE NECK. IT WAS EVIDENT SHE WOULD NOT BE ABLE TO BRING UP ALL OF THE SECRETIONS ON HER OWN AND WAS BECOMING ANXIOUS AND STRUGGLED TO BREATHE. THE NURSE AIDE, (STAFF "A") WAS ALERTED IMMEDIATELY BY THIS SURVEYOR TO INFORM THE NURSE THAT THE RESIDENT NEEDED TO BE SUCTIONED. AT 1:17 P.M., THE ACTIVITY AIDE, (STAFF "B") CAME TO THE ROOM AND STATED SHE WAS GOING TO READ A BOOK TO THE RESIDENT. ACTIVITY AIDE "B" WAS TOLD THAT THE RESIDENT WAS IN NO SITUATION OF HAVING THE BOOK READ TO HER DUE TO THE RESIDENT'S RESPIRATORY DISTRESS. ACTIVITY AIDE "B" WAS AGAIN INFORMED TO GO OUT AND FIND ANY NURSE WHO COULD IMMEDIATELY SUCTION THE RESIDENT. AT 1:30 P.M., THE UNIT MANAGER, (STAFF "C") FINALLY CAME INTO THE ROOM WITH A SUCTION KIT AND THE CONNECTING TUBING FOR THE SUCTION MACHINE. STAFF "C" OPENED THE SUCTION KIT AND PUT ON STERILE GLOVE (KIT ONLY HAD ONE GLOVE) THAT SHE CONTAMINATED TWICE BY TOUCHING A NON STERILE SURFACE. WHEN THE UNIT MANAGER "C" WAS FINALLY READY TO SUCTION THE RESIDENT AFTER AN ADDITIONAL 3 MINUTES SHE FOUND THE SUCTION MACHINE NOT WORKING AS IT HAD NOT BEEN PLUGGED IN. IT TOOK ANOTHER 2 MINUTES TO LOCATE THE ELECTRIC OUTLET TO PLUG IN THE SUCTION MACHINE. UNIT MANAGER "C" LOOKED UNCOMFORTABLE WITH THE USE OF THE SUCTION EQUIPMENT AND WITH PERFORMING THE SUCTIONING. THE RESIDENT'S OXYGEN LEVEL WAS NOT OBSERVED BEING MONITORED DURING THIS TIME PERIOD. AT 1:35 P.M., AFTER NUMEROUS SUCTIONING ATTEMPTS, THE RESIDENT WAS SUCTIONED AND A LARGE THICK BROWN MUCUS PLUG WAS RELEASED WHICH PROVIDED THE RESIDENT WITH IMPROVED BREATHING. THE RESIDENT LOOKED EXHAUSTED. AT 2:30 P.M., UNIT MANAGER "C" AND THE CHARGE NURSE, (STAFF "D") WERE INTERVIEWED REGARDING THE DELAY OF RESPONSE TO SUCTIONING RESIDENT #3. THE CHARGE NURSE, (STAFF "D") WHO HAD BEEN INFORMED BY NURSE AIDE "A" STATED SHE NEEDED TO COMPLETE HER MEDICATION PASS. CHARGE NURSE "D" ADDED SHE TOLD THE UNIT MANAGER "C" TO TAKE OVER SUCTIONING OF THE RESIDENT. UNIT MANAGER "C" STATED SHE HAD BEEN AT THE FACILITY ONLY ONE WEEK AND NEEDED TO LOOK UP THE RESIDENT'S CARE PLAN AND PROCEDURES FOR SUCTIONING AND GATHER SUPPLIES FOR SUCTIONING. ON 8/31/11 AT 3:00 P.M., THE DIRECTOR OF NURSING BROUGHT IN THE AFTERNOON SHIFT NURSE AIDE, (STAFF "E") TO EXPLAIN HOW SHE CARED FOR RESIDENT #3. NURSE AIDE "E" STATED ALTHOUGH THE RESIDENT SOMETIMES LOOKED LIKE HAVING A LOT OF SECRETIONS AND MIGHT NEED SUCTIONING SHE WAS TOLD BY THE NURSES THAT THE RESIDENT SHOULD NOT BE SUCTIONED FREQUENTLY BECAUSE IT WOULD INCREASE MORE SECRETIONS AND NEED FOR SUCTIONING, THUS SHE DID NOT INFORM THE NURSES AND WAS NOT ENCOURAGED TO INFORM THEM OF THE RESIDENT'S NEED FOR SUCTIONING. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE FACILITY "TRACHEAL SUCTION" PROCEDURE MANUAL DATED 10/2010, REFLECTED THE RESIDENT WAS TO "HYPER-OXYGENATE" (TO PREVENT DESATURATION OF RESIDENT DURING SUCTIONING) PRIOR TO SUCTIONING. HOWEVER, THERE WAS NO OXYGEN SOURCE AVAILABLE AT THE RESIDENT'S BEDSIDE. ON 9/1/11 AT 10:00 A.M., THE LICENSED PRACTICAL NURSE (STAFF "J") STATED THE RESIDENT'S ROOMMATE HAD AN OXYGEN CONCENTRATOR THAT COULD BE SHARED AT HER BEDSIDE IF NEEDED. ACCORDING TO THE "CLINICAL SKILLS REVIEW/LICENSED NURSE" THE REGISTERED NURSE UNIT MANGER "C" COMPLETED HER RETURN DEMONSTRATION [MEDICAL CONDITION] TECHNIQUE AND WAS DETERMINED TO BE COMPETENT [MEDICAL CONDITION] TECHNIQUES BY LICENSED PRACTICAL NURSE STAFF "D" AS RECENTLY AS 8/18/11. HOWEVER, STAFF "C" WAS HESITANT HANDLING [MEDICAL CONDITION] EQUIPMENT AND LOOKED UNCOMFORTABLE PERFORMING THE TASK. ( )

THIS CITATION PERTAINS TO INTAKE MI 513. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL BEING FOR 1 (#101) OF 4 SAMPLED RESIDENTS, OUT OF A TOTAL SAMPLE OF 4, WHEN RESIDENT #101 fell OUT OF BED ON 5/30/11 AND SUSTAINED A FRACTURED RIGHT WRIST, WHICH WENT UNDETECTED BY FACILITY STAFF UNTIL 6/12/11, RESULTING IN AN UNTREATED WRIST FRACTURE FOR 13 DAYS, PROLONGED HEALING TIME, AND PAIN FOR RESIDENT #101. FINDINGS INCLUDE: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HIS MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT HE HAD SEVERE COGNITIVE IMPAIRMENT, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR BED MOBILITY, TRANSFERS AND DRESSING, HAD OCCASIONAL MODERATE PAIN AND RECEIVED SCHEDULED PAIN MEDICATION. FACILITY NURSE'S NOTES FOR RESIDENT #101, DATED 5/30/11 AT 9:00 PM, DOCUMENTED THAT RESIDENT #101 WAS FOUND ON THE FLOOR NEXT TO HIS BED AFTER STAFF NURSE #6 HEARD HIS ALARM SOUNDING, WITH NO INJURIES NOTED AND "ORTHOPEDIC" SECTION OF NURSE'S NOTES CHECKED "N/A" (NOT APPLICABLE). FACILITY NURSE'S NOTES FOR RESIDENT #101, DATED 5/31/11 DOCUMENTED RESIDENT #101 DENIED PAIN, "ALTHOUGH RECEIVES [MEDICATION NAME] (NARCOTIC PAIN MEDICATION) FOR PAIN MANAGEMENT", AND "ORTHOPEDIC" SECTION OF NURSE'S NOTES CHECKED "N/A" (NOT APPLICABLE). FACILITY NURSE'S NOTES FOR RESIDENT #101, DATED 6/1/11 DOCUMENTED THAT THE SISTER OF RESIDENT #101 WAS NOTIFIED OF RESIDENT #101'S "ROLL OUT OF BED", THAT RESIDENT #101 RECEIVED ROUTINE [MEDICATION NAME] AS SCHEDULED FOR PAIN MEDICATION, AND DENIED PAIN. NURSE'S NOTES FOR 6/1/11 ALSO HAD THE "ORTHOPEDIC" SECTION OF NURSE'S NOTES CHECKED "N/A" (NOT APPLICABLE). REVIEW OF THE ENTIRE MEDICAL RECORD FOR RESIDENT #101 DID NOT REVEAL ANY FURTHER NURSING DOCUMENTATION REGARDING RESIDENT #101 UNTIL 6/12/11. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 6/12/11 DOCUMENTED AT 11:00 AM, RESIDENT #101'S "HAND WAS A LITTLE SWOLLEN" AND AT 2:00 PM, RESIDENT #101'S "WRIST WAS RED AND WARM TO THE TOUCH", THAT THE PHYSICIAN WAS NOTIFIED, XRAYS AND LABS ORDERED. NURSE'S NOTES FOR THE SAME DAY (6/12/11) AT 7:00 PM DOCUMENTED THAT RESIDENT #101'S HAND AND WRIST WERE SWOLLEN, RED, TENDER AND WARM, THAT THE PHYSICIAN WAS NOTIFIED, XRAYS AND LABS ORDERED. "ORTHOPEDIC" SECTION OF THE NURSE'S NOTES DATED 6/12/11 AT 11:00 AM, DOCUMENTED THAT RESIDENT #101'S RIGHT UPPER EXTREMITY WAS WARM, RED AND HAD "DULL" SENSATION. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 6/13/11 AT 2:00 PM, DOCUMENTED XRAY RESULTS SHOWED A RIGHT WRIST IMPACTED DISTAL FRACTURE, AT 4:45 PM DOCUMENTED A NEW physician's orders [REDACTED]. FACILITY NURSE'S NOTES DATED THE SAME DAY, AT 10:00 PM, DOCUMENTED THAT RESIDENT #101 CAME BACK TO THE FACILITY FROM THE HOSPITAL emergency room COMPLAINING OF PAIN IN RIGHT WRIST, WITH A SPLINT AND A SLING INTACT. FACILITY INCIDENT REPORT DATED 5/30/11 DOCUMENTED THAT AT 8:30 PM, RESIDENT #101 ROLLED OUT OF BED, UNWITNESSED, WITH NO INJURIES NOTED. CORRECTIVE MEASURES DOCUMENTED ON THE INCIDENT REPORT INCLUDED MONITORING FOR LATE EFFECTS OF FALL, VITAL SIGNS EVERY SHIFT FOR 3 DAYS, AND BOLSTER TO BED. FACILITY "FALL ACTION TEAM: FALL REVIEW" FORM DATED 6/1/11 DOCUMENTED RESIDENT #101 HAD A FALL ON 5/30/11, AND TEAM RESPONSE LISTED INCLUDED "MONITOR FOR LATE EFFECTS", "VITAL SIGNS EVERY SHIFT FOR 3 DAYS", AND "BOLSTERS IN BED". REVIEW OF NURSING DOCUMENTATION FOR RESIDENT #101 REVEALED VITAL SIGNS WERE OBTAINED ON RESIDENT #101 ON 5/30/11 DAY SHIFT ONLY, 5/31/11 DAY AND NIGHT SHIFTS, 6/1/11 DAY SHIFT ONLY, AND NO VITAL SIGNS WERE DOCUMENTED ON RESIDENT #101 AGAIN UNTIL 6/7/11. XRAY RESULTS FOR RESIDENT #101 DATED 6/13/11 DOCUMENTED THE ORDER FOR THE XRAY WAS RECEIVED 6/12/11 AT 8:50 PM, WITH THE SERVICE DATE OF 6/13/11 AT 11:33 AM, AND FINDINGS DOCUMENTED AS 1. IMPACTED [MEDICAL CONDITION] RADIUS. 2. QUESTION MILD SCAPHOLUNATE (SMALL BONE IN THE WRIST) WIDENING COMPATIBLE WITH LIGAMENT TEAR. 3. MILD [MEDICAL CONDITION] AND 4. MILD [MEDICAL CONDITION]. HOSPITAL emergency room NURSE'S NOTES DATED 6/13/11 FOR RESIDENT #101 DOCUMENTED THAT RESIDENT #101 HAD PAIN IN HIS RIGHT HAND AND WRIST THAT HE RATED AS A 10 OUT OF 10 ON A PAIN SCALE. HOSPITAL emergency room PHYSICIAN NOTES DATED 6/13/11 FOR RESIDENT #101 DOCUMENTED A CHIEF COMPLAINT OF INJURY TO RIGHT HAND AND WRIST FROM A FALL OUT OF BED ON 6/1/11, AND XRAY RESULTS OF THE RIGHT WRIST SHOWED AN IMPACTED DISTAL RADIUS FRACTURE. IN AN INTERVIEW ON 6/30/11 AT 1:45 PM, STAFF NURSE #6 STATED ON 5/30/11 WHILE SHE WAS PASSING MEDICATIONS, SHE ENTERED RESIDENT #101'S ROOM WITH CNA #8 BECAUSE THEY HEARD RESIDENT #101'S ALARMS SOUNDING AND FOUND HIM ON THE FLOOR NEXT TO HIS BED. NURSE #6 STATED RESIDENT #101 TOLD HER HE FORGOT TO USE HIS CALL LIGHT. NURSE #6 STATED SHE CHECKED RESIDENT #101 ALL OVER, WITH NO INJURIES IDENTIFIED, AND THAT SHE AND CNA #8 GOT RESIDENT #101 BACK UP INTO BED. IN AN INTERVIEW ON 7/1/11 AT 11:35 AM, CNA #8 STATED ON 5/30/11, WHILE SHE WAS IN ANOTHER ROOM SHE HEARD RESIDENT #101'S ALARM, SO HER AND NURSE #6 WENT IN THE ROOM. CNA #8 STATED THAT RESIDENT #101 HAD ROLLED OUT OF BED AND WAS ON HIS FLOOR MAT NEXT TO HIS BED. CNA #8 STATED NURSE #6 "CHECKED HIM OUT AND SAID HE WASN'T HURT", AND THEN THEY (NURSE #6 AND CNA #8) PUT RESIDENT #101 BACK TO BED. IN AN INTERVIEW ON 7/1/11 AT 12:05 PM, STAFF NURSE #7 STATED ON 6/12/11 RESIDENT #101 TOLD HER HE WAS HAVING PAIN IN HIS WRIST AND SHE OBSERVED HIS WRIST WAS SWOLLEN. NURSE #7 STATED SHE GAVE RESIDENT #101 HIS SCHEDULED PAIN MEDICATION AND LATER NOTICED HIS WRIST AND HAND WERE MORE SWOLLEN, RED AND WARM TO THE TOUCH, SO SHE CALLED RESIDENT #101'S PHYSICIAN TO GET AN XRAY AND REPORTED IT TO NURSE MANAGER #9. IN AN INTERVIEW ON 7/1/11 AT 11:35 AM, NURSE MANAGER #9 STATED ON 6/12/11, NURSE #7 ASKED HER TO LOOK AT RESIDENT #101'S HAND AND WRIST, SO SHE DID. NURSE MANAGER #9 STATED RESIDENT #101'S RIGHT WRIST AND HAND WAS RED, SWOLLEN AND TENDER. NURSE MANAGER #9 STATED SHE ASKED RESIDENT #101 IF HE HAD ANY OTHER FALLS SINCE HE ROLLED OUT OF BED, AND HE SAID NO. NURSE MANAGER #9 STATED SHE THOUGHT THE FRACTURE OF RESIDENT #101'S RIGHT WRIST HAPPENED WHEN HE ROLLED OUT OF BED ON 5/30/11. IN AN INTERVIEW ON 6/30/11 AT 2:00 PM, RESIDENT #101 IS OBSERVED SITTING IN A WHEELCHAIR IN THE DAY ROOM, WITH HIS RIGHT LOWER ARM IN A CAST. RESIDENT #101 STATED HIS MEMORY IS BAD, BUT HE DID REMEMBER WHEN HE fell OUT OF BED AND THAT IS HOW HE HURT HIS ARM (POINTED TO HIS CASTED ARM). RESIDENT #101 STATED HIS ARM DID HURT AFTER HE fell OUT OF BED, AND IT STILL HURTS. IN AN INTERVIEW ON 7/1/11 AT 1:10 PM, THE DIRECTOR OF NURSING STATED THAT THE FACILITY INVESTIGATION OF RESIDENT #101'S FRACTURE DID CONCLUDE THAT THE FRACTURE WAS A RESULT OF RESIDENT #101'S ROLL OUT OF BED ON 5/30/11. THE DIRECTOR OF NURSING STATED THAT RESIDENT #101 DENIED PAIN UNTIL 6/12/11. THE SURVEYOR ASKED THE DIRECTOR OF NURSING TO FIND AN ASSESSMENT OF RESIDENT #101'S PAIN OR DOCUMENTATION OF RESIDENT #101'S DENIAL OF PAIN IN THE RESIDENT'S MEDICAL RECORD. AFTER REVIEWING THE MEDICAL RECORD, THE DIRECTOR OF NURSING admitted SHE WAS UNABLE TO LOCATE ANY PAIN ASSESSMENT FROM 6/1/11 THROUGH 6/12/11. THE DIRECTOR OF NURSING STATED THE FACILITY POLICY FOR FALLS STATES THAT AFTER A RESIDENT HAS A FALL, NURSES ARE SUPPOSED TO ASSESS AND DOCUMENT ON THE RESIDENT EVERY SHIFT FOR 72 HOURS. THE SURVEYOR HAD THE DIRECTOR OF NURSING REVIEW THE ENTIRE MEDICAL RECORD FOR RESIDENT #101. THE DIRECTOR OF NURSING admitted THAT THERE WAS NOT A DOCUMENTED ASSESSMENT EVERY SHIFT FOR 72 HOURS FOR RESIDENT #101 AFTER HE fell OUT OF BED ON 5/30/11. THE DIRECTOR OF NURSING admitted THAT THERE WERE NO NURSE'S NOTES FOR RESIDENT #101 FROM 6/1/11 AT 9:00 PM THROUGH 6/12/11 AT 11:00 AM. IN AN INTERVIEW WITH THE FACILITY ADMINISTRATOR ON 7/1/11 AT 1:45 PM, SHE STATED THAT SHE HAD SPOKEN WITH RESIDENT #101 TO SEE IF ANYTHING HAD HAPPENED SINCE HE ROLLED OUT OF BED, AND THE RESIDENT STATED NOTHING HAD HAPPENED. THE FACILITY ADMINISTRATOR STATED THE ONLY THING SHE COULD TRACK THE FRACTURE BACK TO WAS THE ROLL OUT OF BED. THE ADMINISTRATOR REVIEWED THE MEDICAL RECORD FOR RESIDENT #101 AND WAS UNABLE TO LOCATE ANY NURSE'S NOTES OR DOCUMENTATION OF A NURSING ASSESSMENT FOR RESIDENT #101 FROM 6/1/11 AT 9:00 PM, THROUGH 6/12/11 AT 11:00 AM. #

This citation pertains to Re-visit MI# 513 Based on interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well being following falls for 3 (#201, #202, #204) of 4 sampled residents, when 1) resident #201 was found by staff on the floor in front of his bathroom door 2) resident #202 was found by staff on the floor after a fall from standing on a rocking chair in his room resulting in a hematoma to back of his head 3) resident #204 was found on the floor next to his bed resulting in a scratch to his forehead, resulting in potential for discomfort and harm of residents. Findings include: Record review of facility binder for plan of correction in-service on 7/2/11 revealed that staff nurses were in serviced on 'Fall Risk Reduction & Management' policy dated 8/10. The fall management policy bullet point #4 identified that staff should document date and time of incident, brief, factual, and objective description of incident, results of clinical findings, refer to documentation program: Charting Aid/Fall for further information regarding documentation and immediate interventions provided. Both of the nurse's, #4 and #6 signed in on the in-service attendance log. Record review of sampled residents #201, #202, and #204's, 'Resident information sheet' (CNA care guide/care plan) revealed that although each resident had safety devices in place, they were not written on the CNA 'Resident information sheet'. Resident #201 had a floor mat at bedside, but it was not on his 'Resident information sheet'. Resident #202 had a wheelchair alarm, but it was not on his 'Resident information sheet'. Resident #204 had bilateral floor mats, but it was not on his 'Resident information sheet'. Resident #201: Record review of resident #201's accident/incident report dated 7/9/11 at 3:00 PM by nurse #4 revealed resident #201 was found on the floor in front of his bathroom door after he had attempted to toilet himself. Resident #201 would roll his wheelchair to the bathroom door, open it, and attempt to toilet himself. Record review of resident #201's 'Care Tracker' (12 hour) form dated 7/9/11 revealed that the resident was assessed at 4:00 PM. On the back side of the form it was noted: "7/9/11 resident found on floor at 3:00 PM, no injury noted. Stated he tried to take himself to the bathroom. Family and director of nursing notified". There was no noted assessment of the residents left wrist which had a cast in place and no documentation that a pain assessment had been completed. Resident #202: Record review of resident #202's accident/incident report dated 7/14/11 at 3:30 PM by nurse #6 revealed an unwitnessed fall resulting in a hematoma to the back of his head. The cause of the incident was noted as the resident who resides on the dementia secured unit attempted to close his own blinds and stood up on a chair (recliner/rocker) and the resident fell back off of his chair. The accident/incident report noted an injury to back of head, there were no measurements noted, no documentation of drainage or bleeding, no pain assessment noted, no first aide noted, no reason why the resident was unsupervised. The resident was sent to the local emergency room for a CT scan. Record review of resident #202's 'Care Tracker (12 hour) form dated 7/14/11 revealed that at 10:30 AM the resident was assessed and noted to be confused. On the back side of the care tracker form at 3:30 PM the nurse #6 noted that resident had an unwitnessed fall. Found on floor in resident room with feet up on reclining chair, rest of body flat on floor, conscious and talking. Hematoma to back of head. Physician and family notified. The resident was sent to the local emergency room . There was no documentation of hematoma size, whether there was drainage or bleeding, a pain assessment, or whether first aide was administered. Resident #204: Record review of resident #204's accident/incident report dated 7/4/11 at 10:40 AM by nurse #4 revealed that resident #204 rolled from his bed onto the gray mat at bedside. A scratch was noted to the left side of his head. There was no documentation in regards to measurements of the scratch, whether there was drainage or bleeding noted, whether first aid was administered, or that a pain assessment had been completed. Corrective measures for resident #204 were that he be placed on one hourly checks for needs and bolsters (foam rolls placed on edge of mattress to prevent rolling out of bed) were to be checked for proper placement and that they were secured properly. Record review of resident #204's Care Tracker (12 hour) assessment form dated 7/4/11 revealed that during the day shift assessment there was no assessment written by Nurse #4. On the back side of the form there was no written assessment on the incident or the scratch to the forehead or pain assessment. Nurse #4 failed to sign the Care Tracker form for her shift. Record review of resident #204's nursing progress note dated 7/4/11 at 11:50 AM revealed: 'Resident found on floor lying on gray mat. Scratch noted to left side of forehead. Neuro's begun and within normal limits. Record review of resident #202's treatment administration record (TAR) for the month of July 2011 revealed that there were no treatments, measurements, or assessments to describe the left forehead scratch. Record review of resident #204's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview on 8/17/11 with the staff CNA caring for resident #204 on 7/4/11 revealed that she was disciplined for not placing the bed bolsters on residents #204's bed the right way and not latching them properly. On 8/17/11 the facility director of nursing and unit manager both were not able to locate the bed bolster in-servicing for resident #204's bed bolsters that included the staff CNA. The facility plan of correction for the previous citation included in-servicing of licensed nursing staff on post fall assessments and monitoring. #