Every finding on record at Royalton Manor, LLC

This citation pertains to intake #3108154.Based on observation, interview, and record review, the facility failed to maintain equipment to promote healing and ensure the prevention of the worsening of a pressure ulcer for 3 of 3 sampled residents (R100, R101, and R102) reviewed for pressure ulcers. R100, R101, R102 experienced NPWT (non-pressure wound treatment) equipment malfunction. R101 experienced worsening of a pressure ulcer. Findings include:R100 During an observation and interview on 8/11/2026 at 9:30 AM, R100 was awake in bed lying on a non-APM (alternating pressure mattress). R100's left hip pressure ulcer dressing did not have a date or label with staff identifier. A Negative Pressure Wound Therapy (NPWT (wound vac) uses a specialized medical device to apply controlled suction to a wound bed, removing fluid and promoting faster healing) was connected to R100's left hip pressure ulcer. The NPWT was sitting on the floor to the left of R100. The floor underneath R100 was sticky with food and debris. The NPWT display revealed 100 and the battery symbol was blinking. The NPWT was plugged into a red outlet (specialized power delivery system designed for patient safety and uninterrupted operation when utility power fails). The NPWT cannister (storage for fluids pulled from wound bed) was empty. The NPWT was not working as evidenced by the display screen not stating Pressure 125 mmHg. Continuous mode. A closed lock symbol or a clockwise revolving circle. The NPWT had a sticker that stated 8/10. R100 was incontinent of loose bowel movement (BM). The BM was seeping out of R100's brief onto the pad underneath the resident, the fitted bed sheet and top sheet. The dressing covering the left hip wound was puffed up with pooling drainage. No assistive devices were being used to off-load pressure from R100's bony prominences including either hip and heels. Observed placed around R100's room were pressure-relieving boots and wedges. R100 reported he would wear pressure-relieving boots sometimes when staff put them on him. R100 also reported he could not dress himself or put pressure-relieving boots on or take them off. According to R100's Minimum Data Set (MDS) dated [DATE], the resident was cognitively intact with a BIMS (Brief Interview Mental Status) score of 13/15. Section GG-Functional Abilities included partial/moderate assistance with eating, indicated substantial/maximal assistance was needed for bed mobility, an indwelling catheter and always incontinent with bowels. Section M-Skin Conditions indicated R100 was at risk of developing pressure ulcers, he had more than one unhealed pressure ulcer including a stage 4. Review of R100's Diagnoses included sepsis and osteomyelitis (infection of bone). Review of R100's Order Summary dated 7/31/26 revealed, Ensure wound vac is connected, plugged in, functioning properly, and set to 125 mmHg continuous suction every shift. Complete PRN (as needed) dressing change if wound vac is disconnected or malfunctioning for greater than 2 hours every shift for wound vac monitoring. Review of R100's Medication/Treatment Administration Record (MAR/TAR) dated 8/1/26-8/31/26 revealed-7/10/26, revealed, Ensure wound vac is connected, plugged in, functioning properly, and set to 125mmHg continuous suction every shift. Complete PRN dressing change if wound vac is disconnected or malfunctioning for greater than 2 hours. every shift for NPWT monitoring It was noted there was no documentation that the NPWT had been monitored on the night shift of 8/9/26.-7/23/26, revealed, Blue Sage Boots to Bilateral feet whenever feet are resting on surface. every shift for Wound Prevention-7/31/26, revealed, Ensure wound vac is connected, plugged in, functioning properly, and set to 125mmHg continuous suction every shift. Complete PRN (as needed) dressing change if wound vac is disconnected or malfunctioning for greater than 2 hours every shift for wound vac monitoringReview of R100's Care Plan, Actual Impairment to Skin Integrity related to clinically unavoidable left hip stage4 pressure ulcer with 4 openings from surgical I&D (an incision and drainage is a minor surgical procedure used to cut open and drain pocket of infection under the skin), and right hip stage 4 pressure ulcer, dated 8/4/26, with a goal to have no complications. Interventions to meet this goal included applying pressure relieving/reducing mattress, pillows, etc to protect the skin while in bed dated 3/24/26. It was noted there was no documentation associated with this intervention stating R100 refused treatments.encourage good nutrition dated 3/12/26.NPWT to left hip sites.It was noted the intervention for the NPWT did not include ordered settings 125 mmHg continuous suction. Review of R100 Care Plan, Functional Ability Deficit and requires assistance with self-care/mobility, dated 3/17/26. The resident's goal was to improve or maintain current level of functioning including eating and mobility. To meet the goal, nursing staff were to use interventions that included supervision/touching assist, bed mobility as resident requires substantial/maximal assistance with one helper. This includes rolling side to side, lying to sitting on side of bed and sitting to lying. It was noted that a revision update was done after surveyor had entered for survey.During an interview on 8/11/26 at 9:50 AM, Nursing Home Administrator (NHA) A reported the facility had two designated wound nurses (WN F and WN G) and one wound doctor (WD D).Review of a resident list of required eating assistance supplied by the facility on 8/11/26 included R100.During observation and interview on 8/11/26 at 12:11 PM, Registered Nurse (RN) E stated while observing R100 and his NPWT, Just this morning licensed staff was thinking the wound vac (NPWT) machines should not be setting on the floor without a barrier. (R100) requires assisted feeding or supervised eating. CNAs take turns feeding (R100). R100 stated to RN E with a scowl on his face, No they (referring to CNAs) don't. The just put the tray (meal) down and go. RN E stated, (R100) has his wound dressing changed daily. (WD D) comes in tonight around 4:30 PM and will look at R100's wound. (R100's) wound dressing was changed this morning by (WN G). Observed R100's NPWT was not hooked up to the left hip wound. It had been placed in a black bag that was earlier seen on the floor under the resident's bed and now placed in a basin against the wall. RN E stated, I don't know what (R100's) wound vac (NPWT) was set at. (R100's) wound vac was not working this morning. RN E could not state how they know when the NPWT was working correctly. RN E observed R100's mattress stating, (R100) should have an alternating air mattress and he does not. Looking around R100's room, RN E stated, (R100) has pressure relieving boots. At this time, there were no pressure relieving boots in the room. RN E stated, Maybe the order was changed because (R100) came from the hospital with them. Observed no pressure relieving wedges on the floor or in the wheelchair. RN E stated, (R100) should have a wedge to off-load. Observed a black pressure relieving wedge in the straight chair and no pressure relieving device underneath R100. RN E stated, (R100) should be off-loaded. Observed R100 on his right side with knees curled up in same position as observed at 9:36 AM. R100 stated, I'm on the same side as when you were here before. My right big toe hurts. Observed both of R100's feet tangled in the urinary catheter tubing. RN E looked at R100's great toes and told him she would alert the wound doctor. The right great toe appeared darker than the left great toe. R100 stated, My left foot hurts. RN E observed R100's left foot. The lateral side (by pinky toe) was white part way down the length of the foot with a dark pink spot approximately the size of a dime. RN E stated, There was a wound there and the wound doctor got it healed. Observed no wedge under R100's feet or pressure relieving boots on. RN E then took the pressure relieving wedge off the straight chair and placed it under R100's fitted bed sheet and then put both of R100's lower legs on top. RN E stated, It is not on (R100's) MAR/TAR to check or have boots on. When RN E was quired if elevating heels/legs was an intervention for R100, RN E did not reply.Review of facility policy, Skin Management last revised 1/28/26, revealed, It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries.Appropriate preventative measures will be implemented on residents identified a risk and the interventions are documented on the care plan.During an interview on 8/11/26 at 12:40 PM, Wound Nurse (WN) F stated, (R100) has a NPWT and I saw it this morning at 10:00 AM during rounds. The NPWT was not working this morning because the seal was broken. The NPWT was not on and not functioning. I saw during rounds that the foam under the clear bandage was fluffed. The NPWT will vacuum seal the outer dressing and foam dressing to draw out drainage. Since the foam was fluffed it means the NPWT was not working. The NPWT had no barrier underneath it on the floor as it should. That is for infection control. The wound dressing should have been dated/labeled per policy for procedure and infection control. (R100) is on IV (intravenous) antibiotics through a CVC (central line) in his chest.During an observation on 8/11/26 at 12:58 PM, R100 was in bed lying on his right side with eyes closed, appearing to have not been repositioned since last observed (8/11/26 at 12:11 PM).During an observation and interview on 8/11/26 at 1:15 PM, R100 was in bed lying on his right side being assisted with eating by CNA I. CNA I stated, I work with (R100) once in a blue moon (not often). (RN E) said for someone to feed (R100) since you (Surveyor) are here. It was noted that R100 was still positioned on his right side.During an interview on 8/11/26 at 1:20 PM, NHA A stated with Maintenance J, There was a power outage at 1:30 AM this morning. The generator kicked on right away. The battery to (R100's) wound vac went from power cord to battery power even though it was plugged into the red outlet. At 9:30 AM this morning the battery pack was draining and ran out of power (still plugged into red outlet at 9:36 AM when observed by Surveyor). It was okay because (R100's) wound was changed yesterday (8/10/26). I talked to the night nurse that worked last night (RN M) who said the wound vac (NPWT) worked all night. Unit Managers (UM K and L) do (resident) rounds every morning. They look at wound vacs (NPWT). It was noted the Maintenance Director did not state anything about NPWT being plugged into the red outlet and not working off the generator.During an interview on 8/11/26 at 1:36 PM, Unit Manager (UM) L stated, The other UM and me do resident rounds every morning we are here. Neither of us look at residents with wound vacs. (RN/WN F) does that. Neither me or the other UM did rounds with (R100, R101, or R102) they have wound vacs.During an interview on 8/11/26 at 5:10 PM, Director of Nursing (DON) B stated he had triple-checked R100's physician order for the setting of positive pressure for the NPWT. It was to be 125 mmHg.As of 8/11/26 at 5:15 PM, R100's wound vac was known to not be working from 9:36 AM to 4:53 PM. It is unknown how long it was not working before that by either Wound Nurse.During an interview and record review on 8/12/26 at 9:40 AM, RN N stated while reviewing R100's medical records, (R100) has a wound vac. I am to check it once a day to make sure the seal to the dressing is intact. If the machine is beeping I know it is not working and I contact the wound nurse. The wound nurse changes wound dressings and work with the wound vac equipment. RN N was unable to explain other than the wound vac beeping, how to tell if the machine was working.During an observation and interview on 8/12/26 at 9:53 AM, R100 was awake in bed. A wound vac was in a case placed in a basin on the floor to the left side of R100's bed. The machine was plugged into a red outlet with the display screen stating Pressure 125mmHg. Continuous mode. A lock was displayed as closed. A circle was moving in a clockwise direction indicating the machine was working. The machine was softly vibrating, indicating the machine was working. The canister on the machine had dark red drainage in it. R100 was lying on his left side with contracted legs pulled up to his chest.During an interview and record review on 8/12/26 at 9:40 AM, RN N stated while reviewing R100's medical record, (R100) cannot turn all the way to his left or right without assistance. He needs to be at least supervised while eating. He will eat more when staff assist and he really needs to have the staff assist him to eat. He will eat everything when staff assist him.During an interview on 8/12/26 at 10:50 AM, Medical Equipment Representative (MER) O stated, The medical supply company does supply wound vacs. The company has not had contact with the facility in the last 24 hours regarding R100. The last contact the company had with the facility regarding R100 was delivering supplies on August 5, 2026. A wound vac was delivered July 29, 2026, for R100. The machine is set to industry standard of 125 mmHg unless told ahead of time of a different setting. I spoke to (WN F) at time of ordering to verify setting. (R100 and R101) had orders for their respective machines to be set at 125mmHg continuous suction. It can be plugged into a standard outlet and should be able to run for 8 hours on its own battery. When power button is on a revolving circle with an arrow will indicate the pump is working. It will state the pressure setting on the left side. Continuous mode indicates it is set and a lock that is closed. The motor will be softly vibrating. With the display screen showed 100 and a partially filled battery it means the battery is completely charged. However, with a display screen showing 100 and a partially filled battery symbol it also shows the wound vac is not turned on. The machine must display the setting which in (R100) case, it would display Pressure: 125mmHg Continuous mode, and the circling arrow. If the outlet is working the pump should work and the battery is charging. If the pump is working on battery, it will still give the correct display setting. I don't think the power outage could change the pressure setting. The first thing the facility should do when they notice the wound vac is not working is to try a different outlet. The facility should have called us (medical equipment supply company) to make sure they got the pumps running correctly. I usually deal with (WN F). I did not nor is there record of hearing from anyone from the facility yesterday or today. To clarify continuous mode the wound vac machine works continuously to reach positive pressure to 125 mmHg. Then the pump shuts off and holds that pressure. Once the pressure goes below 125 mmHg the pump will start again to reach the positive pressure of 125 mmHg. With the display screen showing 100 and a partially filled battery it means the battery is completely charged. However, with a display screen showing 100 and a partially filled battery symbol it also shows the wound vac is not turned on. The machine must display the setting which in (R100's) case, would be Pressure: 125mmHg Continuous mode, and the circling arrow.During an observation and interview on 8/12/26 at 12:30 PM, WN F stated while observing R100's mattress, he has a T-Flow mattress (specialized therapeutic support surface) because his APM sprung a leak. The T-Flow does not alternate pressure underneath the resident so turning and positioning of the resident is important. (R100) does not always want to be turned/positioned and care plan says he doesn't always want to wear the protective boots. I put in a TELS work order with maintenance.Review of R100's Progress Notes dated 8/10/26 and 8/11/26 indicated that no documentation was made for the non-working wound vac including a description of the display screen that did not have the correct pre-set order for 125mmHg continuous suction.R101According to R101's MDS dated [DATE], the resident was cognitively intact with a score of 14/15 on her BIMS. Section GG-Functional Abilities indicated she required substantial/maximal assistance for bed mobility. Section M-Skin Conditions indicated she had a stage 3 pressure ulcer.Review of R101's Order Summary dated 7/28/26, revealed, Ensure wound vac is connected, plugged in, functioning properly, and set to 125 mmHg continuous suction every shift. Complete PRN (as needed) dressing change if wound vac is disconnected or malfunctioning for greater than 2 hours every shift for wound vac monitoring.Review of R101's MAR/TAR dated 7/29/26 discontinued on 8/11/26 revealed, Ensure wound vac is connected, plugged in, functioning properly, and set to 125 mmHg continuous suction every shift. Complete PRN (as needed) dressing change if wound vac is disconnected or malfunctioning for greater than 2 hours every shift for wound vac monitoring. It was noted there was no documentation the order was completed on 8/9/26.Review of R101's Care Plan Functional Ability Deficit and required assistance with self-care/mobility related to debility and immobility, revised on 3/12/26. The goal was to improve or maintain current level of function with the use of interventions that included partial/moderate assist with bed mobility with one helper.Review of R101's Care Plan, Actual Impairment to Skin Integrity related to stage 3 pressure ulcer sacrum/coccyx was revised on 7/28/26. The goal was to have no complications. Interventions to meet the goal included .pressure relieving FLO-T mattress to protect the skin while in bed.It was noted in WD D interview dated 8/12/26, the pressure ulcer to R101's sacrum had worsened and the NPWT had been removed. No care plan with revision history of discontinued was provided by the facility for a NPWT.During an observation and interview on 8/11/26 at 12:00 PM, R101 was awake in bed lying supine (on back). R101 stated, I recently went to the hospital because the pain on my butt (sacrum) got so bad. The pain was increasing and so was the size of my wound. I had to have some surgery to clean the wound out. I came (original admission) with a teeny wound to my bottom. I have a wound vac (NPWT) on my pressure ulcer, and it seems to be working good. Observed the NPWT plugged into the red wall outlet to the left of R101's head of bed (HOB) and was beeping. The NPWT display screen showed, 125 with the battery symbol fully charged. The display screen did not indicate the machine was working as evidenced by no reading of Pressure 125 mmHg. Continuous Mode. A closed lock symbol or a revolving circle with arrows. There was no drainage in the machine's canister. A sticker on the machine stated 8/10. R101 stated, The wound vac (NPWT) machine was sitting on the floor with nothing under it until this morning after you came. Everyone was running around here checking on things they normally do not.During an observation and interview on 8/11/26 at 12:30 PM, RN E entered R101's room stating, (R101) came to the facility with a small sacrum wound. (R101) is now doing better with wedges to off-load her sacrum. Observed R101's NPWT plugged into a red outlet with the display screen stating 125 with a battery symbol as full. The screen did not display Continuous Mode, pressure setting mmHg, or circling arrows. The machine was audibly beeping. RN E reported when the NPWT was beeping that meant it was working.During an observation and interview on 8/11/26 at 1:10 PM, R101 was visiting with Family Member (FM) H whom stated she believed the cause of R101's pressure wound was because she was not being turned and positioned. But after she returned from the hospital with a NPWT and the wound doctor talking to her about turning and positioning, she believed R101's should be healing. FM H also stated she was told the NPWT should be running all the time (continuously).During an observation and interview on 8/12/26 at 9:20 AM, R101 was awake eating breakfast. R101 stated when wound doctor came last night to look her pressure wound, he said the skin around the wound was blistering and the wound vac was taken off to give my skin a break. No wound vac was visible in the room.During an interview on 8/12/26 at 10:50 AM, MER O stated, If the wound vac was beeping that is an alarm to alert staff that the machine may have an air leak or even placed on stand-by. Either way, the machine was alerting staff that it needed attention.Review of R101's Progress Notes dated 8/10/26 and 8/11/26 indicated that no documentation was made for the wound vac machine alarming via beeping along with the display screen not displaying the pre-set order and the spinning arrow indicating it was working properly.R102 According to R102's MDS dated [DATE], the resident was cognitively impaired with a BIMS score of 9/15. Section M- Skin Conditions indicated he had a stage 3 and stage 4 pressure ulcer.Review of R102's Order Summary dated 7/10/26, revealed, Ensure wound vac is connected, plugged in, functioning properly, and set to 125 mmHg continuous suction every shift. Complete PRN dressing change if wound vac is disconnected or malfunctioning for greater than 2 hours every shift for NPWT monitoring.Review of R102's MAR/TAR dated 8/1/26-8/31/26 revealed, Left heel pressure ulcer.Connect to NPWT at 125 mmHg continuous suction.start date 7/29/26.Review of R102's Care Plan, Actual Impairment to Skin Integrity related to stage 3 pressure ulcer to right heel, stage 4 pressure ulcer to left heel, unstageable pressure ulcer to sacrum. The goal was to have no complications using interventions that included NPWT to left heel stage 4 pressure ulcer dated 7/20/26.During an observation and interview on 8/11/26 at 12:25 PM, RN E entered R102's room stating, (R102) is not seen by the facility's wound doctor. He goes to an outside wound clinic. I really don't know what his wound vac is set at. Yes, he is my resident. Observed a NPWT on top of R102's bed higher than R102's sacrum wound. The NPWT was plugged into a red outlet with the display screen stating 125 with a battery symbol that was full. RN E reported the NWPT was working. Observed the wound vac not to be running. The display screen did not indicate pressure setting including mmHg, Continuous Mode, a closed lock, or a revolving circle with arrows. There was no drainage in the cannister attached to the machine.During an observation and interview on 8/12/26 at 9:30 AM, R102 was awake in bed. A wound vac was in a case placed in a basin on the floor to the left side of R102's bed. The machine was plugged into a red outlet with the display screen stating Pressure 125mmHg. Continuous mode. A lock was displayed as closed. A circle was moving in a clockwise direction indicating the machine was working. The machine was softly vibrating, indicating the machine was working.During an interview on 8/11/26 at 1:30 PM, WN G stated, A wound vac (NPWT) can run off a battery like when a resident goes to an appointment. But the wound vac (NPWT) must be plugged in while it is here (in the facility). (R100) wound vac was to be set at 125 mmHg. All wound vacs are pre-set before they come to the facility to be used. This morning (RN/WN F) told me (R100's) wound vac was not working. That was after 10:00 AM. I did a PRN (as needed) dressing change per doctor's order to do a wet-to-dry dressing change (gauze moistened with sterile saline is packed into a wound, allowed to dry out, and then removed). The wound vac was not working and thought maybe the bowel movement broke the dressing seal? I did (R100's) wound vac dressing change yesterday also. I did not date/label the dressing. The tape did not stick so I put a sticker on the wound vac canister with the date. Staff should know how to look at the canister for a date, but I don't know if they know to look at the canister for a date/label of the last time a dressing change was done. I signed it out in (R100's) MAR/TAR so the nurses could look there if they wanted to know the last time the dressing was done. It doesn't necessarily mean that was when the dressing change was done. (R102) is not seen by the facility's wound doctor he is seen by a wound clinic. (R102's) wound vac came from the hospital wound clinic and was seen yesterday. The facility does (R102's) dressing change when he does not go to the wound clinic. (R102's) wound dressing to his sacrum was done yesterday. (R102's) wound vac was working this morning. It was plugged into a red outlet like (R100's) was. (R101)'s has had a wound vac for 2 to 3 weeks now. (R101's) wound vac was working this morning and was plugged into a red outlet. There is not a lot of drainage coming from her wound and the wound vac is pulling up the wound bed to help it heal.During an interview on 8/12/26 at 11:50 AM, DON B stated, I haven't called the medical supply company to see about (R100's) wound vac. I don't know if the wound vac was plugged into a different outlet to see if it would work. It should be working by battery when not plugged in. When Surveyor explained that wound vac machines observed on 8/11/26 from 9:36 AM to 5:20 PM not working as they should as explained by medical supply company, DON B stated, Okay. When told the medical supply company liaison stated no one from the facility contacted the company on 8/11/26, DON B left the room.During an interview on 8/12/26 at 12:00 PM, WN F stated, I checked on (R101 and R102) yesterday. The facility really does not want the nurses to know how to operate the wound vac. I checked multiple times throughout the day on (R101 and R102) wound vacs and did not document each time I did. I know the wound vacs were working. If the wound vac detects a leak it will display pressure leak. I don't know everything the wound vac states on the display screen, but I know it has a circle that goes around and you can feel the machine running. When it beeps that is an alarm stating it is not working right. R100's wound had improved when (WD D) saw him yesterday. R101 was stable. When WN F was told the resident stated it was removed per WD D because the wound had gotten worse with the skin around it blistering, WN F stated The facility is doing a different treatment on her and removed the wound vac. NHA A stated he misunderstood DON B when DON B was asked to verify pressure setting for R100 that the medical supply company was contacted when DON B had verified through R100's physician orders.During an observation, interview, and record review on 8/12/26 at 12:30 PM, WN F stated while reviewing R102's Care Plan, Skin, dated 7/13/26, (R102's) intervention is to have a pressure relieving mattress. Upon observing R102's mattress, WN F stated, (R102) does not have a pressure relieving air mattress. R102 has a regular foam mattress. He should have a T-Flow mattress. I put the care plan in place. The pressure relieving mattress order did not get done. I just put the TELS Work Order in yesterday for one. I was responsible for the follow up.During an interview on 8/13/26 at 3:06 PM, Wound Doctor (WD) D stated, I was treating (R100) for pressure wounds prior to his most recent transfer to the hospital. When (R100) returned from the hospital he had a diagnosis of osteomyelitis in his left hip that required a surgical intervention for drainage of the wound. (R100) also had an order for a wound vac set at 125 mmHg with continuous suction. Currently, I'm seeing (R101) for a pressure wound. (R101's) present wound is not healing well and not getting better. The facility was working towards determining if (R101) had osteomyelitis with testing but the pain she was experiencing from the wound prompted her to go to the hospital for evaluation. (R101) returned from the hospital with a diagnosis of osteomyelitis and a wound vac. The wound vac machine is pre-set by the supplier. (R100's and R101's) wound vac orders are 125 mmHg continuous suction which is also a standard order for a wound vac. The machines are not set up for intermittent suction. Continuous suction means the machine is not to stop suctioning until it drops below the set 125 mmHg and restart. The wound vac machine should be alarming when the machine is not working right. If there was a power surge the machines may have needed to be started. I wish staff would have known to do that when there was a power outage the other night causing a power surge.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 7/7/26 at 9:35 AM, an interview with Dietary Manager (DM) II found that food in the walk-in cooler is dated for a three-day discard once its opened or prepared. At this time, observation of the cooler found a large container with a couple dozen hard boiled eggs dated 7-1 to 7/3 and six nutritional juices that state to be used within 14 days of thaw that arrived on 6/23/26 and were placed directly into the walk-in cooler.On 7/7/26 at 10:01 AM, observation of the meat slicer found it stored underneath a preparation table. When asked how often it gets used, DM II stated that she has a staff member who used it to cut ham the other day. Observation of the slicer found the guard plate screws with discolored residue on their surfaces and dried stuck on meat shavings on the backside of the blade.On 7/7/26 at 10:03 AM, observation of the underside of the coffee machine found dried black and brown splatter debris on the underside of the spouts.On 7/7/26 at 10:14 AM, observation of stacked pots and pans found two full pans, three half pans, and three eighth pans stacked and stored while still wet. Further review found three of these pans had stuck on food debris visible on their surface.On 7/7/26 at 10:31AM, observation of the refrigeration unit outside of the kitchen found snacks and resident food product. An interview with DM II found that she will clean the unit and discard items that are passed their discard date. DM II stated they hold resident food for three days unless sealed with a manufacturer discard date. Observation inside the unit found the following: an unopened container of fried chicken with a best by date of 6/28/26, an open container of fried chicken with resident name and no date for discard, a yogurt with no name and a best by date of [DATE], and a container of leftover chicken dinner with a room number and no discard date.On 7/7/26 at 10:55 AM, observation of the dish machine found its data plate with the minimum requirements listed as 150F for the wash gauge and 180F for the rinse (gauge as water enters the machine). The food code requires the hot water sanitizing dish machine to reach a contact temperature of 160F as it rinses pots, pans and utensils. Two dish plate thermometers were used to ensure proper working order of the dish machine and after running 4 cycles, found low contact temperatures in seven of the eight readings. Record review of the July 2026 dish machine log found that 11 of the 16 recorded temperatures for the hot water sanitizing rinse were logged below the required 180F with no corrective action listed. Further observation inside of the machine found the smaller top spray arm was missing an end cap.On 7/7/26 at 12:20 PM, during a revisit to the kitchen the following was found in disrepair: the wall outlet to the steamer (currently out of order) was found hanging out of the wall socket behind the machine. The outlet cover, on the right side of the wall where meal carts are stored, was found broken leaving the left side of the outlet open and exposed. The right compartment of the three-compartment sink was found with a leak in the drain. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD.According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on observation, interview, and record review, the facility failed to: 1.) have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), 2.) maintain hydration carts' ice scoop holders in good repair and a sanitary manner, 3.) ensure facility staff use appropriate personal protective equipment (PPE) and enhanced barrier orders were in place in 2 of 2 residents (Resident #69 and Resident #1), reviewed for infection control practices, resulting in increased risk of transmission of multidrug-resistant organisms (MDROs), increased risk of infection among all residents in the facility or consumption of contaminated water. Findings include: On 7/7/26 at 10:13 AM, observation in the kitchen found a water line coming down from the ceiling and heading towards the back of the cookline for equipment, running about 10 feet. At this time, nothing was hooked up to or was using this water line, indicating an area where water would stagnate. On 7/7/26 at 2:01 PM, with Maintenance QQ, observation of the South janitors' closet found discolored water discharge momentarily before running clear from the hot water fixture when turned on. When asked if he saw the discolored water come out initially, Maintenance QQ stated yes. On 7/7/26 at 2:08 PM, an interview with Maintenance QQ, while observing the South Spa, found that staff and residents do not use this spa room often. When asked why, Maintenance QQ stated each room in the South has their own private shower, but he wasn't sure how often they were used either in comparison to residents getting bed baths. When asked if the spa or South personal showers were regularly flushed, Maintenance QQ stated they were not part of the fixatures that are on the flushing schedule. On 7/7/26 at 2:34 PM, observation of the central soiled utility found the hopper with the spray turned off, indicating a stagnant and unused water line. On 7/7/26 at 2:37 PM, observation of the central soiled linen room with a mop sink, found the cold water was turned off to the fixture, indicating a stagnant water line. On 7/7/26 at 2:42 PM, an interview with Maintenance QQ, found that he was unaware of the unused water line on the cookline and stated it's not something that gets flushed currently. When asked what areas are regularly flushed, Maintenance QQ stated that hoppers and water heaters get flushed, as well as purging water in different sections of the building. A record review of the facility document entitled Water Management Team Meeting Minutes dated, 6/11/26, found a section where staff should evaluate the waters cloudiness or turbidity and it was left blank. A further review of the document shows that flushing was complete and is done weekly, but no list or map of fixtures that are flushed. Unsanitary Ice Scoop Storage on Hydration Carts: During an observation on 07/07/2026 at 2:52 PM, a hydration cart (a mobile cart that held water pitchers, ice, an ice scoop, and an ice scoop holder), on the central unit of the 200s hallway, had a cracked plastic ice scoop holder with white and brown debris inside. During an observation on 07/08/2026 at 8:35 AM, a hydration cart, across from nurses' station on the 200s hall, had a cracked plastic ice scoop holder with white and brown debris inside. During an observation on 07/08/2026 at 2:48 PM, a hydration cart, outside of room [ROOM NUMBER] in the hallway, had an ice scoop holder that was cracked in several places, and pink material was present on the interior. During an observation on 07/09/2026 at 8:33 AM, the hydration cart, in the hallway outside of room [ROOM NUMBER], had a cracked ice scoop holder, and pink material was present on the interior. During an interview on 07/09/2026 at 10:07 AM, Infection Preventionist (IP) K reported if an ice scoop's holder was cracked it should be thrown out. IP K reported the staff in the kitchen should clean the carts and scoops after nurse aides bring the carts back to the kitchen and this should be done every shift/every 8 hours. IP K reported the cracked ice scoop holders could harbor bacteria and the kitchen should monitor the condition of the ice scoop holder for cracks and/or being soiled. Resident #69 (R69) Review of a Care Plan for R69 with a reference date of 4/27/26 revealed: (R69) .straight cath (catheterization {inserting tube into the bladder to facilitate urine drainage}) Q (every) 6 hours.Interventions: Enhanced barrier precautions during high contact care. In an interview on 7/7/26 at 10:57am, Durable Power of Attorney (DPOA)/Family Member (FM) ZZ reported she visited R69 throughout most of the day and witnessed staff members not wearing proper PPE during cares. During an observation on 7/7/26 at 11:20am, a PPE cart sat outside R69's room and signage on his door stated, Enhanced Barrier Precautions (EBP).wear gown and gloves for.device care or use: .urinary catheter. During an observation and interview on 7/7/26 at 11:31am, Registered Nurse (RN) P entered R69's room as the resident laid on his bed. RN P donned gloves as she entered the room. RN P reported she was going to complete a scan on R69's bladder and if need be, catheterize R69 to drain the urine from his bladder. RN P scanned R69's bladder but did not put on additional PPE prior to providing care. RN P reported the resident needed to be catheterized. The surveyor left the room and stood outside the closed room door. RN P remained in the room with R69. In an interview outside R69's room on 7/7/26 at 11:56am, Certified Nursing Assistant (CNA) V reported all PPE was kept in the bins outside each resident's room. CNA V reported no PPE was kept in resident rooms. During an observation and interview on 7/7/26 at 12:14pm, RN P emerged from R69's room and entered the hallway. Of note, this was the first time RN P left R69's room since reporting she was going to catheterize his bladder. When queried, RN P confirmed she did not wear a gown while catheterizing R69. RN P stated I should have but I forgot. In an interview on 7/9/26 at 10:07am, Infection Preventionist (IP) K reported it was the expectation that staff wear a gown and gloves when catheterizing a resident and not doing so was a breach of enhanced barrier precautions. Resident #1 (R1) Review of an admission Record revealed R1 had pertinent diagnosis that included: methicillin resistant staphylococcus aureus (MRSA) (type of bacterial infection that is resistant to several types of antibiotics). Review of a Care Plan for R1 with a reference date of 6/8/26 revealed: Focus: (R1) has potential for complications related to.hx (history) of MRSA.Interventions: Enhanced Barrier Precautions. During an observation on 7/7/26 at 11:39am an unknown Certified Nursing Assistants (CNA) entered R1's room as he sat in his wheelchair and approached the restroom. The CNA stated to R1, You need a brief change. The CNA then closed the door. No PPE was outside R1's room and no signage for infection control precautions was present on or near R1's door. During an observation and interview on 7/7/26 at 11:42am, CNA V reported R1 recently moved from another room. CNA V then entered R1's room and pushed R1 into his bathroom before the unknown CNA closed the room door. Neither CNA was wearing a gown. During an observation on 7/7/26 at 11:47am, CNA V and the unknown CNA exited R1's room. CNA V carried a clear bag with a used incontinence brief inside it. In an interview on 7/9/26 at 10:07am, IP K reported any resident who had a previous multi-drug-resistant (MDRO) infection, should remain in EBP precautions while in the facility. When queried, IP K confirmed R1 had been treated for an MDRO and should be on EBP. IP K reported it was her responsibility to ensure physician orders for EBP were in place and precautions were implemented. IP K reported R1 completed treatment for an MDRO infection on 6/8/26 and should have received new isolation orders for EBP on that date but it was overlooked and had not been implemented.

Based on observation and interview, the facility failed to: 1.) minimize the risk of scalding and burns by allowing domestic hot water to exceed safe temperatures, resulting in an increased risk of injury among residents residing in the facility, and 2.) implement appropriate interventions and modify the care plan consistent with resident and/or resident representative's needs and goals to prevent falls and ensure the safety of residents in 1 of 2 residents (R 83) reviewed for safety, resulting in the potential for continued falls and unmet care needs.Findings Include: On 7/7/26 at 11:42 AM, observation of empty resident room [ROOM NUMBER] found that hot water from the bathroom sink reached 130F when tested with a rapid read digital thermometer. Further observation found that there was no point of use mixing valve installed under the sink to temper the water temperature down. On 7/7/26 at 11:45 AM, observation of the North Hall spa room found the hot water at the sink reached 136F with no mixing valve observed, and the far small shower reached 122F (with an internal mixing valve). On 7/7/26 at 11:51 AM, the surveyor informed Nurse Consultant VV of the high-water temperatures and she relayed this information to the NHA. On 7/7/26 at 11:58 AM, observation of resident room [ROOM NUMBER] found the hot water at the sink reach 134F with no mixing valve observed. On 7/7/26 at 12:02 PM, an interview with Maintenance QQ found that the North and Central halls have their own hot water loop and the locked unit on the South has a separate hot water loop. Maintenance QQ stated that the set point for the hot water system on the North is around 140F at the boilers. When asked about the missing mixing valves in the rooms tested above, Maintenance QQ stated that once they failed on the North unit, they removed them and didn't replace them. At this time, Maintenance stated he would go turn down the hot water system to bring down temperatures in the North and Central units. On 7/7/26 starting at 1:39 PM, with Maintenance QQ, observation of rooms in the Central and South unit found temperatures below 120F in resident care areas with no missing mixing valves observed. Resident #83 (R83) Review of an admission Record revealed R83 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: nontraumatic intracranial hemorrhage ( a life-threatening medical emergency not caused by an injury that causes bleeding inside the skull, permanent brain damage, or death), vascular dementia with agitation (decline in thinking and memory skills caused loss of blood flow to the brain with significant behavioral and motor disturbances), and apraxia (neurological motor disorder in which a person is unable to perform purposeful movements, even though they have the physical ability, strength and desire to do so). Review of a Minimum Data Set(MDS) assessment for R83 with a reference date of 6/3/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively impaired. Review of a Care Plan for R83 with a reference date of 5/22/26 revealed the following focuses/goals/approaches: 1. Focus: (R83) is at risk for fall related injury. Goal: Will be free from injury related to falls.Interventions.explain to resident that he is going to be moved in w/c (wheelchair).prior to moving w/c. Review of a Social Services Note for R83 with a reference date of 5/25/26 revealed .Resident does present with difficulty in communicating verbally.behavior appears to be related to frustration of not being able to communicate what he would like. In an interview on 7/7/26 at 12:15pm, Durable Power of Attorney (DPOA) WW reported R83 was left sitting behind the desk at the nurse's station almost every time she came to visit and she had asked the facility not to do that. DPOA WW reported she was told the facility placed R83 behind the desk at the nurse's station because he was at risk for falling. DPOA WW reported R83 came from another long-term care facility where he had 1:1 supervision due to his high risk for falls and when she inquired providing him with 1:1 supervision at this facility, she was told she would have to pay for that herself. DPOA WW reported the facility knew prior to accepting him for admission that R83 required 1:1 supervision and should not have accepted him if they were not able to provide that level of supervision. DPOA WW reported she came to visit R83 around 11pm recently and found him sitting at the nurses' station, sleeping with his head on the desk. Review of a Nursing Progress Note for R83 with a reference date of 6/9/26 revealed .resident was observed attempting to rise from wheelchair.lost his balance and fell.assisted back to wheelchair and situated by the Nursing station, wheelchair both wheels locked. Review of a Nursing Progress Note for R83 with a reference date of 6/11/26 at 2:54am, revealed resident awake and sitting at the nurse's station. Review of a Nursing Progress Note for R83 with a reference date of 6/11/26 at 5:58am revealed resident sitting at the nurse's station for most of the night. Review of a Nursing Progress Note for R83 with a reference date of 6/19/26 at 12:06am revealed Resident.is very hard to redirect.I put him at the nurse's station to monitor him. Review of a Nursing Progress Note for R83 with a reference date of 6/21/26 at 7:18am revealed This writer walked on the unit (memory care unit) and observed res (resident) lying on his back with feet and legs under the nurse's station. Review of a Nursing Progress Note for R83 with a reference date of 6/21/26 at 8:00am revealed Pt (patient) observed on the floor next to the nurse's station. Review of a Nursing Progress Note for R83 with a reference date of 6/30/26 revealed .family came in.they put him to bed and he rested 30 to 40 minutes.he got up and me and a staff member put him in his wheelchair.he started pushing his wheelchair backwards so I put him at the nurses station to.keep him from falling. Review of a Nursing Progress Note for R83 with a reference date of 7/4/26 at 5:29am revealed Resident have (sic) not been to bed because he won't stay in the bed.he is at the nurse's station so we can monitor him. Review of a Nursing Progress Note for R83 with a reference date of 7/7/26 at 4:27am revealed .we got him up at 0400 (4:00am) he did not want to go back to bed so he is up at the nurse's station. During an observation on 7/7/26 at 9:38am, in the memory care unit, R83 sat in a wheelchair behind the desk at the nurse's station by himself. R83 was asleep with his head resting on his chest. R83's wheelchair brakes were locked with the arms of the wheelchair pressed against the countertop of the desk area. During an observation on 7/7/26 at 11:24am, R83 remained asleep, sitting in a wheelchair inside the nurses' station asleep, with his head resting on his chest. During an observation on 7/7/26 at 2:26pm, R83 remained seated in his wheelchair at the nurse's station. His eyes were partially open as he sat unengaged, fidgeting with his own fingers. In an interview on 7/8/26 at 2:25pm, Certified Nursing Assistant (CNA) V reported R83 was a big fall risk so he was placed at the nurse's station so staff could keep an eye on him. CNA V reported R83 was up in his wheelchair, 98% of the time. CNA V confirmed she had been told not to lay R83 down in his bed because he was at risk for falls. In an interview on 7/9/26 at 9:40am, Registered Nurse (RN) G reported R83 was in his wheelchair at the nurse's station when she arrived for her shift on this date. When queried, RN G reported the resident was often brought to the nurse's station because it was easier for the staff to supervise him. RN G reported R83 could not consistently voice any preferences and had an activated DPOA to make decisions for him. In an interview on 7/9/26 at 11:48am, Director of Nursing (DON) B reported R83 had multiple falls in the facility prior to being placed in the memory care unit. DON B confirmed R83 was placed at the nurse's station so staff could easily monitor him and intervene if the resident was at risk for falling. DON B reported R83's ability to express preferences was limited to his basic needs such as needing a drink of water. DON B confirmed he met with R83's family to discuss their care concerns. DON B confirmed the facility had not provided 1:1 supervision for R83. When queried, DON B reported the facility had limited resources, R83 was known to attempt to get up from bed frequently, and staff could not supervise R83 more frequently than every 15 minutes if he was in his room.

Based on observation, interview, and record review, the facility to ensure urinary catheter equipment (internal urine drainage system) was maintained in a sanitary manner for 2 of 5 residents (R6 and R109) reviewed for urinary catheter care resulting in urinary catheter bags and tubing touching the floor resulting the potential for urinary tract infection (UTI).Findings include: R6 According to R6's Minimum Data Set (MDS) dated [DATE], the resident was cognitively intact as evidenced by a score of 13/15 on his BIMS (Brief Interview Mental Status). Diagnoses included obstructive uropathy (a structural or functional blockage in the urinary tract that prevents urine from flowing freely). Required substantial/maximal assist with toileting. Section H-Bladder and Bowel indicated R6 had an indwelling catheter (urinary catheter/foley). Observed on 07/07/26 at 8 AM, R6's urinary catheter bag (holding bag for urine) was resting on the floor of his room. Observed on 07/07/2026 at 12:51 PM, R6 was sitting in a high-backed wheelchair at a table in the common dining room. R6's urinary catheter bag attached to bottom of chair and resting on the floor. Observed on 07/07/2026 at 2:22 PM, R6 sitting crossways in his bed. His catheter tubing was strung taunt from point of entry to urinary catheter bag. The urinary catheter bag was hanging from the bed frame with a blue privacy cover. The urinary catheter bag sitting on the floor with 400 ml light yellow clear urine. Observed on 07/07/2026 at 3:03 PM, R6 was participating in a religious music program in the main dining room. R6's urinary catheter bag was attached to his wheelchair and dragging on the floor. During an interview on 07/08/2026 at 1:09 PM, Unit Manager (UM) C stated, The urinary catheter bag or urinary tubing should not be dragging or resting on the floor for infection control purposes. Observed on 07/08/26 at 1:55 PM R6 outside of the south dining room hall sitting in his wheelchair. R6's urinary catheter bag was in his wheelchair, noted urine in the tubing. Observed on 7/8/26 at 4:45 PM, R6 in hall slowly self-ambulating in hall. R6's urinary catheter bag was in the seat next to him with urine filling the tubing that was kinked and coiled. Observed on 7/9/26 at 8:30 AM, R6 was in bed with eyes closed. Urinary catheter bag was attached to the frame of bed and resting on the floor under the bed. On the floor under the bed where the catheter bag was touching was dust and debris. Resident #109 (R#109): Review of R#109's urinary catheter care plan, dated 1/21/2026, stated, .(R#109) is at risk for urinary tract infection (an infection of the urinary system which can result in painful burning, pressure, and frequent urge to urinate) and catheter-related trauma (injury to the body's tissues caused by insertion, removal, or pulling/tugging): has Suprapubic Catheter (a tube surgically placed directly into the urinary bladder through the abdomen just above the pubic bone).to gravity drainage (urine flows downward into a collection bag) r/t (related to) Neurogentic (sic) bladder/ Urinary Retention (urine doesn't empty from the bladder as it should).Date Initiated: 01/21/2026.Interventions.Ensure the drainage bag (urine collection bag) is secured properly.Date Initiated: 02/20/2026. During observations on 07/07/2026 at 10:43 AM and 07/07/2026 at 12:19 PM, R#109 was seated in his wheelchair in his room. R#109's urinary catheter bag was attached to the wheelchair's frame below the seat, and the catheter bag, privacy cover, and tubing were all resting directly on the floor. During an observation on 07/08/2026 at 2:56 PM, R#109 was seated in his wheelchair in his room. R#109's urinary catheter bag was attached to the wheelchair's frame below the seat, and the catheter bag and privacy cover were resting directly on the floor. During an observation on 07/09/2026 at 8:52 AM, R#109 was seated in his wheelchair in his room. R#109's urinary catheter bag was resting directly on the front right wheelchair wheel. During an interview on 07/09/2026 at 10:07 AM, Licensed Practical Nurse S reported a urinary catheter bag should be not on the floor. Review of the facility's Urinary Catheter policy, dated 12/17/2025, stated, .don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI (catheter-associated urinary tract infection).

Based on interview and record review the facility failed to notify a resident's responsible party regarding a change in condition for 1 (R114) of 2 residents reviewed for change in condition resulting in the potential for care needs not being met. Findings include:According to R114's admission Record, the resident's Family Member (FM) YY was his responsible party and #1 emergency contact.During an interview o 7/09/2026 at 1:03 PM, Family Member (FM) YY stated, My husband (R114) had two falls on Sunday (7/5/26). Staff never called me. That concerns me that my husband who is a fall risk, fell, and no one said anything to me.During an interview on 7/9/26 at 1:00 PM, DON B stated, I heard something happened with (R114) over the weekend. I don't know if (R114's) was notified. If something happens with a resident like a fall or change in condition and has a responsible party or emergency contact, that person should be notified to keep them informed.Review of the facility's policy Notification of Change dated 2/14/2024 revealed, The facility must inform.the resident representative(s) when there is a change in status.a change in status would include.an accident involving the resident.

Based on interview, and record review, the facility failed to maintain complete and accurate medical records for 1 resident (Resident #9) of a total sample of 22, resulting in the lack of proper documentation of blood sugar monitoring and a potential for medical needs to go unrecognized. Resident #9 (R9)Review of an admission Record revealed R9 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes (chronic health condition causing elevated blood sugar levels).Review of a Minimum Data Set(MDS) assessment for R9 with a reference date of 6/10/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 4/15, which indicated the resident was severely cognitively impaired. Section N of the MDs revealed R9 received insulin (hormone that lowers blood sugar levels) daily.Review of Physician's Orders for R9 revealed 1. Insulin Glargine Subcutaneous Solution 100 UNIT/ML (milliliters) Inject 25 unit subcutaneously in the evening for diabetes hold if blood sugar <100, (less than), Order status: Active, Order date 4/5/26. 2. Blood sugar check twice daily. Morning and Evening, Order status: Active, Order date 6/13/26.Review of a Medication/Treatment Administration Record for R9 with a reference date of 7/26 revealed no documented blood sugar levels.Review of a Blood Sugar Summary for R9 with a reference date range of 4/2/26-7/8/26 revealed R9's blood sugar level was recorded 5 times during a 90-day period.In an interview on 7/8/26 at 10:49am, Director of Nursing (DON) B confirmed R9's blood sugar level was only documented 5 times during a 90-day period. DON B confirmed it was the expectation that nurses follow professional standards and complete the physician's orders as written. DON B confirmed without proper documentation, the providers could not effectively manage R9's blood sugar levels.

Based on observation, interview, and record review the facility failed to ensure residents were assess to be appropriate for self-administration of medications for 1( Resident #59) of 6 residents reviewed for medication administration, resulting in medications being left unsecured at the resident's bedside, resident self-administering medications without staff assessment, and the potential for negative outcomes from taking/applying/instilling too much or too little medications. Findings include:On 7/7/26 at 10:16 am, an unknown resident was observed holding an inhaler on her lap as she rolled in her wheelchair down the central east hall. When queried, the unknown resident reported she was going to return the inhaler to the nurse, since they just leave it for me to do when I'm ready.Resident #59 Review of an admission Record revealed Resident #59 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: neuromuscular dysfunction of the bladder (nerve damage disrupts communication between the brain, spinal cord, and the bladder leading to urinary control problems), malignant neoplasm of the stomach (cancer of the stomach that spread to other areas of the body), and apraxia (neurological disorder that impairs the brain's ability to plan and execute purposeful movements).Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 5/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #59 was cognitively intact.In an interview and observation on 7/7/26 at 10:39 am Resident #59 had a plastic container of (Brand Name Omitted) fiber powder supplement (a fiber supplement made from psyllium husk that supports digestive health) on her over the bed table in her room. Resident #59 reported she supplied it herself, and she took it every day. Review of Resident #59's medical record revealed no noted order for (Brand Name Omitted) fiber powder supplement nor any documentation regarding Resident #59's ability to self-administer medications.On 7/7/26 at 4:30 pm, (Brand Name Omitted) fiber powder supplement was present on Resident #59's over the bed table in her room.In an interview on 7/7/26 at 5:00 pm, Director of Nursing (DON) B reported that no residents in the building self-administered medications.In an interview on 7/8/26 at 8:01 am Registered Nurse (RN) O reported no residents self-administered medications.On observations and interview on 7/8/26 at 8:50 am and 2:38 pm, (Brand Name Omitted) fiber powder supplement was noted on the over the bed table in Resident #59's room in the same position as it was observed the day before.In an interview on 7/8/26 at 3:18 pm, Resident #59 reports that she takes (Brand Name Omitted) fiber powder supplement every day and has since she admitted last September to the facility.In an interview and observation on 7/9/26 at 8:53 am, Resident #59 reported she was upset now that the nurse had come in and taken her (Brand Name Omitted) fiber powder supplement this morning. Resident #59 stated it will be concrete by the time they get it to me. Resident #59 reported having her (Brand Name Omitted) fiber powder supplement had not been a problem until the state arrived at the facility. Resident #59, when queried, reported that the (Brand Name Omitted) fiber powder supplement powder had to be put in the cup first, and that she saved her water cup from the day before. Resident #59 reported she added the powder, put in the water, stirred and drank it every day, the staff did not provide her with the cup, spoon, straw or (Brand Name Omitted) fiber powder supplement. Resident #59 then demonstrated she had an empty cup stacked with her current water cup on the bedside table in her room, reporting that was the cup she planned to use to take her (Brand Name Omitted) fiber powder supplement.In an interview on 7/9/26 at 8:57 am, Licensed Practical Nurse (LPN) T reported she had observed the (Brand Name Omitted) fiber powder supplement in Resident #59's room and was unsure if she was supposed to have it. LPN T reported she spoke to DON B who instructed her to put Resident #59's (Brand Name Omitted) fiber powder supplement into the medication cart; Which she did. LPN T stated I couldn't find an order for Resident #59 to have (Brand Name Omitted) fiber powder supplement .I don't even know why she was taking it. LPN T reported residents needed to be assessed by management to be able to self-administer medications and Resident #59 had not been assessed.In an interview on 9:18 am, DON B reported he had instructed LPN T to remove the (Brand Name Omitted) fiber powder supplement from Resident #59's room this morning. DON B reported Resident needed to be assessed, IDT (interdisciplinary team) would discuss the findings of the assessment, and then the medical director would be informed and if they medical director agreed that the resident was capable of self-administering medications, they would provide an order and the resident's care plan would be updated. DON B reviewed Resident #59's medical record and confirmed Resident #59 had no assessment to self-administer medications, no order to self-administer medications, and had no order for (Brand Name Omitted) fiber powder supplement. DON B reported Resident #59 had a BIMS of 15 and he knew she would be able to self-administer medications fine.Review of facility policy Medication Administration with a revision date of 10/17/23 revealed .Resident medications are administered in an accurate, safe.manner.Physician's Orders-Medications are administered in accordance with written orders of the attending physician.Self-Administration-Resident are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administering process. A self-administration evaluation will be completed prior to the resident starting the self-administering process. Self-administration of medication will be reflected in the resident care plan along with any special instructions.

This citation pertains to intake 3028987.Based on interview and record review the facility failed to ensure facility staff obtained a resident's consent before searching through their personal property for 1 (Resident #5) of 7 residents reviewed for dignity resulting in feelings of anger and frustration. Findings include:Review of R#5's functional ability care plan, dated 8/4/2025, stated, .(R#5) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): debility (weakness), immobility.Bed Mobility: Resident is dependent with two helpers. This is including rolling side to side, lying to sitting on side of bed and sitting to lying. The care plan included pertinent diagnoses which included insomnia (sleep disorder that can cause difficulty falling asleep, staying asleep, or waking too early), depression, anxiety, lack of coordination (broad category covering various coordination impairments not specified elsewhere).Review of Resident #5 (R#5)'s brief interview for mental status, dated 6/24/26, was scored 15 which reflected R#5 was cognitively intact.Review of the facility's Disciplinary Action Record Work Rules document, which pertained to Resident #5 (R#5), dated 3/11/26, stated, Employee Name: (Registered Nurse (RN) M).Written Warning #1 issued on: 3/11/26.Disciplinary action to be taken.Written Warning #1.Date of Infraction: 3/9/26.Describe the reason(s) for disciplinary action, including date, time and supporting documentation: Follow policy and procedure for personal property.Specific Plan for Improvement, Ask permission from resident.Employee Comments: I reviewed the policy, my intention was the patient's (R#5) safety. I do not agree with it.During an interview on 07/07/2026 at 11:11 AM, R#5 reported she was frustrated and upset that RN M, on 3/9/26, had searched her purse and removed [Name brand of medication omitted; the reported medication's active ingredients were acetaminophen (a pain reliever) and diphenhydramine Hydrochloride (sleep aid)] without explanation, her knowing about it, or getting her consent to search. R#5 reported after this event happened, she understood she couldn't have medications in her room, but reported it made her feel bad to have her personal property looked through by RN M without her consent.During a follow up interview on 07/09/2026 at 8:06 AM, R#5 reported the medication RN M removed was not out in plain view and confirmed it was in her closed purse in a closed dresser drawer that night. R#5 reported when she woke up, she had asked a worker, unknown, to hand her purse, as she was not physically able to get it herself, and became aware the medication wasn't in her purse at that time. R#5 reported when RN M came to her room next, he initially denied going into her purse but then he admitted to her that he had. R#5 reported she was initially worried because she was uncertain if other items had been taken from her purse. R#5 stated, made me feel like garbage regarding her property being searched without prior consent. During a phone interview on 07/08/2026 at 4:39 PM, Registered Nurse (RN) M could not recall what medication he removed from R#5's room on 3/9/26, but reported it was two bottles of medication that were not provided by the facility. RN M was unable to recall where he found the medication in R#5's room and reported different locations including on her table (bedside table) or an open bedside drawer but was unable to recall how the dresser was opened. RN M confirmed R#5 was asleep when he searched and removed the items from her room. During an interview on 07/08/2026 at 5:00 pm, Nursing Home Administrator (NHA) A confirmed the disciplinary action form, dated 3/9/26, was issued to RN M because RN M had gone into R#5's room to check to make sure she didn't have any medications, not provided by the facility, in her purse. NHA A reported it was his understanding that RN M had found medications that were out in view on R#5's table or in an open drawer, but that RN M was given the disciplinary action because RN M went into R#5's purse. NHA A confirmed RN M did not get R#5's consent to search her purse and he should have before going into her purse. During an interview on 07/09/2026 at 12:32 PM, Director of Nursing (DON) B reported he remembered talking to RN M that night but couldn't remember what RN M had told him other than he had found medication in R#5's room and RN M took it away. DON B confirmed the way in which RN M searched for medications was done improperly. DON B confirmed there was no documentation, other than the disciplinary action form dated 3/9/26, that addressed what happened on 3/9/26 with RN M and R#5's personal property.Review of the facility's Resident Rights policy, dated 5/14/2024, stated, .The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination .These rights include the resident's right to .Exercise his or her rights .Privacy .

Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for 1 of 22 residents (R38) reviewed for accommodation of needs, resulting in the potential for the resident to not meet their highest practicable level of well-being.Findings include:According to R38's Minimum Data Set (MDS), the resident was moderately cognitively impaired as evidenced by a score of 11/15. Diagnoses included heart failure, diabetes, non-Alzheimer's dementia, and anxiety. R38 was able to independently roll from side to side in bed.Observed on 07/07/2026 at 10:38 AM, R38 in bed with call light underneath the bed on the floor. The call was out of sight and inaccessible to the resident.Observed on 07/07/2026 at 12:47 PM, R38 in bed with call light underneath the bed on the floor. The call was out of sight and inaccessible to the resident.Observed on 07/07/26 at 3:00 PM, R38 in bed with call light underneath the bed on the floor. The call was out of sight and inaccessible to the resident. Observed on 07/08/26 at 8:30 AM, R38 in bed with eyes closed. R38's call light was positioned from over the head of the bed behind her. The call light was out of sight and inaccessible to the resident. In an interview on 07/08/2026 at 1:18 PM, Unit Manager (UM) C stated, A resident's call light should be kept within reach and sight. (R38) will sometimes use her call light especially in the evenings. During an observation on 07/9/26 at 8:30 AM, R38 was in her bed with eyes closed snoring. R38's call light came out from under her covers and hanging down between the mattress and bed frame making it out of sight and inaccessible.

Based on observation, interview, and record review, the facility failed to develop person centered, comprehensive care plan for 1 resident (Resident #83) of 22 sample residents reviewed for care planning, resulting in the resident experiencing unmanaged edema (swelling caused by fluid collection in the body's tissues), pain in his legs and a potential for additional medical complications. Findings include:Resident #83(R83)Review of an admission Record revealed R83 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: nontraumatic intracranial hemorrhage ( a life-threatening medical emergency not caused by an injury that causes bleeding inside the skull, permanent brain damage, or death), vascular dementia with agitation (decline in thinking and memory skills caused loss of blood flow to the brain with significant behavioral and motor disturbances), and apraxia (neurological motor disorder in which a person is unable to perform purposeful movements, even though they have the physical ability, strength and desire to do so).Review of a Minimum Data Set(MDS) assessment for R83 with a reference date of 6/3/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively impaired.Review of a Care Plan for R83 with a reference date of 5/22/26 revealed the following focuses/goals/approaches: 1. Focus: (R83) is at risk for cardiac complications.Goal: Will be free from s/sx (signs and symptoms) of cardiac complications.Interventions. observe/document/report.any s/sx of cardiac distress.dependent edema (swelling caused by fluid pooling in the lowest parts of the body due to gravity) . Of note the care plan did not reflect interventions to address the significant edema R83 developed while at the facility.During an observation on 7/7/26 at 9:38am, in the memory care unit, R83 sat in a wheelchair behind the desk at the nurse's station by himself. R83 was asleep with his head resting on his chest. His feet hung down and rested on the floor.During an observation on 7/7/26 at 11:24am, R83 remained asleep, sitting in a wheelchair inside the nurses' station asleep, with his head resting on his chest.During an observation on 7/7/26 at 2:26pm, R83 remained seated in his wheelchair at the nurse's station. His eyes were partially open as he sat unengaged, fidgeting with his own fingers.In an interview on 7/7/26 at 12:15pm, Durable Power of Attorney (DPOA) WW reported R83 was left sitting behind the desk at the nurse's station, with his feet on the floor, almost every time she came to visit and she had asked the facility not to do that because R83 had developed edema in both of his lower legs. DPOA WW reported she came to visit R83 around 11pm recently and found him sitting at the nurses' station, sleeping with his head on the desk and his legs hanging in a dependent position. DPOA WW reported she visited at night and stayed up to 4 hours at a time so R83 could lay down in bed and elevate his feet.In an interview on 7/9/26 at 9:36am, Rehabilitation Manager (RM) XX confirmed R83 had swelling in both lower legs at this time. When queried, RM XX reported R83 did not have swelling or pain in his legs when she evaluated him for physical therapy upon his admission to the facility. RM XX described the swelling in R83's legs and dependent edema (swelling caused by sitting for long periods of time).In an interview on 7/8/26 at 2:25pm, Certified Nursing Assistant (CNA) V reported R83 was a big fall risk so he was placed at the nurse's station, where he sat in his wheelchair, so staff could keep an eye on him. CNA V reported R83 was up in his wheelchair, 98% of the time. CNA V reported R83 had increased swelling in both lower legs and would benefit from elevating his legs more often. During an observation on 7/8/26 at 2:33pm, R83 sat in his wheelchair at a dining table. The brakes for the wheelchair were locked. R83's feet rested on the floor between the foot pedals of his wheelchair. R83 was wearing regular socks, swelling was noted on both legs from the ankle to the knee. CNA V approached R83, told the resident she was going to elevate his legs and slowly placed his feet on the leg rests. R83 winced and furrowed his brow, verbalized ahhh! as his legs were moved.In an interview on 7/9/26 at 11:25am, Registered Nurse (RN) G reported she regularly cared for R83. RN G confirmed the facility had not implemented options for elevating R83's legs in effort to reduce his edema. Review of a Provider Progress Note for R83 with a reference date of 6/18/26 revealed .Patient seen for fall follow up and medication adjustment due to persistent bilateral lower extremity edema.Review of a Nursing Progress Note for R83 with a reference date of 6/21/26 revealed 3+ pitting edema (swelling where pressing on a swollen body part leaves behind a pit that takes up to 60 seconds to refill, measured on a scale of 1 to 4, 4 being the worst) to bil (bilateral) lower ext (extremities) and feet. New order to elevate feet when in bed. Of note, the intervention to elevate R83's feet when he was in bed was not added to his care plan.Review of an Administration Note for R83 with a reference date of 6/29/26 at 1:33am revealed [NAME] hose (compression stockings used to reduce swelling) on bil lower ext.Unable to don (apply) d/t (due to) 2+ pitting edema. Of note, the intervention to apply [NAME] hose to R83's legs was not added to his care plan.In an interview on 7/9/26 at 11:48am, Director of Nursing (DON) B confirmed R83 was placed at the nurse's station in his wheelchair with his legs in dependent position a lot so he could be supervised. DON B confirmed R83 developed significant swelling in both his legs. DON B reported the facility did not have a routine in place that supported R83 laying down regularly. When queried DON B confirmed the facility had not pursued a therapy evaluation to determine if R83 would benefit from elevating leg rests on his wheelchair, a reclining wheelchair or a specialty chair. DON B confirmed the facility had not provided a recliner to sit in but that could be revisited. DON B confirmed the facility did not have a care plan to address R83's order to elevate his feet or for the use of [NAME] hose.

Based on observation, interview, and record review the facility failed to ensure professional standards of nursing were maintained during medication administration resulting in the potential for medication administration errors to occur. Findings include:On 7/8/26 at 8:49 am, Licensed Practical Nurse (LPN) R was observed reaching into the top drawer of the medication cart on the east central unit after unlocking and opening the top drawer, LPN R retrieved a plastic medication cup with several pills in it, palmed it in her left hand, and placed it into the left pocket of her scrub top.On 7/8/26 at 8:54 am, LPN R dispensed 4 pills into a plastic medication cup and left the medications on top of the medication cart outside of a room while she went into the room. LPN R was observed to leave the cart, leaving the medications out of her sight. At 8:58 am LPN R was observed placing the dispensed medications into the top drawer of the medication cart. At 8:59 am, LPN R was observed preparing medications for a different resident, and the medication cup of 4 pills remained in the top drawer of the medication cart.At 9:05 am, LPN R was observed at the mediation cart with the last cup of prepared medications and placed it onto the top of the medication cart stating she refused these. LPN R then went into a resident room while leaving the medications in a cup on top of the mediation cart still parked in the hallway and the cart out of her sight.At 9:11 am, LPN R returned to the medication cart, unlocked the cart, opened the top drawer and retrieved the stored cup of pills, and placed the cup still sitting on top of the cart into the cart and closed the drawer and locked the cart.In an interview on 7/8/26 at 2:10 pm, LPN R reported she did store medications in the top drawer of the medication cart and she knew she should not do that. LPN R reported she was nervous. LPN R reported she should not have left a cup of pills on top of the medication cart where 'someone could grab it.In an observation on 7/8/26 at 2:20 pm, Registered Nurse (RN) P unlocked a medication cart on the south unit, and it was noted there was a plastic medication cup in the top drawer with two white pills in it. RN P stated oh, that's just Tylenol.it's for later while waving her hand and shrugging her shoulder. Director of Nursing (DON) B was present during the observation.In an interview on 7/8/26 at 2:22 pm, DON B reported dispensed medications should not be stored in the top drawer of the medication cart. DON B stated his expectations were that they medication was administered when dispensed or discarded.

Based on observation, interview, and record review, the facility failed to provide consistent nail care for 1 (Resident #109) of 4 residents reviewed for activities of daily living for dependent residents resulting in long dirty fingernails, feeling bad about oneself, and the potential to contribute to spread of infection. Findings include:Review of R#109's admission Record, dated 7/8/26, indicated he was a [AGE] year old male, was admitted to the facility on [DATE], and pertinent diagnoses included unspecified dementia. (decline in mental abilities) and flaccid (lack of normal muscle tone) hemiplegia (condition causing partial or complete loss of voluntary muscle function affecting one side of the body) affecting left nondominant side.Review of R#109's brief interview for mental status score, dated 4/28/26, was scored 10 which reflected he had moderately impaired cognition.Review of R#109's functional ability care plan, dated 1/21/2026, stated, .(R#109) has a functional ability deficit and requires assistance with self care (sic).Interventions.Keep finger nails (sic) trimmed and clean. Date initiated: 01/21/2026.Personal Hygiene (.nail care.): Resident is Dependent with one helper.During observation and interview on 07/07/2026 at 12:19 PM, R#109 was seated in his wheelchair in his room and his fingernails were long and soiled. R#109's 10 fingernails were long, approximately 1/4 inch - 3/8 inch past the fingertips and were visibly soiled with dark dried debris on the underside of the nails. On R#109's right hand, there was also what appeared to be food debris that was stuck under the nails. R#109 reported he didn't like his fingernails that long, it made him feel bad, was unable to trim his own nails, and he needed staff to do his nail care for him. During observation and interview on 07/08/2026 at 8:43 AM, R#109's fingernails remained long and soiled. R#109 was eating his breakfast in his room, and the biscuit's white flaky debris was getting stuck under his right hand's fingernails. R#109 proceeded to scratch the right side of his head with his right hand and some of the biscuit material that was stuck under his nail came off and stuck to his hair. R#109 reported he didn't know when staff were supposed to trim his fingernails and confirmed he had not refused to have his nails trimmed. R#109 reported the long fingernails made eating more difficult. During an interview on 07/08/2026 at 12:06 PM, Director of Nursing (DON) B, reported the expectation was that staff would routinely trim residents' nails and nails were often taken care of on weekly shower (bathing) days. DON B confirmed there was no documentation to show when nail care had been completed or offered. DON B reported he would get R#109's nail care addressed.During observation and interview on 07/08/2026 at 2:54 PM, R#109 was seated in his wheelchair in his room with his nails trimmed shorter than they were during previous observations. R#109 stated, It took too long for them to trim his fingernails and confirmed staff had not been offering to trim his nails.Review of the Centers for Disease Control (CDC) and Prevention's Healthy Habits: Nail Hygiene resource (www.cdc.gov/hygiene/about/nail-hygiene.html), dated 4/16/2024, stated, .Dirt and germs can live under your fingernails and cause some infections. Keep nails short and clean to prevent nail infections.More dirt and bacteria can gather under long nails than short nails.To help prevent the spread of germs and nail infections: Keep nails short and trim them often. Scrub the underside of nails with soap and water.

This citation pertains to intake 3027977. Based on observation, interview, and record review the facility failed to ensure the appropriate head of bed angle was maintained during tube feeding (delivers liquid nutrition through a flexible tube into the body) and as ordered between meals for 1 (Resident #14) of 1 resident reviewed for tube feeding resulting in the potential for aspiration (inhalation of substances into the airway), aspiration pneumonia (lung infection caused by inhaling foreign material), and/or discomfort. Findings include:Review of Resident #14 (R#14)'s admission Record, dated 7/9/26, indicated she was a [AGE] year old female, was admitted to the facility on [DATE], and pertinent diagnoses included Dementia (decline in mental abilities), Other symptoms and signs concerning food and fluid intake, and Dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (condition affecting the blood vessels and blood supply to the brain).Review of R#14's Order Summary Report, dated 7/9/26, included physician orders:- Nothing By Mouth diet, start date, 5/28/26.- [Name brand of tube feeding formula omitted] 1.5 Cal (calories; 1.5 calories for each milliliter of formula)/Fiber Enteral (tube feeding) Liquid (Nutritional Supplements) Give 55 ml/hr (milliliters per hour) via G-Tube (Gastrostomy (medical procedure that creates a small opening through the abdomen directly into the stomach in which a feeding tube (G-Tube) is inserted to provide liquid nutrition/hydration) one time a day for feeding off at 0900 (9:00 AM) back on at 1300 (1:00 PM), start date, 5/28/26.- keep head of bed elevated 45 degrees to prevent aspiration every day and evening shift for aspiration precautions, start date, 5/28/26.Review of R#14's hospital notes, dated 5/21-5/28/2026, stated, .Hospital Problems .Acute aspiration pneumonia .Date Noted 05/22/2026 .Aspiration pneumonia. Date Noted 05/20/2023 .Review of R#14's hospital note, dated 6/20/26, stated, .XR (x-ray; medical imaging test) Chest.Possible asp (aspiration) PNA (pneumonia).Impression.Lingular infiltrate (abnormal substance in the upper area of the left lung) or atelectasis (lung sacs have collapsed or deflated). Review of R#14's nutrition care plan, revised 4/28/26, stated, (R#14) is unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube/PEG (Percutaneous Endoscopic Gastrostomy; a type of gastrostomy) Tube r/t (related to): CVA (cerebrovascular accident; term for a stroke), dysphagia, dementia.Goal.will be free of aspiration.Interventions.Elevate the HOB (head of bed) for (R#14) to semi-Fowlers (sic) position during and thirty minutes after tube feed.During an observation on 07/08/2026 at 8:56 AM, R#14 was nonverbal and lying in bed on her back, the head of bed angle was measured to be 22 degrees, and her tube feeding was running (tube feeding pump (medical device that delivers liquid nutrition/hydration) was on and infusing the tube feeding formula into the stomach). On the right side of the bed frame, where the angle of the head of the bed adjusts up or down, had black markings that indicated the position required for the head of the bed to be at a 45 degree angle.During an interview on 07/08/2026 at 11:48 AM, Director of Nursing (DON) B reported R#14 went to the hospital recently, 6/20/26, and a swallow study indicated it was possible that she was aspirating her secretions (oral secretions; natural fluids, saliva, produced in the mouth). DON B reported the facility marked R#14's bed frame to indicate the correct setting to keep the head of the bed at a 45 degree angle. DON B confirmed the usual head of the bed angle recommendation for tube feeding administration was 30-45 degrees during tube feeding and maintained at that level for 1 hour after. DON B confirmed because of her aspiration risk they were to have her positioned all day at a 45 degree head of bed angle.During an observation on 07/09/2026 at 7:43 AM, R#14 was asleep, lying in bed on her back, tube feeding was running, and the head of bed angle was measured to be 28 degrees.Review of the facility's Enteral Nutrition policy, dated 9/22/2023, stated, .A resident who is fed by .gastrostomy.receives the appropriate treatment and services to reduce the risk of aspiration pneumonia, diarrhea, vomiting.The resident should be in a semi-Fowler's position (a medical posture where a patient lies on their back with the head and upper body elevated at an angle of 30 to 45 degrees) during administration and for 30 minutes to one hour afterward to prevent aspiration.

Based on observation, interview, and record review, the facility failed to ensure 1.) hairnets were worn in the kitchen and 2.) desserts from the kitchen were covered that were transported across the facility, resulting in the potential for increased risk of foodborne illness and contamination of food. Findings include: During an observation on 3/18/2026 at 1:25 PM in the memory care unit, a dietary aide brought a black cart from the kitchen carrying 6 resident trays. All 6 resident trays had dessert (sweet potato pie) on the tray and they were not covered and were exposed to air. Then, at 1:30 PM, another black cart was brought in from the kitchen and 3 resident trays had desserts and they were not covered and were exposed to air. During an observation on 3/19/2026 at 12:30 PM, Dietary Manager (DM) M walked across the kitchen without a hairnet on and to the door to help a staff member that requested orange juice and milk for a resident. DM M went back to the kitchen without a hairnet on, didn't wash her hands and retrieved orange juice and milk for the staff. During an interview on 3/19/2026 at 12:35 PM, DM M stated that she had a hairnet and forgot to put it on but she doesn't touch the food. DM M said since she was in and out of the kitchen a lot she didn't put it on. When discussing washing hands every time she or other dietary staff enters the kitchen, DM M said she forgot to wash her hands but she didn't touch any food. Also discussed dietary staff taking resident trays from the kitchen to the memory care unit and the desserts not being covered and DM M stated that the staff knew to cover food during transport and they shouldn't have done that. According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by. (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings. Review of the Nutritional Services Department Dress Code with a revision date of 3/11/2026 revealed . Nutritional services staff must wear hair restraints (e.g. hairnet, hat and beard restraint) to prevent their hair from contacting exposed food (according to the 2009 FDA food code Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens; and unwrapped single service and single use articles). On 3/18/26 at 9:14 AM, Dietary Manager (DM) N was observed entering the kitchen, approaching the steam table, speaking to Dietary [NAME] (DC) FF, accepting a plate of food from DC FF and placing the plate of food onto a tray. DM N was not wearing a hair net.

Based on observation, interview, and record review, the facility failed to ensure 1.) the published menu was served as planned, 2.) residents were informed of the menu change in advance and 3.) the Registered Dietitian (RD) was notified about these menu changes resulting in the potential for all residents that consume food from the kitchen to be dissatisfied with their meal service and for meals to not be nutritionally adequate.Findings include:Review of the menu posted outside the main dining room on 3/18/2026 revealed Lunch: BBQ Chicken, Macaroni and Cheese, Collards, Corn Bread, Sweet Potato Pie.Review of the menu spreadsheet provided by the facility revealed Lunch: BBQ Chicken, Macaroni and Cheese, Collards, Corn Bread, Sweet Potato Pie.During an observation in the kitchen on 3/18/2026 at 1:30 PM, the test lunch tray was noted to have green beans and no collard greens. During an interview on 3/18/2026 at 1:35 PM, Dietary Manager (DM) M stated that she didn't have collard greens to serve at lunch so she substituted green beans. When asked if this substitution was approved by the facility RD, DM M said No. DM M stated that she usually ran changes to the published menu by the RD and made changes on the board outside the dining room, but she didn't get a chance to do that. When asked if she keeps a log of substitution changes and whether the RD approved it, she said no.

Based on observation, interview, and record review the facility failed to ensure dignity with dining for 1 (Resident #110) of 3 residents reviewed for dignity with dining resulting in Resident #110 taking another resident's meal and consuming it.Findings include:Resident #110 Review of an admission Record revealed Resident #110 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), and anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #110, with a reference date of 2/18/26 revealed Functional Abilities as dependent for eating, indicating a helper does all of the effort, Resident does none.Review of Kardex (a concise patient information system used by nurses to quickly reference and organized key details about resident needs) for Resident #110 revealed CNA (certified nurse assistant) will assist Resident #110 with meals as needed.provide diet as ordered, regular diet mechanical soft texture, thin liquids.Review of Order Summary for Resident #110 revealed Regular diet, Level 3 Advanced (Mechanical Soft) texture, Thin consistency, Enriched foods, TID (three times a day) for diet with a start date of 12/17/2025.On 3/17/26 at 1:11 PM, Resident #110 was sitting alone at a table in the dining room. Resident #110 was the last resident served and received his meal tray at 1:25 PM.On 3/18/26 at 1:30 PM, Resident #110 was observed sitting at a table in the dining room with two other male residents. Both other residents had plates of food in front of them. Resident #110 did not have any food.On 3/18/26 at 1:40 PM, an unknown resident was observed pushing an open carton of milk across the tabletop to Resident #110. Resident #110 was then observed picking up the carton of milk given to him by the unknown resident seated across the table from him and drinking from it.On 3/18/26 at 1:43 PM, Resident #110 was observed reaching to his right, into the place setting area set for an unknown male resident seated next to him at the table. Resident #110 retrieved a bowl and a spoon and began to eat the dessert from the bowl with the unknown resident's spoon.On 3/18/26 at 1:45 PM, Resident #110 was observed reaching to his right into the place setting area for an unknown male resident seated next to him at the table and retrieving the plate and began to eat the food still present on the plate. The unknown male resident was observed reaching for his plate, speaking out loud single words of protest Hey! and Mine!, and Resident #110 was observed moving his arm to keep the plate out of the reach of the unknown resident. During this observation Certified Nurse Assistant (CNA) U, CNA Z, CNA GG were present in the dining room and Social Worker (SW) D was seated at the nurse's station directly across from the table the three residents were sitting at. No staff observed or intervened when Resident #110 took and consumed the food of two unknown male residents.In an interview and observation on 3/18/26 at 1:47 PM, CNA U reported Resident #110 was a mechanical soft diet with thin liquids and what he was eating was a pureed. CNA U stated I have no words for what is happening right now, I don't know what to say. CNA U disposed of the plate of food Resident #110 was eating, moved him to a different table, and then sent CNA GG to the kitchen to retrieve a replacement meal for the unknown male resident.In an interview on 3/18/26 at 1:49 PM, SW D reported she was there if they needed assistance with residents, but she did not assist with meal service.In an interview on 3/18/26 at 1:50 PM, Licensed Practical Nurse (LPN) NN reported her responsibility on the unit was to supervise and over see the unit.In an interview on 3/18/26 at 2:24 PM, Director of Nursing (DON) B reported his expectations were that each resident at the table be served at the same time and to get all resident meal trays served timely.

This citation pertains to intakes #2628754 and #2727216.Based on observation, interview, and record review, the facility failed to monitor the effectiveness of post elopement interventions for 1 resident (Resident #100) of 3 residents reviewed for accidents/hazards, resulting in Resident #100 who was assessed as an elopement risk and liked to have his door closed to potentially elope again.Findings include: Resident # 100 (R100)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R100's initial admission date was on 9/2/2025 with pertinent diagnoses including dementia with psychotic disturbance (hallucinations or delusions which often causes severe distress and safety concerns) and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 4 out of 15 which indicated R100 was severely cognitively impaired. Review of the Facility Reported Incident (FRI) Report dated 9/17/2025 revealed . Incident Summary: It was reported to the writer at 8:48p (PM) that resident (R100) a resident of memory care unit of the facility, broke his room window and eloped. Search protocol initiated, resident was found at 9:01 PM 300 yards off the property, unharmed. Daughter/POA (power of attorney), police and physician notified, one on one initiated for safety.Further review of the FRI Report revealed .Immediate Facility Response.Corrective Measures and Follow-Up Actions.One-on-one supervision initiated on 9/16/2025. One on one terminated as window secured per CMS (Centers for Medicare and Medicaid Services) and NFPA (National Fire Protection Association) guidelines on 9/17/2025.Order date: 9/16/2025.Order Summary: One on one until window amended.Review of R100's Risk for Elopement admission assessment completed on 9/4/2025 revealed a score of 13 which indicated he was at risk for elopement and that he was ambulatory and had attempts to elope in the last 3 months. It also revealed .Wandering: behavior of this type occurred 1 to 3 days. does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility)? Yes. Review of R100's last completed Risk for Elopement assessment dated [DATE] revealed a score of 13 which indicated he was still at risk for elopement and that he was ambulatory and had attempts to elope in the last 3 months. It also revealed .Wandering: behavior of this type occurred 1 to 3 days . Review of R100's MDS dated [DATE] revealed .Section E0900. Wandering-Presence and Frequency: 1. Behavior of this type occurred 1 to 3 days.Review of R100's Care Plan revealed .Focus: (R100) is at risk for wandering r/t (related to): new environment and new dx (diagnosis) of altered mental status. Date initiated: 9/2/2025.Review of R100's Care Plan revealed .Focus: (R100) has history of elopement out of window and risk for elopement r/t dx dementia. New Custom Goal: resident will remain safe and in building until follow-up. New Custom Intervention.1:1 care initiated until window repaired from elopement. Review of R100's Care Plan revealed .Focus: (R100) is at risk for exit seeking and wandering. Hx (history) of elopement .Date initiated: 10/27/2025.Review of R100's progress notes dated 9/30/2025 at 0800 (8:00 AM) . Notified by nursing that patient is aggressive and suicidal and saying things like he is going to break and jump out window.Review of R100's progress notes dated 9/30/2025 at 0800 (8:00 AM) revealed .Patient was heard by nursing staff saying that he is going to break and jump out window and shoot himself. Patient was sent to ER for further evaluations.Review of R100's progress notes dated 9/30/2025 at 17:49 (5:49 PM) revealed .Resident reported to me he is going to kick out the window and leave so maybe then he will get shot and die.Review of R100's progress notes dated 10/2/2025 at 0455 (4:55 AM) revealed .Resident is on 15min check (checks) he was wandering and exit seeking earlier in the shift.Review of R100's progress notes dated 10/13/2025 at 0800 (8:00 AM) revealed . Patient was heard by nursing staff saying that he is going to break and jump out window.Review of R100's progress notes dated 10/27/2025 at 2200 (10:00 AM) revealed .he (R100) got up and started wandering up and down the hall going from doors and he kept standing by the door in the tv room.Review of R100's progress notes dated 10/30/2025 revealed Wandering hall, went SW (to southwest) exit door and is pushing door, trying to get it open, this writer went to try to redirect res (resident).Review of R100's progress notes dated 2/7/2026 revealed Resident was packing his belongings last night he said he have to leave and was exit seeking all night going from door to door asking do we have his keys so he can go.During an interview on 3/17/2026 at 3:00 PM Certified Nursing Assistant (CNA) DD stated that R100 liked to have his door closed even when his daughter wasn't visiting. CNA DD said R100 stated that he wanted to get out of the facility and break the walls and his daughter should come and get him. During an interview on 3/17/2026 at 12:57 PM, Licensed Practical Nurse (LPN) JJ stated that R100 liked his door shut. LPN JJ said management assessed the window after R100 eloped but she didn't know what interventions they put in place. During an interview and observation on 3/17/2026 at 1:24 PM, Family Member (FM) II stated that after R100 eloped on 9/16/2025, management put another screw in the windowsill so the window could only open 3-4 inches. The screw was observed to be almost flat against the windowsill and the screen on the window was busted at the bottom. FM II said she was able to pull the window up the other day even though the screw was on the windowsill. FM II was observed unlocking the window and demonstrated using little force and pulled the window all the way up over the screw. FM II stated she was going to bring her screwdriver in and pull the screw out more so R100 doesn't try to get out of the window again. During an interview on 3/17/2026 at 1:34 PM, Maintenance Director (MD) O stated after R100 eloped on 9/16/2025, he came to work on 9/17/2025 and put a new screw in R100's window since the screw was flush from opening and closing the window and he checked all the windows in the facility to make sure they had a screw to prevent further elopements. During an observation in R100's room on 3/17/2026 at 1:50 PM, MD O unlocked his window, and couldn't open the window because of the screw in place and proceeded to lock the window. Then, this surveyor unlocked the window, noticed the screw was barely out from the windowsill and pulled the window all the way up over the screw. During an interview on 3/17/2026 at 2:02 PM, MD O reported after the elopement on 9/16/2025 he didn't document any follow-up on R100's window or other resident windows since that day to make sure the intervention was working. MD O said I visualize that screws are on the windowsill, but I don't physically try to open the windows to see if it works, and I wasn't told that I should do that. I would lie if I told you I do that. MD O stated that he went back to R100's room and pulled the screw out more on R100's windowsill after this surveyor was able to pull the window up over the screw so the window wouldn't be able to open all the way.During an interview on 3/18/2026 at 8:52 PM, Director of Nursing (DON) B stated that MD O checked on all resident windows the next day after the elopement but they didn't have documentation on it. When discussing that this surveyor was able to open R100's window and pull it up over the screw, DON B said that he thought all the windows were repaired. DON B also stated that R100 and his daughter like the door closed. During an interview on 3/18/2026 at 9:05 AM, when discussing this surveyor being able to open R100's window and pull it up over the screw, Nursing Home Administrator (NHA) A stated that R100 was below the threshold so he can't open the window now. NHA A said there wasn't a regulation to have documentation on checking resident windows after an elopement occurred and the window should be able to be opened in case of a fire. During an interview on 3/18/2026 at 9:50 AM, Activity Aide (AA) OO stated that R100 used to say he wanted to go home all the time and he would wait for his daughter to pick him up. During an interview on 3/18/2026 at 10:10 AM, LPN V stated that R100 was exit seeking for a while even after the elopement on 9/16/2025. During an interview on 3/18/2026 at 10:14 AM, Registered Nurse (RN) NN stated that R100 would talk about leaving the facility a lot for the first few months after admission. During another interview on 3/19/2026 at 11:38 AM, MD O restated that all he did after the elopement was put the screw on R100's windowsill and then he made sure all other resident windowsills had a screw but he didn't test them to see if he could open them all the way. MD O reported that all resident windows had a screw except the memory care unit which included 15 resident rooms so he put them in on 9/17/2026. During another interview on 3/19/2026 at 10:25 AM, when discussing post elopement interventions and this surveyor being able to open the window, NHA A stated that any force can open the window whether there was a screw on the windowsill or not and the facility did a good job keeping R100 safe.

Based on observation, interview, and record review the facility failed to ensure palatable and appetizing food was served to 2 (Resident #108 and Resident #109) of 2 residents reviewed for receiving palatable and appetizing food, resulting in potential for decreased oral intake.Findings include:Resident #108Review of an admission Record revealed Resident #108 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: bipolar disorder (a mental health condition characterized by significant mood swings), anxiety, and depression.Review of Order Summary for Resident #108 revealed Regular diet, regular texture, Thin consistency for Diet Order with a start date of 11/3/2025.In an interview on 3/17/26 at 3:25 PM, Resident #108 reported the food was yucky and sometimes cold. She reported the staff did not reheat it when she asked them to.In an interview on 3/18/26 at 7:50 AM, Resident #108 reported breakfast today should be french toast sticks. Resident #108 stated I will get the french toast sticks and I will eat them, but they will probably be cold.In an observation and interview on 3/18/26 at 9:35 AM, Resident #108's breakfast tray was on her over the bed table, beside her bed, with the lid on the plate. Resident #108 reported the temperature of her food was ok, but the sausage was under cooked and the french toast sticks were hard as a rock. Resident #108 reported she was unable to cut them with a fork and only one was soft enough for her to bite into. Resident #108 reported she only ate one of the four french toast sticks she was served. Resident #108 reported she had to eat the french toast stick with her fingers after it had been covered in syrup. Resident #108 then removed the lid from her plate on the tray to show two sausage links and three French toast sticks still on the plate, covered in syrup. Resident #108 picked up a French toast stick from the plate and tapped it on the plate to demonstrate that it was hard as a rock. Resident #108 picked up the fork off the tray and demonstrated her inability to cut through the french toast stick. It was noted in the sound and visualization that the French toast stick was hard.Resident #109Review of an admission Record revealed Resident #109 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: unspecified dementia, weakness, and history of falling.Review of Order Summary for Resident #109 revealed Regular diet, regular texture, Thin consistency for Diet Order with a start date of 11/3/2025.In an observation and interview on 3/18/26 at 9:30 AM, Resident #109 was asked how was breakfast? Resident #109's reply was It sucked. When further queried, Resident #109 reported the food was cold, the sausage could have been cooked longer, and the french toast sticks were rock hard. Resident #109 reported she could not eat any of it. Resident #109 was noted to have two bowls of oatmeal on her tray that was on the over the bed table in her room and two cups of fruit. Resident #109 reported she had no idea why she got two bowls of oatmeal; she wouldn't even eat one, much less two, but the fruit was ok. Resident #109 reported that the food was not great.In an interview on 3/18/26 at 2:45 PM, Resident #109 reported lunch was terrible and it did not taste good. Resident #109 reported she did not even get served what was on the menu. Resident #109 reported the menu said 'collards' but she got green beans. Resident #109 stated they are not the same thing. In an observation and interview on 3/19/26 at 9:01 AM, Resident #109 was in her wheelchair in the hallway. She reported she was headed to the kitchen to get come fruit because whatever they served her this morning needed some help. Resident #109 reported .no idea what breakfast was, but she couldn't eat it. Resident #109 reported I don't know who was cooking, but it isn't good. Resident #109 reported she had called the kitchen to order some fruit and was on her way to get it. Resident #109 was observed at the kitchen doorway speaking with the kitchen staff about a bowl of fruit.Review of Menu revealed Wednesday 3/18 breakfast sausage link, cereal of choice, French toast sticks, juice of choice.Lunch.chicken BBQ, Macaroni & Cheese, Collards, Cornbread, Sweet Potato Pie.In an interview on 3/18/26 at 2:55 PM, Dietary Manager (DM) N reported residents can ask for alterative choices if they do not like something. DM N reported there is a list of always ready foods that a resident could request as an alternative meal.

This citation pertains to MI00152746. Based on interview and record review, the facility failed to ensure nursing staff had appropriate skill sets for medication administration for 1 resident (Resident #1) of 4 residents reviewed for medication administration, resulting in the potential for residents residing in the facility to be unable to maintain the highest practicable physical, mental and psychosocial well-being and the potential for decreased resident safety. Findings include: Resident #1 (R1) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including osteomyelitis of vertebra, lumbar region (inflammation of the bone in the spine). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R1 was cognitively intact (13 to 15 cognitively intact). She was discharged on 5/2/2025 from the facility. During a phone interview on 6/25/2025 at 11:02 AM, R1 stated that she had a PICC line (peripherally inserted central catheter; long, thin, flexible tube inserted into a vein in your upper arm, usually above the elbow and threaded into a large vein into your heart) prior to admission and was on antibiotics which were administered through the PICC line due to an infection in her lumbar region. R1 reported that on 4/1/2025 she was waiting for therapy to work with her when Licensed Practical Nurse (LPN) K went into her room and administered antibiotics (ertapenem) through her PICC line. R1 saw initials on the antibiotics B.W. and it wasn't cephazolin which was her ordered antibiotic. R1 stated she told a CNA (Certified Nursing Assistant) and then LPN K that the antibiotics weren't hers and told her to take it out. R1 stated that LPN K said she grabbed the wrong medication. Review of R1's physician orders revealed Cefazolin in sodium chloride intravenous (IV) solution 2-0.9 gm (gram)/100ml (milliliters)-% (percent) (Cefazolin sodium in sodium chloride) use 2 grams intravenously every 8 hours for sepsis. Start date 3/28/2025. Review of the Medication and Treatment Incident Report dated 4/1/2025 revealed Resident: (R1). Date reported: 4/1/2025. Date Discovered: 4/1/2025 by resident, told CNA Description of Event: Resident alerted CNA, CNA looked for attending nurse and could not (find her), and found staff developer who entered room, found ertapenem IV (intravenous) ball labeled to resident with initials P.W. Resident had stopped infusion. Resident confirms she has no med (medication) allergies, line was flushed. Nurse notified, NP (Nurse Practitioner) notified, VS (vital signs) obtained. Medication Error: Wrong Drug. Medication Error Classification: Error occurred, resulted in need for increased monitoring, no harm. The form was signed by LPN K and the Medical Director. Review of LPN K's Licensed Nurse Department Orientation Checklist on her date of hire of 3/27/2025 revealed IV therapy: hypodermoclysis (method of fluid administration where fluids are injected under the skin rather than intravenously) with LPN K's initials. Documentation on IVs, Identification of IVs midline, PICC lines, and how to identify valved and non-valved, flush protocol and how to write orders, IV pump usage/set up/troubleshoot, tubing change, mediports, TPN (total parenteral nutrition; all nutrients/nutrition are provided directly into the bloodstream through a catheter), IV back-up cart did not have LPN K's initials next to them. The checklist was signed on 3/29/2024 by LPN K and Staff Development Coordinator (SDC) I. Review of the Licensed Nurse Competency Evaluation {RN (Registered Nurse) and LPN} which was completed 4/3/2024 revealed the section IV therapy (Peripheral lines and PICC) . all 9 lines related to that section were either left blank, had a line through it or NA (not applicable) written on it. The checklist was signed by LPN K. Review of the Charge Nurse Job Description revealed .Essential Functions and Job Responsibilities 2. Provides safe and accurate medication related interventions to residents. A. Administers and documents medications and treatments according to each resident's medication schedule using current standards of medication pass technique. Medication administration includes .X. IV therapy. During an interview on 6/26/2025 at 11:50 AM, LPN K reported that on 4/1/2025 she got R1's medication from the refrigerator since it was an antibiotic and she thought she verified that but she obviously missed it and gave the wrong medication to R1. LPN K stated that she wasn't aware of the medication error until R1 pointed it out to her. LPN K said she received 1:1 education by SDC I after the error. Review of the Disciplinary Action Record Work Rules Form dated 4/1/2025 revealed .Written Warning #1. Date of Infraction: 4/1/2025 Failure to administer correct medication to resident. Failure to adhere to rights of medication administration. Nurse administered incorrect medication via IV route. Medication was labeled to give to another resident. No harm came to the resident as a result, but we must work to reduce errors in medication administration. Specific Plan for improvement .Adhere to medication administration guidelines and policy The form was signed by LPN K and SDC I on 4/1/2025. During an interview on 6/26/2025 at 10:41 AM, SDC I reported that he filled out the Medication and Treatment Incident Report dated 4/1/2025 and filled out the Disciplinary Action Record Work Rules Form. SDC I said that LPN K was getting medications ready and didn't look at label with the resident name and the name of the medication. SDC I stated that R1 was frustrated when she found out she was given the wrong medication, so the medication was unhooked and the PICC line was flushed. He said R1 didn't have any adverse signs or symptoms. The correct medication was given 1-2 hours later. SDC I stated that LPN's can give medications through the PICC line but they need to be educated and trained on how to do it. SDC I stated if there isn't a resident with a unique condition at the time of orientation, return demonstration may not be able to be done and but they will talk about the procedure. During an interview on 6/26/2025 at 9:25 AM, Nurse Practitioner (NP) U stated that LPN K said she pulled the wrong antibiotics for R1 and thought it was the only one in the refrigerator. NP U said that R1 was monitored afterwards and no harm was identified. During an interview on 6/26/2025 at 10:40 AM, Director of Nursing (DON) B reported that LPN K did not receive any PICC line education or training since her orientation which started on 3/27/2024 besides her 1:1 education after the medication error. When discussing LPN K's Licensed Nurse Competency Evaluation (RN and LPN) which was completed 4/3/2024 and the section of IV therapy (peripheral lines and PICC) either having blanks, a line through it or NA (not applicable) on the different areas, DON B didn't have anything to say about it. DON B stated that they educated and did training for all nurses after the incident and they will be starting a skills fair for nurses to ensure they have the skills set needed to take care of residents with unique conditions. Review of the Medication Administration Policy with a revision date of 10/17/2023 revealed .2. Verify the medication label against the medication administration record for resident name, time, drug, dose, and route. A. The nurse is responsible to read and follow precautionary instructions on prescription labels .4. Follow safe preparation practices .b. Never administer medications supplied for one resident to another resident . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education with nursing staff on proper medication administration with a PICC line. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #11) reviewed for restraints, resulting in the restriction of mobility, episodes of anxiety and frustration, a potential for decline in physical functioning, and an increased risk of injury. Findings include: Review of Physical restraint in older people: an opinion from the Early Career Network of the International Psychogeriatric Association, October 2023, www.researchgate.net , revealed: .The fundamental rationale for employing physical restraints is ostensibly to ensure the safety of the patient .common justi?cations for resorting to physical restraints include: . To reduce the risk of falls or accidents in ambulant patients with safety concerns .These well-intended motives, however, are not supported by the evidence. On the contrary, many studies show that restraints do not prevent falls and can instead increase the likelihood of injury from falls ([NAME], et al., 2011). Review of Restraint Definition and Examples, [NAME] D [NAME], OTR/L, 2015, phsyicaltherapy.com revealed: .examples of restraints: .A reclining geri-chair (a specialized reclining chair which cannot be propelled by the user, and restricts movement in a resident that is able to propel in a manual wheelchair) would be considered an example of a restraint .An upright geri-chair with a lap tray .that prevents the resident from rising from the seat .they are not able to stand up. Review of an Admission Record revealed Resident #11 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive deterioration of cognitive skills), anxiety disorder (excessive worry and fear that are persistent, intense, and often out of proportion to the situation), major depressive disorder (persistent depressed mood or loss of interest in activities causing significant impairment in daily life) and edema (buildup of fluid in the body's tissue, most commonly in the legs and feet). Review of a Minimum Data Set (MDS) assessment for Resident #11 with a reference date of 1/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #11 was unable to complete the evaluation. Section E revealed Resident #11 did not exhibit behavioral symptoms of verbal/vocal screaming or making disruptive sounds during the 14-day assessment period. Section GG revealed Resident #11 could ambulate 10' with supervision or light touching assistance and could propel a standard wheelchair up to 150' with moderate assistance. Section M revealed Resident #11 was at risk for developing pressure ulcers. Section P revealed no physical restraints were used on Resident #11. Review of a Care Plan for Resident # 11 with a reference date of 1/30/25, revealed a focus/goal/interventions of: (Resident #11) is at risk for complications due to they (sic) require use of a Gerichair (sic) w/tray (with tray) to enable her up related to multiple falls. Goal: (Resident #11) will be free from complications related to the use of Gerichair w/tray through next review. interventions: Apply Gerichair w/tray when up and release tray after meals or when in bed .Release and reposition q2 hours, with supervised meals, supervised activities and with toileting. During an observation on 4/15/25 at 9:21 am, Resident #11 sat in a geri-chair in the common area of the memory care unit. The arms of the geri-chair pushed against a table and the brakes locked. Resident #11 sat upright, supported her torso with her trunk muscles with her back unsupported. Resident #11 rocked her trunk back and forth as a staff member passed by and said to her (Resident #11's name) what's wrong? We're going to do a history activity in twenty minutes. Resident #11's feet hung unsupported above the floor with her feet extended, causing her toes to point toward the floor. Resident #11's feet appeared swollen. During an observation on 4/15/25 at 9:58 am, Resident #11 sat unsupported at the edge of her bed with the geri-chair parked against the wall across from the foot of her bed. A lap tray for the geri-chair was propped against the wall. No staff were in her room and the call light was activated. In an interview on 4/15/25 at 12:15pm, Certified Nursing Assistant (CNA) U reported the nursing and hospice staff decided to use a geri-chair with a table across it for Resident #11 after the resident had multiple falls. When asked if the resident seemed upset about using the geri-chair with the lap tray, CNA U reported Resident #11 hates it. CNA U reported Resident #11 was not able to get out of the chair with the lap tray in place and frequently made statements such as get me out of here while in the chair. CNA U reported Resident #11 was less frustrated if the geri-chair did not have the tray on it but was pushed up against a table, although the resident still could not stand when she was in this position. In an interview on 4/15/25 at 1:49pm, Social Services Director (SSD) T reported Resident #11 started using the geri-chair after she had been hospitalized and returned too weak to maintain good trunk control. SSD T reported Resident #11's strength had improved, and she could now sit unsupported. When queried regarding the use of the lap tray across the chair, SSD T confirmed the lap tray was affixed across Resident #11's lap at times and to her knowledge, was used so Resident #11 could pursue tabletop leisure interests. SSD T reported the geri-chair and tray were not used to reduce Resident #11's fall risk and she was not aware of any negative response the resident had to it. In an interview on 4/16/25 at 9:27am Activity Aide (AA) E reported Resident #11 had become more anxious and agitated in recent months. When further queried, AA E reported in the past Resident #11 was very proud of her independence and felt the resident was experiencing more distress now due to her loss of independence and the inability to move around as much. In an interview on 4/16/25 at 9:32am, CNA HH reported Resident #11 was screaming out, calling staff names and hitting at them more frequently than she had a few months ago. CNA HH described Resident #11 as irritated with the lap tray when it was on her chair. In an interview on 4/16/25 at 9:51am, CNA U reported Resident #11 frequently pounded on the lap tray of the geri-chair and stated, get me out of this thing. CNA U reported Resident #11 had regained the strength she lost during a recent hospitalization , could walk short distances again and had been found with one leg over the lap tray of the geri-chair as she tried to get out of it unassisted. CNA U reported the use of the geri-chair and lap tray had been detrimental to Resident #11's mood and described it as agitating to the resident. CNA U reported Resident #11 had difficulty expressing her thoughts but the resident commonly, clapped her hands and said yay! when CNA U removed the lap tray in preparation to transfer the resident out of the geri-chair. During an observation on 4/16/25 at 10:16am, Resident #11 sat in a geri-chair with a hard plastic lap tray affixed across her lap in the common area of the memory care unit. 2 staff members sat next to Resident #11. In an interview on 4/16/25 at 10:20am, Resident #11 was asked about the geri-chair and although she did not verbally respond, she grabbed the lap tray of the chair and rattled it side to side several times. During an observation on 4/16/25 at 10:46am, Director of Nursing (DON) B walked past Resident #11 as she sat in the common area of the memory care unit, in the geri-chair with the lap tray affixed across her lap, as she engaged in a supervised activity. DON B waved to Resident #11. In an interview on 4/16/25 at 10:51am, Registered Nurse/Hospice Care Coordinator (RNCC) GG reported Resident #11 was provided with the geri-chair in February 2025 after a hospitalization . RNCC GG reported Resident #11 needed the geri-chair for trunk support and to maintain proper positioning while eating but she did not recommend the use of the tray table. RNCC GG reported it was her expectation that the facility would communicate to her if Resident #11 regained her strength and could sit unsupported or if the resident began to express any distress related to using the geri-chair. RNCC GG reported it was important that the facility share this type of information because the resident would need to be reassessed to see if another type of wheelchair would better meet her needs. RNCC GG stated we want her to be more mobile and more independent if she can be because that will maintain her best quality of life. RNCC GG reported she was not aware the facility was using the lap-tray on Resident #11's geri-chair, that doing so would be considered a restraint and could be detrimental to the resident's overall psychosocial well-being. RNCC GG stated She (Resident #11) is already behavior prone, and we should not do anything that makes her more anxious. When further queried, RNCC GG reported that Resident #11 being found with her leg over the lap-tray indicated she felt anxious and trapped and increased her risk of falling. In an interview on 4/16/25 at 11:19am, RN Unit Manager (UM) X reported she did not know why a geri-chair and lap-tray had been implemented for Resident #11. UM X reported the lap tray should be removed anytime the resident voices that she wants it off, and that Resident #11 cannot remove the tray herself. UM X reported she had heard Resident #11 multiple times as she banged on the lap-tray and said repeatedly that she wanted to lay down. UM X reported the staff usually assisted Resident #11 to bed at that time. UM X reported she was not aware Resident #11 had been found with one of her legs over the lap-tray as she tried to climb out of the geri-chair, which put her at greater risk for injury, and that staff were expected to report this type of information to her. In an interview on 4/16/25 at 12:05pm, DON B reported the facility implemented the use of a geri-chair with a lap tray for Resident #11 in effort to reduce the number of falls the resident had. DON B reported Resident #11 had become very restless, at times wanted to lay down or get up every 15 minutes and the staff did not have time to assist her with doing that, so the geri-chair was implemented. DON B reported the intent for use of the geri-chair and lap-tray was to keep Resident #11 comfortable but out of her room and in one place. DON B reported the only other way to keep Resident #11 safe would have been to assign 1 staff member to her and that was not feasible. When asked about Resident #11's current ability to sit unsupported, DON B reported he believed her core isn't strong and he was unsure if the resident was able to stand up. DON B reported Resident #11's most recent Physical Restraint Reduction assessment was 1/29/25. When asked if staff members had reported Resident #11 having any behaviors related to the geri-chair and the lap tray, DON B did not respond. When further queried about any anxiety the resident had exhibited because of the use of the geri-chair and lap tray, DON B stated she was banging on the tray this morning, saying she wanted to go to bed when I tried to talk to her. DON B reported when Resident #11 banged on the lap tray and asked to go to bed during his interaction with her on this date, he responded by consoling her. In an interview on 4/16/25 at 2:26pm, AA Z reported she had seen Resident #11 trying to get out of the geri-chair at times and that the resident could not remove the lap-tray on her own. Review of a Physical Restraint Reduction Assessment for Resident #11 with a reference date of 1/29/25 revealed 2. Is the resident a candidate for restraint reduction? Yes. 2a. If yes, what actions are going to be taken (include less restrictive measure to be used and start date for when reduction is going to begin) .1/29/25 remove tray table q (every) 2 hours and prn (as the situation demands) and when in supervised activity. Review of a Nursing Progress Notes for Resident #11 revealed: 4/11/25 at 6:59pm, Banging hands on tray and yelling. 4/10/25 at 4:14am, resident .trying to get up out of her chair this shift .we found a chair just like hers because she (sic) getting out of this one . 4/9/25 at 5:35pm, clamp that hold tray onto geri-chair broke off . 3/30/25 at 2:15am, Resident have(sic) been yelling and beating on her table . 3/28/25 at 2:00pm, Res started yelling and banging the board on her chair, hard to be redirected. 3/25/25 at 9:00pm, Resident was very agitated beating on table and yelling out. 3/25/25 at 9:40am, Yelling out nonsensical statements, hitting lap tray with her hand, unable to redirect. 3/25/24 at 1:48am, she have (sic) been hitting on the table and getting out of her recliner chair yelling out to get up we have taken her to the bathroom and laid her down when she asked and she would get up from bed in 5-10min after we put her in because she asked to go to bed, she is up in recliner chair at this time because we caught her getting out of bed . 3/16/25 at 3:35am resident .was yelling to get up and hitting the table she got out of her chair . Review of a Behavior Monitoring Log with a reference date of 1/1-1/31/25 revealed Resident #11 demonstrated behavioral symptoms (frequent crying, repeated movements, yelling, wandering, grabbing, hitting) 38 times during the 31-day period. Review of Physician Orders for Resident #11 with a reference date of 1/29/25 revealed Geri chair with lap tray to enable her to be up with reduction in falls. Review of a Behavior Log for Resident #11 with a reference date range of 3/18/25-4/15/25 revealed the resident displayed behavioral symptoms (frequent crying, repeated movements, yelling, wandering, grabbing, hitting) 97 times during the 30-day period. Review of a facility Restraint Management policy with a reference date of 3/7/23 revealed Policy: Restraints are not used unless the resident has medical symptoms that warrant the use of the restraint. Overview: Physical restraints are not used for the purpose of .convenience .physical restraints include .lap trays the resident cannot easily remove .placing a resident in a chair .that prevents a resident from rising .Guidelines .8. Residents using physical restraints will have a Physical Restraint Reduction Evaluation completed .with any significant change of condition for the use and appropriateness of physical restraints. Attempts to contact Resident #11's legal guardian were unsuccessful at the time of the completion of the survey. Using the reasonable person concept, though Resident #11 could not recall and verbalize the degree of emotional distress she experienced because of being physically restrained, she clearly demonstrated a desire to be free from the chair and lap tray that limited her movement, and experienced increased anxiety from the confinement.

This citation pertains to intake #MI00147013 Based on observations, interview, and record review the facility failed to provide prompt medical care after a fall for 1 (Resident #100) of 4 residents reviewed for falls resulting in Resident #100 experiencing significant pain, suffering, and a delay in emergent care after a fall with fracture. Findings include: Resident #100 Review of an Admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: age-related osteoporosis (disease that causes the bones to become weak and more likely to break), alzheimer's disease (disease that causes loss of cognitive abilities), fracture of pelvis, and falls. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 7/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #100 was unable to complete the assessment. Section E of the MDS revealed Resident #100 did not reject care during the assessment period. Section GG revealed Resident #100 ambulated up to 50' with supervision and no device. Review of a Care Plan for Resident #100, with a reference date of 7/10/23, revealed a focus/goal/interventions of: Focus: (Resident #100) is at risk for fall related injury and falls R/T (related to) hx (history) of multiple falls .Goal: Will be free from injury related falls .Interventions: Encourage resident to be out in common area when seen ambulating .redirect resident with activity when beginning to wander . Review of an Incident Report for Resident #100 with a reference date of 9/16/24 revealed at 8:00pm, the resident had a witnessed fall during which she landed on her bottom. A section titled Injuries Observed at Time of Incident revealed no injuries observed at time of incident. Review of a Change of Condition Evaluation for Resident #100, written by LPN E on 9/17/24 at 12:48am, a section titled Signs and Symptoms Identified revealed: fall, pain, trauma .right leg is turned outward and shorter than left leg significantly . Review of a Pain Scale report for Resident #100 revealed the resident's pain level was assessed as an 8 out of 10 by LPN E on 9/17/24 at 1:08am. Review of Resident #100's medical record revealed no Change of Condition Evaluation, or post fall assessment completed by RN D for the resident's fall on 9/16/24. Review of Resident #100's physician's orders revealed an order for a two view right hip x-ray was entered by LPN E at 12:28am. Review of a Radiology Report for Resident #100 with a reference date and time of 9/17/24 at 1:03am revealed: Findings: there is an acute communicated right femoral intertrochanteric fracture (hip fracture) . In an interview, Emergency Medical Technician (EMT) G reported he cared for Resident #100 as she was transported to the local acute care hospital on 9/17/24 at approximately 1:15am. EMT G reported Resident #100 yelled out in pain with any movement and had an obvious shortening and rotation of her right leg. Review of a History and Physical report for Resident #100 with a reference date of 9/17/24, from a local emergency room , revealed Extremities: Exam of right lower extremity reveals diffuse tenderness (widespread pain) with any hip movement, shortening and external rotation of the leg . Review of a Physician Discharge Summary for Resident #100, from a local acute care hospital, with a reference date of 9/20/24, revealed a summary of hospital stay: .femur fracture with intramedullary nailing (surgical repair) on 9/17/24 . During an observation on 10/2/24 at 3:49pm, Resident #100 sat in the community room in a wheelchair, wore a hospital gown, grimaced and furrowed her brow, as she rubbed her right upper thigh. In an interview on 10/3/24, at 9:18am, Registered Nurse (RN) D reported she was the nurse who responded when Resident #100 fell on [DATE] at 8:00pm. RN D reported Resident #100 was lying on her right side in the hallway near her room. When queried about assessing Resident #100 for injuries while she was on the floor, RN D stated At that time I didn't do an assessment. I wanted to get her off the floor. RN D reported she and 2 Certified Nursing Assistants (CNAs) lifted Resident #100 into a wheelchair and then transferred her to bed. RN D reported she assessed Resident #100 as she laid in bed and at that time, noticed Resident #100's right foot had an outward rotation which was an indication of a potential fracture. When further queried, RN D reported she did not pursue getting an order to transport Resident #100 to the hospital because she thought it was protocol to get an x-ray first. RN D reported she could not recall if she informed the provider of Resident #100's outward leg rotation. In an interview on 10/3/24 at 12:37pm, Certified Nursing Assistant (CNA) M she responded when Resident #100 fell on [DATE]. CNA M described Resident #100 as hysterical, yelling Ow repeatedly as she laid on the floor. CNA M reported she, RN D, and another CNA assisted Resident #100 to standing but the resident could not bear weight on her right leg and was ultimately transferred to a wheelchair. CNA M reported Resident #100 grimaced and pointed to her right leg as she sat in the wheelchair. In an interview on 10/3/24 at 2:57pm, Certified Nursing Assistant (CNA) K reported Resident #100 complained of hip pain immediately after her fall on 9/16/24. CNA K reported prior to the fall, Resident #100 could walk without assistance but after the fall, the resident could not bear weight on her right leg. CNA K reported Resident #100 struggled to verbally express herself due to her dementia, but in the hours after her fall, she appeared painful, refused to allow anyone to touch her, guarded her leg, and repeatedly said I fell , I fell . In an interview on 10/3/24, at 8:50am, Licensed Practical Nurse (LPN) E reported on 9/16/24 a few hours after the fall, RN D asked LPN E to come take a look at Resident #100 and at that time, RN D also asked if she should call a provider to inquire about getting an x-ray for the resident. LPN E reported when she assessed Resident #100, the resident was complaining of pain in her right leg, had a shortening and rotation of her right leg, and could not tolerate passive range of motion to the extremity. LPN E reported a resident who fell should never be moved prior to the completion of a thorough assessment for injury and that a failure to properly assess the resident could result in lack of identification of injuries and the development of complications. LPN E reported Resident #100 should have gone to the hospital immediately after her fall. In an interview on 10/3/24 at 11:15am (RN) C reported a full assessment should be completed immediately after a resident fall, prior to moving the resident. If the resident was painful or has a gross anomaly such as foot rotation or shortening of a leg, the physician should be contacted immediately, and the resident should be sent to the emergency room for further evaluation. In an interview on 10/3/24 at 2:19pm, Director of Nursing (DON) B reported a post fall assessment should be completed by the nurse prior to moving a resident who had fallen. The post fall assessment should include taking vital signs, assessing for pain, performing range of motion, checking pedal pulses, visual inspection for physical injuries. Upon completion of the assessment, the nurse should then report the findings to the primary care provider and take the action of the provider as directed. In an interview on 10/3/24 at 8:34am, Family Member (FM)/Durable Power of Attorney (DPOA) I for Resident #100 reported he received notification of the resident's fall on 9/16/24 at approximately midnight. When queried about his wishes for Resident #100 regarding hospitalization , FM I reported he wanted Resident #100 to be transported to the emergency room for evaluation if she fell and appeared to have an injury. FM I reported he believed it would have been in Resident #100's best interest to go to the hospital at the time of the fall. FM I reported Resident #100 had intense pain prior to the surgical repair of the hip fracture that she suffered during the fall on 9/16/24. In an interview on 9/17/24 at 2:35pm, Medical Director (MD) F reported a resident who had a rotation or shortening of a leg after a fall should be transported to the emergency room immediately because those were signs of a serious injury.

This citation pertains to intake #MI00137836 Based on observation, interview, and record review the facility failed to prevent the development of and worsening of pressure ulcers in 2 resident (Resident #9 and Resident #13) of 2 residents reviewed for pressure ulcers resulting in the development of (3) facility acquired pressure ulcers and the worsening of existing pressure ulcer. Findings include: Resident #9 Review of an Admission Record revealed Resident #9 had pertinent diagnoses which included: type 2 diabetes, and peripheral vascular disease (the narrowing of blood vessels away from the heart in arms and legs), and cerebellar stoke syndrome (when circulation to the cerebellum (part of the brain) is impaired (blocked)). Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 1/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #9 was moderately cognitively impaired. Review of Progress Notes for Resident #9 dated 8/22/23 at 12:05 PM., revealed .a previous wound that is now reopened. The wound is on the right lateral ankle measuring 1cm x 1.4 cm x 0.3, draining a small amount of pus mixed with serosanguinous drainage (thin watery drainage with a light red or pink hue) . Review of Progress Notes for Resident #9 dated 8/22/23 at 14:46 PM., revealed . new order for Keflex 500mg 3 x daily x 10 days and to clean and dress wound with CaAg (Calcium Alginate) and border gauze daily. Review of Progress Notes for Resident #9 dated 8/22/23 at 15:34 PM., revealed .new chronic recurring right outer ankle pressure wound . does not get out of bed . body habitus causes her outer feet and ankle to always be touching the bed. History of refusal of care . Review of Progress Notes for Resident #9 dated 8/25/23 at 12:54 PM., revealed .continues with ABT (antibiotics) for infection to the outer right ankle wound. Dressing to area changed as ordered . Review of Progress notes for Resident #9 dated 9/26/23 at 15:52 PM., revealed . Resident seen by wound care (Name Omitted) to re-evaluate wound on right lateral ankle. Evidence shown wound is healed. Review of Care Plan for Resident #9 revealed .at risk for skin breakdown/pressure injury r/t (related to) decreased mobility . does not always allow for her feet to be floated in bed .created on 10/11/2017 . revision on 8/23/24 . Review of wound provider Progress Note Details for Resident #9 dated 1/2/24 revealed .Right Lateral Ankle, onset 8/29/23, context Pressure, supportive surface, sponge boots, offloading pillows . Wound #8 Lateral Ankle is a stage 4 Pressure Injury Pressure Ulcer . Initial wound encounter measurements 2.5 cm length x 2 cm width x 0.3 cm depth . Float heals while n bed- specifically float the ankle. The pillow should not be touching the ankle but be above the calf .measurements post skin/subcutaneous tissue level surgical debridement with a total area of debrided of 1 sq cm muscle and subcutaneous were removed along with devitalized tissue: necrotic/eschar. Debridement Measurements: 2.5 cm length x 2 cm width x 0.3 depth . Review of Progress Notes for Resident #9 dated 1/3/24 at 20:04 PM., revealed .no new skin issues reported or noted at this time . Review of Progress Notes for Resident #9 dated 1/9/24 at 9:34 AM., revealed .on 1/3 staff found stage 4 wound on residents right ankle due to resident external hip rotation of right leg causing resident ankle to lie flat on the bed. Residents wound exposing hardware in ankle .right ankle x-ray, apply skin prep to bilateral heels Q (every) shift, elevate while in bed with pillow to offload heels, every shift for preventative, cleanse right lateral ankle with wound cleanser, pat dry, apply hydrofera blue (cutting to the size of the wound only) cover with foam border gauze. Change Tues, Thu, Sat and as needed if soiled . Review of Progress Notes for Resident #9 dated 1/16/24 at 21:31PM., revealed .Resident sent to (Name omitted) acute care hospital at 1635 per (Name Omitted), wound doctor, d/t (due to) infection/exposed hardware to right ankle . Review of Progress Notes for Resident #9 dated 1/27/24 at 6:44 AM., revealed .continue wound tx (treatment) to right lateral ankle as ordered . Review of wound provider Progress Note Details for Resident #9 dated 1/30/24 revealed .Right Lateral Ankle, onset 8/29/23, context Pressure, saw orthopedic surgeon last week, surgery to remove hardware, possible wound vac on 1/31 . Wound #8 Lateral Ankle is a stage 4 Pressure Injury Pressure Ulcer . The wound is deteriorating .Float heals while n bed- specifically float the ankle. The pillow should not be touching the ankle but be above the calf .measurements 3 X 2.5 X 0.6 .refer to ortho for surgical intervention. Review of Progress Notes for Resident #9 dated 1/31/24 at 22:57 PM., revealed . post -op assessment . dsg. (dressing) on right foot in place, wound vacuum is functioning properly with draining fresh red discharge .Order of doxycycline (antibiotic) po (by mouth) continue for 60 days . Review of Case Information for Resident #9 from (Name Omitted) acute care hospital with surgery note dated for 1/31/24 at 9:54 AM., revealed .removal hardware lower body right ankle lateral aspect .preoperative diagnosis right 3 x 3 cm lateral ankle wound . postoperative diagnosis right 3 x 3 lateral ankle wound . name of operation . application of right lateral ankle wound VAC . Review of Progress Notes for Resident #9 dated 1/31/24 at 22:57 PM., revealed . post -op assessment . dsg. (dressing) on right foot in place, wound vacuum is functioning properly with draining fresh red discharge .Order of doxycycline (antibiotic) po (by mouth) continue for 60 days . Review of Orders for Medications as directed and reviewed for Resident #9 dated 2/27/24 as ordered from (Name Omitted) wound clinic revealed .return to wound clinic in one week . Wear sage boots . Review of Progress Notes for Resident #9 dated for 3/12/24 revealed .wound care provided to R ankle sight .some undermining noted . current dressing change orders as prescribed by wound care clinic . In an interview on 3/25/24 at 3:10 PM., Registered Nurse/Unit Manager/Wound Nurse (RN/UM/WN) M reported that Resident #9 was seen weekly at the wound clinic and her dressing was to be changed daily. During an observation on 3/26/24 at 9:20 AM., Resident #9's wound to the lateral right ankle was visualized. Right lower extremity had extreme dentition due to the pressure of the moon boot and edema in the right lower extremity. A foul odor was noted through a surgical mask and the dressing was noted to be saturated with drainage and no date. The foam of the dressing was black in color and the wound was noted to have red in color and dried drainage surrounding the wound. RN/UM/WN M was observed vigorously scrubbing Resident #9's skin surrounding the wound on the right lateral ankle to remove the dried drainage. In an interview on 3/26/24 at 9:40 AM., RN/UM/WN M reported that Resident #9's dressing to her right ankle should have been changed last night and it was not. RN/UM/WN M reported that the dressing had no date, it was saturated and should have been changed. Review of Progress notes for Resident #9 dated for 3/26/24 revealed .wound care provided to R lateral ankle site. Moderate serosanguinous drainage noted to dressing, some odor noted .Continue current dressing orders per wound care clinic, next appointment scheduled for 4/3/24 . In an interview on 3/26/24 at 9:55 AM., Director of Nursing (DON) B reported that Resident #9's wound began as pressure but was reclassified as surgical after surgical intervention. DON B reported that Resident #9 was to be seen by the wound clinic weekly, and had appointments scheduled on 2/19, 2/23, 2/27 and 3/5. Resident #9 was last seen by the wound clinic on 2/27/24. DON B reported that Resident #9 missed appointments at wound clinic due to lack of transportation. Review of Progress note dated 3/26/24 at 10:48 AM., revealed . wound care clinic next appointment scheduled for 4/3/24 . Review of Care plan for Resident #9 revealed Focus - at risk for skin breakdown/pressure injury r/t (related to) decreased mobility . Float heels, R foot pillow boot, as she will allow . initiated 10/2018, revised on 7/2022 .Heel protector boot to right foot . Created and Initiated on 3/25/24 .has actual skin impairment to skin integrity r/t decreased mobility; R lateral ankle wound initiated on 1/16/24 .Goal - Will have no complications r/t wounds on the R Lateral malleolus initiated on 1/16/24 . interventions -Follow facility protocols for treatment of injury initiated on 1/16/24, Observe for s/s (signs and symptoms) of infection . observe location, size and treatment of skin injury . Treatment to skin impairment per orders initiated on 1/16/24 . Review of Care Plan for Resident #9 revealed no noted care plan interventions in place related to post-surgical intervention of the right lateral ankle wound and/or the use of a wound vac, and/or the additional wound care clinic specialist (name omitted) and/or antibiotic use. In an interview on 3/26/24 at 10:55 AM., MDS coordinator (MDSC) R reported that she was the person that updates care plans if they need to be updated. MDSC R reported that care plans should be updated quarterly, with significant changes, and if there is an identified need for the care plan to be updated. MDSC R reported that any wound would require an individual care plan with person centered interventions. MMSC R reported that the director of nursing and wound nurse can also update care plans. In an interview on 3/26/24 at 11:12 AM., DON B reported that care plans can be updated by all nursing staff and IDT team. Resident #13 Review of an Admission Record revealed Resident #13 had pertinent diagnoses which included: dementia with other behavioral disturbance, alzheimer's disease with late onset, muscle wasting, and protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 1/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #13 was severely cognitively impaired. Review of Braden Scale for Resident #13 dated for 1/13/24 revealed high risk 12.0 . no subsequent Braden Scale assessments noted in Resident #13's record. Review of Skin and Wound Evaluation for Resident #13 dated for 2/22/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to right elbow .in-house acquired .New . Review of Nurses Notes for Resident #13 dated for 2/22/24 12:22 PM., revealed New pressure ulcer noted to R elbow .Dressing change orders placed as well as orders for elbow protector to be in place at all times as she allows . Review of Progress Note for Resident #13 dated for 2/25/24 5:59 AM., revealed .resident has a stage II pressure ulcer to back of left knee measuring 2 x 2 x 0.1 . Review of Skin and Wound Evaluation for Resident #13 dated for 2/27/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to right elbow .in-house acquired .manual measurements included 1.2 X 0.8 X 0.1 . Review of Resident at Risk for Resident #13 dated for 2/27/24 revealed new wound found to R elbow . Review of wound provider Progress Note Details for Resident #13 dated for 2/27/24 revealed .wound location right elbow, left medial knee .date of onset February 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer .initial wound encounter measurements are 1.2 cm length X 0.8 cm width X 0.1 cm depth . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer .initial wound encounter measurements are 2.1 cm length x 2.2 cm width x 0.1 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . Review of Physician Order for Resident #13 dated for 2/28/24 revealed Ensure that a pillow is always place between knees when in bed . Elbow protector to R (right) elbow as resident allows . Review of Skin and Wound Evaluation for Resident #13 dated for 2/27/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to left popliteal Fossa, Medial .in-house acquired .new .manual measurements included 2.1 X 2.2 X 0.1 .reinforced turning and repositioning every 2 hours with pillow between knees . Review of wound provider Progress Note Details for Resident #13 dated for 3/11/24 revealed .wound location right elbow, left medial knee .date of onset February 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer .wound encounter measurements are 1 cm length X 0.7 cm width X 0.2 cm depth . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer .wound encounter measurements are 2.2 cm length x 2.3 cm width x 0.5 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . Review of wound provider Progress Note Details for Resident #13 dated for 3/21/24 revealed .wound location right elbow, left medial knee, right lateral knee .date of onset February 2024 and March 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 0.9 cm length X 0.9 cm width X 0.2 cm depth . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 2 cm length x 2.7 cm width x 0.4 cm depth . Wound #16 Right Lateral Knee is an unstageable pressure injury obscured full-thickness and tissue loss pressure ulcer . initial wound encounter measurements 1.8 cm length X 1.5 cm width X 0.1 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . Review of Total Body Skin Assessment for Resident #13 dated 3/25/24 at 1:20 AM., revealed .continues with stage 3 to left posterior knee and stage 2 to right lateral knee and right elbow with treatments in place . During an observation on 3/24/24 at 1:16 PM., Resident #13 was sitting in her wheelchair, in her room, next to her bed. Resident #13's arms are both inside the arms of the wheelchair pressed against the wheelchair arms. Resident #13 did not have heel protectors in place on both feet. During an observation on 3/25/24 at 8:09AM., Resident #13 was sitting in her wheelchair, in her room, next to her bed. Resident #13's right arm is inside her wheelchair arm rest and resting against the chair. Resident #13 did not have heel protectors in place on both feet. During an observation on 3/25/24 at 9:59AM., Resident #13 was sitting in her wheelchair, in the dining room with activities personnel. Resident #13 was noted to have a wedge-shaped pillow in the right side of her wheelchair between her body and the side of the wheelchair. Resident #13 did not have heel protectors in place on both feet. In an interview on 3/25/24 at 3:07 PM., Registered Nurse/Unit Manager/Wound Nurse (RN/UM/WN) M reported that Resident #13 was seen weekly by wound specialist at the facility. During an observation on 3/26/24 at 8:14 AM., Resident #13 was sitting in her wheelchair, in her room, next to her bed. Resident #13 has a wedge-shaped pillow or her right side along with an elbow protector in place on her right elbow. Resident #13's right elbow was wedged next to the arm rest of the wheelchair. During an observation on 3/26/24 at 9:36 AM., Resident #13 was observed sitting in her wheelchair in the dining room with a black in color padded board noted in the left side of her wheelchair. During an interview on 3/26/24 at 3:23 PM., RN/UM/WN M reported that Resident #13 used the black padded board for positioning in her wheelchair. Review of Kardex for Resident #13 on 3/27/24 revealed .Resident Care . reposition approx. q2 (every 2) hours .bathing resident was dependent .bed mobility . resident was dependent, provide extensive assistance to reposition frequently and as needed .skin, bilateral heel protectors, cure to reposition self as needed. Follow facility policies/protocols for prevention/treatment of impaired skin integrity. observe skin with showers/care .turn/reposition resident as needed and PRN . During an observation on 3/26/24 at 4:05 of Resident #13's wound dressing change it was noted the left knee was visualized to have tendon exposed. In an interview on 3/26/24 at 4:05 Registered Nurse/Unit manager/Wound Nurse (RN/UM/WN) M reported that Resident #13 wound was on the inner aspect of her left knee from her legs being pressed together. During an observation on 3/26/24 at 4:10 PM., Wound Care Medical Doctor (WCMD) RRR verbalized during wound care that Resident #13's tendon was exposed in the wound present on the left lateral knee and scraping for debridement was not recommended. WCMD RRR pointed to an area inside of Resident #13's wound on the lateral left knee as stated, that is the tendon. During an interview on 3/26/24 at 4:45 PM., RN/UM/WN M reported that Resident #13's wounds are pressure related. RN/UM/WN M reported that Resident #13's bony knees pressing against each other is the how the wound on her lateral left knee occurred. RN/UM/WN M stated I know where the breakdown was, the wounds were not being done. I'm just grateful her wounds didn't deteriorate further. Review of wound provider Progress Note Details for Resident #13 dated for 3/27/24 revealed .wound location right elbow, left medial knee, right lateral knee .date of onset February 2024 and March 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 1.6 cm length X 1.2 cm width X 0.1 cm depth . Wound is deteriorating . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 2.5 cm length x 2.7 cm width x 0.8 cm depth .Wound is deteriorating .Wound #16 Right Lateral Knee is an unstageable pressure injury obscured full-thickness and tissue loss pressure ulcer .wound encounter measurements 2.7 cm length X 2.5 cm width X 0.1 cm depth .Wound #17 Left, Lateral knee is partial thickness skin tear .initial wound encounter measurements are 1.9 cm length X 2.3 cm width X 0.1 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . In an interview on 3/27/24 at 1:40 PM., Occupational Therapist (OT) SSS reported that Resident #13 was not receiving therapy services but was evaluated at family request. OT SSS reported that when Resident #13 was seen in October of 2023 for wheelchair positioning and to preserve skin integrity. OT SSS reported that Resident #13 had contractures when she admitted to the facility. OT SSS reported that the most recent evaluation of Resident #13 resulted in a high back wheelchair, cushion to the wheelchair seat, lateral support to be used on either left or right side, and a wedge cushion for trunk support while in her wheelchair. Review of Care plan for Resident #13 revealed no noted interventions related to lateral support or a wedge cushion use, nor an actual present wound. In an interview on 4/2/24 at 1:20 PM., Family Member (FM) MMM reported that the staff does not know how to position Resident #13 in her wheelchair. FM MMM reported that every staff member does it differently, FM MMM reported that the staff needs to be educated on the wheelchair positioning needs of Resident #13. During an observation on 1:20 PM., Resident #13 was sitting in her wheelchair in her room with a black padded board on the left side of her body in the wheelchair, a wedge-shaped cushion on the right side of her body, elbow protector noted on right elbow, right elbow wedged between the wedge-shaped cushion and the wheelchair arm rest, a board noted on the foot rests under Resident #13's heels and no heel protectors noted on both feet and both arm rests of the wheelchair are wrapped with ace bandages. During an interview on 4/2/24 at 2:34 PM., Director of Nursing (DON) B reported that care plans were just continued during the review and not updated to reflect the resident specifics. DON B stated I know there is an issue with care plans. In an interview on 4/2/24 at 3:02 PM., RN/UM/WN M reported that anyone with a wound should have a care plan in place. RN/UM/WN M reported that she did not know that there were different care plans for the risk of pressure ulcers and actual pressure ulcers. In an interview on 4/3/24 at 8:41 AM., when asked what does follow facility policies/protocols for the prevention/treatment of impaired skin integrity means, RN/UM/WN M and DON B reported whatever the policy says to do, such as redness apply z-guar (barrier cream) let the DON know, do an incident report, put information into the doctor's book. DON B reported that the policies can be accessed on every desktop. DON B reported that facility policy does not include resident specific interventions. Review of Care Plan for Resident #13 revealed problem . actual impaired skin integrity .interventions: repositioned every hour when in w/c .initiated 3/29/24 .to be turned every 2 hours when in bed .initiated on 3/29/24 . wear elbow protector tor right elbow at all times, document any refusals .initiated 3/28/24 .bed mobility, resident is dependent with one helper, this is including rolling side to side, lying to sitting on side of bed, and sitting to lying, initiated on 1/18/2024 . has an actual impaired skin integrity related to pressure injury. Site: R elbow, L posterior knee, right lateral knee, stage: unstageable . dated initiated 3/15/2024 .interventions conduct skin assessments weekly and measure area (s) and document characteristics .observe for signs of infection .requires occupational therapy r/t decline in W/C positioning .will present with good upright and midline posture with use of W/C positioning equipment with reported of no skin breakdown .selection of positioning equipment and staff education and training .initiated on 3/29/24 . Review of Timeline provided by DON B regarding Resident #13's wound care revealed .prevention of pressure ulcer interventions in place prior to 1/13/24 included heel protectors 4/26/23, pressure reduction cushion to w/c 5/2/23, pressure reduction mattress 3/22/23. Prevention from 1/13/24 to 2/25/24 included, TX (treatment) to right elbow pressure ulcer with wound care referral 2/22/24. Prevention from 2/25/24 to 3/15/24-elbow protectors ordered, 2/28/24, heel protectors ordered 2/28/24, pillow between knees ordered 2/28/24, care plan updated to address wound prevention 3/15/24 . Review of facility policy Skin Management dated 12/15/2022 revealed .the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .resident with wound and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing .appropriate preventative measures will be implemented on guests/resident identified at risk an the interventions are documented on the car plan .if the guest/resident is at risk for or has a pressure injury the comprehensive care plan may address . preventative devices, preventative skin care, positioning requirements .the licensed nurse will document preventative measures on the care plan/Kardex .the DON (Director of Nursing)/designee will document any changes in the care plan/Kardex at the meeting . Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, .Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours .Some patients are able to sit in a chair. Make sure to limit the total amount of time they sit to 2 hours or less. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed). St. Louis: Mosby. p. 1196-1197.

Based on observation, interview and record review the facility failed to ensure residents received care in accordance with treatment orders and professional standards for non-pressure wounds in 2 of 3 residents (Resident #100 and #13) reviewed for quality of care, resulting in the worsening of existing wound for Resident #100 and a delay in treatment of a new wound for Resident #13. Findings Include: Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/12/23 revealed resident originally admitted to the facility on [DATE], and a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #100 was cognitively intact. Review of the Functional Status revealed that Resident #100 required extensive assistance of 2 staff for toileting and was frequently incontinent of bowel and bladder. Review of Resident #100's Care Plan revealed, .actual impaired skin, integrity and abrasion on left elbow, open area to left hip and buttock related to periods of incontinence .Date Initiated 3/23/22. Revision on 3/19/23 .Interventions: .Treatment as ordered to each area. Date Initiated 3/17/23 . In an interview on 3/28/23 at 10:24 A.M., Licensed Practical Nurse (LPN) D reported that Resident #100 had several wounds; left hip that was being treated with Medi-Honey (topical for wound healing) and a wound covering, left buttock that was being treated with Exuderm (protective wound covering), an area on his left 2nd toe, and an area on his left elbow. LPN D reported that the wound dressings were due to be changed and would be completed later that day by the wound doctor. In an interview on 3/28/23 at 10:31 A.M., Resident #100 reported that he had sores on his bottom and that they burn. Resident #100 was in his room sitting in his wheelchair. In an interview on 3/28/23 at 10:38 A.M., Wound Nurse (WN) C reported that the wound doctor was not able to come in that day, and that WN C would be completing the wound evaluations and dressing changes. WN C reported that Resident #100 had several wounds that were being managed; an Unstageable Pressure Ulcer on his left hip, MASD (moisture associated skin damage) on his left buttock, an infected wound on his left 2nd toe, and a skin tear on his left elbow. In an interview on 3/28/23 at 11:42 A.M., Resident #100 reported that the wounds on his bottom are very aggravating. Resident #100 was in his room sitting in his wheelchair as previously observed. This surveyor informed Resident #100 that staff would be in soon to look at his wounds, and Resident #100 stated, Good .its burning . During an observation and interview on 3/28/23 at 11:52 A.M. Resident #100 was transferred into bed and observed lying in bed on his right side. Resident #100's buttocks were observed with a bandage on the left hip dated 3/25/23 and an open wound on the left middle buttock that did not have a bandage on it. WN C reported that the wound on Resident #100's left middle buttock was supposed to be covered with Exuderm and that WN C was not aware that the dressing was missing. The wound was measured by WN C and revealed, 3.8 cm x 1.2 cm. WN C reported that the wound had gotten bigger and that WN C wound need to get a larger dressing for it. WN C applied a large Exuderm dressing that covered the wound and the surrounding area. WN C reported that the wound was new last week and it was a lot smaller at that time. WN C reported that it was very important to keep moisture away from the wound, and that he would look at the treatment records to make sure that the wound dressings have been completed every 3 days as ordered. In an interview on 3/28/23 at 12:37 P.M., Certified Nursing Assistant (CNA) K reported that she was not aware that Resident #100's wound dressing was missing. CNA K reported that Resident #100 was continent, stayed dry, often tried to toilet himself and did not like to wear an incontinence brief. In an interview on 3/28/23 at 12:39 P.M., LPN D reported that he had not been informed that Resident #100's wound dressing was missing and stated, .if I had, then I would have put one on him . Review of Resident #100's Treatment Administration Record (TAR) revealed the current treatments for buttocks were as follows: 1. Inzo (barrier cream) to buttocks q (every) shift and PRN (as needed) with incontinent episodes. every shift for Redness Start Date 10/11/2022 at 10:00 P.M. 2. Open area to left buttock to be cleansed with NS, pat dry, apply hydrocolloid (for wound healing) dressing 3x week and PRN for soiled, removed, or saturated dressing. every day shift every Tue, Thu, Sat for treatment Start Date 03/23/2023 at 6:00 A.M. Review of Resident #100's Wound Note dated 3/21/23 revealed, .MASD .Left buttock .in-house acquired .new .Length 1.0 cm Width 0.5 cm .healable .Staff educated on importance of incontinence care and turning/repositioning every 2 hours as well as notifying nurse if dressing becomes removed, soiled or saturated. Review of Resident #100's Wound Note dated 3/28/23 revealed, .MASD .Left buttock .in-house acquired .1 week .Length 3.8 cm Width 1.2 cm .healable .Staff educated on importance of incontinence care and offering toileting to resident approximately every 2 hours. Also notifying nurse if dressing becomes removed, soiled or saturated. Resident #100's wound had worsened. Review of Resident #100's Total Body Skin Assessment dated 3/28/23 at 6:13 A.M. (completed by the third shift licensed nurse (LPN H) indicated, no new skin conditions and no additional comments related to existing wounds or wound dressings. An attempt was made to contact LPN H via phone on 3/28/23 at 3:47 P.M.; no return call received. Resident #13 Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 1/4/23 revealed an original admission date of 7/1/22, and a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Status revealed that Resident #13 required extensive assistance of 2 staff for bed mobility and toilet use, and was always incontinent of bowel and bladder. Review of Resident #13's Care Plan revealed, .At risk for skin breakdown and urinary tract infection related to bladder incontinence. Date initiated 7/13/22. Interventions: .Provide incontinence care with each incontinent episode. Apply moisture barrier as indicated. Date Initiated 7/13/22 . In an interview on 3/28/23 at 10:15 A.M., Resident #13 was lying in her bed with the HOB (head of bed) at approximately 45 degrees. Resident #13 reported that her buttocks were always sore, and that the CNA's get some kind of salve from the nurse's station and smear it all over her bottom and stated, .it stops the burning .works pretty good if I sit still . In an interview on 3/28/23 at 10:24 A.M., LPN D reported that Resident #13 has a treatment in place for a fungal infection on her breasts and groin and stated, .I haven't heard anything about her having a breakdown on her bottom .she is not getting any treatments on her bottom . During an observation on 3/28/23 at 12:34 P.M. Resident #13 was sitting in her wheelchair in her room. During an observation and interview on 3/28/23 at 2:23 Resident #13 was sitting in her wheelchair in her room. Resident #13 reported that her butt hurts and she hoped to lay down soon. Resident #13 reported that if the CNA didn't put the salve on her bottom, she would not be able to sleep because the burning is so bad. During an observation on 3/28/23 at 2:26 P.M. Resident #13 was transferred to bed by CNA G and CNA L, CNA L then left the room and CNA G prepared to provide incontinence care to Resident #13. Resident #13's buttocks were observed red with deep creases from her brief and/or clothing, and there was a large patch of skin on Resident #13's left upper thigh that was bright red, with several open areas and was bleeding. Resident #13 stated, .it burns really bad .feels like its on fire .I keep telling everybody .it even hurts me to sit down in the chair . CNA G reported that they (CNA's) were putting Inzo on it, and that the nurse was aware. This surveyor requested that WN C observe. WN C observed Resident #13's bottom at 2:37 P.M. and reported that he had not previously been made aware of this concern, and proceeded to obtain supplies to treat the area. Review of Resident #13's subsequent Wound Evaluation dated 3/28/23 revealed, MASD .in-house acquired .new 3/28/23 .6.0 cm length 2.9 cm width .bleeding .pink or red .healable . Review of the facilities Plan of Correction related to Treatment/Services to Prevent/Heal Pressure Ulcer revealed .Residents who are incontinent and require assistance with turning and repositioning have the potential to be affected. Skin sweep of all current residents completed on 2-22-23 and skin issues identified were appropriately addressed, Licensed Nurses will be re-educated on Facility Skin Management Program. Nurse Aides will be re-educated on standard of care in regards to incontinence care and turning and repositioning. QA (quality assurance) committee reviewed Skin Management policy and deemed appropriate, In Morning Clinical Meeting, completion of weekly skin assessments are verified and reviewed for compliance. Rounds will be completed randomly by DON/Designee to ensure incontinence care and turning and repositioning is provided. Rounds will be documented 5 times weekly for 2 weeks, 3 times weekly for 2 weeks, then weekly for 3 months. Results will be summarized and presented to monthly QA committee for further recommendations, Compliant by 3-8-23, Licensed Administrator will be responsible for compliance.

Based on observation, interview, and record review the facility failed to provide preventative care consistent with professional standards of practice for 1 resident (Resident #10), out of a total sample of 15 residents, resulting in the avoidable development of a facility acquired stage 3 pressure ulcer and the potential for further skin breakdown, infection, and an overall deterioration in health status. Findings include: Review of an Admission Record revealed Resident #10 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure, cardiomyopathy, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 12/20/2022 revealed Resident #10 was totally dependent on staff for toileting and personal hygiene. Review of a current incontinence Care Plan intervention for Resident #10, initiated 12/15/2022, directed staff that resident uses disposable briefs and requires to be checked for incontinence every two hours and as needed. Review of a current activities of daily living Care Plan intervention for Resident #10, initiated 12/30/2022, directed staff that resident requires total dependence of one staff for personal hygiene and toilet use. Review of wound timeline for Resident #10 provided by the facility revealed that Resident #10 was identified as having MASD (moisture associated skin damage) on her left buttock on 12/15/2022 and treatment was initiated for barrier cream after each episode of incontinence. In an interview on 2/6/2023 at 12:21 PM, Registered Nurse (RN) D reported that she worked on 12/25/2022 with only 2 other nurses and 2 CNAs for the whole building. RN D reported that residents were complaining about missed care and long wait times to be changed. RN D stated, I literally ran my butt off, no break, it was kind of a disaster. In an interview on 2/6/2023 at 1:59 PM, CNA EE reported that she worked as the only aide on south hall on 12/25/2022, stating that it went terrible. CNA EE reported that she worked with Registered Nurse Y, who had COVID and kept leaving the floor because she was coughing and throwing up. CNA EE reported that residents went without being fed, she was not able to check and change residents every two hours, and showers were not completed. In an interview on 2/6/2023 at 2:32 PM, CNA F reported that she worked on day shift on 12/25/2022 as the only CNA on central. CNA F reported that it was not possible to check and change, toilet, or turn residents every 2 hours. CNA F stated, somebody should have came and helped. In a telephone interview on 2/7/2023 at 8:19 AM, Licensed Practical Nurse (LPN) E reported that he worked on 12/24/22 and 12/25/22, stating that it was hectic. LPN E reported that good staffing on central is with 4 CNA's, 3 is doable, 2 is not safe, and 1 is not possible. LPN E stated, with one CNA, we are lucky to get one round done, reporting that residents wouldn't get cleaned at times, wouldn't get showers, check and changes, or turning, and feeding would not be possible. LPN E stated, I can honestly tell you that weekend (Christmas weekend) was really rough, it's other times too, even without COVID, working with 2 CNAs on central. In a telephone interview on 2/8/2023 at 4:59 PM, CNA K reported that he stayed over to help on day shift on 12/24/2022 after working night shift the previous night and was the only CNA working central unit. CNA K reported that 2-hour check and changes, repositioning, and showers could not be done this shift. In a telephone interview on 2/8/2023 at 7:45 AM, Licensed Practical Nurse (LPN) M reported that she stayed over to help on 12/25/2022 and there were only two CNAs in the building. LPN M reported that she did not have any aide down here hall, stating I wasn't able to give good care, just the bare minimum. LPN M reported that she could not do two-hour check and changes or showers. Further review of Resident #10's wound timeline revealed that a wound was identified on her left buttock on 1/5/2023 with orders placed for wound care, and hospice authorized a wound care evaluation. Review of Resident #10's Nurses Note, dated 1/5/2023 at 3:24 PM, revealed that a new wound was identified on Resident #10's left buttock. Review of Resident #10's wound evaluation on 1/10/2023 by Wound Physician RR revealed .The patient is an [AGE] year old female admitted to (facility) on 12/14/22 . Nursing staff noted a wound on the buttock and a consult was placed for Wound Specialist to eval and treat . Wound #1 Left Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed . Initial wound encounter measurements are 3.8cm length by 1.8cm width by 0.1cm depth . In an observation and interview on 2/7/2023 at 3:07 PM, RN CC and Wound Physician RR evaluated and dressed left buttock wound. Wound Physician RR reported that the wound measured 0.8cm by 0.8cm by 0.1cm. Review of facility policy/procedure Skin Management, effective 12/15/2022, revealed .Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . Review of the Fundamentals of Nursing (Potter and Perry) revealed, Continual exposure of the skin to body fluids increases a patient's risk for skin breakdown and pressure ulcer formation .exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations 71867-71870). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review the facility failed to ensure residents received care in accordance with treatment orders and professional standards for non-pressure wounds in 2 of 3 residents (Resident #100 and #13) reviewed for quality of care, resulting in the worsening of existing wound for Resident #100 and a delay in treatment of a new wound for Resident #13. Findings Include: Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/12/23 revealed resident originally admitted to the facility on [DATE], and a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #100 was cognitively intact. Review of the Functional Status revealed that Resident #100 required extensive assistance of 2 staff for toileting and was frequently incontinent of bowel and bladder. Review of Resident #100's Care Plan revealed, .actual impaired skin, integrity and abrasion on left elbow, open area to left hip and buttock related to periods of incontinence .Date Initiated 3/23/22. Revision on 3/19/23 .Interventions: .Treatment as ordered to each area. Date Initiated 3/17/23 . In an interview on 3/28/23 at 10:24 A.M., Licensed Practical Nurse (LPN) D reported that Resident #100 had several wounds; left hip that was being treated with Medi-Honey (topical for wound healing) and a wound covering, left buttock that was being treated with Exuderm (protective wound covering), an area on his left 2nd toe, and an area on his left elbow. LPN D reported that the wound dressings were due to be changed and would be completed later that day by the wound doctor. In an interview on 3/28/23 at 10:31 A.M., Resident #100 reported that he had sores on his bottom and that they burn. Resident #100 was in his room sitting in his wheelchair. In an interview on 3/28/23 at 10:38 A.M., Wound Nurse (WN) C reported that the wound doctor was not able to come in that day, and that WN C would be completing the wound evaluations and dressing changes. WN C reported that Resident #100 had several wounds that were being managed; an Unstageable Pressure Ulcer on his left hip, MASD (moisture associated skin damage) on his left buttock, an infected wound on his left 2nd toe, and a skin tear on his left elbow. In an interview on 3/28/23 at 11:42 A.M., Resident #100 reported that the wounds on his bottom are very aggravating. Resident #100 was in his room sitting in his wheelchair as previously observed. This surveyor informed Resident #100 that staff would be in soon to look at his wounds, and Resident #100 stated, Good .its burning . During an observation and interview on 3/28/23 at 11:52 A.M. Resident #100 was transferred into bed and observed lying in bed on his right side. Resident #100's buttocks were observed with a bandage on the left hip dated 3/25/23 and an open wound on the left middle buttock that did not have a bandage on it. WN C reported that the wound on Resident #100's left middle buttock was supposed to be covered with Exuderm and that WN C was not aware that the dressing was missing. The wound was measured by WN C and revealed, 3.8 cm x 1.2 cm. WN C reported that the wound had gotten bigger and that WN C wound need to get a larger dressing for it. WN C applied a large Exuderm dressing that covered the wound and the surrounding area. WN C reported that the wound was new last week and it was a lot smaller at that time. WN C reported that it was very important to keep moisture away from the wound, and that he would look at the treatment records to make sure that the wound dressings have been completed every 3 days as ordered. In an interview on 3/28/23 at 12:37 P.M., Certified Nursing Assistant (CNA) K reported that she was not aware that Resident #100's wound dressing was missing. CNA K reported that Resident #100 was continent, stayed dry, often tried to toilet himself and did not like to wear an incontinence brief. In an interview on 3/28/23 at 12:39 P.M., LPN D reported that he had not been informed that Resident #100's wound dressing was missing and stated, .if I had, then I would have put one on him . Review of Resident #100's Treatment Administration Record (TAR) revealed the current treatments for buttocks were as follows: 1. Inzo (barrier cream) to buttocks q (every) shift and PRN (as needed) with incontinent episodes. every shift for Redness Start Date 10/11/2022 at 10:00 P.M. 2. Open area to left buttock to be cleansed with NS, pat dry, apply hydrocolloid (for wound healing) dressing 3x week and PRN for soiled, removed, or saturated dressing. every day shift every Tue, Thu, Sat for treatment Start Date 03/23/2023 at 6:00 A.M. Review of Resident #100's Wound Note dated 3/21/23 revealed, .MASD .Left buttock .in-house acquired .new .Length 1.0 cm Width 0.5 cm .healable .Staff educated on importance of incontinence care and turning/repositioning every 2 hours as well as notifying nurse if dressing becomes removed, soiled or saturated. Review of Resident #100's Wound Note dated 3/28/23 revealed, .MASD .Left buttock .in-house acquired .1 week .Length 3.8 cm Width 1.2 cm .healable .Staff educated on importance of incontinence care and offering toileting to resident approximately every 2 hours. Also notifying nurse if dressing becomes removed, soiled or saturated. Resident #100's wound had worsened. Review of Resident #100's Total Body Skin assessment dated [DATE] at 6:13 A.M. (completed by the third shift licensed nurse (LPN H) indicated, no new skin conditions and no additional comments related to existing wounds or wound dressings. An attempt was made to contact LPN H via phone on 3/28/23 at 3:47 P.M.; no return call received. Resident #13 Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 1/4/23 revealed an original admitted [DATE], and a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Status revealed that Resident #13 required extensive assistance of 2 staff for bed mobility and toilet use, and was always incontinent of bowel and bladder. Review of Resident #13's Care Plan revealed, .At risk for skin breakdown and urinary tract infection related to bladder incontinence. Date initiated 7/13/22. Interventions: .Provide incontinence care with each incontinent episode. Apply moisture barrier as indicated. Date Initiated 7/13/22 . In an interview on 3/28/23 at 10:15 A.M., Resident #13 was lying in her bed with the HOB (head of bed) at approximately 45 degrees. Resident #13 reported that her buttocks were always sore, and that the CNA's get some kind of salve from the nurse's station and smear it all over her bottom and stated, .it stops the burning .works pretty good if I sit still . In an interview on 3/28/23 at 10:24 A.M., LPN D reported that Resident #13 has a treatment in place for a fungal infection on her breasts and groin and stated, .I haven't heard anything about her having a breakdown on her bottom .she is not getting any treatments on her bottom . During an observation on 3/28/23 at 12:34 P.M. Resident #13 was sitting in her wheelchair in her room. During an observation and interview on 3/28/23 at 2:23 Resident #13 was sitting in her wheelchair in her room. Resident #13 reported that her butt hurts and she hoped to lay down soon. Resident #13 reported that if the CNA didn't put the salve on her bottom, she would not be able to sleep because the burning is so bad. During an observation on 3/28/23 at 2:26 P.M. Resident #13 was transferred to bed by CNA G and CNA L, CNA L then left the room and CNA G prepared to provide incontinence care to Resident #13. Resident #13's buttocks were observed red with deep creases from her brief and/or clothing, and there was a large patch of skin on Resident #13's left upper thigh that was bright red, with several open areas and was bleeding. Resident #13 stated, .it burns really bad .feels like its on fire .I keep telling everybody .it even hurts me to sit down in the chair . CNA G reported that they (CNA's) were putting Inzo on it, and that the nurse was aware. This surveyor requested that WN C observe. WN C observed Resident #13's bottom at 2:37 P.M. and reported that he had not previously been made aware of this concern, and proceeded to obtain supplies to treat the area. Review of Resident #13's subsequent Wound Evaluation dated 3/28/23 revealed, MASD .in-house acquired .new 3/28/23 .6.0 cm length 2.9 cm width .bleeding .pink or red .healable . Review of the facilities Plan of Correction related to Treatment/Services to Prevent/Heal Pressure Ulcer revealed .Residents who are incontinent and require assistance with turning and repositioning have the potential to be affected. Skin sweep of all current residents completed on 2-22-23 and skin issues identified were appropriately addressed, Licensed Nurses will be re-educated on Facility Skin Management Program. Nurse Aides will be re-educated on standard of care in regards to incontinence care and turning and repositioning. QA (quality assurance) committee reviewed Skin Management policy and deemed appropriate, In Morning Clinical Meeting, completion of weekly skin assessments are verified and reviewed for compliance. Rounds will be completed randomly by DON/Designee to ensure incontinence care and turning and repositioning is provided. Rounds will be documented 5 times weekly for 2 weeks, 3 times weekly for 2 weeks, then weekly for 3 months. Results will be summarized and presented to monthly QA committee for further recommendations, Compliant by 3-8-23, Licensed Administrator will be responsible for compliance.

This citation pertains to Intake #MI 496 and MI 527. Based on interview and record review the facility failed to ensure residents received quality care based on professional standards for 1 resident (Resident #103) of 3 residents reviewed for unwitnessed falls, resulting in the lack of monitoring post fall, a delay in notification to the physician of head injury while on an anticoagulant (blood thinner), and a delay in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/18/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Review of the Functional Status revealed that Resident #103 was independent for transfers and required limited assistance of 1 person for walking. Review of Resident #103's Incident & Accident Report dated 3/23/22 at 20:50 (8:50 P.M.) revealed, .observed laying on the floor next to bed. Resident was facing foot of bed. She indicated she was adjusting bedding, missed bed the (sic) fell .(Nurse Practitioner (NP) E) notified .Physician Statement: (Note: (1) explain injuries, (2) treatment orders, (3) disposition of person involved and (4) hospitalization ): Resident with bump on left side of head.(Responsible Party (RP) R) notified .Resident was assisted into bed and reminded to use call light when needing assistance . Review of Resident #103's Neurological Assessment (Neuro's) initiated on 3/23/22 at 21:00 (9:00 P.M.) indicated all normal findings were recorded following the fall, up until the time Resident #103 was transferred to the hospital. The neuro findings from 21:00 (9:00 P.M.)-0745 (7:45 A.M.) are exactly the same, indicating all normal. This assessment included ROM (range of motion) of all limbs, indicating all normal. Review of Resident #103's Hospital Records from Emergency Department to Admission on 3/24/22 at 13:42 (1:42 P.M.) revealed, complaints of GLF (ground level fall) and hip pain .ground level fall last night. The staff assessed her and believed she was not injured and helped her up to bed. In the morning patient was found with N/V (nausea/vomiting) and after a quick assessment the staff decided to send patient to ED (emergency department) after realizing that she may have hit her head and is on anticoagulants. Patient reports that she fell but does not remember The details of the fall. She states her pain is well controlled at this time but the head bruise behind her left ear hurts when touched .Additionally she reports that she only has pain in her hip when she tries to lift the leg .CT (cat scan image) of the left hip .Exam date: 3/24/22 at 3:48 P.M.Impression: Subcapital left femoral neck (hip) fracture with mild impaction .CT head .Exam date: 3/24/22 at 2:27 P.M .Impression: No acute intracranial (brain) abnormality . During an interview on 6/3/22 at 2:32 P.M., Certified Nursing Assistant (CNA) K reported that on 3/23/22 he came out of a resident room and heard a faint call for help from Resident #103, and when he got to her room she was lying on the floor. CNA K reported that he called for a nurse to help and Licensed Practical Nurse (LPN) F came in to assist and stated, .(LPN) I was her nurse, but I didn't know where she was . CNAK reported that LPN F assessed Resident #103 to see if she had any broken bones and they stood her up and transferred her into bed. CNA K reported that Resident #103 requested pain medication for a headache and stated, .she kept saying that she was o.k. During an interview on 6/2/22 at 4:37 P.M., LPN F reported that a full ROM (range of motion) assessment was performed following Resident #103's fall and the resident had no complaints of pain, except for a headache from the bump on her head. LPN F reported that Resident #103 was assisted back to bed using a gait belt and 2 people and stated, .I don't know if she was on a blood thinner .she could not get up by herself .normally with head injuries we send to the hospital . LPN F reported that Resident #103's nurse (LPN I) was not able to be located at the time of the fall, but that when she returned to the building, he (LPN F) reported the details of Resident #103's fall, and did not have any involvement with the resident after that. LPN F reported that he did not notify the physician. During an interview on 6/2/22 at 3:45 P.M., LPN I reported that she was taking a break during the time of Resident #103's fall on 3/23/22 and stated, .when I came back, (LPN F) had already done the initial assessment .(Resident #103) was in bed .she said she hit her head .she had a bump on the back left side .she didn't have any other pain .I did not touch her .she said that she could move her arms and legs fine .I don't know if she could stand . LPN I reported that she left a message for the provider (Nurse Practitioner (NP) E) but did not talk with her .it was time for me to leave . LPN I reported that if Resident #103 had complained of pain, then she would have been sent to the hospital and stated, .she was taking [MEDICATION(S)] (a medication to thin the blood) . During an interview on 6/7/22 at 11:11 A.M., LPN D reported that she was assigned to Resident #103 on third shift, after the resident had fallen on second shift. LPN D reported that the second shift nurse indicated that the resident did not have any injuries and stated, .(Resident #103) did not put her call light on that night .I peeked in on her 2 times .I did not do ROM (range of motion) on her .I completed the neuro sheet . LPN D reported that she was the only nurse for the entire facility from 3:00 A.M.-5:00 A.M. that shift and stated, .that happened a lot . LPN D reported that she was concerned about meeting the needs of residents when working short staffed, especially when there are so many falls to attend to. During an interview on 6/3/22 at 12:59 P.M., CNA P reported that she was assigned to Resident #103 the morning after her fall and stated, .but they did not tell me in report that she had fallen .she is normally continent .she calls to go to the bathroom .and she sleeps in late . CNA P reported that she checked in on Resident #103 when the shift started at 7:00 A.M. and she was sleeping and then went in at approximately 10:30 A.M. to start the resident's normal morning routine. CNA P reported that she knew something was wrong when Resident #103 was complaining of nausea and not able to walk to the bathroom as normal. CNA P reported that Resident #103 started talking about falling the night before and saying that no one had checked on her. CNA P reported that she notified LPN C immediately and when LPN C moved Resident #103's left leg she complained of pain. CNA P reported that she thought that Resident #103 was going to be sent to the hospital, so she continued her work on the hall with other residents. CNA P reported that RP R was at the facility, and Resident #103 left the facility by ambulance after lunch, approximately 3 hours later. During an interview on 6/2/22 at 2:30 P.M., LPN C reported that she received report of Resident #103's fall when she came in on 3/24/22 around 7:00 A.M. and stated, .it was not until the CNA came and asked me to check her out that I knew anything was wrong .she couldn't stand .complaining of pain . LPN C reported that she called NP E to get some x-rays ordered, and then NP E called back and wanted Resident #103 to go to the hospital immediately. LPN C reported that she did not know if Resident #103 had hit her head during the fall or if she was taking anticoagulants at the time of the fall and stated, .when someone on blood thinners falls .they are sent out to get checked . During an interview on 6/3/22 at 12:04 P.M., Unit Manager (UM) G reported that at approximately 1:00 P.M. on 3/24/22 Resident #103 had a change of condition to include nausea, vomiting, pain and headache and stated, I spoke with (RP R) .I called (NP E) .the resident was on [MEDICATION(S)] and (NP E) told us to send her out . UM G reported that the facility has a lot of falls and stated .it wouldn't happen if we had more people here .the dementia unit has so many residents that wander, get up and walk when they shouldn't, behaviors .so many falls . During an interview on 6/3/22 at 11:50 A.M., NP E reported that if a resident that is taking an anticoagulant (blood thinner) falls and hits their head, the standard of care is to have them evaluated at the hospital. NP E reported that she was not on call the night of Resident #103's fall and did not receive a notification until the next day and stated, .I would have sent her to the hospital right away . During an interview on 6/2/22 at 4:06 P.M., DON reported that Resident #103 denied pain following her fall on 3/23/22 and stated, .the next morning she complained of pain in her head and nausea . DON reported that it is not standard that the facility send residents to the hospital after a head injury and stated, .they should have neuros done .we would expect a bleed to be picked up on neuros . DON reported that if staff notifies the physician by leaving a message, but doesn't indicate concerns, the provider may not call back. Review of Resident #103's Progress Note dated 3/23/22 at 21:32 (9:32 P.M.) revealed, 20:50 (8:50 P.M.) Resident observed laying on her left side, on the left side of the bed. Resident was facing the foot of the bed. Resident stated she hit her head on the floor. Resident alert, Neuros within normal limits. Resident able to narrate to this nurse what happened. Resident said she was trying to adjust linen on the bed and missed the bed and fell . Resident has a bump on the left back of the head. No other injuries. ROM positive all four extremities .(RP R)called and notified. physician notified too . Review of Resident #103's Nurses Note dated 3/24/22 at 13:02 (1:02 P.M.) revealed, I (UM G) called report into (hospital named) and called 911 at 1pm today .sending out due to the pt (patient) n&v (nausea and vomiting), pain and headache pt is on [MEDICATION(S)] (anticoagulant). (NP E) was called . Review of Resident #103's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility policy Fall Management dated 7/14/21 revealed, .When a fall occurs, the licensed nurse will evaluate the guest/resident for injury. Do not move the individual until he/she has been examined by a nurse. The first responder (the first person to identify that the guest/resident has fallen) will summon a nurse after ensuring the guest/resident is safe, and then ask the guest/resident what they were attempting to do .5. If a potential head injury is present, complete the Neurological Record. 6. The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record. 7. The nurse will communicate via the 24-hour report /dashboard to the interdisciplinary team of the guest/resident fall .

Based on interview and record review, the facility failed to 1.) promptly respond to an abnormal blood test/laboratory result and 2.) recheck an abnormal lab per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of a Face Sheet revealed Resident #30 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 0, out of a total possible score of 15, which indicated Resident #30 was severely cognitively impaired. Review of a current Care Plan for Resident #30 revealed a focus of .is at risk for nutrition/hydration declines r/t (related to) PMH (past medical history) of HF (heart failure) .dementia, [CONDITION(S)]. He may be at increased risk for dehydration due to diuretic use . with interventions which included: Obtain lab/diagnostic work as ordered. Report abnormal results to MD and follow up as indicated with a date initiated of 8/30/19. Review of Resident #30's Lab Results Report dated 11/8/21 at 3:45 P.M. revealed a Na (Sodium) result of 154 H (high) (noted as Verified by Repeat Analysis). Reference range for Sodium is 136-145. Review of Resident #30's Lab Results Report dated 11/11/21 at 4:37 P.M. revealed a Na (Sodium) result of 159 H (high) (noted as Verified by Repeat Analysis). Review of a Skilled Nursing Facility Acute Progress Note for Resident #30 written by MD GG on 11/15/21 revealed, . is being seen at (facility name omitted) on 11/15/2021 for anxiety .HPI (history of present illness) (age omitted) well known to this facility for LTC (long term care) due to dementia, stroke, He has had behaviors in the past, mostly redirectable; Was hospitalized from 10/15 - 11/2 for aspiration pneumonia and CHF Since his return, his health has been much worse; he spends most of his time in bed, where previously he was in wheelchair in doorway; Nurses report that his anxiety has been greater over the past week; I reviewed meds about a week ago and did not feel that any adjustments would be helpful; In the past two days I reviewed calls about anxiety, restlessness, a fall without injury; Yesterday I prescribed a [NAME] (benzodiazepine) for prn use; That did seem to help, as patient was more sedate this morning and nurse gives no negative report . Note that Resident #30's Sodium result of 159 on 11/11/21 was not addressed at this time. Review of a Physician Note for Resident #30 written by MD GG and dated 11/17/21 at 10:31 A.M. revealed, reviewed labs; Na (sodium) = 159 (I don't think this is true; all [NAME] (sic) while he was recently in the hospital showed Na level no higher than 150, mostly in 140s) repeat BMP (basic metabolic panel includes measurement of Sodium level) this week. Review of Resident #30's medical record on 12/16/21 at 3:35 P.M. revealed no repeat BMP was completed for Resident #30 from 11/17/21 through 11/25/21. Review of Resident #30's eMar - Medication Administration Note dated 11/26/21 revealed, resident admitted to hospital 11/25/21. Review of Resident #30's 11/25/21 - 12/7/21 hospital records revealed, Physician Discharge Summary (hospital name omitted) .admitted [DATE] discharge date [DATE] .Reason for Admission: Somnolence (sleepiness) and [CONDITION(S)] (low level of oxygen in the blood) Brief Summary of Hospital Stay .male with a history of cognitive impairment due to [CONDITION(S)] .Patient has had 2 recent admissions to (hospital name omitted) .At discharge of November 2 patient had a serum sodium of 142 and creatinine was 1.2. Today, he presents to emergency department for increased somnolence and altered mental status from baseline along with SPO2 (oxygen level in the blood) of 70%. Hypoxemia readily corrected with supplemental oxygen. Further evaluation where she (sic) department showed a profound [CONDITION(S)] (profoundly elevated sodium level in the blood) with a serum sodium of 179. Review of records provided for patient shows a basic metabolic profile done on November 11 his sodium had been 159. His creatinine is also up to 2.2. Hospitalist service has been asked to see for further evaluation and management of [CONDITION(S)] and acute kidney injury. He was initiated on IVFs (intravenous fluids) and his Na (sodium) was monitored closely. Home diuretics held. Recommend holding further until his PO (by mouth) intake improves. Home ACEi held as well as BP was normotensive. His Na level normalized and his PO intake improved .He was discharged back to (facility name omitted) in stable condition . Review of Resident #30's Nursing Summary dated 12/7/21 revealed, Resident returned back to facility from the hospital at 1625 (4:25 P.M.). readmitted to room (room number omitted) after being sent to the hospital on 11/25/21 for altered mental status . In an interview on 12/16/21 at 10:54 A.M., Director of Nursing (DON) B reviewed Resident #30's medical record and reported MD GG had reviewed Resident #30's lab results from 11/8/21 on 11/10/21. DON B reported MD GG saw Resident #30 on 11/15/21 but did not address Resident #30's 11/11/21 lab results at that time. DON B reported MD GG reviewed Resident #30's lab results from 11/11/21 on 11/17/21. In an interview on 12/16/21 at 12:10 P.M., Registered Nurse (RN) L reported a nurse was supposed to call the doctor to notify them of a resident's abnormal lab results. RN L reported the nurse should write a progress note to document that the physician was notified and what orders, if any, the physician gave to address the abnormal lab result. RN L reviewed Resident #30's progress notes and reported there was no documentation that the physician was notified of Resident #30's 11/11/21 Sodium level result of 159 but that the doctor should have been notified of that lab result. RN L reviewed Resident #30's medical record and reported there was no repeat BMP completed for Resident #30 after 11/11/21 before he went to the hospital on 11/25/21. In an interview on 12/16/21 at 3:42 P.M., Licensed Practical Nurse Unit Manager (LPN) P reported Resident #30 had not had a repeat BMP per Resident #30's Physician Note dated 11/17/21 because it had not been ordered. LPN P reported the requested repeat BMP was not documented anywhere except the Physician Note and stated, unless he puts an order in for us, unless he tells us, we wouldn't know. In an interview on 12/20/21 at 8:28 A.M., MD GG reported was Resident #30's physician. MD GG reported had seen Resident #30 on 11/15/21 for anxiety but had not reviewed Resident #30's 11/11/21 lab results which included the abnormal Sodium level of 159 at that time and reported could not specifically say why hadn't. MD GG reported had reviewed Resident #30's 11/11/21 labs on 11/17/21, noted the Sodium level of 159, and wanted a repeat BMP done. MD GG reported the repeat BMP had not been done. MD GG reported should have put an order in the computer for the repeat BMP or asked the nurse to put it in the computer but hadn't and it had gotten missed. Review of the policy/procedure Standards of Nursing Practice, dated 8/2021, revealed .We believe the use of the nursing process ensures appropriate care and services for each guest/resident .The delivery of nursing care in the facility is based on a thorough evaluation of the guest/resident to identify his or her care needs. Once guest/resident needs are identified, a comprehensive care plan is developed to attain individualized guest/resident goals. The care plan is implemented by the interdisciplinary team and is continually evaluated for effectiveness .The nurse collects data regarding the guest's/resident's current health status and potential risk areas .Data collected is analyzed to identify actual or potential health problems or risk areas that independent nursing actions can resolve. Guest/resident problems that are medical in nature and require interventions by the physician and other members of the health care team are considered to be collaborative. It is the role of the nursing staff to implement physician prescribed interventions and monitor the guest/resident for their response or any complications . Review of the policy/procedure Physician's Order, dated 6/2021, revealed .Physician orders are obtained to provide a clear direction in the care of the guest/resident .

This citation refers to Intake Numbers: MI 123, MI 990 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement and ensure the safety of one resident (Resident #101), of three residents reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 9/21/2021, Resident #101 exited the facility through an unsecured door, unbeknownst to facility staff, and was discovered by off duty facility staff on the edge of the roadway, with the likelihood of begin struck by a vehicle resulting in serious harm, injury and/or death. Findings include: Review of the Facility Investigation report written by Administrator A dated 9/28/21, revealed on 9/21/21 .Resident #101 successfully eloped from Long Term Care (LTC) facility and was discovered outside of the facility at about 5:55 AM by Maintenance staff (Maintenance Director C) . Review of submitted documents revealed there was no statement provided related to an interview with Maintenance Director C about the incident. During an interview on 10/4/21 at 1:15 PM, Maintenance Director C stated, .When coming into the parking lot she (Resident #101) was sitting in her wheelchair and I stayed with her while I called the building to let them know she was in the parking lot .They came out and retrieved her .She had on crocs and was dressed .She was in the side staff parking lot .I don't know for sure how she got outside .This is my third week here .The alarms are internal there is not an outside company that monitors them .The wanderguard has a separate keypad that the staff can put in a code to disarm .The keys well I believe the nurses, maintenance director and believe .hoping the majority of the managers have them .I am trying to chase them down on all who has keys .I believe the logs for checking the doors and my log is entered in to the Tells program .I just got access . During an interview on 10/4/21 at 4:13 PM, Receptionist H stated, .It was about 6:00 AM, I was driving to work and I came around the first curve and saw something by the road .I saw (Resident #101) in her wheelchair and I pulled over and turned on my flashers .She was at the end of the driveway where it meets the road .In that dip there .I saw the maintenance man walking across the parking lot on his phone .He was calling the building as he had seen her too .She just waved . And I got out of the car and went over to talk with her and told her who I was and she said that she didn't think she knew me and we talked and told her I would get her back inside .I just held her hand until the nurse came out, assessed her and pushed her up the hill and took her back inside .I didn't want to move her until the nurse assessed her .It was early in the morning and it was still dark out . Review of an Admission Record revealed Resident #10 was originally admitted to the facility on [DATE], with pertinent diagnoses which included dementia, repeated falls, [CONDITION(S)], stroke, and [CONDITION(S)] (bones become weak and brittle) with a fracture. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/23/21 revealed Resident #101 was unable to complete the interview. Staff Assessment for Mental Status indicated Resident #101 is severely impaired, never/was unable to make decisions. Review of current Care Plan: for Resident #101, revised on 9/21/2021, revealed the focus, .Wandering .(Resident #101) wheels self throughout facility, going to look out windows, or in search of a snack .She has hx (history) of going into other rooms .A trail period of taking off the wanderguard will take place from 8/23-8/27, and if all goes well, the wanderguard will be removed .9/21/21 wanderguard replaced on right ankle . with the intervention .Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversations, etc .Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as other resident rooms when not invited, behind nurses stations, shower rooms. Attempts to exiting facility, etc .Provide reassurance/Redirect as needed when in an area resident should not be in .Use a calm approach .Res enjoys sitting by window in dining room and looking outside, assist her to the window as she is willing .She enjoys wheeling up front to get suckers or fruit .When wandering, attempt to find out what she is looking for, if she has a physical need that can be met and address it .Provide structured activities, toileting, walking inside and outside with supervision as needed .Refer to psych services as needed . Review of Order dated 6/22/17, revealed, .Confirm placement of wanderguard on resident . Review of Risk for Elopement dated 6/29/2021, revealed, .I. Clinical Conditions .4. Does the resident wander? .1. Yes .6. What is the mental status of the resident? 3. Cognitively Impaired (Decreased safety awareness/disturbance in judgement) .III. Wandering .1. Has the resident wandered .3. Behavior of this type occurred daily .2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? .1. Yes . Review of Nursing Comprehensive -Quarterly dated 8/24/21, revealed, .J. Elopement Risk: Mobility 1. Resident Status .2. Mobile with a device or Ambulatory .Placement Perception (STOP if resident is verbalizing desire to leave place - at risk.) .Score 13.0 .Category: At Risk . Review of Progress Notes dated 8/28/21 at 13:24 PM, revealed, .Resident observed sitting on floor in an empty room .Resident who is alert but confused, unable to answer questions correctly and state what she was doing . Review of Progress Notes dated 8/30/21 at 06:47 AM, revealed, .Resident up most of the night in hallway in w/c (wheelchair) self propelling from door to door .Resident offered to go to bed several times no c/o (complaints of) pain or discomfort noted .Will continue to observe . Review of Order dated 9/2/21, revealed, .Wanderguard DC' d . Review of Progress Notes dated 9/19/21 at 21:55 PM, revealed, wandering was noted. In an interview on 10/5/21 at 12:52 PM, Social Worker (SW) E we do clinical and when we place interventions in place it helps too to if we go to the nursing staff as they interact with the residents all day We decided to do trial period to see how Resident #101 responded .She would go from one door to the other door at the ends of the hallway and she had done this for the longest time .We would talk about her during morning meeting .We made the decision to take her wanderguard off during first shift and I kept it in my office .I would go and put it back on at 3:30 PM .The nursing staff were supposed to help with watching and monitoring her and how it was going for her .It was entered into her care plan . Review of the medical record SW E stated, .There are no progress notes or documentation which documents her behaviors and actions during this trial period .I don't have any documentation of my observations or interactions with her prior to the incident . In an interview on 10/5/21 at 11:14 AM, Registered Nurse (RN) I stated, .Some nights she roams the halls and some nights she stays in her room .She always goes from one door to the other .I am thinking she had a wanderguard on, I didn't know she had her wanderguard removed .When I was told one of our patients was found outside, I thought it couldn't be as there was no alarm going off .She has exit seeking behaviors going back and forth from door to door that is her normal behavior .We have found her down on the East hall in another bed .It was a few months ago .There was no review of the elopement policy or discussion about the keys and the alarm system with me, not at all . In an interview on 10/5/21 at 11:47 AM, Registered Nurse (RN) J stated, .She (Resident #101) had a wanderguard for years .When she was on the South Unit (Dementia unit) she had it then .It was discontinued a few weeks before and I didn't get information at to why directly from those who decided to discontinue it .She will do the wandering around like she does from one door to the other . In an interview on 10/5/21 at 12:00, Certified Nursing Assistant (CNA) K stated .She (Resident #101) does it all the time .Going from door to door .They took it (wanderguard) off of her .She went up and down and she would set off the alarms all the time .We can't answer the if we are in the room with another resident and we all would have to hear the alarm until someone shuts it off . In an interview on 10/5/21 at 12:09, Certified Nursing Assistant (CNA) L stated .I don't know what time she left out .I checked on her when I came on for my shift and she was laying in her bed on top of the covers with her clothes on .I visually saw her around 3:45 AM when I was answering a call light for one of my other residents .She was in bed with all her clothes on and she was laying on top of the covers in the position she was in when I came on .When I did my rounds at 5:00 AM, I didn't make it to her room .I over heard one of the nurses say the maintenance man is outside with someone .There were no alarms going off on the Central Unit .The only ones that were going off that night were on the South Unit (Dementia unit) .I didn't know that she had had her wanderguard removed .No one talked to me about it .It was brand new to me that she didn't have a wanderguard .There was no additional documentation they asked us to do or no additional checks other than the q2s (every two hours) .I didn't get educated on the policies or alarms .It is hard for third shift to get in-services .Usually they leave something for us with the nurses for us to sign . In an interview on 10/5/21 at 2:56 PM, Certified Nursing Assistant (CNA) M stated, .I don't know anything about them taking the wanderguard off her .Her wanderguard was on her wheelchair .From what I knew she had a different chair because she soiled her chair and when I came back the next day it (wanderguard) wasn't going off and they either took it off the chair or they switched her chairs and never replaced it . In an interview on 10/5/21 at 2:58 PM, Housekeeping/Laundry Supervisor N stated, .I check the alarms on the doors in the morning .I do it when I come in at 07:30 AM .I got to each door and push it open and it alarms .I know that it has to make 3 chirps and the light has to be blinking red for it to be engaged .I have been doing it since August when the maintenance staff left .My lead laundry staff does it on the weekends that she works and my other housekeeper does it on the other weekend .Everything was fine on Monday and then on Tuesday (9/21/21) there were two doors not alarmed and I wrote that on the paperwork and reset the doors to make sure they were alarmed .They were the Central West door and South Northwest door (the door immediately to the right when enter the South unit) .Both of those were unlocked . Review of (Facility Name) Door Alarm Audit form for 9/20/21 indicated all door alarms were engaged in the building. Review of (Facility Name) Door Alarm Audit form for 9/21/21 indicated two doors not alarmed, .Central West, South Northwest door . Per interview 10/5/21 at 2:58 PM with Housekeeping/Laundry Supervisor N the Central West was the door by the staff parking lot on the hallway Resident #101 resided on. Review of (Facility Name) Door Alarm Audit form revealed, .Nurses for other shifts will look at alarm to see red light, this light will flash and this indicates door is alarmed .if no red light is flashing, the nurse is to re-arm the door. If door does not reset, IMMEDIATELY NOTIFY MAINTENANCE . 10/5/21 Administrator A stated, .No one admitted to it .They could have went to their car or pizza or smoke .No one fessed up to disarming the door . In an interview on 10/5/21 at 10:31 AM, Activity Aide P stated, .The keys go back to the activity room and are in the drawer in the activity area . Review of Quality Assurance AD/HOC Committee meeting minutes dated 9/21/21 revealed, .Investigation determined door alarms had been checked the previous day and intact. At 8:00 AM on this date, the door to the parking lot from Central was discovered unarmed and presumed to be the door where resident exited facility to the parking lot. All doors were re-set and checked to be sure alarms function properly . In an interview on 10/6/21 at 10:04 AM, Certified Nursing Assistant (CNA) O stated, .I got a call that said a resident was outside the building and I let the nurse know .I did not see her (Resident #101) .If I recall correctly, her door was shut .Mostly she will wander up and down the hallway .Looking out the windows .And you would notice because the alarm would go off if she was close to the door .When she was wearing the wanderguard the alarm would go off .That happened a lot and have to reset the alarms for both of the ends of the hallways .She does have the potential to open the door . In an interview on 10/6/21 at 11:22 AM, Assistant Director of Nursing (ADON) D stated, .I was not aware of the trail period and I started on 8/17/21 .I was told she used to have a wanderguard and they had to remove it because she was always setting off the alarms and there were complaints by the other residents . In an interview on 10/6/21 at 1:02 PM, Licensed Practical Nurse (LPN) F reported Resident #101 would say things when you were helping her get dressed about not wanting to be here. LPN F stated, .She (Resident #101) has tried to push on the doors before .The alarm goes off when you are pretty close to the doors .It does go off before they get to the door .We would get complaints from the other resident especially down her hallway as she was always setting the door alarms off .I never hear that her wanderguard was off during the day and put back on at night time .It was on her wheelchair . Review of Progress Notes, Behavior Monitoring, Miscellaneous section, etc. showed no indication Resident #101 was monitored during the trial period of August 23rd - August 27th prior to the wanderguard being discontinued on 9/2/2021. In an interview on 12/6/21 at 12:30 PM, Director of Nursing (DON) B stated, .There was no office statement written by me for the maintenance man interview .After discussions and IDT gave that she was not attempting to go out the door and we trialed it Monday to Friday with it being off when we were in the building and the social worker would put it back on and during that 5 days there was on elopement .There was a statement in the care plan .I can't tell you for sure that I gave them the directive to keep an eye on her .After hours they would have been just monitoring .She would become lost and we would need to redirect her .She would go from one end to the next .Sometimes she would be sitting down there and looking out the window and all the time setting the door alarm off .I can't give exact feet maybe 6-7 feet and the alarm would go off . In an interview on 10/6/21 at 3:20 PM, Nurse T stated, .It was around 5:50 AM, I was notified there was a resident outside in the woods .thought that was strange .I was on the South Unit with the CNA because she was over there by herself .I didn't want her over there by herself in case something happened or she needed help .The other nurse and two CNAs were on the Central Unit .When I came out of South Unit, I went straight to (Resident #101)'s room as she is a big elopement risk and she was gone .I knew it was her that was outside .When I last saw her, she was in the bed dressed with her clothes on and that is unusual for her .She is a big elopement risk and I don't know what happened to the wanderguard and what the reason was to take it off .Her behavior is she goes back and forth to each door .She has opened the door once before .When I brought her back inside she started crying and said to me, .I'm just gonna die in here .She has always been on a wanderguard and I was surprised they were taking her wanderguard off .She has had a wanderguard since she has been here .2017 .She can move fast .She can get in her wheelchair and go to the bathroom before you even know it .She moves real quick and real good .Not take too long for her to get out of the bed and into her wheelchair . In an interview on 10/6/21 at 2:32 PM, Administrator A reported when informed Resident #101 was in another resident's room on 8/28/21 indicated she was unaware of the incident until now. Administrator A stated, .The facility has a new team with many new team members and have missed important documentation .We had a systemic breakdown .And a new system was put in place .I assumed when the DON B contacted me she had completed the interviews and had received statements from all of those involved with the elopement incident .I relied on my staff to inform me of the events .We discussed in our morning meetings the decision to start the trial for Resident #101 .I relied on my team to keep me informed of how the resident was progressing . I didn't realize we were not documenting the progress of Resident #101 under the trial period .I thought the trial was going great based on the information reported back to me in the meetings .I relied on my clinical section to address any concerns . Review of Elopement Policy revised on 10/2019, revealed, .It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility .Wandering is random or repetitive locomotion/ambulation. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless .Elopement occurs when a guest/resident who needs supervision leaves a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .1. The facility will evaluate guest's/resident's risk for elopement upon admission, weekly x4, quarterly, and with a significant change .2. After the Risk for Elopement is completed, and a guest/resident is deemed at risk for elopement . On 10/4/2021, Administrator A was notified of an Immediate Jeopardy that began on 9/21/2021 when Resident #101, who was identified as an elopement risk, eloped from the facility unbeknownst to facility staff. On 10/6/2021, the facility presented and immediacy removal plan and began implementation of the following to remove the immediacy. 1. Immediately upon notification the nurse assessed R101 in the parking lot and returned her to the facility. (9/21/21 6:00 am) She had a wander guard placed at 7:33 am after a comprehensive assessment was completed and the family and physician was notified. On 9/21/21 at 6:45 am, R101 was put on 15 minute checks until it was discontinued on 9/22/21 when she was moved to the secure unit at 5 pm. Her elopement risk assessment was redone and her care plan was updated. The wander- guard was added to the care plan and her face sheet and photo was added to the elopement book on 9/22/21. Elopement books are kept at the front desk and on each nurse's station. 2. Housekeeping Supervisor and Maintenance Director inspected all emergency exits on 9/21/21 a door on the central unit was found to be turned off and It was secured at that time. All 5 residents who have wander guards on were assessed and they are functioning properly. This was in addition to our policy in which the nurses check wander-guards for functionality daily and placement every shift. DON/designee will validate weekly that documentation occurred of wander guards placement each shift and functions daily. 3. Maintenance Director or Housekeeping Supervisor continues our ongoing process to check doors and document on a log M-F and Laundry/Environmental staff check doors and document on a log on weekends and holidays. Housekeeping supervisor/Designee checks and logs all exit doors for proper function and documents results 7 days a weeks and the results are documented on the log. Administrator will review logs weekly to validate the process occurs. 4. The ADON /DON began education for facility staff on Elopement policy which includes when to call a code search or W, what to do when an alarms door goes off, what to do when a guest is exhibiting exit seeking behavior. On 9/21/21, 26 out of 87 staff were educated the remainder of employees will be re-educated upon arrival to work before reporting to their assignment. On 10/4/21 81 out of -87, staff have been educated, the remaining are either on FMLA or PRN and will be educated upon the first day they work. 5. Facility staff has been educated on our ongoing process regarding the Elopement Policy and procedure, including residents who are actively exit seeking are to have a Wander guard to be applied, added to Missing Guest Book and reviewed by Interdisciplinary team for further interventions and update of care plan to reflect intervention. 6. The DON/Designee reviewed all guests for elopement risk on 9/21/21. The IDT did not identify any other guests at risk for elopement, other than R101 who was added to the list. On 9/21/21 all 66 residents were reassessed for elopement risk utilizing the evaluation tool in PCC. 12 of the resident elopement risk assessments were revised. The Nurses will continue the ongoing process of assessing residents for risk of Elopement upon Admission, quarterly and change of condition. 7. On 9/21/21 the Administrator reviewed the investigation performed by the DON who began her investigation and interviewed all staff that worked the night shift and had arrived prior to 6 am and completed the investigation later that day. 8. The Administrator and QA committee ad hoc reviewed the missing guest policy and deemed it appropriate during the QA meeting 9/21/21. 9. SW audited the elopement books and deemed them to be updated and accurate on 9/21/21. 10. New employee orientation will continue to include the missing guest policy and procedure education. 11. Maintenance Director/Designee checks the alarmed doors 5 days a week to ensure functioning properly which has always been an ongoing aspect of the of Preventative Maintenance program. Any concerns will be addressed and findings submitted to QAPI committee for review and recommendations. The Administrator will review logs weekly to validate this process occurs. 12. Code search drills were held on 9/21/21, 9/22/21. Facility will ongoing process of Code Search Drills performed once per shift on a quarterly basis. 13. Medical Director was made aware of the elopements on 9/21/21. 14. Incident reviewed in QAPI meeting on 9/21/21 and reviewed with IDT on 9/22/21. At QAPI root cause analysis (RCA) determined the cause of the incident was due to parking lot door unarmed resulting in the resident exiting the building without staff awareness. The QAPI committee decided who would have keys to door alarms. 15. At the Ad Hoc QA on 9-21-21, the decision had been made to assign one key to nurses. On 10-4-2021, Nurse Management and the Administrator agreed to assign 1 key to each charge nurse on each unit. An inventory of Detex door alarm keys occurred last week. At that time is was decided 1 key permitted for Laundry/environmental area for 7 day per week testing, 1 to maintenance supervisor for testing and maintenance, 1 to Administrator. On 10-5 all keys to exit doors have been removed from the Activity department. Activity staff have been informed the ongoing practice to utilize the courtyard in the South Unit, will require the charge nurse to unlock the doors. 16. The remaining 6 employees who had not worked have received the education per phone as of 3:00pm on 10-5-2021. Although the immediate jeopardy was removed on 10/5/2021, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

Based on interview and record review, the facility failed provide adequate supervision and revise care plan interventions to prevent falls in 1 of 3 residents (Resident #102) reviewed for falls, resulting in a fall with an acute right humerus (upper arm) fracture and the potential for a decline in physical, mental and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: [CONDITION(S)] (paralysis) affecting right dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 6/1/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of the Functional Status revealed that Resident #102 required supervision (oversight, encouragement or cueing) for walking and locomotion on the unit and assist of one person for toileting. Review of Resident #102's Fall Care Plan revealed, (Resident #102) is at risk for injury related to falls due to history of [CONDITION(S)] (stroke) (R) sided weakness, medication side effects, decreased safety awareness due to his desire to be independent as possible Date Initiated: 09/09/2014. INTERVENTIONS: .Family aware to let staff know if resident has fall on outing. Date Initiated: 06/22/2015, Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position Date Initiated: 06/20/2017, Place the call light within reach and encourage him to use it for assistance as needed. Date Initiated: 09/09/2014, Remind resident that he needs to call for assistance when up. Date Initiated: 02/05/2021 . Review of Resident #102's Activities of Daily Living (ADL) Care Plan revealed, (Resident #102) requires assistance with ADL due to history of [CONDITION(S)] and (R) sided weakness .Date Initiated: 01/04/2017. INTERVENTIONS: mod (modified) independent with hemiwalker (a walking device that can be used with one hand) indoors as resident tolerated Date Initiated: 06/08/2016, Transfer: Independent Date Initiated: 01/02/2019, R (right) [CONDITION(S)]/weakness precaution Date Initiated: 09/23/2014 Resolved Date: 06/15/2016, TOILET USE: Independent Date Initiated: 01/02/2019 . Review of Resident #102's Incident Report dated 8/8/2021 at 8:15 A.M. revealed, Fall Description Details: .walking down hallway towards his room .foot did not move far enough so when weight shifted he lost his balance .What type of assistance was the guest/resident receiving at the time? none .Last time of guest/resident observation? at time of fall he walked from his room around the nurses station and was right in front of his room door when he fell . Review of Resident #102's Incident Report dated 8/16/21 at 6:00 P.M. revealed, Fall Description Details: trying to get out of recliner .observed on floor .in guest/resident room .What type of assistance was the guest/resident receiving at the time? none .Resident was sitting in recliner prior to fall, ambulates self to the bathroom . Review of Resident #102's Incident Report dated 8/17/21 at 6:30 A.M. revealed, Fall Description Details: returning from the bathroom .Resident/guest lost their balance .observed on floor .What type of assistance was the guest/resident receiving at the time? none .Describe initial intervention: encouraged to call for assist and not get up by himself . Review of Resident #102's most recent Physical Therapy Evaluation revealed, .6/24/2020-9/19/2020 .Patient Goals: To prevent future falls .Reason for Referral: Patient exhibits new onset of decrease in strength, reduced ability to safely ambulate . Review of Resident #102's Physical Therapy Discharge Summary revealed, Dates of service 6/24/2020-7/28/2020 .Prognosis: .good with consistent staff follow-through. Functional Outcomes: .Transfers: SBA (stand by assist) .Level Surfaces: SBA . During an interview on 9/9/21 at 2:47 P.M., Physical Therapist (PT) U reported that Resident #102 was able to walk with his walker with staff present for stand by assistance and stated, he was not safe to walk alone in the hallway .you had to remind him to lift his foot up so that he didn't trip .we should redirect him and reeducate on using his call light .or supervise him so that he doesn't fall . PT U reported that staff should look at the care plan to determine what a resident requires for assistance with walking. During an interview on 9/13/21 at 3:37 P.M., Director of Nursing (DON) B reported that Resident #102 walked independently with his walker and stated, .the care plan states modified independent with hemiwalker .that means that he would walk independently with a walker .stand by assist means you have to be walking with him . During an interview on 9/13/21 at 3:40 P.M., Regional Nurse (RN) N reported that Resident #102's care plan did not indicate that he required stand by assistance with transfers or walking, and indicated that the care plan interventions for ambulation come directly from the physical therapy evaluations. During an interview on 9/8/21 at 3:11 P.M., Registered Nurse (RN) I reported that she had witnessed Resident #102 fall on 8/8/21 and stated, .he was in the hall with his tripod walker .he had made it down and around the nurses station .I saw him fall .he said his leg brace got hooked and he tripped over it . RN I reported that Resident #102 had landed on his right side and stated, he hit his head and had some bruising on his right forearm .but he had no feeling in that arm because of his stroke .he was sent to the hospital because he had a headache and was dizzy .when he came back to the facility they said that everything was negative . RN I reported that Resident #102 later developed bruising on his right arm and was found to have a fractured humerus. Review of Resident #102's Hospital Records dated 8/17/21 at 8:31 A.M., chief complaint: .presents to the emergency department from nursing facility for fever and recent falls .was seen here on 08/08/2021 for falls and was discharged after a normal head CT, later found to have right-sided humerus fracture treated with sling by orthopedic surgeon . During an interview on 9/8/21 at 3:53 P.M., Licensed Practical Nurse (LPN) C reported that Resident #102 walked independently with a cane. During an interview on 9/9/21 at 3:29 P.M., Certified Nursing Assistant (CNA) V reported that she had been working in the facility for the past 5 years and stated, .(Resident #102) walked by himself .he was independent and didn't call on us .he did not need assistance . Review of a facility policy Fall Management dated 7/20/2021 revealed, .The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk evaluation, treatment, evaluation and monitoring of guest/residents falls The licensed nurse will complete: .Review and/or revise care plan and guest/resident kardex (care plan) .The IDT (Interdisciplinary Team) will review all guest/resident falls within 24-72 hours at the stand-up/clinical-ops meeting to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care .The DON/designee will document any changes in the care plan and kardex at the meeting.

This citation pertains to Intake: MI 308 Based on observation, interview, and record review, the facility failed to properly follow Infection Control Practices per Centers for Disease Control (CDC) and Local Health Department (LHD) guidance to prevent the spread of COVID-19 for 16 of 18 sampled residents (Resident #s 100, 102, 103, 104, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, and 118) reviewed for infection control, resulting in an immediate jeopardy when; 1.) beginning [DATE] the facility began to allow staff whose COVID-19 positive status was unknown (for greater than 48 hours) to work and provide direct resident care for Resident #s 100, 102, 103, 104, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, and 118 who then began to test positive for COVID-19 on [DATE] and where 6 residents expired after contracting COVID-19; 2.) ensure staff used adequate personal protective equipment (PPE) for transmission based precautions (TBP) while caring for COVID-19 positive residents, and 3.) ensure consistent, accurate, timely process and outcome surveillance (including tracking and trending) for infection control. These deficient practices resulted in serious harm and 6 resident deaths. Findings include: On [DATE] at 3:30 P.M., the Nursing Home Administrator (NHA) was verbally notified and received written notification of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] due to the facility failure to follow infection control practices. A written plan for removal for the Immediate Jeopardy was received on [DATE] and the following was verified on [DATE] and [DATE]: 1. [DATE] - The facility will use the POC test kits as they are available if PCR tests are taking greater than 48 hours to test residents and staff for Covid-19. Test supplies are delivered by Abbott based on NHSN reporting. We will continue NHSN reporting weekly. Additional supplies can be obtained through the MDHHS link for obtaining supplies. 2. [DATE] - Staff who test Covid-19 positive who are asymptomatic will only work and provide care to residents who are Covid-19 positive per the CDC Guidelines. Staffing sheets will be monitored on a daily basis to separate Covid-19 positive and Covid-19 negative staff. The facility intends to end critical staffing on [DATE] and will continue to monitor on a daily basis the need to utilize critical staffing. 3. Staff began using PPE on [DATE] for transmission-based precautions (TBP) while caring for residents that are Covid-19 positive. N95 mask, face shield, gown, and gloves are the PPE used when caring for Covid-19 positive residents per the Covid-19 policy. The Director of Nursing, Assistant Director of Nursing, and Unit Manager trained staff on the appropriate PPE. On [DATE], the individual identified by the surveyor who breached PPE protocol was given a final written warning and was re-educated. 42 out of 149 employees have been re-educated on proper PPE and the remaining will be re-educated before their next shift. 4. [DATE] - The facility will continue to follow Berrien County Health Department recommendations and CDC guidelines. 5. The facility policy on COVID-19, The Pandemic Policy, the Hand Hygiene policy and the Infection Prevention Program Overview policy were reviewed and deemed appropriate on [DATE]. The COVID-19 policy and Pandemic Policy include testing of staff, emergency staffing use, CDC guidelines for contingent staffing and PPE use. The staff were not following the policies. 6. The staff education began on [DATE] at 6:00pm the staff are being re-educated on the policy on COVID-19, The Pandemic Policy, Hand Hygiene policy and the Infection Prevention Program Overview policy. The remaining employees will be re-educated prior to the start of their next shift scheduled. There are currently 149 employees and re-education began as of [DATE] at 8:00pm, 27 out of 149 of employees were re-educated. 7. Beginning [DATE] The Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Infection Preventionist, and Unit Managers) will observe staff using personal protective equipment (PPE) for transmission based precautions (TBP) while caring for residents that are Covid-19 positive on all 3 shifts on audit forms. 8. [DATE] The Administrative Nurses will review the Covid-19 test results daily to determine if the results are taking greater than 48 hours to result and POC testing is needed. POC tests will be performed long as supplies are in stock. Test supplies are automatically delivered by Abbott based on NHSN reporting. We will continue NHSN reporting weekly. Additional supplies can be obtained through the MDHHS link for obtaining supplies. 9. [DATE] The Administrative Nurses will review the staff that is scheduled to work to ensure Staff who test Covid positive who are asymptomatic will only work and provide care to residents who are Covid positive and will make every attempt to not be in contact with Covid negative staff. The staffing sheets will be reviewed and documented on daily. 10. The Facility Infection Control Preventionist will be trained by the corporate Infection Control Preventionist on [DATE] to ensure consistent, accurate, timely process and outcome surveillance (including Tracking and Trending). Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of widespread and a severity of actual harm due to the fact that not all staff education is complete and sustained compliance has not been verified by the State Agency. Review of the Centers for Medicare and Medicaid Services (CMS) QSO-,[DATE]-NH dated [DATE] revealed, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency .To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The QSO-,[DATE]NH further revealed, Facilities without the ability to conduct COVID-19 POC (point of care) testing should have arrangements with a laboratory to conduct tests to meet these requirements. Laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) should be selected to rapidly inform infection prevention initiatives to prevent and limit transmission. Review of the Centers for Disease Control and Prevention (CDC) Strategies to Mitigate Healthcare Personnel Staffing Shortages updated [DATE] revealed, .Crisis Capacity Strategies to Mitigate Staffing Shortages .When staffing shortages are occurring, healthcare facilities and employers .may need to implement crisis capacity strategies to continue to provide patient care . If shortages continue despite other mitigation strategies, as a last resort consider implementing criteria to allow HCP (healthcare personnel) with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection who are well enough and willing to work . If HCP are allowed to work .they should be restricted from contact with severely immunocompromised patients .2. Allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care only for patients with confirmed [DIAGNOSES REDACTED]-CoV-2 infection .3. Allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care for patients with suspected [DIAGNOSES REDACTED]-CoV-2 infection .If HCP are permitted to return to work .they should still adhere to all .recommendations .Facemasks should be worn even when they are in non-patient care areas such as breakrooms .They should practice social distancing from coworkers at all times .If they must remove their facemask, for example, in order to eat or drink, they should separate themselves from others. Accessed from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html In an interview on [DATE] at 2:45 P.M., Local Health Department (LHD) Confidential Informant (CI) EE - indicated when a facility has someone positive working, they need to be put that person only with other positives - residents or staff (meaning that COVID-19 positive staff should not be working with residents or staff who have not yet tested positive for COVID-19). In an interview on [DATE] at 10:08 A.M., General Administration (GA) WW employee indicated was responsible doing the nursing staff schedule since approximately [DATE]. GA WW indicated assigned the Certified Nursing Assistants (CNAs) to work on a specific hall (unit) and then the Nurse (on that hall) assigned the CNA what residents to work with. GA WW indicated Nurses would know which staff to put with which residents (referring to staff COVID-19 status) because they would be on the schedule as a Covid Nurse or Covid Aide. This surveyor looked at a nursing staff schedule with GA WW and visually observed the notation on the schedule, Covid Nurses & Aides can ONLY work as Covid Nurses Aids. GA WW reported Covid Nurses and Aids (CNAs) would be either 1) a Nurse or CNA that solely agreed to work only with COVID positive residents or 2) a Nurse or CNA who tested positive for COVID-19 and therefore could only work with COVID positive residents. GA WW reported any staff on the schedule not classified as a Covid Nurse or Aide would have either been done with quarantine or never tested positive (meaning they could work with any resident). Review of a facility document summary of Staff COVID-19 Test Results revealed, CNA L had a COVID-19 specimen collected on [DATE] and the COVID-19 positive result from lab reported [DATE] (indicating results received from lab 7 days after testing). Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed CNA L worked on ,[DATE] on the Central Unit, ,[DATE] on the South (Memory Care) Unit, ,[DATE] on the Central Unit, ,[DATE] on the South (Memory Care) Unit, ,[DATE] on the Central Unit, ,[DATE] on the South (Memory Care) and Central Units, and ,[DATE] on the Central Unit. At no point on the days worked was CNA L designated on the Staff Schedules as a Covid Aid. Review of a facility document summary of Staff COVID-19 Test Results revealed, Registered Nurse (RN) RN M had a COVID-19 specimen collected on [DATE] and the COVID-19 positive result from lab reported [DATE] (indicating results received from lab 6 days after testing). Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed RN M worked on South (Memory Care) Unit on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. At no point on the days worked was RN M designated on the Staff Schedules as a Covid Nurse. Review of a facility document summary of Staff COVID-19 Test Results revealed, CNA T had a COVID-19 specimen collected on [DATE] and the COVID-19 positive result from lab reported [DATE] (indicating results received from lab 7 days after testing). Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed CNA T worked on South (Memory Care) Unit on ,[DATE], ,[DATE], ,[DATE], ,[DATE]. At no point on the days worked was CNA I designated on the Staff Schedules as a Covid Aid. In an interview on [DATE] at 11:58 A.M., CNA T stated, They did not tell me not to work with negative residents after testing positive for COVID-19. CNA T reported worked with multiple negative residents on the memory care unit because didn't know shouldn't after testing positive. Review of a facility document summary of Staff COVID-19 Test Results revealed, Activities Aide (AA) X had a COVID-19 specimen collected on [DATE] and the COVID-19 positive result from lab reported [DATE] (indicating results received from lab 6 days after testing). Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed AA X worked on South (Memory Care) Unit on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. In an interview on [DATE] at 11:24 A.M., Activities Director (AD) U indicated does the scheduling for the Activities Aides. AD U indicated thought AA X tested positive for COVID-19 but has not had any symptoms. AD U reported was told that AA X could work if did have any symptoms. AD U reported was not told that COVID-19 positive staff who returned to work (as part of the crisis capacity staffing) could not work with residents or staff who had not yet tested positive for COVID-19. In an interview on [DATE] at 2:15 P.M., AA X reported tested positive for COVID-19 but had no symptoms. AA X indicated had worked with residents all over South (Memory Care) Unit because only one AA is on that unit at a time. AA X reported did not know COVID-19 positive staff could not work with negative residents or staff. AA W indicated only one staff break room on South (Memory Care) Unit, so COVID-19 positive and COVID-19 negative staff would have been in the same break room eating lunch sometimes. Review of a facility document summary of Staff COVID-19 Test Results revealed, CNA V had a COVID-19 rapid test performed on [DATE] that revealed a COVID-19 positive result. Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed CNA V worked on South (Memory Care) Unit on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. At no point on the days worked was CNA V designated on the Staff Schedules as a Covid Aide. Review of a facility document summary of Staff COVID-19 Test Results revealed, CNA DD had a COVID-19 rapid test performed on [DATE] that revealed a COVID-19 positive result. Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed CNA DD worked on South (Memory Care) Unit on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. At no point on the days worked was CNA DD designated on the Staff Schedules as a Covid Aide. During an observation/interview on [DATE] at 2:15 P.M., CNA DD reported had tested positive for COVID-19 on [DATE]. CNA DD indicated worked exclusively on the Memory Care Unit. CNA DD indicated continued to work after COVID-19 positive test and there were four residents on the Memory Care Unit (at the time of CNA DD's positive test) whose COVID-19 status was negative. CNA DD indicated was never told COVID-19 positive staff could not work with negative residents or staff Review of a facility document summary of Staff COVID-19 Test Results revealed, CNA AA had a COVID-19 specimen collected on [DATE] and the COVID-19 positive result from lab reported [DATE] (indicating results received from lab 5 days after testing). Review of a Time Card Report and Staff Schedules for the period beginning [DATE] revealed CNA AA worked on South (Memory Care) Unit on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. At no point on the days worked was CNA AA designated on the Staff Schedules as a Covid Aide. In an interview on [DATE] at 1:32 P.M., CNA AA reported just found out today ([DATE]) from the Local Health Department (LHD) of positive COVID-19 status. CNA AA indicated has not yet heard anything from employer about test results. Resident #103 Review of a Face Sheet revealed Resident #103 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #103's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #104 Review of a Face Sheet revealed Resident #104 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #104's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #107 Review of a Face Sheet revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #107's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #108 Review of a Face Sheet revealed Resident #108 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED].). Review of Resident #108's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #109 Review of a Face Sheet revealed Resident #109 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #109's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #110 Review of a Face Sheet revealed Resident #110 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #110's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #111 Review of a Face Sheet revealed Resident #111 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. properly use sugar from the blood), [MEDICAL CONDITION] (high levels of fat in the blood), hypertension (high blood pressure), and [MEDICAL CONDITION]. Review of Resident #111's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #112 Review of a Face Sheet revealed Resident #112 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #112's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #113 Review of a Face Sheet revealed Resident #113 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #113's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of Resident #113's death certificate revealed resident expired on [DATE], with cause of death listed as COVID. Resident #114 Review of the Face Sheet revealed Resident #114 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Certificate of Death dated [DATE] revealed Resident #114's cause of death was Acute Covid-19, Respiratory Disease. Resident #115 Review of a Face Sheet revealed Resident #115 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #115's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of Resident #115's medical record revealed resident expired on [DATE]. Resident #116 Review of a Face Sheet revealed Resident #116 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #116's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of Resident #116's (medical record/death certificate) revealed resident expired on [DATE]. Resident #117 Review of a Face Sheet revealed Resident #117 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #117's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of a public record (obituary) for Resident #117 revealed resident expired on [DATE]. Resident #118 Review of a Face Sheet revealed Resident #118 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #118's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of Resident #118's medical record revealed resident expired on [DATE]. Failure to Perform Process and Outcome Surveillance Review of the Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes updated [DATE] revealed, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 .As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP) COVID-19 prevention and response activities .developing IPC policies and procedures, performing infection surveillance, providing competency-based training of HCP, and auditing adherence to recommended IPC practices. Accessed from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of a document INFECTION PREVENTION PROGRAM OVERVIEW with a revision date of ,[DATE] revealed, II. SCOPE OF THE INFECTION PREVENTION PROGRAM The major activities of the program are: A. Surveillance of infections with implementation of control measures and prevention of infections * There is on-going monitoring for infections among guests/residents and personnel and subsequent documentation of infections that occur .IV. REPORTING MECHANISMS FOR INFECTION PREVENTION .C. Compliance with Infection Prevention practice is monitored and documented by the IP (Infection Preventionist) through surveillance . In an interview on [DATE] at 8:20 A.M., Registered Nurse (RN) C indicated Licensed Practical Nurse (LPN) O had been helping out with the Infection Control Program until a new Infection Preventionist was hired but LPN O had been working on the floor as a floor nurse ever since COVID-19 hit the building. RN C indicated the staff tried to keep up with the infection control program and the surveillance as best they could, but that didn't work out. RN C indicated that all the management staff (including LPN O) had been working on the floor so (LPN O) did not have time to do any infection control administrative work. RN C stated, I kept up with the tracking as best I could with everything else I was doing. In an interview on [DATE] at 11:55 A.M., LPN O indicated helped out with the Infection Control Program but was not in charge of the entire Infection Control Program. LPN O reported was also a Unit Manager and had been working on the floor a lot due to staffing. Social Distance and Hand Hygiene Resident #103 Review of a Face Sheet revealed Resident #103 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #103's medical record revealed resident tested positive for COVID-19 on [DATE]. Resident #104 Review of a Face Sheet revealed Resident #104 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #104's medical record revealed resident tested positive for COVID-19 on [DATE]. During an observation on [DATE] beginning at 12:45 P.M., noted Resident #104 seated at a table in the Memory Care Dining Room. Noted Resident #103 seated at the same table as Resident #104. Resident #103 was picking her nose. Residents were seated across from each other, not socially distanced (less than 6 feet apart). Certified Nursing Assistant (CNA) DD served Resident #104 her lunch tray. No hand hygiene was performed on or offered to Resident #104 prior to meal being served. Certified Nursing Assistant (CNA) DD then served Resident #103 her lunch tray. No hand hygiene was performed on or offered to Resident #103 prior to meal being served. In an interview on [DATE] at 12:50 P.M., Certified Nursing Assistant (CNA) DD indicated supposed to offer or perform hand hygiene for residents prior to serving meal. CNA DD indicated hand cleansing wipes are typically sent by the kitchen on the resident trays for were not provided on this day. CNA DD stated, there is just so much going on right now. In an interview on [DATE] at 12:55 P.M., Activities Aide (AA) X indicated residents should be socially distanced (meaning should be at least 6 feet apart from one another). AA X confirmed Residents #103 and #104 should not have been seated at the same table to eat lunch because they were not 6 feet apart. AA X indicated the kitchen had not sent hand cleaning wipes, so hand hygiene was not performed for Residents #103 and #104 prior to their meals being served. In an interview on [DATE] at 11:58 A.M., CNA T indicated resident hand cleaning before meals is not consistent and that sometimes it happens and sometimes it doesn't. During an interview on [DATE] at 1:40 PM, Licensed Practical Nurse (LPN) Z stated she was tested for COVID-19 on [DATE] but I found out on the 29th ([DATE], indicated test results 10 days later). LPN Z stated the reason for the delay in COVID-19 test results was the lab (laboratory) was behind. LPN Z stated, Yes she worked her normal hours between [DATE] and [DATE] and stated, I (LPN Z) was working with non COVID (COVID-19) while waiting for my test results. LPN Z stated, by the time I got my test results (COVID-19 test results) back my quarantine time was already completed. Review of the Laboratory COVID-19 Report revealed LPN Z had a COVID-19 specimen collected on [DATE] and the test reported result was on [DATE] (indicated 10 days for test results). The Laboratory COVID-19 Report revealed LPN Z was Positive for COVID-19. During an interview on [DATE] at 12:13 PM, Certified Nurse Aide (CNA) GG stated, yes she was positive for COVID-19. CNA GG stated, I was tested on [DATE]nd (2020) and was called on [DATE]th (2020) with the positive COVID-19 results. CNA GG stated, I had no symptoms of COVID-19 and I was (working) on the non COVID (COVID-19) side of the facility. CNA GG stated, I worked the 8th, 9th and the 10th of December without her known positive COVID-19 status. Review of the Laboratory COVID-19 Report revealed CNA GG had a COVID-19 specimen collected on [DATE] and the test reported result was on [DATE] (indicated results 6 days after testing). The Laboratory COVID-19 Report revealed CNA GG was Positive COVID-19. During an interview on [DATE] at 12:50 PM, LPN HH stated, On the 9th of December (2020) I was told I was positive for COVID-19. LPN HH stated I was tested on [DATE]th (2020). LPN HH stated, yeah I worked from the test time of [DATE]th, 2020. LPN HH stated, I never had any symptoms of COVID-19 and she was never off work because of the COVID-19 positive test result. Review of the Laboratory COVID-19 Report revealed LPN HH had a COVID-19 specimen collected on [DATE] and the test reported result was on [DATE] (indicated results 5 days after testing). The Laboratory COVID-19 Report revealed LPN HH was Positive for COVID-19. Review of the Policy Droplet Precautions dated ,[DATE] revealed, Droplet Precautions shall be used in addition to Standard Precautions for Guests/Residents with infections that can be transmitted by droplets .Droplets may be generated may be generated by the Guest's/Resident's coughing, sneezing, talking, or during the performance of procedures. The Policy further revealed Eye protection is goggles, face shields or safety glasses .Eye protection must be worn during all tasks . Resident #100 Review of the Face Sheet revealed Resident #100 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Laboratory Covid-19 Report dated [DATE] revealed Resident #100 was Positive for Covid-19. During an observation on [DATE] at 10:26 AM, Certified Nurse Aide (CNA) G entered Resident #100's room. CNA G was observed wearing an N95 mask, gown and gloves. No face shield was observed on CNA G when she entered Resident #100's room. CNA G was observed to perform peri-care on Resident #100. During an interview on [DATE] at 10:26 AM, CNA G stated, everybody is Covid (Covid-19) positive on this hall. CNA G stated, yeah, I'm supposed to wear a face shield I forgot to put mine on today. Resident #102 Review of the Face Sheet revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Rapid Covid-19 test dated [DATE] revealed Resident #102 was Positive for Covid-19. Review of the Nurses Notes dated [DATE] at 11:11 AM revealed Resident #102 had a .positive Covid-19 result. During an observation on [DATE] at 1:08 PM, CNA K went into Resident #102's room without a face shield. During an interview on [DATE] at 1:12 PM, CNA K stated, yes Resident #102 was Covid-19 positive. CNA K stated her face shield was left down here (CNA K pointed to the service hallway) and stated, yep, supposed to have it (face shield) on when in Covid-19 rooms. During an interview on [DATE] at 12:10 PM, Registered Nurse (RN) C stated staff were to wear a fac (TRUNCATED)

Based on observation, interview and record review the facility failed to provide interventions to prevent pressure sore/ulcers for 1 of 24 residents (Resident #87) reviewed for pressure sore/ulcer resulting in the potential for delayed wound healing and skin breakdown. Findings include: Review of the Face Sheet revealed Resident #87 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS dated [DATE] revealed Resident #87 had a BIMS score of 15 out of 15 which indicated he was cognitively intact. The MDS further revealed Resident #87 was an extensive assist of 2 staff for bed mobility and was total dependence of 2 staff for transfer. Review of the Nursing comprehensive evaluation dated 12/13/19 revealed Resident #87 was confined to bed or chair and had actual skin breakdown care plan with intervention for staff to Turn and Reposition q2 (every 2) hours and PRN (as needed). The Nursing comprehensive evaluation further revealed Resident #87 had a Stage 4 pressure ulcer/sore to his left Ishium (hip area), Stage 4 to his right Ishium and a stage 3 pressure sore/ulcer to his sacral region. Review of the Care Plan Potential for skin breakdown dated 12/13/19 revealed Resident #87 was at risk for skin breakdown related to being a paraplegic (an impairment in motor or sensory function of the lower extremities) and decreased mobility and intervention to Turn/reposition resident every 2 hours and PRN. Review of the kardex (a guide for resident care) un-dated revealed Resident #87 was to be turned and repositioned .approximately q2hr (every 2 hours) as he will allow. In an interview on 01/15/20 at 02:06 PM, Resident #87 stated he had it (pressure sore/ulcer) for a couple of months. In an observation on 01/16/20 at 02:46 PM, Resident #87 was noted to be in bed on his back. In an observation on 01/16/20 at 03:58 PM, Resident #87 was noted to be in bed on his back. In an observation on 01/16/20 at 04:57 PM, Resident #87 was noted to be in bed on his back. In an observation on 01/17/20 at 08:46 AM, Resident #87 was noted to be in bed on his back. In an observation on 01/17/20 at 10:09 AM , Resident #87 was noted to be in bed on his back. In an observation on 01/17/20 at 11:26 AM, Resident #87 was noted to be in bed on his back. In an observation on 01/17/20 at 01:21 PM, Resident #87 was noted to be in his bed on his back. In an interview on 01/17/20 at 01:22 PM, Resident #87 stated, no staff member had turned or repositioned him yesterday (1/16/2020), last night or today (1/17/2020). In an observation on 01/17/20 at 11:29 AM, Registered Nurse (RN) S removed Resident #87's wound vac to reveal 3 (three) open wounds to his buttocks. The open wound were observed to be on Resident #87's left and right Ishium and an open area to his sacral area of his buttocks. In an interview on 01/17/20 at 01:24 PM, Registered Nurse (RN) F stated Resident #87 pressure sore/ulcer intervention was turning and repositioning him every 2 hours to prevent further skin breakdown. In an interview on 01/17/20 at 01:27 PM, Certified Nurse Aide (CNA) LL stated she would turn and reposition Resident #87 if he want to be turned (sic) and repositioned. CNA LL stated, no she had not turned and repositioned Resident #87 today (1/17/2020). In an interview on 01/17/20 at 02:12 PM, Director of Nursing (DON) B, stated to assist in pressure sore/ulcer healing staff were to have been .turning him (Resident #87), supposed to be every 2 hours or the pressure sore/ulcer could get worse.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for 1 of 12 residents (Resident #50) reviewed for accidents and hazards, resulting in a fall with a [MEDICAL CONDITION], increased anxiety, and recurrent fear of falling during care. Findings include: Review of an Admission Record revealed Resident #50 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 2/11/2020, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #50 was cognitively intact. Further review of the MDS indicated Resident #50 required extensive assistance of two persons physical assist for positioning while in bed. Review of the Quarterly MDS dated [DATE], revealed Resident #50 required extensive physical assistance of two persons for positioning while in bed. Review of Resident #50's Incident and Accident Report dated 12/1/2019 revealed, The resident was noted laying close to the edge of the bed while being changed by the CNA (certified nursing assistant). As the CNA was pulling the old linen from underneath the resident, the resident's weight shifted causing the resident to roll off the edge of the bed .The resident was noted to have a great deal of pain to the L (left) hip .Fall Description Details .7. What type of assistance was resident receiving at time of fall? Assisted per care plan . Post Fall Evaluation .Care Plan/Kardex Updated New Interventions after IDT (interdisciplinary team) review: same to use second person if need to go to the other side of bed . Review of Resident #50's Care Plan ADL Self-Care Performance Deficit revealed, Focus: .requires assistance with ADL's (activities of daily living) and mobility r/t (related to) progression Disease Process(sic) .Revision on: 12/28/2019 .Goals: .will maintain current level of function in bed mobility, .toilet use and personal hygiene through the review date. Date Initiated: 1/20/2019 .Interventions .Bed Mobility: Extensive x 2 assist .Revision on 12/31/2019 . The revision for Resident #50's goal of maintain current level of function did not have a revision until after the start of the abbreviated survey. Further review of the ADL care plan revealed bed mobility x 2-person assist had been an intervention since (YEAR). An intervention was initiated, created, and revised on 1/9/2020, Hip Precautions when rolling resident and repositioning, keep left leg in line with left hip (as tolerated), when (resident name) is on his back, prop the left knee up with pillow under the knee and wedge to the outside of the knee to maintain leg position. Resident #50 returned from the hospital after a fall with a left fracture hip on 12/14/2019. Review of Resident #50's Kardex (document used by nurse aides to provide care), undated, revealed, Resident Care: Keep in middle of bed as much as he will allow .Safety: Use another person on the other side of the bed if needed to put linens on .Mobility: Bed Mobility: Extensive x 2 assist . On 3/12/2020 at 9:02 AM, observed Unit Manager/Registered Nurse (UM) FF rolling Resident #50 onto his right side to edge of bed in preparation of wound dressing changes. Resident #50 repeatedly stated in an anxious tone of voice throughout dressing changes, Don't drop me, don't drop me. Don't let me fall. Resident #50's left arm was dangling between UM FF and edge of bed. During an observation and interview on 3/13/2020 at 9:40 AM, Resident #50 sought out surveyor and requested to speak in private. Resident #50 stated, I want to talk to you about a fall I had. They (referring to the facility) are making it sound like it was my fault. I was getting care from a CNA and when he went to the other side of the bed, I fell out of bed, landed on my left hip and fractured it. The doctor told me the 2 balls in the hip socket were broken. I could have surgery but at my age I might not come out of it so I didn't have the surgery. I'm in quite a bit of pain and waiting for my hip to heal. I'm supposed to have two staff to move me with a hoyer (mechanical lift). The CNA was trying to clean me up by himself and reached over the top of me. I was lying in my bed and the CNA had the bed away from the wall. He was on my left side between the wall and my bed. I was lying on my right side on the edge of the bed. I started to fall off the edge of the bed and the CNA tried to grab me and couldn't catch me. I fell on to my left hip and 2 balls broke in the hip and it hurts quite a bit. I get worried I'll fall again. During an interview on 3/13/2020 at 2:25 PM Director of Nursing (DON) B stated, (Resident #50's) fall could have been prevented. I reenacted the incident with the CNA that was involved. The CNA could have waited for another staff before he started care. The resident was rolled onto his right side. The CNA then stepped to the head-of-bed (HOB) to pull the fitted sheet to the opposite top corner. The CNA moved the bed away from the wall so he could get around to that corner of the HOB. (Resident #50) was still on his right side and his left moved and that momentum carried him over the edge of the bed and onto the floor. When the CNA demonstrated the incident, the resident was not that close to the edge of bed. It was when (Resident #50's) left leg moved over and it carried him off the bed. Care plan interventions state there should be two staff for bed mobility turning. I believe (Resident #50) requires 2 staff persons for care. Staff should know their resident. During an interview on 3/13/2020 at 3:07 AM, CNA U stated, I was working a double on 12/1/2019; the facility was short-staffed. I think there was 3 aides out of the 4 needed, but staff was able to meet resident needs although staff was cutting it close and running a little faster. (Resident #50's) call-light was on and I answered it. I wasn't assigned to him. I just saw it on. He needed to be changed; he had a loose BM (bowel movement). It was on his sheets it was so loose. I went and got supplies to clean him up then turned him towards the wall on his left side. The left side of his bed is against the wall to give him a feeling of security. Once he was cleaned on his right side, I tucked the sheet under him and put a clean sheet there to get ready to change the sheets. I then turned him on his right side towards me and made sure he was stable on his side. There was a good comfortable margin of him being 4-5 from edge of bed. At this time CNA U showed the width of his hand. I moved (Resident #50's) head-of-bed (HOB) away from the wall and then went around the top of the bed over to the wall. I made sure he was stable and steady. I had one hand on his back, but he is kind of unsteady with only one leg. Where there ways to prevent the fall? I could have brought somebody in with me. At that time aides were busy with other residents, nurses were passing meds, and the dinner trays were in the hall waiting to be passed. With the liquid BM he had just had, I especially couldn't leave him like that. Dinner was ready to be passed, and I didn't want to leave him like that. It would have been until after dinner before anyone could have gotten to him because of how busy staff was. I'm supposed to be working all over the facility, like a float staff. I always see the other aides doing him as a 1 person assist for direct care and bed mobility. I can look on the Kardex to see what a resident needs. Come to find out he was a 2-person assist at that time. Communication between CNAs could improve. During an interview on 3/13/2020 at 3:45 PM, Physical Therapist (PT) WW stated, I trained four CNAs that regularly work on that hall with (Resident #50). Those staff would then show other staff how to roll him. It is complicated with a [MEDICAL CONDITION] that was not surgically repaired and the other leg amputated. It was verbally told to nursing staff that he was a 2-person bed mobility. During an interview on 3/13/2020 at 4:00 PM DON B stated, Staff would know how to turn (Resident #50) by the Kardex. The Kardex will tell them how to position his leg and turn them. Staff should be using the Kardex for care.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for 1 of 12 residents (Resident #50) reviewed for accidents and hazards, resulting in a fall with a [MEDICAL CONDITION], increased anxiety, and recurrent fear of falling during care. Findings include: Review of an Admission Record revealed Resident #50 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 2/11/2020, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #50 was cognitively intact. Further review of the MDS indicated Resident #50 required extensive assistance of two persons physical assist for positioning while in bed. Review of the Quarterly MDS dated [DATE], revealed Resident #50 required extensive physical assistance of two persons for positioning while in bed. Review of Resident #50's Incident and Accident Report dated 12/1/2019 revealed, The resident was noted laying close to the edge of the bed while being changed by the CNA (certified nursing assistant). As the CNA was pulling the old linen from underneath the resident, the resident's weight shifted causing the resident to roll off the edge of the bed .The resident was noted to have a great deal of pain to the L (left) hip .Fall Description Details .7. What type of assistance was resident receiving at time of fall? Assisted per care plan . Post Fall Evaluation .Care Plan/Kardex Updated New Interventions after IDT (interdisciplinary team) review: same to use second person if need to go to the other side of bed . Review of Resident #50's Care Plan ADL Self-Care Performance Deficit revealed, Focus: .requires assistance with ADL's (activities of daily living) and mobility r/t (related to) progression Disease Process(sic) .Revision on: 12/28/2019 .Goals: .will maintain current level of function in bed mobility, .toilet use and personal hygiene through the review date. Date Initiated: 1/20/2019 .Interventions .Bed Mobility: Extensive x 2 assist .Revision on 12/31/2019 . The revision for Resident #50's goal of maintain current level of function did not have a revision until after the start of the abbreviated survey. Further review of the ADL care plan revealed bed mobility x 2-person assist had been an intervention since (YEAR). An intervention was initiated, created, and revised on 1/9/2020, Hip Precautions when rolling resident and repositioning, keep left leg in line with left hip (as tolerated), when (resident name) is on his back, prop the left knee up with pillow under the knee and wedge to the outside of the knee to maintain leg position. Resident #50 returned from the hospital after a fall with a left fracture hip on 12/14/2019. Review of Resident #50's Kardex (document used by nurse aides to provide care), undated, revealed, Resident Care: Keep in middle of bed as much as he will allow .Safety: Use another person on the other side of the bed if needed to put linens on .Mobility: Bed Mobility: Extensive x 2 assist . On 3/12/2020 at 9:02 AM, observed Unit Manager/Registered Nurse (UM) FF rolling Resident #50 onto his right side to edge of bed in preparation of wound dressing changes. Resident #50 repeatedly stated in an anxious tone of voice throughout dressing changes, Don't drop me, don't drop me. Don't let me fall. Resident #50's left arm was dangling between UM FF and edge of bed. During an observation and interview on 3/13/2020 at 9:40 AM, Resident #50 sought out surveyor and requested to speak in private. Resident #50 stated, I want to talk to you about a fall I had. They (referring to the facility) are making it sound like it was my fault. I was getting care from a CNA and when he went to the other side of the bed, I fell out of bed, landed on my left hip and fractured it. The doctor told me the 2 balls in the hip socket were broken. I could have surgery but at my age I might not come out of it so I didn't have the surgery. I'm in quite a bit of pain and waiting for my hip to heal. I'm supposed to have two staff to move me with a hoyer (mechanical lift). The CNA was trying to clean me up by himself and reached over the top of me. I was lying in my bed and the CNA had the bed away from the wall. He was on my left side between the wall and my bed. I was lying on my right side on the edge of the bed. I started to fall off the edge of the bed and the CNA tried to grab me and couldn't catch me. I fell on to my left hip and 2 balls broke in the hip and it hurts quite a bit. I get worried I'll fall again. During an interview on 3/13/2020 at 2:25 PM Director of Nursing (DON) B stated, (Resident #50's) fall could have been prevented. I reenacted the incident with the CNA that was involved. The CNA could have waited for another staff before he started care. The resident was rolled onto his right side. The CNA then stepped to the head-of-bed (HOB) to pull the fitted sheet to the opposite top corner. The CNA moved the bed away from the wall so he could get around to that corner of the HOB. (Resident #50) was still on his right side and his left moved and that momentum carried him over the edge of the bed and onto the floor. When the CNA demonstrated the incident, the resident was not that close to the edge of bed. It was when (Resident #50's) left leg moved over and it carried him off the bed. Care plan interventions state there should be two staff for bed mobility turning. I believe (Resident #50) requires 2 staff persons for care. Staff should know their resident. During an interview on 3/13/2020 at 3:07 AM, CNA U stated, I was working a double on 12/1/2019; the facility was short-staffed. I think there was 3 aides out of the 4 needed, but staff was able to meet resident needs although staff was cutting it close and running a little faster. (Resident #50's) call-light was on and I answered it. I wasn't assigned to him. I just saw it on. He needed to be changed; he had a loose BM (bowel movement). It was on his sheets it was so loose. I went and got supplies to clean him up then turned him towards the wall on his left side. The left side of his bed is against the wall to give him a feeling of security. Once he was cleaned on his right side, I tucked the sheet under him and put a clean sheet there to get ready to change the sheets. I then turned him on his right side towards me and made sure he was stable on his side. There was a good comfortable margin of him being 4-5 from edge of bed. At this time CNA U showed the width of his hand. I moved (Resident #50's) head-of-bed (HOB) away from the wall and then went around the top of the bed over to the wall. I made sure he was stable and steady. I had one hand on his back, but he is kind of unsteady with only one leg. Where there ways to prevent the fall? I could have brought somebody in with me. At that time aides were busy with other residents, nurses were passing meds, and the dinner trays were in the hall waiting to be passed. With the liquid BM he had just had, I especially couldn't leave him like that. Dinner was ready to be passed, and I didn't want to leave him like that. It would have been until after dinner before anyone could have gotten to him because of how busy staff was. I'm supposed to be working all over the facility, like a float staff. I always see the other aides doing him as a 1 person assist for direct care and bed mobility. I can look on the Kardex to see what a resident needs. Come to find out he was a 2-person assist at that time. Communication between CNAs could improve. During an interview on 3/13/2020 at 3:45 PM, Physical Therapist (PT) WW stated, I trained four CNAs that regularly work on that hall with (Resident #50). Those staff would then show other staff how to roll him. It is complicated with a [MEDICAL CONDITION] that was not surgically repaired and the other leg amputated. It was verbally told to nursing staff that he was a 2-person bed mobility. During an interview on 3/13/2020 at 4:00 PM DON B stated, Staff would know how to turn (Resident #50) by the Kardex. The Kardex will tell them how to position his leg and turn them. Staff should be using the Kardex for care.

Based on observation, interview and record review, the facility failed to provide appropriate/timely psychosocial support for emotional health concerns for 1 resident (Resident #50) of 12 residents reviewed for negative psychosocial outcomes, after Resident #50 fell from bed sustaining a serious injury, aspirated on food resulting in hospitalization , and could no longer eat, resulting in potential of psychosocial distress, increased anxiety, and recurrent fear of falling from bed. Findings include: According to the State Operations Manual Psychosocial Outcome Severity Guide, Anxiety refers to the apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness, or somatic symptoms of tension. Somatic symptoms of tension may include, but are not limited to, restlessness, irritability, hyper- vigilance, an exaggerated startle response, increased muscle tone, and teeth grinding. The focus of anticipated danger may be internal or external. Depressed mood (which does not necessarily constitute [MEDICAL CONDITION]) is indicated by negative statements; self-deprecation; sad facial expressions; crying and tearfulness; withdrawal from activities of interest; and/or reduced social interactions .Humiliation refers to a feeling of shame due to being embarrassed, disgraced, or depreciated. Some individuals lose so much self-esteem through humiliation that they become depressed. Review of facility policy Behavior Management dated 10/2019, revealed, Policy The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors. Overview Guests/residents with behavioral symptoms or those receiving psychoactive medications are evaluated, monitored, and managed by an interdisciplinary behavior management team including, but not limited to, facility clinical staff (nursing staff, social worker/social service staff, and activity staff) physician and pharmacist. The IDT works with the guest/resident and/or family/legal representative to determine an appropriate plan of care to identify the cause of the behavior and/or treat the behavioral symptoms. It is essential that behaviors be recognized as a form of communication, rather than as a random, unpredictable or meaningless event. Attempting to identify causes of behaviors will assist with developing the appropriate plan, with appropriate interventions, to respond to these behaviors Certain behavior may be anticipated and sometimes may be preventable based on understanding the underlying causes and possible triggers for each individual. Definitions Behavior: The response of an individual to a wide variety of factors, generated through brain function, which is in turn influenced by input from the rest of the body. Specific behavioral responses depends on many factors, including personal experience and past learning, inborn tendencies and genetic traits, the environment and response to the actions and reactions of other people .Behavioral Interventions: Individualized approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a guest's/guest's/resident's distress or loss of abilities. Person-Centered Care: Care that is individualized by being tailored to all relevant considerations for that individual, including physical, functional and psychosocial aspects .Practice Guidelines: .4. The IDT, in collaboration with the practitioner, guest/resident and/or family, will evaluate the guest's/resident's behavior for cause identification. Attempt to identify possible risk and causal/contributing factors for behaviors such as: .Changes in customary routine (i.e. a new caregiver, change to daily routine such as medication, meal or shower times) .loss of independence .residents receiving counseling will be reviewed until guest's/resident's psychosocial well-being is stable and documentation by the psychiatrist/psychologist reflects the stability of the guest's/resident's psychological status .5. To aid with cause identification, the IDT will attempt to determine: When did the behavior begin? What happened in sequence leading to the behavior? Who or what affected the behavior? Frequency of the behavior exhibited? Duration of the behavior? What happened over time with the display of the behavior? Consequences of the behavior? (impact on self .) Include related items such as .thought content, attention, .How has the behavior impacted the guest's/resident's quality of life .6. The IDT will implement a care plan with the guest/resident and/or guest/resident representative or update existing care plan, with interventions that target behavioral symptoms, identified causes, guest/resident specific goals and guest/resident specific behaviors .Behavior care plans will be established for those with behaviors related to dementia, mental illness or other needs. Interventions will include specific non-pharmacological interventions and behavior management strategies developed specifically for the guest/resident. The IDT will review and revise the plan of care at least quarterly, or with change in condition, and update interventions and goals, as appropriate. The care plan review should include, but is not limited to: effectiveness of nonpharmacological interventions and pharmacological interventions . Review of an Admission Record revealed Resident #50 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 2/11/2020, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #50 was cognitively intact. Further review of the MDS indicated Resident #50 required extensive assistance of two-person physical assist for positioning while in bed. Review of Resident #50's Incident and Accident Report dated 12/1/2019 revealed, The resident was noted laying close to the edge of the bed while being changed by the CNA (certified nursing assistant). As the CNA was pulling the old linen from underneath the resident, the resident's weight shifted causing the resident to roll off the edge of the bed .The resident was noted to have a great deal of pain to the L (left) hip .Fall Description Details .7. What type of assistance was resident receiving at time of fall? Assisted per care plan . Post Fall Evaluation .Care Plan/Kardex Updated New Interventions after IDT (interdisciplinary team) review: same to use second person if need to go to the other side of bed . Review of Resident #50's Order Summary Report dated 1/3/2020 revealed an active dietary order was put in place indicating Nothing By Mouth diet, Nothing By Mouth texture, Nothing By Mouth consistency. Further review of Resident #50's Order Summary Report revealed on 12/29/2019 an order was placed for Bilateral heel suspension with pillow, along with Turning and repositioning schedule every 2 hours. On 2/12/2020 a Video swallow study was ordered with ST (speech therapy) to eval (evaluate) only ordered on [DATE]. Review of Resident #50's Care Plan revealed, Focus: Mood .has history has the potential for fluctuations in mood possibly related to dx (diagnosis) of depression, multiple medical dx, he can become upset by yelling/screaming at others, and rarely will come out of his room or participate in activities .revision on: 2/28/2020 .Goals: .Will not have increased symptoms of depression through next review as evidenced by no increase PHQ scored .revision on: 3/11/2020 .Target Date: 5/13/2020 .Interventions .arrange for psych consult, follow up as indicated, .Revision on 11/02/2015. Further review of the Mood Care Plan indicated on 10/5/2016 an intervention was created and initiated to Attempt non-pharmacological interventions to decrease mood exacerbation: such as .provide reassurance, offer food/beverage, . Review of Order Summary Report dated 1/3/2020 indicating Resident #50 was to have Nothing By Mouth was not revised on the care plan. Review of Resident #50's Care Plan ADL Self-Care Performance Deficit revealed, Focus: .requires assistance with ADL's (activities of daily living) and mobility r/t (related to) progression Disease Process(sic) . Revision on: 12/28/2019 .Goals: .will maintain current level of function in bed mobility, .toilet use and personal hygiene through the review date. Date Initiated: 1/20/2019 Interventions .Bed Mobility: Extensive x 2 assist .Revision on 12/31/2019 . The revision for Resident #50's goal of maintaining current level of function did not have a revision until after the start of the abbreviated survey. Further review of the ADL care plan revealed bed mobility x 2-person assist had been an intervention since (YEAR). An intervention was initiated, created, and revised on 1/9/2020, Hip Precautions when rolling resident and repositioning, keep left leg in line with left hip (as tolerated), when (resident name) is on his back, prop the left knee up with pillow under the knee and wedge to the outside of the knee to maintain leg position. Resident #50 returned from the hospital with a left fracture hip on 12/14/2019. Review of Resident #50's Care Plan revealed, Focus: Behavior .refuses his showers d/t (due to) resident preferring certain staff to give him a shower, his showers are scheduled accordingly. Date initiated and created: 1/10/2015 .Further review of the care plan revealed there were no Goals or Interventions documented to support or reflect the person-centered care needs of the resident. Review of Resident #50's Kardex revealed, Resident Care: Keep in middle of bed as much as he will allow. Keep left lower extremity as stable as possible when turning and repositioning .right above-knee amputation .Turn and reposition q2 hours and PRN as will allow .Safety: Use another person on the other side of the bed if needed to put linens on .Bed Mobility: float heels as resident will allow .Bed Mobility: Hip precautions when rolling resident and repositioning, keep left leg in line with left hip (as tolerated), when (resident name) is on his back, prop the left knee up with pillow under the knee and wedge to the outside of the knee to maintain leg position .Mobility: Bed Mobility: Extensive x 2 (person) assist .Resident Care (company name Only) Calf buddy in place as patient allows .Monitoring (company name Only) Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .Activities: Encourage resident not to attend food related activities as it is upsetting to see others eating .Behavior/Mood .Attempt non-pharmacological interventions to decrease mood exacerbation: such as; assist in repositioning, provide reassurance, offer food/beverage, .attempt diversional activities, attempt to change environment/decrease stimulation. Skin .Float boot at all times, as resident will allow. Float boot at all times, as resident will allow (sic) .turn and reposition approximately every 2 hours as resident will allow. Turn and reposition approximately every 2 hours, as resident will allow (sic) .Bathing: CNA's (sic) to report (resident name) refusal for showers because the CNA he wants is not assigned to him and report to nurse. Nursing will discuss importance of showers and remind (resident name) that the CNA's (sic) assigned to his group will be providing showers . During an interview on 3/11/2020 at 10:00 AM, Director of Nursing (DON) B stated, (Resident #50) has been on an antibiotic for aspiration pneumonia. He was NPO (not by mouth) due to dysphasia (inability to swallow) and he had a feeding tube all related to a stroke. Someone gave him an apple and he ate it. His lungs did not sound good after a few days, so he was sent to the emergency room (ER) for evaluation. This happened the middle of (MONTH) right after he came back from previous hospital stay because he fell out of bed and fractured his hip. The fall happened during care; he moved his leg while the CNA was cleaning him up and it dragged him right over the edge of the bed. He has been pretty upset lately. First, he lost the use of his electric wheelchair; but he got it back. Then he fell out of bed on (MONTH) 1st of this last year (2019) and fractured his hip. He was and is in a lot of pain. He was at the hospital for about 2 weeks with that. Then when he came back to the facility, he aspirated. He has been NPO for a long time. We just had an IDT (interdisciplinary team) meeting with him, his wife, and speech therapy. It was about him not being able to eat food. He failed his swallow study. He is upset he can't eat. Those are three things that have happened lately that are bothering him. I talk to him, but nothing is documented. Observed on 3/12/2020 at 9:02 AM, Unit Manager/Registered Nurse (UM) FF rolling Resident #50 onto his right side to edge of bed in preparation of wound dressing changes. Resident #50 repeatedly stated in an anxious tone of voice throughout dressing changes, Don't drop me, don't drop me. Don't let me fall. Resident #50's left arm was dangling between UM FF and edge of bed. During an interview on 3/12/2020 at 3:20 PM Social Services (SS) GG stated, (SS X) and I do daily rounds with all residents and ask generalized questions, like, How are you doing? Our staff is pretty good at knowing their residents. During an observation and interview on 3/13/2020 at 9:40 AM, Resident #50 sought out surveyor and requested to speak in private. Resident #50 stated, I want to talk to you about a fall I had. They (referring to the facility) are making it sound like it was my fault. I was getting care from a CNA and when he went to the other side of the bed, I fell out of bed, landed on my left hip and fractured it. The doctor told me the 2 balls in the hip socket were broken. I could have surgery but at my age I might not come out of it so I didn't have the surgery. I'm in quite a bit of pain and waiting for my hip to heal. I'm supposed to have two staff to move me with a Hoyer (mechanical lift). The CNA was trying to clean me up by himself and reached over the top of me. I was lying in my bed and the CNA had the bed away from the wall. He was on my left side between the wall and my bed. I was lying on my right side on the edge of the bed. I started to fall off the edge of the bed and the CNA tried to grab me and couldn't catch me. I fell on to my left hip and 2 balls broke in the hip and it hurts quite a bit. Staff forget about my hip and throw me around. Do I feel safe? It's alright but I get worried I'll fall again. Staff move me around with a Hoyer. When staff move my leg around it feels like something moves around in my hip. I have to wait for it to heal. I was supposed to go for a swallow test but I was in the hospital with the [MEDICAL CONDITION]. I did get a swallow test last week. The speech therapist came to my room with supper. She stayed for about 15 minutes. I was never so disappointed in my life. She gave me a spoonful of carrots, which by the way, I hate carrots. She and also gave me a tablespoon of thickened water. The water went down fine. I feel like the staff don't care about the fall and what happened to me. The staff doesn't say anything to me about it. I hurt. During an interview on 3/13/2020 at 10:30 AM SS X stated, I talk to (Resident #50) at care conferences with him and his wife. Most recently about his swallow study and that he can't eat food now. I go around in the halls and talk to my residents but in a non-formal way. I don't document those conversations. I don't have anything documented about talking to him regarding his fall. He has never said anything about being upset. During an interview on 3/13/2020 at 1:18 PM SS X stated, (Resident #50) should be on palliative care. The progress note dated 12/20/2020 indicated the nurse practitioner asked if a referral may be needed for hospice services and (Resident #50) was currently on palliative care. When (Resident #50) came back from his hospital stay I would have gone through hospital records and would have seen at that time if he was on palliative care. The social worker here at the facility would make the referral for palliative care or hospice. I don't know who does the follow-up with continuing palliative care here at the facility. The social services reevaluation on 1/4/2020 indicates Admissions told me (Resident #50) was on hospice/palliative care. The social worker provides the care plan to evaluate depression or anxiety the resident is experiencing. The evaluation is used to see if there are services the resident would like. All care plans have goals and interventions. At this time, surveyor requested from Nursing Home Administrator (NHA) A palliative care plans for Resident #50. No palliative care plans were received by exit of survey. During an interview on 3/13/2020 at 1:47 PM, Physical Therapist (PT) WW, stated, I know (Resident #50). On 12/14/2019 he came back from the hospital due to a fall. I remember he was in a lot of pain when he came back due to the fracture of his left hip. He had previous left sided weakness from an old [MEDICAL CONDITION]. He had deficients from [MEDICAL CONDITION] pain in the hip with a resting pain of 4 out of 10. Moving pain was 8 out of 10 from an evaluation on 12/16/2019. His transfers and bed mobility are total assistance from staff. As a therapist, I can roll him in bed by myself, but floor staff/nursing would be different because I know what to do. For bed mobility (Resident #50) was a total assist from staff; meaning he is not helping at all and the staff would have to move him entirely with rolling right to left and sitting at the edge of bed. Therapy did a care giver education with direct care staff for him to be rolled toward the person giving care. (Resident #50) is a high risk of falling and therapy never recommended him to be rolled away from the person giving care. There were four CNAs that therapy picked that worked frequently with him. Those CNAs were given the training on how to roll him with the [MEDICAL CONDITION] and the other leg being previously amputated. Therapy expected the unit manager to have all the CNAs trained to train other staff and to also put it on the care plan. After the fall with fracture his pain was high, and he required two staff for bed mobility. Therapy saw him in 2019 only after the fall with fracture. During an interview on 3/13/2020 at 2:25 PM Director of Nursing (DON) B stated, The importance of communication is you can't operate the facility without it. Staff must know what is going on with the residents. I expect the unit managers (UM) to know their residents. The UMs and nursing staff can look through care plans, Kardex, along with H & P (history and physical documents) and family. The importance of care plans and the Kardex is they are what drives the care for the CNAs (certified nursing assistants). The care plan tells all staff specifically what the resident needs, wants, and prefers. The care plan starts with the admitting nurse, who drives the baseline care plan. The nursing evaluation drives the baseline care plan and then the IDT (interdisciplinary team) and further nursing evaluations tweaks and adds to the comprehensive care plan. The importance of care plan inventions is what works for the resident. Staff changes the care plan when the interventions don't work. During an interview on 3/13/2020 at 2:25 PM Director of Nursing (DON) B stated, (Resident #50's) fall could have been prevented. I reenacted the incident with the CNA that was involved. The CNA could have waited for another staff before he started care. The resident was rolled onto his right side. The CNA then stepped to the head-of-bed (HOB) to pull the fitted sheet to the opposite top corner. The CNA moved the bed away from the wall so he could get around to that corner of the HOB. (Resident #50) was still on his right side and his left moved and that momentum carried him over the edge of the bed and onto the floor. When the CNA demonstrated the incident, the resident was not that close to the edge of bed. It was when (Resident #50's) left leg moved over and it carried him off the bed. Care plan interventions state there should be two staff for bed mobility turning. Therapy evaluated the resident for turning. I believe (Resident #50) requires 2 staff persons for care. I talked to (Resident #50), he went through a difficult time because of not having his electric wheelchair for a time. He also had a difficult time because of not being able to eat due to his aspiration pneumonia. I talked to him again about not being able to eat. He was upset because therapy was not being positive about him being able to eat again and must use his feeding tube. He and I talked about working on his eating. He is very sad, upset, and mad. Social services were in the meeting as well. (Resident #50) is being seen by psychiatry and is on an antidepressant. This documentation is all in the nurses notes and should be on his Kardex. Staff should know their resident. During an interview on 3/13/2020 at 3:00 PM Unit Manager (UM) FF stated, I try to be as familiar as I can with all residents. I know (Resident #50). He does not like to turn for care; he has a fear of falling. The thought of falling is scary for him during the time he is getting turned. (Resident #50) was rolled away from the CNA when he fell out of bed, not towards the CN[NAME] There is an open space when you roll a resident away from you. That is staff is to roll the resident towards you to keep them safe from falling. (Resident #50) did say to me during the wound dressing change you observed yesterday (referring to the surveyor), Don't drop me. I reassured him I wouldn't drop him. The facility doesn't have nay care plans or Kardex for psychosocial stuff. I don't hand psychological behaviors; that is someone's else's job. I don't deal with that stuff. I did not know (Resident #50) was afraid or anxious about the fall he had from his bed. I don't think it is messing with his quality of care. I don't see him being anxious about falling. I think is acting anxious during wound dressing change is him trying to get staff to hurry his care. He is fine when his care is done. I don't see his comment of Don't drop me as messing with his quality of life. I didn't know about his [MEDICAL CONDITION]. Yes, he is one of the residents I am responsible for. I don't see a difference in the way to care for him. (Resident #50) care is easy. I've done it by myself. You undo the bed's brake, move the bed so you can get between it and the wall, and put the brake back on. There is no intervention for his care that I am aware of. There is no new care for (Resident #50). There is just the normal care for him, no special rolling. Therapy has to assess safety for all residents. Using the reasonable person concept, although Resident #50 had a BIMS of 15, Resident #50 did not have want his feelings to be disregarded by nursing staff when 1. he fell out of bed and was told it was his fault for his leg falling and dragging him over causing a [MEDICAL CONDITION], 2. when he voiced his concern regarding therapy's and physician's orders [REDACTED]. nursing intervention to not be in an activity with food or be around others that are eating. Resident #50 was able to voice some evidence of harm, and it is reasonable to anxiety with anxiety and helplessness due to the possibility of being harmed during cares and staff's disregard of his painful hip, communicated his concerns with care and treatment, diminishing his level of confidence in the quality of care and respect he receives from staff during care, desire to eat and drink, or to be around others that can, which could increase the potential for even more increased anxiety and depression that he could express in non-compliant behavior(s), and feelings of hopelessness.

Based on observation, interview and record review, the facility failed to provide appropriate/timely psychosocial support for emotional health concerns for 1 resident (Resident #50) of 12 residents reviewed for negative psychosocial outcomes, after Resident #50 fell from bed sustaining a serious injury, aspirated on food resulting in hospitalization , and could no longer eat, resulting in potential of psychosocial distress, increased anxiety, and recurrent fear of falling from bed. Findings include: According to the State Operations Manual Psychosocial Outcome Severity Guide, Anxiety refers to the apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness, or somatic symptoms of tension. Somatic symptoms of tension may include, but are not limited to, restlessness, irritability, hyper- vigilance, an exaggerated startle response, increased muscle tone, and teeth grinding. The focus of anticipated danger may be internal or external. Depressed mood (which does not necessarily constitute [MEDICAL CONDITION]) is indicated by negative statements; self-deprecation; sad facial expressions; crying and tearfulness; withdrawal from activities of interest; and/or reduced social interactions .Humiliation refers to a feeling of shame due to being embarrassed, disgraced, or depreciated. Some individuals lose so much self-esteem through humiliation that they become depressed. Review of facility policy Behavior Management dated 10/2019, revealed, Policy The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors. Overview Guests/residents with behavioral symptoms or those receiving psychoactive medications are evaluated, monitored, and managed by an interdisciplinary behavior management team including, but not limited to, facility clinical staff (nursing staff, social worker/social service staff, and activity staff) physician and pharmacist. The IDT works with the guest/resident and/or family/legal representative to determine an appropriate plan of care to identify the cause of the behavior and/or treat the behavioral symptoms. It is essential that behaviors be recognized as a form of communication, rather than as a random, unpredictable or meaningless event. Attempting to identify causes of behaviors will assist with developing the appropriate plan, with appropriate interventions, to respond to these behaviors Certain behavior may be anticipated and sometimes may be preventable based on understanding the underlying causes and possible triggers for each individual. Definitions Behavior: The response of an individual to a wide variety of factors, generated through brain function, which is in turn influenced by input from the rest of the body. Specific behavioral responses depends on many factors, including personal experience and past learning, inborn tendencies and genetic traits, the environment and response to the actions and reactions of other people .Behavioral Interventions: Individualized approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a guest's/guest's/resident's distress or loss of abilities. Person-Centered Care: Care that is individualized by being tailored to all relevant considerations for that individual, including physical, functional and psychosocial aspects .Practice Guidelines: .4. The IDT, in collaboration with the practitioner, guest/resident and/or family, will evaluate the guest's/resident's behavior for cause identification. Attempt to identify possible risk and causal/contributing factors for behaviors such as: .Changes in customary routine (i.e. a new caregiver, change to daily routine such as medication, meal or shower times) .loss of independence .residents receiving counseling will be reviewed until guest's/resident's psychosocial well-being is stable and documentation by the psychiatrist/psychologist reflects the stability of the guest's/resident's psychological status .5. To aid with cause identification, the IDT will attempt to determine: When did the behavior begin? What happened in sequence leading to the behavior? Who or what affected the behavior? Frequency of the behavior exhibited? Duration of the behavior? What happened over time with the display of the behavior? Consequences of the behavior? (impact on self .) Include related items such as .thought content, attention, .How has the behavior impacted the guest's/resident's quality of life .6. The IDT will implement a care plan with the guest/resident and/or guest/resident representative or update existing care plan, with interventions that target behavioral symptoms, identified causes, guest/resident specific goals and guest/resident specific behaviors .Behavior care plans will be established for those with behaviors related to dementia, mental illness or other needs. Interventions will include specific non-pharmacological interventions and behavior management strategies developed specifically for the guest/resident. The IDT will review and revise the plan of care at least quarterly, or with change in condition, and update interventions and goals, as appropriate. The care plan review should include, but is not limited to: effectiveness of nonpharmacological interventions and pharmacological interventions . Review of an Admission Record revealed Resident #50 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 2/11/2020, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #50 was cognitively intact. Further review of the MDS indicated Resident #50 required extensive assistance of two-person physical assist for positioning while in bed. Review of Resident #50's Incident and Accident Report dated 12/1/2019 revealed, The resident was noted laying close to the edge of the bed while being changed by the CNA (certified nursing assistant). As the CNA was pulling the old linen from underneath the resident, the resident's weight shifted causing the resident to roll off the edge of the bed .The resident was noted to have a great deal of pain to the L (left) hip .Fall Description Details .7. What type of assistance was resident receiving at time of fall? Assisted per care plan . Post Fall Evaluation .Care Plan/Kardex Updated New Interventions after IDT (interdisciplinary team) review: same to use second person if need to go to the other side of bed . Review of Resident #50's Order Summary Report dated 1/3/2020 revealed an active dietary order was put in place indicating Nothing By Mouth diet, Nothing By Mouth texture, Nothing By Mouth consistency. Further review of Resident #50's Order Summary Report revealed on 12/29/2019 an order was placed for Bilateral heel suspension with pillow, along with Turning and repositioning schedule every 2 hours. On 2/12/2020 a Video swallow study was ordered with ST (speech therapy) to eval (evaluate) only ordered on [DATE]. Review of Resident #50's Care Plan revealed, Focus: Mood .has history has the potential for fluctuations in mood possibly related to dx (diagnosis) of depression, multiple medical dx, he can become upset by yelling/screaming at others, and rarely will come out of his room or participate in activities .revision on: 2/28/2020 .Goals: .Will not have increased symptoms of depression through next review as evidenced by no increase PHQ scored .revision on: 3/11/2020 .Target Date: 5/13/2020 .Interventions .arrange for psych consult, follow up as indicated, .Revision on 11/02/2015. Further review of the Mood Care Plan indicated on 10/5/2016 an intervention was created and initiated to Attempt non-pharmacological interventions to decrease mood exacerbation: such as .provide reassurance, offer food/beverage, . Review of Order Summary Report dated 1/3/2020 indicating Resident #50 was to have Nothing By Mouth was not revised on the care plan. Review of Resident #50's Care Plan ADL Self-Care Performance Deficit revealed, Focus: .requires assistance with ADL's (activities of daily living) and mobility r/t (related to) progression Disease Process(sic) . Revision on: 12/28/2019 .Goals: .will maintain current level of function in bed mobility, .toilet use and personal hygiene through the review date. Date Initiated: 1/20/2019 Interventions .Bed Mobility: Extensive x 2 assist .Revision on 12/31/2019 . The revision for Resident #50's goal of maintaining current level of function did not have a revision until after the start of the abbreviated survey. Further review of the ADL care plan revealed bed mobility x 2-person assist had been an intervention since (YEAR). An intervention was initiated, created, and revised on 1/9/2020, Hip Precautions when rolling resident and repositioning, keep left leg in line with left hip (as tolerated), when (resident name) is on his back, prop the left knee up with pillow under the knee and wedge to the outside of the knee to maintain leg position. Resident #50 returned from the hospital with a left fracture hip on 12/14/2019. Review of Resident #50's Care Plan revealed, Focus: Behavior .refuses his showers d/t (due to) resident preferring certain staff to give him a shower, his showers are scheduled accordingly. Date initiated and created: 1/10/2015 .Further review of the care plan revealed there were no Goals or Interventions documented to support or reflect the person-centered care needs of the resident. Review of Resident #50's Kardex revealed, Resident Care: Keep in middle of bed as much as he will allow. Keep left lower extremity as stable as possible when turning and repositioning .right above-knee amputation .Turn and reposition q2 hours and PRN as will allow .Safety: Use another person on the other side of the bed if needed to put linens on .Bed Mobility: float heels as resident will allow .Bed Mobility: Hip precautions when rolling resident and repositioning, keep left leg in line with left hip (as tolerated), when (resident name) is on his back, prop the left knee up with pillow under the knee and wedge to the outside of the knee to maintain leg position .Mobility: Bed Mobility: Extensive x 2 (person) assist .Resident Care (company name Only) Calf buddy in place as patient allows .Monitoring (company name Only) Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .Activities: Encourage resident not to attend food related activities as it is upsetting to see others eating .Behavior/Mood .Attempt non-pharmacological interventions to decrease mood exacerbation: such as; assist in repositioning, provide reassurance, offer food/beverage, .attempt diversional activities, attempt to change environment/decrease stimulation. Skin .Float boot at all times, as resident will allow. Float boot at all times, as resident will allow (sic) .turn and reposition approximately every 2 hours as resident will allow. Turn and reposition approximately every 2 hours, as resident will allow (sic) .Bathing: CNA's (sic) to report (resident name) refusal for showers because the CNA he wants is not assigned to him and report to nurse. Nursing will discuss importance of showers and remind (resident name) that the CNA's (sic) assigned to his group will be providing showers . During an interview on 3/11/2020 at 10:00 AM, Director of Nursing (DON) B stated, (Resident #50) has been on an antibiotic for aspiration pneumonia. He was NPO (not by mouth) due to dysphasia (inability to swallow) and he had a feeding tube all related to a stroke. Someone gave him an apple and he ate it. His lungs did not sound good after a few days, so he was sent to the emergency room (ER) for evaluation. This happened the middle of (MONTH) right after he came back from previous hospital stay because he fell out of bed and fractured his hip. The fall happened during care; he moved his leg while the CNA was cleaning him up and it dragged him right over the edge of the bed. He has been pretty upset lately. First, he lost the use of his electric wheelchair; but he got it back. Then he fell out of bed on (MONTH) 1st of this last year (2019) and fractured his hip. He was and is in a lot of pain. He was at the hospital for about 2 weeks with that. Then when he came back to the facility, he aspirated. He has been NPO for a long time. We just had an IDT (interdisciplinary team) meeting with him, his wife, and speech therapy. It was about him not being able to eat food. He failed his swallow study. He is upset he can't eat. Those are three things that have happened lately that are bothering him. I talk to him, but nothing is documented. Observed on 3/12/2020 at 9:02 AM, Unit Manager/Registered Nurse (UM) FF rolling Resident #50 onto his right side to edge of bed in preparation of wound dressing changes. Resident #50 repeatedly stated in an anxious tone of voice throughout dressing changes, Don't drop me, don't drop me. Don't let me fall. Resident #50's left arm was dangling between UM FF and edge of bed. During an interview on 3/12/2020 at 3:20 PM Social Services (SS) GG stated, (SS X) and I do daily rounds with all residents and ask generalized questions, like, How are you doing? Our staff is pretty good at knowing their residents. During an observation and interview on 3/13/2020 at 9:40 AM, Resident #50 sought out surveyor and requested to speak in private. Resident #50 stated, I want to talk to you about a fall I had. They (referring to the facility) are making it sound like it was my fault. I was getting care from a CNA and when he went to the other side of the bed, I fell out of bed, landed on my left hip and fractured it. The doctor told me the 2 balls in the hip socket were broken. I could have surgery but at my age I might not come out of it so I didn't have the surgery. I'm in quite a bit of pain and waiting for my hip to heal. I'm supposed to have two staff to move me with a Hoyer (mechanical lift). The CNA was trying to clean me up by himself and reached over the top of me. I was lying in my bed and the CNA had the bed away from the wall. He was on my left side between the wall and my bed. I was lying on my right side on the edge of the bed. I started to fall off the edge of the bed and the CNA tried to grab me and couldn't catch me. I fell on to my left hip and 2 balls broke in the hip and it hurts quite a bit. Staff forget about my hip and throw me around. Do I feel safe? It's alright but I get worried I'll fall again. Staff move me around with a Hoyer. When staff move my leg around it feels like something moves around in my hip. I have to wait for it to heal. I was supposed to go for a swallow test but I was in the hospital with the [MEDICAL CONDITION]. I did get a swallow test last week. The speech therapist came to my room with supper. She stayed for about 15 minutes. I was never so disappointed in my life. She gave me a spoonful of carrots, which by the way, I hate carrots. She and also gave me a tablespoon of thickened water. The water went down fine. I feel like the staff don't care about the fall and what happened to me. The staff doesn't say anything to me about it. I hurt. During an interview on 3/13/2020 at 10:30 AM SS X stated, I talk to (Resident #50) at care conferences with him and his wife. Most recently about his swallow study and that he can't eat food now. I go around in the halls and talk to my residents but in a non-formal way. I don't document those conversations. I don't have anything documented about talking to him regarding his fall. He has never said anything about being upset. During an interview on 3/13/2020 at 1:18 PM SS X stated, (Resident #50) should be on palliative care. The progress note dated 12/20/2020 indicated the nurse practitioner asked if a referral may be needed for hospice services and (Resident #50) was currently on palliative care. When (Resident #50) came back from his hospital stay I would have gone through hospital records and would have seen at that time if he was on palliative care. The social worker here at the facility would make the referral for palliative care or hospice. I don't know who does the follow-up with continuing palliative care here at the facility. The social services reevaluation on 1/4/2020 indicates Admissions told me (Resident #50) was on hospice/palliative care. The social worker provides the care plan to evaluate depression or anxiety the resident is experiencing. The evaluation is used to see if there are services the resident would like. All care plans have goals and interventions. At this time, surveyor requested from Nursing Home Administrator (NHA) A palliative care plans for Resident #50. No palliative care plans were received by exit of survey. During an interview on 3/13/2020 at 1:47 PM, Physical Therapist (PT) WW, stated, I know (Resident #50). On 12/14/2019 he came back from the hospital due to a fall. I remember he was in a lot of pain when he came back due to the fracture of his left hip. He had previous left sided weakness from an old [MEDICAL CONDITION]. He had deficients from [MEDICAL CONDITION] pain in the hip with a resting pain of 4 out of 10. Moving pain was 8 out of 10 from an evaluation on 12/16/2019. His transfers and bed mobility are total assistance from staff. As a therapist, I can roll him in bed by myself, but floor staff/nursing would be different because I know what to do. For bed mobility (Resident #50) was a total assist from staff; meaning he is not helping at all and the staff would have to move him entirely with rolling right to left and sitting at the edge of bed. Therapy did a care giver education with direct care staff for him to be rolled toward the person giving care. (Resident #50) is a high risk of falling and therapy never recommended him to be rolled away from the person giving care. There were four CNAs that therapy picked that worked frequently with him. Those CNAs were given the training on how to roll him with the [MEDICAL CONDITION] and the other leg being previously amputated. Therapy expected the unit manager to have all the CNAs trained to train other staff and to also put it on the care plan. After the fall with fracture his pain was high, and he required two staff for bed mobility. Therapy saw him in 2019 only after the fall with fracture. During an interview on 3/13/2020 at 2:25 PM Director of Nursing (DON) B stated, The importance of communication is you can't operate the facility without it. Staff must know what is going on with the residents. I expect the unit managers (UM) to know their residents. The UMs and nursing staff can look through care plans, Kardex, along with H & P (history and physical documents) and family. The importance of care plans and the Kardex is they are what drives the care for the CNAs (certified nursing assistants). The care plan tells all staff specifically what the resident needs, wants, and prefers. The care plan starts with the admitting nurse, who drives the baseline care plan. The nursing evaluation drives the baseline care plan and then the IDT (interdisciplinary team) and further nursing evaluations tweaks and adds to the comprehensive care plan. The importance of care plan inventions is what works for the resident. Staff changes the care plan when the interventions don't work. During an interview on 3/13/2020 at 2:25 PM Director of Nursing (DON) B stated, (Resident #50's) fall could have been prevented. I reenacted the incident with the CNA that was involved. The CNA could have waited for another staff before he started care. The resident was rolled onto his right side. The CNA then stepped to the head-of-bed (HOB) to pull the fitted sheet to the opposite top corner. The CNA moved the bed away from the wall so he could get around to that corner of the HOB. (Resident #50) was still on his right side and his left moved and that momentum carried him over the edge of the bed and onto the floor. When the CNA demonstrated the incident, the resident was not that close to the edge of bed. It was when (Resident #50's) left leg moved over and it carried him off the bed. Care plan interventions state there should be two staff for bed mobility turning. Therapy evaluated the resident for turning. I believe (Resident #50) requires 2 staff persons for care. I talked to (Resident #50), he went through a difficult time because of not having his electric wheelchair for a time. He also had a difficult time because of not being able to eat due to his aspiration pneumonia. I talked to him again about not being able to eat. He was upset because therapy was not being positive about him being able to eat again and must use his feeding tube. He and I talked about working on his eating. He is very sad, upset, and mad. Social services were in the meeting as well. (Resident #50) is being seen by psychiatry and is on an antidepressant. This documentation is all in the nurses notes and should be on his Kardex. Staff should know their resident. During an interview on 3/13/2020 at 3:00 PM Unit Manager (UM) FF stated, I try to be as familiar as I can with all residents. I know (Resident #50). He does not like to turn for care; he has a fear of falling. The thought of falling is scary for him during the time he is getting turned. (Resident #50) was rolled away from the CNA when he fell out of bed, not towards the CN[NAME] There is an open space when you roll a resident away from you. That is staff is to roll the resident towards you to keep them safe from falling. (Resident #50) did say to me during the wound dressing change you observed yesterday (referring to the surveyor), Don't drop me. I reassured him I wouldn't drop him. The facility doesn't have nay care plans or Kardex for psychosocial stuff. I don't hand psychological behaviors; that is someone's else's job. I don't deal with that stuff. I did not know (Resident #50) was afraid or anxious about the fall he had from his bed. I don't think it is messing with his quality of care. I don't see him being anxious about falling. I think is acting anxious during wound dressing change is him trying to get staff to hurry his care. He is fine when his care is done. I don't see his comment of Don't drop me as messing with his quality of life. I didn't know about his [MEDICAL CONDITION]. Yes, he is one of the residents I am responsible for. I don't see a difference in the way to care for him. (Resident #50) care is easy. I've done it by myself. You undo the bed's brake, move the bed so you can get between it and the wall, and put the brake back on. There is no intervention for his care that I am aware of. There is no new care for (Resident #50). There is just the normal care for him, no special rolling. Therapy has to assess safety for all residents. Using the reasonable person concept, although Resident #50 had a BIMS of 15, Resident #50 did not have want his feelings to be disregarded by nursing staff when 1. he fell out of bed and was told it was his fault for his leg falling and dragging him over causing a [MEDICAL CONDITION], 2. when he voiced his concern regarding therapy's and physician's orders [REDACTED]. nursing intervention to not be in an activity with food or be around others that are eating. Resident #50 was able to voice some evidence of harm, and it is reasonable to anxiety with anxiety and helplessness due to the possibility of being harmed during cares and staff's disregard of his painful hip, communicated his concerns with care and treatment, diminishing his level of confidence in the quality of care and respect he receives from staff during care, desire to eat and drink, or to be around others that can, which could increase the potential for even more increased anxiety and depression that he could express in non-compliant behavior(s), and feelings of hopelessness.

This citation pertains to intake number MI 0207. Based on observation, interview, and record review, the facility failed to ensure the safety of 1 (Resident # 103) of 4 residents reviewed for accidents and hazards out of a total sample of 4 residents when a Certified Nurse Aide (CNA) failed to follow the care plan, resulting in a fall, a laceration to the head requiring staples, and an emergency room (ER) visit. Findings include: Resident # 103 Resident # 103 was an [AGE] year old female who originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment with a reference date of 10/17/18 revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated Resident # 103 was cognitively intact. Review of Section G revealed Resident # 103 required limited assistance with one staff member for transfers and ambulation in her room. Review of the MDS ADL Self Performance section under Coding revealed, 2.) Limited Assistance: Resident is highly involved in activity; staff provide guidance, maneuvering of limbs or other non-weight bearing assistance. Review of an Incident/Accident report dated 1/1/19 revealed the fall occurred in the resident's room at 6:00 a.m. The incident report indicated, CNA weighted resident in weight chair, after she helped her up, then she took the weight chair back, then she said she heard a noise and went back into the room and (Resident # 102) on back on the floor- resident left standing with walker when she took the chair back. (sic) Laceration to back of head/sent to hospital for evaluation. Res was in bed resting- CNA (CNAM) woke her up to weigh her after weighing her she left her standing with walker while she took the chair back. New Intervention after IDT review: Follow Kardex Review of a CT head without contrast result 1/1/19 revealed, FINDINGS: .5 . Right posterior parietal stapled soft tissue laceration. Review of the CNA Kardex dated 1/9/19 revealed, Mobility: Ambulation: With staff with (Front Wheeled Walker) FFW and gait belt on and with limited assist. Transfer: Resident requires assistance with transfers with one staff assistance. Review of an Activities of Daily Living (ADL) care plan intervention revealed, AMBULATION: With staff with FWW and gait belt on and with limited assist. 10/31/17 On 1/9/19 at 2:46 PM (CNA M) was called on cell phone. The voicemail box was full. Her home phone was called, and voicemail was left with return call instructions. In an interview on 1/9/19 at 4:02 PM CNAs H and J and Licensed Practical Nurse (LPN) F reported that stand-by assistance is when you are close in proximity, but the residents are doing the work. Limited assistance is when you are offering non-weight bearing assistance. CNA H stated, We look to the kardex to know what each resident needs. CNA J stated, You never leave them alone if it's standby or limited assistance. In an interview on 1/9/19 at 4:05 PM, Therapy Director O stated, In neither stand-by or limited can you leave them alone. Only in independent or modified independent can you leave them alone. In an observation and interview on 1/9/19 at 4:12 PM Resident # 103 was at rest, awake in her recliner and her daughter was on the bed. Resident # 103 smiled and conversed easily. Resident # 103 reported she could not remember the fall or events that led to the fall, but stated, I guess I was standing and the staff member left me. Review of an Educational Opportunity for CNA M dated 1/3/19, revealed, Facts surrounding educational opportunity: Failed to follow Kardex information of resident in regards to transfer/ambulation status. Failed to stay with resident that was a limited assist resident . Supervisor comments: Read Kardex prior to care. You follow Kardex directions in regards to care. If do not understand directions you are to clarify with prior to doing care. Failure to follow Kardex information will result in disciplinary action. On 1/1/19, the facility identified the instance of noncompliance and took the following measure to correct the deficiency: 1. The facility identified CNA M failed to implement the Resident #103's care plan/Kardex for limited assistance. 2. On 1/3/19, CNA M received 1 on 1 education regarding the facility's expectations for reading and using the Kardex and follow the information for resident care. 3. On 1/1/19 the facility identified other residents who have the potential to be affected and reviewed the Kardex's for accuracy. 4. Beginning 1/1/19, the facility provided education to all nursing staff regarding the need to consistently implement the care plan/Kardex for each resident. All staff received education prior to working the next schedule shift. The education was completed by 1/2/19. 5. Beginning 1/1/19, the Director of Nursing/designee began audits of transfer/ambulation status of the residents that will be conducted weekly for a month then monthly thereafter. The results of the audits will be reported to the quality assurance committee. During the onsite survey from 1/7/19-1/9/19, this surveyor discovered no current noncompliance in regards to falls or care plan/Kardex implementation. Observations and interviews with nursing staff confirmed they had received education regarding care plan/Kardex implementation. Audits that had started were reviewed. Resident #103 had no known long [MEDICATION NAME] physical, mental, or psychosocial effects related to the fall. A past non-compliance was granted with a compliance date of 1/3/19.

This citation pertains to Intake # MI 199. Based on interview, and record review, the facility failed to ensure that sufficient pain management was provided in 1 of 3 residents (Resident #103) reviewed for pain management, from a total sample of 3, resulting in uncontrolled pain after a fall with a [MEDICAL CONDITION]. Findings include: Review of the policy and procedure for Pain Management, revised 8/16, revealed .The facility will evaluate and identify residents for pain, determine the type, location and severity and develop a care plan for pain management .Pain is an unpleasant sensory and emotional experience that can be acute, recurrent, or persistent .The pain experience is very subjective; pain is whatever the resident says it is .A comprehensive evaluation of pain includes .The resident's goals for pain management and his or her satisfaction with the current level of pain control .residents will be monitored for the presence of pain and be evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected .Following the pain evaluation notify the physician if indicated and implement new orders as received .The licensed nurse will communicate any new onset of resident pain or change in resident pain to the physician . Review of a facility provided resource from Lippincott Procedures online, used to guide physician notification, titled Change in status, identifying and communicating, long-term care, revised 5/18, revealed .In a long-term care setting, it's important to identify and address any change in a resident's status from baseline .Upon recognition of a potentially life-threatening condition or a significant change in status, you must communicate with other health care providers to meet the resident's needs .Particular changes to note include a decline in functional status, new or increasing confusion, incontinence .acute onset of pain .deteriorating mobility, falls, and behavior changes .A change in status can happen rapidly in minutes or slowly over hours or days. The condition may manifest as a change in cognition, such as [MEDICAL CONDITION], or a physical change, such as an alteration in vital signs .As a nurse, you're responsible for communicating a resident's change in status, including the assessment findings, to the practitioner . Review of an Admission Record revealed Resident #103 was a [AGE] year-old male, originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/25/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated that Resident #103 was cognitively intact. Further review of Resident #103's MDS assessment, with a reference date of 9/25/18, revealed Resident #103 took scheduled pain medications, and had frequent pain in the five days prior to the reference date, rated as a 5/10 at it's worst. Review of an Incident and Accident Report, revealed Resident #103 had a fall out of his bed and was observed by staff on the floor at 4:15 a.m. on 11/6/18. Per the report, type of injury was listed as .unknown . with the details .assessed but STAT (left) hip xray ordered due to c/o (complaints of) pain 6/10 has decreased ROM (range of motion) @ (at) baseline . Details included .At time immediately following fall only pain c/o was 6/10 to (left) hip STAT (left) hip xray ordered . Further review of the Incident and Accident Report for Resident #103's fall on 11/6/18, revealed Physician R was notified of the fall on 11/6/18 at 4:45 a.m., and an order was obtained for a STAT left hip X-ray. Review of a Progress Note for Resident #103 written by RN H, dated 11/6/18, revealed .0415 (4:15 a.m.) Called to room by (Certified Nursing Assistant (CNA) N) .Upon entering room resident was observed laying on his L (left) side facing the underneath of his bed with his head resting on the palm side of his L hand. He stated that he rolled over in bed and then fell on to the floor. He states he is having pain in his L hip that he rates at 6/10. At baseline resident has limited extension and flexion ROM (range of motion) at the bilat (bilateral) hip and knee. This made it difficult to assess any change in the length of his L leg in relation to suspected fracture or injury .Neuro assessment was at resident's baseline upon initial assessment. BP (blood pressure) 103/75 .By the time resident was placed back in bed it was 0430 (4:30 a.m.). DON (Director of Nursing) notified at this time and due to original c/o of (sic) pain to L hip area was advised to get order for STAT L hip xray when speaking with MD (physician) on call. Spoke to Physician R at 0445 (4:45 a.m.). Obtained order for STAT L hip xray 1 view. Spoke with (staff name) at (radiology service name) at approx. (approximately) 0530 (5:30 a.m.) and placed STAT 1 view L hip xray .AT (sic) 0630 (6:30 a.m.) resident started to c/o on (sic) increasing pain severity and L hip area. He was also unable to tell me the correct year when he was able to do so upon initial assessment Area assessed again and no change noted from previous physical assessment other than report of increase in pain .At approx. 0645 (6:45 a.m.) this RN noted that resident BP had dipped down into low 90's SBP (systolic blood pressure) and that his pain level was noted to have been gradually increasing in severity since time of fall. This RN asked if he would like to be sent to ER (emergency room ) due to his pain and because this nurse thought due to his fluctuation in blood pressure, increase in pain and slight change in orientation to current year that he could benefit from more in depth testing. Informed resident that he could have injured himself more extensively when he fell and that we did not have the ability to do all the proper testing in the proper time frame to establish the full extent of his injuries he may have sustained. Informed him that he would benefit from better pain management due to theER on site doctors who could order him something stronger. It should also be noted that Resident had refused to take his scheduled Tylenol at 0630 (6:30 a.m.) because he stated that it would not do him a bit of good due to his current pain status. Still at 0700 (7:00 a.m.) He was rating pain at 9/10 and is refusing Tylenol and refusing to go to ER. At 0715 (7:15 a.m.) report was given to on coming shift nurse. Advised her that STAT L hip xray had been ordered but had not at that time been completed .At 0815 (8:15 a.m.) resident stated that his L hip pain was the now (sic) 'the worst pain I have ever had in my life' .Spoke with (Assistant Director of Nursing (ADON) C) and she spoke with resident again regarding going to the ER and he agreed. Due to resident's now 10/10 pain .911 was called for a more emergent transfer .Voicemail left for MD on call notifying of decision to transfer. STAT L hip xray cancelled (sic) with (radiology service name) as they had not been out to perform test as of yet .Family at bedside awaiting arrival of ambulance. At 0935 (9:35 a.m.) ambulance arrived and resident was taken to (hospital name) ER . In an interview on 11/29/18 at 4:52 p.m., CNA N reported that she was not assigned to Resident #103 at the time of his fall on 11/6/18. CNA N reported that at approximately 4:15 a.m., as she walked down the hall, she heard Resident #103 singing that he had fallen onto the floor. CNA N entered the room and observed Resident #103 on the floor, and then immediately notified RN H. CNA N reported that she and RN H assisted Resident #103 back into bed after RN H completed an assessment. In an interview on 11/30/18 at 11:59 a.m., CNA K reported that she was Resident #103's assigned CNA at the time of his fall on 11/6/18. CNA K reported that RN H notified her that Resident #103 had fallen while she was on break. CNA K reported that she went in to check on Resident #103 after the fall and noted that his brief was wet. CNA K stated .He was in so much pain I couldn't clean him up .he wouldn't let me touch him . CNA K reported that she notified RN H of the pain and her inability to change Resident #103's wet brief several times before the end of her shift. In an interview on 11/30/18 at 8:35 a.m., RN H reported that she was notified by CNA N that Resident #103 was on the floor beside his bed at approximately 4:15 a.m. on 11/6/18. RN H reported that she assessed Resident #103 but wasn't confident about his baseline physical status. RN H reported that Resident #103 complained of moderate pain, rated as a 6 out of 10, that was originally generalized but then became localized to his left hip. RN H reported that she did not offer anything at the time of the fall for pain because Resident #103 had scheduled Tylenol that he could take as early as 5:00 a.m., and the resident agreed to wait until that time to take the medication. RN H notified Director of Nursing (DON) B of Resident #103's fall and was directed to contact the physician for an X-ray of Resident #103's hip to rule out a fracture. RN H reported that the physician was contacted and an order was obtained for a left hip X-ray due to increased pain. When RN H returned at 5:00 a.m., Resident #103 was asleep, therefore she did not wake him to take the Tylenol. RN H reported that when Resident #103's pain began to increase she .said he should probably go to the hospital .he really didn't want to go . RN H reported that Resident #103 had scheduled Tylenol for 6:00 a.m. but he refused it because per the resident, .it wouldn't help . RN H stated .I made it clear, the ER can give better stuff for pain . RN H reported that when Resident #103 refused the Tylenol, she also noted a change in his mental status and blood pressure. RN H reported that she did not contact the physician about Resident #103's increase in pain at 6:30 a.m., and stated .because at that point, what would he (the physician) have done? He (the physician) could have ordered something for pain, but by the time we did that he (Resident #103) could be at the ER . RN H reported that she was going to attempt an ice pack as a non-pharmacological intervention to help with Resident #103's pain but .I just couldn't find them . RN H reported that at the time Resident #103 refused the Tylenol, she gave report and .passed the baton . to the oncoming shift nurse, RN G. RN H reported that the physician was not contacted in regard to Resident #103's increased pain, refusal of pain medication, change in mental status, change in blood pressure, and refusal to be transferred to the ER because .I wanted someone else to assess him .I wanted somebody there (at the facility) .I would have called him (the physician) if he (Resident #103) kept refusing .we all eventually did agree that he (Resident #103) should go out (to the ER) .it was not very long after that before he went out .didn't seem like that long after 7:00 (a.m.) that he was sent . RN H reported that for PRN (as needed) pain medication orders a prescription must be sent to the pharmacy and and authorization to pull must be obtained. RN H stated .It could literally take hours .by the time he would have that script (prescription) we could have him at the hospital getting pain meds . Note that Resident #103 was not sent out to the ER until after 9:00 a.m., approximately 5 hours after he was observed on the floor of his room and almost 3 hours after reports of increased pain, a change in mental status, and a change in blood pressure were identified by facility staff. In an interview on 11/30/18 at 1:36 p.m., RN G reported that she worked first shift on 11/6/18 and received report from RN H in regard to Resident #103's fall. RN G reported that RN H notified her of Resident #103's increased pain and refusal of Tylenol for pain. RN G reported that when she checked on Resident #103, he was guarding his left side and declined her offer of Tylenol which was .what we had at the time . RN G stated that in regard to Resident #103's increased pain and refusal of Tylenol .We usually contact the doctor right away .the night nurse was kind of behind because of the fall .we were going to get a new med but then he was being sent out . RN G reported that the physician should be notified .right away any time we (the nurses) notice something that needs further intervention . In an interview on 11/30/18 at 12:29 a.m. CNA O reported that she was assigned to Resident #103 for first shift on 11/6/18. CNA O reported that she attempted to change Resident #103's brief when she arrived, but .He said he couldn't do it . CNA O reported that Resident #103 told her he was hurting .really bad . and stated .He wouldn't let me touch him he was in so much pain . Review of a Progress Note for Resident #103 written by ADON C, dated 11/6/18, revealed .Prior being sent out to ER this nurse approached resident asking what happened and it was stated he rolled out of bed and landed on the floor. The night shift nurse that was caring for him approached this nurse approx. 0830 (8:30 a.m.) stating resident was starting to have a change since the fall and is now having increase pain, and some confusion. This nurse asked resident if he would like to be sent out and he stated 'No, what are they going to do there that you can't do here'. I explained to him if it (hip) was fractured the hospital would be able treat it and control his severe pain that he is now experiencing. I asked why he refused the Tylenol and he stated 'it will do nothing for this kind of pain'. Resident finally agreed to be sent out . In an interview on 11/30/18 at 10:30 a.m., ADON C reported that she arrived at the facility on 11/6/18 at approximately 8:15 a.m. and was notified of Resident #103's fall and increased pain by RN H. ADON C reported that when she entered Resident #103's room .He was in the fetal position .He told me his pain was so severe Tylenol wouldn't work . ADON C reported that Resident #103 initially refused to go to the hospital, but later agreed and was sent out .within the hour . ADON C stated .We maintained his (Resident #103) comfort as much as we could . ADON C reported that if a resident refuses a pain medication and complains of increased pain, the physician should be contacted to obtain a new order. In an interview on 11/28/18 at 10:55 a.m., Family Member Q reported that Resident #103 had a fall on 11/6/18 and was found on the floor of his room by a staff member at 4:15 a.m. Family Member Q reported that upon arrival to the facility on [DATE] at approximately 9:15 a.m., Resident #103 was .in a lot of pain. He was begging for pain meds . Review of an Order Summary Report for Resident #103, printed 11/29/18, revealed an order for [REDACTED].[MEDICATION NAME] Patch 5% Apply to lower back topically in the morning for pain and remove per scheduled . with a start date of 6/28/18 and no end date. No other pain medication orders were noted for Resident #103 on 11/6/18. Review of a Care Plan for Resident #103, closed 11/20/18, revealed .(Resident #103) is at risk for pain r/t (related to) has back pain . with the goal .(Resident #103) will verbalize adequate relief of pain or ability to cope with incompletely relieved pain . and interventions which included .Administer [MEDICATION NAME] per physician's orders [REDACTED]. initiated 7/2/18. Review of a Medication Administration Record [REDACTED].[MEDICATION NAME] Tablet 325 mg Give 2 tablet by mouth every 8 hours for pain . scheduled for 6:00 a.m. on 11/6/16, was documented as refused by Registered Nurse (RN) H. No other pain medications were were documented as administered or offered on 11/6/18. Review of a MAR for Resident #103, dated (MONTH) (YEAR), revealed .assess pain every shift for pain level . Per the MAR, Resident #103's pain level was documented as 0/10 for all shifts from 11/1/18 through evening shift on 11/5/18. No pain level was documented on the night shift from 11/5/18 to 11/6/18 (the night of Resident #103's fall out of bed). Review of a Nursing Home to Hospital Transfer Form for Resident #103, dated 11/6/18, revealed .Resident rolled out of bed, landed on left side, didn't complain of severe pain until 2 hours after. Refused to go to hospital but was encouraged to go . Review of a Post Fall Evaluation for Resident #103, completed 11/6/18 at 4:15 a.m., revealed .Alert (and) mildly confused at times. At baseline is oriented to self, place, and the year but not the correct month or date and is a little confused as to situation . Review of a Care Plan for Resident #103, closed 11/20/18, revealed .(Resident #103) is at risk for decline in cognition or impaired thought processes d/t (due to) being a new admission and psych dx (diagnosis) of major [MEDICAL CONDITION]/anxiety to which could have an effect on his cognition (sic) . with interventions which included .Observe and report to MD (physician) any changes in cognitive function including but not limited to decision making ability, memory, changes in baseline, recall and general awareness, difficulty expressing self, difficulty understanding . initiated 7/2/18. In an interview on 11/30/18 at 12:45 p.m., Physician R reported that he is typically notified when a resident has a fall, and should be contacted for any increase in pain, and changes in mental status and vital signs. Physician R reported that if a resident were to refuse pain medications the nurse should contact the physician to obtain an order for [REDACTED]. Review of a Patient Care Report for Resident #103, obtained electronically from the ambulance service provider, revealed that on 11/6/18 an ambulance was dispatched to the facility at 9:22 a.m. and arrived at the facility at 9:34 a.m. Per the report, Resident #103 complained of bilateral hip pain from a fall out of his bed at 4:00 a.m., and Resident #103 was .unable to straighten either legs (sic) without pain 10/10 on pain scale . In an interview on 11/30/18 at 12:59 p.m., Ambulance Staff U stated in regard to Resident #103's transfer to theER on [DATE] .He was in an extreme amount of pain when we got there .He could hardly move . In an interview on 11/30/18 at 2:39 p.m., DON B reported that she was notified of Resident #103's fall by RN H via phone at approximately 4:30 a.m. on 11/6/18. DON B reported that she directed RN H to contact the physician for a STAT X-ray order. DON B reported that if a resident refuses a pain medication, the nurse should try to offer something else. If nothing else is available, the physician should be contacted. Review of an EMR (Electronic Medical Record) Report, obtained from the hospital where Resident #103 was transported on 11/6/18, revealed X-ray results, dated 11/6/18, .Mildly displaced and impacted [MEDICAL CONDITION] femoral neck .

This citation pertains to intake # MI 199. Based on interview and record review, the facility failed to immediately notify the resident's physician of a change in condition in 1 of 3 residents (Resident #103) reviewed for physician notification, from a total sample of 3, resulting in uncontrolled pain and delayed transport to the emergency room after a fall with a [MEDICAL CONDITION]. Findings include: A licensed nurse shall, in a complete and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and 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 (MONTH) 19, 2011, from http://www.hgexperts.com/article.) Review of a facility provided resource from Lippincott Procedures online, used by facility staff to guide physician notification, titled Change in status, identifying and communicating, long-term care, revised 5/18, revealed .In a long-term care setting, it's important to identify and address any change in a resident's status from baseline .Upon recognition of a potentially life-threatening condition or a significant change in status, you must communicate with other health care providers to meet the resident's needs .Particular changes to note include a decline in functional status, new or increasing confusion, incontinence .acute onset of pain .deteriorating mobility, falls, and behavior changes .A change in status can happen rapidly in minutes or slowly over hours or days. The condition may manifest as a change in cognition, such as [MEDICAL CONDITION], or a physical change, such as an alteration in vital signs .As a nurse, you're responsible for communicating a resident's change in status, including the assessment findings, to the practitioner . Review of the policy and procedure for Pain Management, revised 8/16, revealed .The facility will evaluate and identify residents for pain, determine the type, location and severity and develop a care plan for pain management .Pain is an unpleasant sensory and emotional experience that can be acute, recurrent, or persistent .The pain experience is very subjective; pain is whatever the resident says it is .A comprehensive evaluation of pain includes .The resident's goals for pain management and his or her satisfaction with the current level of pain control .residents will be monitored for the presence of pain and be evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected .Following the pain evaluation notify the physician if indicated and implement new orders as received .The licensed nurse will communicate any new onset of resident pain or change in resident pain to the physician . Review of an Admission Record revealed Resident #103 was a [AGE] year-old male, originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/25/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated that Resident #103 was cognitively intact. Further review of Resident #103's MDS assessment, with a reference date of 9/25/18, revealed Resident #103 took scheduled pain medications, and had frequent pain in the five days prior to the reference date, rated as a 5/10 at it's worst. Review of a Care Plan for Resident #103, closed 11/20/18, revealed .(Resident #103) is at risk for decline in cognition or impaired thought processes d/t (due to) being a new admission and psych dx (diagnosis) of major [MEDICAL CONDITION]/anxiety to which could have an effect on his cognition (sic) . with interventions which included .Observe and report to MD (physician) any changes in cognitive function including but not limited to decision making ability, memory, changes in baseline, recall and general awareness, difficulty expressing self, difficulty understanding . initiated 7/2/18. Review of an Incident and Accident Report, revealed Resident #103 had a fall out of his bed and was observed by staff on the floor at 4:15 a.m. on 11/6/18. Per the report, type of injury was listed as .unknown . with the details .assessed but STAT(immediate) (left) hip xray ordered due to c/o (complaints of) pain 6/10 has decreased ROM (range of motion) @ (at) baseline . Details included .At time immediately following fall only pain c/o was 6/10 to (left) hip STAT (left) hip xray ordered . Further review of the Incident and Accident Report for Resident #103's fall on 11/6/18, revealed Physician R was notified of the fall on 11/6/18 at 4:45 a.m., and an order was obtained for a STAT left hip X-ray. No new orders for pain medication were obtained at this time by Registered Nurse (RN) H. Review of a Progress Note written by RN H for Resident #103, dated 11/6/18, revealed .0415 (4:15 a.m.) Called to room by (Certified Nursing Assistant (CNA) N) .Upon entering room resident was observed laying on his L (left) side facing the underneath of his bed with his head resting on the palm side of his L hand. He stated that he rolled over in bed and then fell on to the floor. He states he is having pain in his L hip that he rates at 6/10. At baseline resident has limited extension and flexion ROM (range of motion) at the bilat (bilateral) hip and knee. This made it difficult to assess any change in the length of his L leg in relation to suspected fracture or injury .Neuro assessment was at resident's baseline upon initial assessment. BP (blood pressure) 103/75 .By the time resident was placed back in bed it was 0430 (4:30 a.m.). DON (Director of Nursing) notified at this time and due to original c/o of (sic) pain to L hip area was advised to get order for STAT L hip xray when speaking with MD (physician) on call. Spoke to Physician R at 0445 (4:45 a.m.). Obtained order for STAT L hip xray 1 view. Spoke with (staff name) at (radiology service name) at approx. (approximately) 0530 (5:30 a.m.) and placed STAT 1 view L hip xray .AT (sic) 0630 (6:30 a.m.) resident started to c/o on (sic) increasing pain severity and L hip area. He was also unable to tell me the correct year when he was able to do so upon initial assessment. Area assessed again and no change noted from previous physical assessment other than report of increase in pain .At approx. 0645 (6:45 a.m.) this RN noted that resident BP had dipped down into low 90's SBP (systolic blood pressure) and that his pain level was noted to have been gradually increasing in severity since time of fall. This RN asked if he would like to be sent to ER (emergency room ) due to his pain and because this nurse thought due to his fluctuation in blood pressure, increase in pain and slight change in orientation to current year that he could benefit from more in depth testing. Informed resident that he could have injured himself more extensively when he fell and that we did not have the ability to do all the proper testing in the proper time frame to establish the full extent of his injuries he may have sustained. Informed him that he would benefit from better pain management due to theER on site doctors who could order him something stronger. It should also be noted that Resident had refused to take his scheduled Tylenol at 0630 (6:30 a.m.) because he stated that it would not do him a bit of good due to his current pain status. Still at 0700 (7:00 a.m.) He was rating pain at 9/10 and is refusing Tylenol and refusing to go to ER. At 0715 (7:15 a.m.) report was given to on coming shift nurse. Advised her that STAT L hip xray had been ordered but had not at that time been completed .At 0815 (8:15 a.m.) resident stated that his L hip pain was the now (sic) 'the worst pain I have ever had in my life' .Spoke with (Assistant Director of Nursing (ADON) C) and she spoke with resident again regarding going to the ER and he agreed. Due to resident's now 10/10 pain .911 was called for a more emergent transfer .Voicemail left for MD on call notifying of decision to transfer. STAT L hip xray cancelled (sic) with (radiology service name) as they had not been out to perform test as of yet .Family at bedside awaiting arrival of ambulance. At 0935 (9:35 a.m.) ambulance arrived and resident was taken to (hospital name) ER . In an interview on 11/30/18 at 11:59 a.m., CNA K reported that she was Resident #103's assigned CNA at the time of his fall on 11/6/18. CNA K reported that RN H notified her that Resident #103 had fallen while she was on break. CNA K reported that she went in to check on Resident #103 after the fall and noted that his brief was wet. CNA K stated .He was in so much pain I couldn't clean him up .he wouldn't let me touch him . CNA K reported that she notified RN H of the pain and her inability to change Resident #103's wet brief several times before the end of her shift. In an interview on 11/30/18 at 8:35 a.m., RN H reported that she was notified by CNA N that Resident #103 was on the floor beside his bed at approximately 4:15 a.m. on 11/6/18. RN H reported that she assessed Resident #103 but wasn't confident about his baseline physical status. RN H reported that Resident #103 complained of moderate pain, rated as a 6 out of 10, that was originally generalized but then became localized to his left hip. RN H reported that she did not offer anything at the time of the fall for pain because Resident #103 had scheduled Tylenol that he could take as early as 5:00 a.m., and the resident agreed to wait until that time to take the medication. RN H reported that the physician was contacted and an order was obtained for a left hip X-ray due to increased pain. RN H reported that the physician was contacted initially to be notified of Resident #103's fall, and then shortly after to obtain an order for [REDACTED].I wanted somebody there (at the facility) .I would have called him (the physician) if he (Resident #103) kept refusing .we all eventually did agree that he (Resident #103) should go out (to the ER) .it was not very long after that before he went out .didn't seem like that long after 7:00 (a.m.) that he was sent . RN H reported that for PRN (as needed) pain medication orders a prescription must be sent to the pharmacy and and authorization to pull must be obtained. RN H stated .It could literally take hours . Resident #103 was not sent out to the ER until after 9:00 a.m., approximately 5 hours after he was observed on the floor of his room and almost 3 hours after reports of increased pain, a change in mental status, and a change in blood pressure were identified by facility staff. In an interview on 11/30/18 at 1:36 p.m., RN G reported that she worked first shift on 11/6/18 and received report from RN H in regard to Resident #103's fall. RN G reported that RN H notified her of Resident #103's increased pain and refusal of Tylenol for pain. RN G reported that when she checked on Resident #103, he was guarding his left side and declined her offer of Tylenol which was .what we had at the time . RN G stated that in regard to Resident #103's increased pain and refusal of Tylenol .We usually contact the doctor right away .I think everything happened so quickly because of change of shift .the night nurse was kind of behind because of the fall .we were going to get a new med but then he was being sent out . RN G reported that the physician should be notified .right away any time we (the nurses) notice something that needs further intervention . In an interview on 11/30/18 at 12:29 a.m. CNA O reported that she was assigned to Resident #103 for first shift on 11/6/18. CNA O reported that Resident #103 told her he was hurting .really bad . and stated .He wouldn't let me touch him he was in so much pain . In an interview on 11/30/18 at 10:30 a.m., ADON C reported that she arrived at the facility on 11/6/18 at approximately 8:15 a.m. and was notified of Resident #103's fall and increased pain by RN H. ADON C reported that when she entered Resident #103's room .He was in the fetal position .He told me his pain was so severe Tylenol wouldn't work . ADON C reported that if a resident refuses a pain medication and complains of increased pain, the physician should be contacted to obtain a new order. ADON C reported that the physician should also be contacted if a resident refuses an emergent hospital transfer. In an interview on 11/28/18 at 10:55 a.m., Family Member Q reported that Resident #103 had a fall on 11/6/18 and was found on the floor of his room by a staff member at 4:15 a.m. Family Member Q reported that upon arrival to the facility on [DATE] at approximately 9:15 a.m., Resident #103 was .in a lot of pain. He was begging for pain meds . Review of a MAR for Resident #103, dated (MONTH) (YEAR), revealed .assess pain every shift for pain level . Per the MAR, Resident #103's pain level was documented as 0/10 for all shifts from 11/1/18 through evening shift on 11/5/18. No pain level was documented on the night shift from 11/5/18 to 11/6/18 (the night of Resident #103's fall out of bed). In an interview on 11/30/18 at 12:45 p.m., Physician R reported that there are two systems for physician notification. Staff may call and leave a message to notify him of changes if the situation is not emergent, or he can be paged if immediate action is needed. Physician R reported that he is typically notified when a resident has a fall, and should be contacted for any increase in pain, and changes in mental status and vital signs. Physician R reported that if a resident were to refuse pain medications the nurse should contact the physician to obtain an order for [REDACTED]. In an interview on 11/30/18 at 2:39 p.m., DON B reported that she was notified of Resident #103's fall by RN H via phone at approximately 4:30 a.m. on 11/6/18. DON B reported that if a resident refuses a pain medication, the nurse should try to offer something else. If nothing else is available, the physician should be contacted. DON B reported that the physician should be notified if a resident refuses a transfer to the ER.

This citation pertains to MI 345. Based on observation, interview and record review the facility failed to prevent, monitor and treat the development of pressure wounds for 1 supplemental resident (#56) and 1 resident (#50) out of 6 evaluated for pressure ulcers from a total sample of 6 resulting in the development of painful, stage 2 pressure ulcers on the sacrum for resident #50 and painful, stage 2 pressure ulcers on the back of the heel for Resident #56. Findings include: Resident #50 According to the facility admission record Resident #50 was a [AGE] year old female admitted tot he facility on 3/24/14 for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 6/30/14, Resident #50 had significant memory impairment, unclear speech, rarely understood, sometimes understood others, rejected cares and was verbally abusive to others. Resident #50 required the assist of 1 staff for pushing her wheel chair, dressing, eating, hygiene and toileting, and the assist of 2 staff for bed (change position), transfers and bathing. Resident #50 was incontinent of bowel and bladder. According to information found online at http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm, a pressure ulcer is an area of skin that breaks down when something keeps rubbing or pressing against the skin. You are more likely to get a pressure ulcer if you use a wheelchair or stay in bed for a long time, are an older adult, cannot move certain parts of your body without help, have a disease that affects blood flow, including diabetes or vascular disease, have fragile skin, have dementia, have urinary incontinence and have poor nutrition. According to the admission nurse's notes, dated 3/24/13, "Skin assessment indicates resident (#50) has two scars from healed bed sores to her right buttock". The admission assessment, undated, contains anatomical drawings of a person. From the posterior (back) view, 2 areas are blackened and measurements indicated for the scarred areas as follows: coccyx, 2 X 2 centimeters (cm) and right buttock area near the gluteal fold, 3 X 2.5 cm. According the the facility's "Resident Care Guide", dated 3/24/14 and used by the Certified Nurse Assistants (CNA) to know how to care for each resident, Resident '#50 was checked as being incontinent of bowel and bladder and 1 assist with bed mobility. Under the section, "Risk Factors", the item "pressure ulcer development" was not checked. According to the care plan, dated 4/11/14, Resident #50 was frequently incontinent of bowel and bladder, and the intervention was, "assist with toileting and incontinence (sic) care prn (as needed)". On the care plan, dated 4/29/14, for Resident #50's risk of urinary tract infection was, "Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas". According to labwork, dated 3/16/14, Resident # 50 had the following below normal results which contribute to the formation of pressure wounds: -[MEDICATION NAME] - 3.1, (normal = 3.5 - 5.5). -hemoglobin - 11.3, (normal = 13 - 18). -blood urea nitrogen - 14, (normal = 20 - 40). On the care plan, dated 5/8/14, for Resident #50's stage 2 (blister or open area on skin, surrounding area may be red and irritated) pressure ulcers to the right buttock included, "provide pressure relieving mattress to protect skin while in bed, provide air cell w/c (wheel chair) cushion to protect the skin while up in chair, Educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry. use lotion on dry skin, observe location, size and treatment of [REDACTED]. to MD (physician), obtain blood work as ordered by Physician, treatment to skin impairment (SPECIFY) per order. On 8/5/14, at 9:30 a.m., during a phone interview, Resident #50's daughter reported that on Friday, 5/23/14, she was told by the wound nurse that (Resident #50) had 5 small sores on her bottom from moisture. According to the "Order Summary Report (physician's orders [REDACTED].#50 was to have protective ointment zinc to buttocks every shift. According to untitled facility notes, dated 7/4/14, Resident #50 was noted to have open areas on the left and right buttock. Missing, were measurements and appearance of the open areas. At the bottom of the note "2. The identified area(s) are: Existing Area(s)". Although requested, weekly skin checks of Resident #50's skin from 5/8/14 through 6/30/14 were not provided by Wound Nurse "E" by end of survey. No weekly facility notes of this type were provided for the following week by end of survey on 8/8/14 According to untitled facility notes, dated 7/15/14, Resident #50 was noted to have an open area on the right buttock from an existing area. Again, there were no measurements or description of the open area, nor was the left buttock mentioned. On 7/17/14, the wound nurse wrote a note as follows, "Treatments to excoriated areas from moisture to buttocks have been treated with....which all small openings noted (less than 0.5 cm X 0.5 cm X 0.1 cm) have closed. Also assessed was the right buttock, and decision made to send resident #50 to the wound clinic to rule out possible cyst as area is excoriated with small amount of serous drainage noted". According to untitled facility notes, dated 7/22/14, Resident #50 was noted to have open areas on the coccyx and right gluteal fold. The comments, which did not state which area, described, "pressure ulcer with yellow slough, reddish pink tissue approx. (approximately) 2 cm X 5 cm. The area at the bottom of the note, "2. There was no description at the bottom of the note. According to untitled facility notes, dated 7/25/14, Resident #50 was noted to have an open area on the sacrum, described as, "open with yellow green center, moderate red drainage. 11 cm X 10 cm X 0.1 cm". The area at the bottom of the note described the area as new. On a progress notes, dated 7/31/14, was reflected, "wound noted on 7/28/14. the wound is as follows: Sacrum - pressure: Length = 6 cm, Width = 9.5 cm, Depth = 0.2 cm, - State 2, The wound's progress is Deteriorated...Resident experienced pain relating to the wound...small amount of brown non-viable (dead) tissue present at right upper wound edge. Deterioration from previously noted superficial excoriation". On 8/5/14, at 9:30 a.m., Resident #50's daughter was interviewed via phone. The daughter reported that on some occasions when the call light was activated or the daughter asked for staff to change Resident #50's brief, she would be reminded by the nursing staff that they were busy. resident #50's daughter and was told by an aide, "(Resident #50) is not assigned to me", when waiting for someone to change Resident #50's wet/soiled briefs, or take her to the bathroom. The daughter reported that a nurse told her, "I'm busy right now, someone will come". On 8/8/14 at 1:55 p.m., Certified Nurse Assistant (CNA) "L" was interviewed. When asked, CNA "L" recalled that Resident #50's sores on her bottom were quite painful, especially when up in her wheel chair, "as soon as we got her up, (Resident #50) wanted to go right back to bed". When asked, CNA "L" said that Resident #50 did receive pain medications that helped the pain. On 8/8/14 at 2:25 p.m., Wound Nurse "E" was interviewed. When asked if residents are turned regularly, Wound Nurse "E" said that she believes they are, "I try to watch, but I have residents all over the facility". Wound Nurse "E" agreed that Resident #50's pressure wounds were due to maceration or moisture, as the wound doctor wrote in his progress note, dated 7/29/14. ( ) Resident #56 According to the admission record, Resident #56 was a [AGE] year old male admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the minimum data set (resident assessment), dated 6/2/14, Resident #56 had moderate memory impairment, resisted cares, usually understood, had disorganized thinking and could be verbally aggressive with staff and residents. According to information found online at http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm, a pressure ulcer is an area of skin that breaks down when something keeps rubbing or pressing against the skin. You are more likely to get a pressure ulcer if you use a wheelchair or stay in bed for a long time, are an older adult, cannot move certain parts of your body without help, have a disease that affects blood flow, including diabetes or vascular disease, have fragile skin, have dementia... According to an untitled facility document, dated 7/19/14, a 0.3 centimeter (cm) X 0.5 cm open blister developed on the back (not bottom) of Resident #56's left heel and was identified as a new area. No new interventions were care planned to keep pressure off the heel while Resident #56 self-propelled his wheelchair. Daily dressing changes were ordered. There was no documentation, at all, on Resident #56's untitled facility document, dated 7/26/14. A review of Resident #56's care plan reflected no interventions for monitoring the feet and heels, especially because of the way he dug his heels in to self-propel his wheel chair. According to progress notes for Resident #56, dated 8/1/14, "...wound's progress is Not changed...Care plan update was performed...Resident experiencing pain relating to the wound". On 8/4/14 at 2:00 p.m., Resident #56 was observed as he self-propelled his wheelchair in the hall by digging the heels of his tan-colored shoes into the floor. Resident #56 was dressed in pants, shirt and a sweater, and was neatly groomed. He smiled and chatted with this surveyor. On 8/5/14 at 2:00 p.m., Resident #56 was observed with a tan shoe on his right foot and a blue sticky sock on his left foot. When asked why he was wearing the sock, Resident #56 said that he had, "apparently, developed a sore on his heel", and was given the sock to wear instead of his shoe. Resident #56 mentioned that the sock made it quite painful to propel his wheelchair as he did (walking on his heels), but the nurses were taking care of the sore. On 8/7/14 at 10:20 a.m., Wound Nurse "E" was observed as she changed Resident #56's heel dressing in his room. Resident #56's left foot was observed to be much more swollen than the right foot. After the dressing was removed and cleansed with sterile saline, during which Resident #56 repeatedly made comments of "ouch"and "it's sore", Wound Nurse "E" measured the wound as follows: 1.3 cm X 0.9 cm X 0.1 cm. Wound Nurse "E" said that the surrounding area of the wound was larger and darker today. Resident #56 was provided with an off-load boot to keep his heel off any surfaces and free of pressure, and the care plan was updated. When asked about the 2 week gap in monitoring of Resident #56's heel wound, Wound Nurse "E" said that she was unsure since she was not in the building at the time, but she thought she recalled the wound was a scrape at the onset, not a blister or open area. On 8/8/14, Assistant Director of Nurses (ADON) "C" was able to explain the lack monitoring for Resident #56's heel pressure wound on or around 7/26/14. When the nurse first documented the pressure wound and the dressing change on 7/20/14, she wrote the order as, "Cleanse left heel area with saline...cover with bandaid daily for 7 days then reevaluate and discontinue", and failed click a box on the electronic medical record system that would remind nursing to reevaluate on 7/27/14. There was no documentation that Resident #56's heel wound was assessed or dressed until 12 days later, on 8/1/14. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND TREATMENT TO PREVENT PRESSURE ULCERS FOR 3 OF 6 RESIDENTS (#1,3, 17) AND 1 SUPPLEMENTAL RESIDENT (#25) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL 23 SAMPLED RESIDENTS, RESULTING IN A DEVELOPMENT OF AN AVOIDABLE LEFT BUTTOCK STAGE 4 PRESSURE ULCER ACCOMPANIED WITH SIGNIFICANT PAIN AND SIGNS AND SYMPTOMS OF INFECTION FOR RESIDENT #1, UNSTAGEABLE PRESSURE ULCERS FOR BILATERAL ISCHIAL (HIP) FOR RESIDENT #17, UNSTAGEABLE LEFT HEEL PRESSURE ULCER AND TWO STAGE 2 LEFT ISCHIAL PRESSURE ULCERS FOR RESIDENT #3, AND A STAGE 2 LEFT INNER ANKLE FOR RESIDENT #25. FINDINGS INCLUDE; THE BUREAU OF HEALTH CARE SERVICES, LONG TERM CARE DIVISION, DEPARTMENT OF LARA HAS IDENTIFIED "A SITUATION IN WHICH THE PROVIDER'S NONCOMPLIANCE WITH ONE OR MORE REQUIREMENTS OF PARTICIPATION HAS CAUSED OR IS LIKELY CAUSE, SERIOUS INJURY, HARM, IMPAIRMENT, OR DEATH TO A RESIDENT." (SEE 42 CFR PART 489.3). ON 11/28/12 AT 9:25 A.M., AN IMMEDIATE JEOPARDY WAS IDENTIFIED AT ROYALTON MANOR AS A RESULT OF RESIDENT #1 WHO HAS BEEN HARMED BY INCONSISTENT SKIN ASSESSMENT, MONITORING AND EVALUATION OF LEFT BUTTOCK WOUND THAT WAS FIRST IDENTIFIED ON 11/7/2012 AS A STAGE 2 (PARTIAL THICKNESS LOSS OF OUTER LAYER OF SKIN) AND DETERIORATED INTO A STAGE 4 (FULL THICKNESS TISSUE LOSS INVOLVING BONE, TENDON OR MUSCLE) PRESSURE ULCER. THE FACILITY FAILED TO RECOGNIZE AND ASSESS RISK FACTORS WHICH PLACED RESIDENT #1 AT RISK FOR DEVELOPING A PRESSURE ULCER, THOROUGHLY INVESTIGATE THE LEADING CAUSE OF NEWLY DEVELOPED PRESSURE ULCER AND FAILED TO IMPLEMENT APPROPRIATE INTERVENTIONS BY THE INTERDISCIPLINARY TEAM, ALLOWING THE PRESSURE ULCER TO FURTHER DETERIORATE. ON 11/30/12 AT 11:30 A.M., THE ADMINISTRATOR OF ROYALTON MANOR AND DIRECTOR OF NURSING (DON) WERE NOTIFIED OF IMMEDIATE JEOPARDY REGARDING RESIDENT #1 WITH A NEWLY ACQUIRED STAGE 4 LEFT BUTTOCK PRESSURE ULCER. THE FACILITY PRESENTED THE FOLLOWING MEASURES TO REMOVE THE IMMEDIATE JEOPARDY SITUATION: 1. RESIDENT #1'S LEFT BUTTOCK PRESSURE ULCER WAS EVALUATED BY THE MEDICAL DIRECTOR. 2. RESIDENT #1'S CARE PLAN AND INTERVENTIONS WERE REVIEWED, UPDATED AND CHANGES MADE. 3. NEW BRADEN SCALE FOR RESIDENT #1 WAS COMPLETED. 4. ORDERS FROM THE WOUND CLINIC PHYSICIAN FOR RESIDENT #1 WERE RECEIVED REGARDING WOUND STATUS AND FOLLOW-UP APPOINTMENT WAS MADE. 5. RESIDENT #1'S PAIN ASSESSMENT WAS COMPLETED ON 11/30/12. 6. THE FACILITY'S NURSES AND NURSE MANAGERS ARE COMPLETING A SKIN SWEEP OF ALL RESIDENTS, ASSESSING FOR ANY UNIDENTIFIED SKIN AREAS, AND REVIEWED ON 11/30/12. 7. THE FACILITY POLICY ON SKIN MANAGEMENT WAS REVIEWED BY THE INTERDISCIPLINARY TEAM AND CONDUCTED EDUCATION FOR 22 LICENSED STAFF WITH 13 REMAINING LICENSED STAFF SCHEDULED TO BE EDUCATED. 8. THE FACILITY WILL CONDUCT DAILY QUALITY ASSESSMENT AND ASSURANCE AUDITS AND SUBMIT FINDINGS TO THE QA COMMITTEE. EMPLOYEES WHO REGULARLY WORK AT THE FACILITY RECEIVED TRAINING BY 12/3/12 AT 3:00 P.M. AT WHICH TIME THE IMMEDIATE JEOPARDY WAS REMOVED, AND THE SCOPE WAS CHANGED TO ISOLATED AND THE SEVERITY OF ACTUAL HARM. ACCORDING TO THE MONTHLY physician's order [REDACTED]. ON 11/27/12 AT 11:00 A.M., DURING AN INITIAL TOUR, THE " NORTH " NURSING UNIT MANAGER, (STAFF "B" ) STATED RESIDENT #1 WAS admitted for REHABILITATION SERVICE BUT WOULD BE A LONG TERM CARE RESIDENT DUE TO HIS COMPLEX MEDICAL CONDITION. STAFF " B " ALSO STATED RESIDENT #1 HAD AN UNSTAGEABLE COCCYX (TAIL BONE) PRESSURE ULCER THAT HAD DEVELOPED AFTER HE WAS admitted TO THE FACILITY. RESIDENT #1 HAD GONE TO A DOCTOR'S OFFICE FOR AN APPOINTMENT AND WAS NOT AVAILABLE FOR AN INTERVIEW FOR MOST OF THE DAY. ON 11/28/12 AT 10:30 A.M., RESIDENT #1 STATED HE WAS AT THE FACILITY RECEIVING THERAPY AFTER HAVING A "DOUBLE" PNEUMONIA AT THE HOSPITAL. THE RESIDENT STATED HE COULD WALK WITH HIS WALKER DURING THE THERAPY, BUT HE COULD NOT WALK BY HIMSELF. RESIDENT #1 ALSO STATED HE HAD A MAJOR ACCIDENT INVOLVING HIS LEFT HIP ABOUT 8 YEARS AGO. SINCE THAT ACCIDENT THE RESIDENT STATED HE HAD TO WEAR "BUILD-UP" SHOE ON HIS LEFT FOOT. RESIDENT #1 EMPHASIZED THE FACT THAT HE ALWAYS HAD WEAKNESS ON HIS LOWER EXTREMITIES, ESPECIALLY ON HIS LEFT SIDE. THE ADMISSION "NURSING COMPREHENSIVE EVALUATION" FORM DATED 9/7/12 REFLECTED RESIDENT #1 WAS 5 FOOT 10 INCHES TALL AND WEIGHED 226.6 POUNDS. UNDER CARDIOVASCULAR SECTION RESIDENT #1 WAS DESCRIBED AS HAVING MILD SWELLING ON HIS BILATERAL LOWER LIMBS AND FEET. UNDER NEUROLOGICAL SECTION RESIDENT #1 WAS DESCRIBED AS ALERT, ORIENTED TO TIME, PLACE AND PERSON. HE WAS COOPERATIVE, HAD CLEAR SPEECH WITH ADEQUATE HEARING. THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED RESIDENT #1 HAD BIM ( BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 13 OUT OF 15 TOTAL SCORE, 15 BEING NO IMPAIRMENT WITH COGNITION. RESIDENT #1 WAS STATED AS HAVING WEAKNESS IN HIS LOWER LIMBS. UNDER ACTIVITIES OF DAILY LIVING SECTION RESIDENT #1 WAS DESCRIBED AS BEING INCONTINENT OF BOWEL AND BLADDER, REQUIRED 1 PERSON WITH TRANSFER ALTHOUGH "HOYER" WAS CHECKED FOR TRANSFER DEVICE, WAS NOT WEIGHT-BEARING, REQUIRED 2 ASSISTS WITH BED MOBILITY AND TOILETING NEEDS. UNDER THE SKIN SECTION RESIDENT #1 WAS DESCRIBED AS HAVING "LEFT HIP HEALED ULCER" AND "SOFT, MUSHY, RED" BILATERAL HEELS. THE BRADEN SCALE-FOR PREDICTING PRESSURE SORE RISK HAD TOTAL SCORE OF 15, REPRESENTING MILD RISK (12 OR LESS REPRESENTS HIGH RISK). THE SKIN CONDITION BY THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED RESIDENT #1 HAD NO PRESSURE ULCERS BUT WAS AT RISK OF DEVELOPING PRESSURE ULCERS. THE CARE PLAN INITIATED 9/20/12 REFLECTED RESIDENT #1 WAS "AT RISK FOR IMPAIRED SKIN INTEGRITY DUE TO DECREASED MOBILITY DUE TO HER (RESIDENT IS A MALE) AGE, INCONTINENCE AND PREFERENCE OF LIKING TO LAY ON HIS BACK IN WHICH HE STATED HE HAS DONE FOR YEARS." THE INTERVENTIONS INCLUDED "ASSIST WITH FREQUENT POSITION CHANGES, ENCOURAGE HIM TO LAY ON HIS SIDE, RESPECT REFUSAL EDUCATE PRN (AS NEEDED), BRADEN SCALE QUARTERLY, CUSHION TO WHEEL CHAIR, LABS AS ORDERED, MEDS AS ORDERED, PRESSURE RELIEVING MATTRESS, TREATMENTS AND SUPPLEMENTS AS ORDERED AND WEEKLY SKIN ASSESSMENT." THE CARE PLAN FAILED TO INCLUDE PERTINENT RISK FACTORS SUCH AS HAVING A HISTORY OF HEALED ULCER (STRONG PREDICTOR FOR RECURRENCE), SWELLING (STRONG PREDICTOR FOR SKIN BREAKDOWN) OF BOTH FEET AND ACUTE ILLNESS SUCH AS UPPER RESPIRATORY INFECTION, PNEUMONIA (INCREASES RISK) RESIDENT #1 HAD ON ADMISSION. THE "NURSING WEEKLY (HEAD-TO-TOE) SKIN ASSESSMENT" DATED 9/14/12 THROUGH 11/16/12 REFLECTED THE ASSESSMENTS WERE NOT DONE CONSISTENTLY (16 DAYS APART BETWEEN 10/3/12 AND 10/19/12, 9 DAYS APART BETWEEN 10/26/12 AND 11/4/12, 3 DAYS APART BETWEEN 11/9/12 AND 11/12/12), REGULARLY (11 ASSESSMENTS FROM 16 POTENTIAL SCHEDULED OPPORTUNITIES) AND HAD MINIMAL INFORMATION SUCH AS "BRUISES FROM INJECTION, RIGHT EAR ABRASION, WOUND LEFT BUTTOCK-TREATMENT IN PLACE." IN ADDITION, THERE WAS NO FURTHER "NURSING WEEKLY (HEAD-TO-TOE) SKIN ASSESSMENT" DOCUMENTATION AFTER 10/26/12. THE MEDICATION ADMINISTRATION RECORD (MAR) DATED SEPTEMBER THROUGH NOVEMBER 2012 REFLECTED EITHER OMISSION OR MISMATCHING OF CHECK BOXES FROM SEPARATE WEEKLY SKIN ASSESSMENTS. FOR EXAMPLE, WHEN THE "NURSING WEEKLY SKIN ASSESSMENT" FORM WAS COMPLETED ON 10/3/12 OR 11/4/12 THE WEEKLY SKIN ASSESSMENT ON MAR WAS CHECKED ON 10/5/12 OR 11/2/12. ON 11/28/12 AT 2:00 P.M., STAFF "B" STATED SHE HAD NOTICED THE DISCREPANCY OF ASSESSMENT DATES BUT WAS NOT ABLE TO EXPLAIN WHAT MAY HAVE BEEN THE REASON. IN ADDITION, THE DAILY MEDICARE CHARTING (CHECK BOXES OF EACH ORGAN SYSTEM) FROM 9/8/12 TO 10/30/12 AND FROM 11/24/12 TO 11/29/12 REFLECTED NO CHECK BOXES FOR SKIN, MEANING THE RESIDENT WAS NOT ASSESSED FOR HIS SKIN CONDITIONS AT ALL. STAFF "B" STATED MEDICARE CHARTING REQUIRED ONLY ONCE DAILY DOCUMENTATION WHETHER IT WAS DAY, AFTERNOON OR NIGHT SHIFT. FOR EXAMPLE, IF THE RESIDENT WAS CHARTED ON NIGHT SHIFT, THE ONLY PERTINENT EVENT THAT HAPPENED ON NIGHT WOULD BE CHARTED. ALTHOUGH RESIDENT #1 HAD SKIN ISSUES THAT MAY HAVE BEEN SIGNIFICANT IN TERMS OF POSITIONING OR THE RESIDENT'S ROUTINE HABITS ON DAY SHIFT, NONE OF THE DAY STAFF HAD DOCUMENTED ON DAY SHIFT COLUMN EXCEPT THE WOUND CARE NURSE ON A NARRATIVE NOTES. ON 11/28/12 AT 9:25 A.M., THE DRESSING CHANGE TO RESIDENT #1 ' S LEFT BUTTOCK WAS OBSERVED IN HIS ROOM. REGISTERED NURSE/WOUND CARE NURSE, (STAFF " A " ) STATED RESIDENT #1 HAD BEEN MEDICATED WITH NARCOTIC ( [MEDICATION NAME] 5/500 MG THREE TIMES DAILY AS NEEDED ordered on [DATE]) BECAUSE HE USUALLY HAD SIGNIFICANT PAIN WITH DRESSING CHANGES. STAFF "A" REMOVED "[MEDICATION NAME]" COVER DRESSING AND BEGAN TO PULL A LONG, HEAVILY SATURATED, OFFENSIVE ODOR BEARING GUAZE STRING FROM A ROUND DEEP HOLE ON THE RESIDENT'S LEFT BUTTOCK. THE WOUND LOOKED APPROXIMATELY 3 CM LONG AND 3 CM WIDE. STAFF "A" STATED SHE HAD NOTICED THE WOUND AS HAVING STRONG ODOR ON THANKSGIVING DAY (11/22/12), BUT WAS NOT ABLE TO COLLECT THE SPECIMEN DUE TO A LACK OF RIGHT SPECIMEN CONTAINERS. STAFF "A" STATED SHE FINALLY OBTAINED THE TUBINGS YESTERDAY (5 DAYS LATER) AND SENT IT TO THE LABORATORY. STAFF "A" CLEANSED THE WOUND WITH SALINE BUT IT WAS DIFFICULT TO DETERMINE HOW WELL THE WOUND WAS CLEANED BECAUSE THE BASE OF WOUND WAS TOO DEEP TO VISUALIZE CLEARLY. STAFF "A" COMPLETED DRESSING CHANGE BY INSERTING 12 INCH" MAXABSORB ALGINATE SILVER, ANTIMICROBIAL, " ROPE" (GAUZE STRING) INTO THE HOLE AND COVERED WITH "OPTIFORM" DRESSING. IMMEDIATELY AFTER THE DRESSING CHANGE STAFF "A" WAS ASKED WHAT MAY HAVE CAUSED RESIDENT #1'S LEFT BUTTOCK PRESSURE ULCER. STAFF "A" STATED SHE HAD NOTICED THE RESIDENT WAS UP LONG PERIODS OF TIME, USED ONE FOOT TO WHEEL HIMSELF IN HIS WHEELCHAIR, LEANED FORWARD AND DID NOT NOTIFY STAFF WHEN HE WAS INCONTINENT OF BOWEL AND BLADDER. STAFF "A" ADDED THAT SHE HAD ORDERED "AIR CELL" CUSHION AS WELL AS AIR MATTRESS WHEN SHE FIRST DISCOVERED THE WOUND ON 11/7/12. STAFF "A" ALSO STATED THE WOUND WAS QUICKLY PROGRESSING AND IT WAS AT A STAGE 4 WITH SIGNIFICANT DEPTH. HOWEVER, STAFF "A" CONTINUED TO STATE THAT THE DIRECTOR OF NURSING HAD A DISAGREEMENT ABOUT STAGING OF THE WOUND, INSTRUCTED HER NOT TO MARK AS A STAGE 4 AND NOT TO RECORD THE DEPTH OF WOUND. THE "NURSE'S NOTES" DATED 11/7/12 REFLECTED: "THIS NURSE (WOUND NURSE) ASSESSED SKIN ON BUTTOCKS THIS AM, NOTED STAGE 2 AREA LEFT BUTTOCKS APPROX 3.1 X 2.0 X < .1; 100 % RED, SMALL BAND OF PURPLE DISCOLORATION IN CENTER .5 X 2.0; AREAS D/T SHEARING TRAUMA, RES. BUTTOCKS SLIDES FORWARD IN W/C ... " THE WOUND " NURSE'S NOTES' DATED 11/12/12 REFLECTED: "AREA ON LEFT BUTTOCKS ASSESSED; INCREASED NECROTIC TISSUE; PERIWOUND INDURATED WITH [DIAGNOSES REDACTED]. ... " THE WOUND NURSE'S NOTE" DATED 11/15/12 REFLECTED: "THIS NURSE OBSERVED RES. IN HALLWAY; LEANING BACK WITH UPPER TORSO AND HIPS SLID FORWARD. RES. REPOSITIONED AND EDUCATED ON IMPORTANCE OF GETTING BUTTOCKS BACK INTO SEAT OF W/C TO PREVENT SHEARING PRESSURE ... " HOWEVER, THERE WAS NO REVIEW OF CARE PLAN TO INCLUDE THIS PERTINENT CAUSAL RISK FACTORS AS A PROBLEM OR INTERVENTIONS TO CORRECT THE PROBLEM. ON 12/3/12 AT 2:15 P.M., NURSE AIDE, (STAFF "N") STATED RESIDENT #1 USUALLY GOT UP AT 9:30 A.M. AND STAYED UP TILL 2-2:30 P.M., PUSHED HIMSELF IN HIS WHEELCHAIR AND FREQUENTLY SLID DOWN TO THE EDGES OF CHAIR. WHENEVER HE WAS PULLED UP IN HIS CHAIR HE WOULD SLIDE RIGHT BACK DOWN. HE WAS TRIED ON A CUSHION WITH A HUMP IN THE MIDDLE, BUT IT DID NOT HELP. STAFF "N" ADDED RESIDENT #1 PREFERRED EITHER SITTING UP IN BED TO WATCH TELEVISION OR LAID DOWN ON HIS BACK TO SLEEP. THE NURSES NOTE DATED 11/20/12 REFLECTED,: "RESIDENT HAS DECLINED IN TRANSFER STATUS, NOW REQUIRING 2 ASSIST. NOT WHEELING HIS W/C EVEN SHORT DISTANCES." THE NURSES NOTE DATED 11/22/12 REFLECTED: "DRESSING TO LEFT BUTTOCKS WOUND REMOVED BY THIS NURSE; NOTED WOUND OPEN WITH MODERATE DRG (DRAINAGE) OF PURULENT EXUDATE; SOFT TAN SLOUGH ADHERING TO WOUND BED AND LYING LOOSELY ON WOUND BED; ON 11/19/12 THIS NOTED INTACT NECROTIC TISSUE 10 % YELLOW SLOUGH 90 % MOIST BLACK ESCHAR. WOUND OPENING 2.0 X 2.2 X 3.7 ; UNDERMINING BEGINNING AT 9 O'CLOCK .8 CM AT 12 O'CLOCK 4.0 CM ENDING AT 2 O'CLOCK 2.0 CM...DOCTOR (DOCTOR'S NAME) HERE AT FACILITY AND SUMMONED IMMEDIATELY TO EVALUATE WOUND. REFERRAL TO WOUND CLINIC AND WOUND CULTURES TO BE OBTAINED ON 11/23/12." (THIS ENTRY WAS THE ONLY ENTRY THAT CONTAINED A MEASUREMENT OF DEPTH) THE physician's orders [REDACTED]. RESIDENT #1'S "TREATMENT TO WOUND LEFT BUTTOCK; CLEANSE, APPLY SUREPREP OPEN AREA TO PERIWOUND; APPLY EXUDERM DRESSING; CHANGE EVERY 3 DAYS AND AS NEEDED FOR SOILING OR DISLODGEMENT." THE NEXT PHYSICIAN'S TREATMENT ORDER WAS DATED 11/22/12 (15 DAYS LATER). THE ORDER STATED: 1) DISCONTINUE PREVIOUS TREATMENT TO LEFT BUTTOCK WOUND, 2) CLEANSE; PACK WITH CALCIUM ALGINATE WITH ALGINATE ROPE; COVER WITH OPTIFORM DRESSING, 3) CHANGE DAILY. THE INITIAL SKIN TREATMENT ORDER FOR CALMAZYME OINTMENT TO BUTTOCKS AND HEELS WAS NOTED TO HAVE BEEN DISCONTINUED ON 10/8/12. THE PHYSICIAN' S ORDER DATED 11/9/12 REFLECTED RESIDENT #1 WAS TO RECEIVE "PROSTAT AWC" 30 CC TWICE DAILY FOR 60 DAYS. THE RESIDENT'S [MEDICATION NAME] (PROTEIN SUBSTANCE USED TO PROMOTE WOUND HEALING) LEVEL ON 8/29/12 ( IN HOSPITAL) WAS 3.5 G/DL (NORMAL RANGE: 3.6-5.1 G/DL). THE [MEDICATION NAME] LEVEL ON 11/12/12 (3 DAYS AFTER INITIATION OF PROSTAT) WAS 2.8 G/DL (NORMAL RANGE: 3.6-5.1 G/DL). THE [MEDICATION NAME] LEVEL ON 11/26/12 (15 DAYS AFTER THE INITIATION OF PROSTAT) WAS 2.2 G/DL, DECREASING FURTHER. ON 11/28/12 AT 9:30 A.M., THE WOUND CARE NURSE, (STAFF " A " ) WAS NOT SURE THE REASON FOR THE DECLINE. HOWEVER, THE MEDICATION ADMINISTRATION RECORD (MAR) DATED NOVEMBER 2012 REFLECTED RESIDENT #1 WAS DOCUMENTED AS NOT RECEIVING 11 DAYS (FROM 11/10/12 THROUGH 11/20/12 WITH CIRCLED INITIALS ON EACH DAY, REPRESENTING OMISSION OF 21 DOSES) WITH EXCEPTION OF ONE MORNING DOSE ON 11/10/12. THERE WAS NO EXPLANATION WHY THE "PROSTAT" WAS NOT ADMINISTERED EXCEPT ON 11/20/12 AS WRITTEN "REFUSED." ON 11/30/12 AT 9:00 A.M., RESIDENT #1 STATED HE NEVER REFUSED PROSTAT, A LIQUID MEDICINE. ON 12/3/12 AT 2:00 P.M., REGISTERED NURSE, (STAFF "R") WHO HAD WRITTEN "REFUSED" COMMENT IN THE BACK OF MAR STATED SHE OFFERED PROSTAT ON 11/20/12 AND THE RESIDENT HAD REFUSED. STAFF "R" WAS ASKED IF SHE COULD RECALL THE REASON WHY THE RESIDENT HAD REFUSED WHEN HE HAD NOT RECEIVED PROSTAT FOR CONSECUTIVE 10 DAYS PRIOR TO THIS TIME STAFF "R" COULD NOT EXPLAIN THE REASON. ON 11/30/12 AT 12 NOON, LICENSED PRACTICAL NURSE, (STAFF "X") STATED "RESIDENT TOOK (THE PROSTAT) WELL ONCE WE GOT THE PROSTAT, BUT IT WAS SIMPLY NOT AVAILABLE. STAFF "X" WENT ON SAYING, "I KEPT ASKING UNIT CLERK WHO ORDERED THOSE PRODUCT, BUT I WAS NOT ABLE TO FIND THEM." ON 11/30/12 AT 12:15 P.M., THE UNIT CLERK, (STAFF "P") WAS ASKED WHAT HAPPENED TO ORDERING OF PROSTAT. STAFF "P" STATED SHE HAD BEEN IN HOSPITAL BUT CAME BACK ON 11/10/12 AND ORDERED THE PRODUCT AND IT WAS DELIVERED ON 11/12/12 (WAS VERIFIED BY SHIPMENT ORDER DATE). HOWEVER, RESIDENT #1 WAS NOT ADMINISTERED PROSTAT FOR 11 DAYS IN WHICH PERIOD HIS PRESSURE ULCER HAD WORSENED SIGNIFICANTLY AND RESIDENT#1'S ALREADY LOW [MEDICATION NAME] LEVEL AT 2.8 G/DL ON 11/12/12 FURTHER DECLINED TO 2.2 G/DL ON 11/26/12. ON 11/30/12 AT 11:00 A.M., REGISTERED DIETITIAN (RD), (STAFF "D") WAS INTERVIEWED REGARDING RESIDENT #1'S LOW [MEDICATION NAME] LEVEL AS WELL AS OMISSION OF PROSTAT FOR 11 DAYS. STAFF "D" STATED SHE NOTED THE DECREASED LEVEL OF [MEDICATION NAME] FROM 11/12/12 TO 11/26/12 AND ATTEMPTED TO FIND OUT THE REASON. STAFF "D" STATED SHE HAD ASKED NURSING STAFF WHETHER THE RESIDENT HAD [MEDICAL CONDITION] (ASSOCIATED WITH LOW [MEDICATION NAME]) OR NOT. STAFF "D" ALSO STATED SHE DID LOOK AT THE MAR AND NOTED RESIDENT #1 WAS NOT ADMINISTERED PROSTAT FOR MANY DAYS, BUT DID NOT EXPLAIN WHAT ACTION SHE TOOK TO CORRECT THE PROBLEM. CONTRARY TO HER STATEMENT, THE "NUTRITIONAL PROGRESS NOTES" DATED 11/28/12 REFLECTED: "...RESIDENT 'CONTINUES TO RECEIVE PROSTAT AWC 30 CC TWICE DAILY FOR 60 DAYS' TO ASSIST WOUND HEALING." THE NOTE CONTINUED TO STATE, " RESIDENT CONSUME 75-100 %...THE LAB ON 11/13/12 INDICATES RESIDENT HAS [MEDICAL CONDITIONS] WITH FOLIC ACID OR VITAMIN B 12." THE " WOUND/SKIN HEALING RECORD " DATED 11/7/12 (ONSET DATE) REFLECTED RESIDENT #1 ' S LEFT BUTTOCK PRESSURE ULCER WAS A STAGE 2 WITH MEASUREMENT OF 3.1 X 2.0 X <.1. THE WOUND RECORD DATED 11/12/12 (5 DAYS FROM THE ONSET) REFLECTED THE LEFT BUTTOCK WOUND WAS NOW AT AN UNSTAGEABLE WITH MEASUREMENT OF 3.0 X 2.5 X UD (UNABLE TO DETERMINE). THE WOUND BED WAS COVERED WITH 10 % SLOUGH AND 90 % BLACK ESCHAR. THE WOUND RECORD DATED 11/19/12 REFLECTED THE LEFT BUTTOCK WOUND WAS STILL AT AN UNSTAGEABLE WITH MEASUREMENT OF 3.0 X 3.4 X UD. THE WOUND BED WAS COVERED WITH 5 % PINK TISSUE, 40 % SLOUGH AND 50 % MOIST BROWN ESCHAR. THE WOUND WAS DESCRIBED AS HAVING PURULENT DRAINAGE WITH MODERATE ODOR. THE RESIDENT WAS CHECKED AS HAVING PAIN SCORE OF 4 FROM 10 BEING THE MOST SEVERE PAIN FROM 1-10 SCALE. THE WOUND RECORD DATED 11/26/12 REFLECTED RESIDENT #1 ' S LEFT BUTTOCK PRESSURE ULCER REMAINED AT AN UNSTAGEABLE WITH MEASUREMENT OF 3.0 X 3.0 X UD. THE WOUND WAS COVERED WITH 100 % SLOUGH AND HAD MODERATE AMOUNT PURULENT DRAINAGE. ALSO 3 UNDERMINING'S (9 O'CLOCK = 1.0 CM, 12 O'CLOCK = 8.0 CM, 2 O'CLOCK = 2.5 CM). THE RESIDENT WAS DESCRIBED AS HAVING PAIN LEVEL OF 7 FROM 1-10 SCALE, 10 BEING THE MOST SEVERE PAIN. ON 11/29/12 AT 3:30 P.M., THE DIRECTOR OF NURSING WAS ASKED WHY RESIDENT #1'S LEFT BUTTOCK PRESSURE ULCER WAS LEFT AT UNSTAGEABLE WHEN THE WOUND HAD OPENED UP AND ABLE TO MEASURE THE DEPTH. DIRECTOR OF NURSING (DON) STATED AS LONG AS THE WOUND HAD SLOUGH AND ESCHAR SHE WOULD STAGE IT AS AN UNSTAGEABLE. DON ALSO MADE A CONTRADICTORY STATEMENT SAYING, "I KNOW THE WOUND IS AT LEAST A STAGE 4." ON 11/30/12 AT 3:00 P.M., RESIDENT #1 CAME BACK FROM A FIRST TRIP TO WOUND CLINIC. THE REPORT STATED: "THE PATIENT IS COMING FOR INITIAL EVALUATION TO THE WOUND CLINIC OF HIS NON HEALING LEFT ISCHIAL/BUTTOCK WOUND. THE PATIENT REPORT STARTING WITH A NEW SORE ON HIS BUTTOCK APPROXIMATELY ONE MONTH AGO ....THERE WAS A SIGNIFICANT ODOR ON THE WOUND AND SOME PURULENT MATERIAL ...THE WOUND APPEAR BEEN VERY DEEP AND THE PATIENT POORLY TOLERATED THE EVALUATING. BONE WAS NOT PALPABLE BUT THE BONY STRUCTURES ARE CLOSE TO BE EXPOSED ...WILL ORDER X-RAY TO R/O ANY POSSIBLE OSTEO[DIAGNOSES REDACTED] ...WILL CONSIDER WOUND VAC DUE TO THE DEPTH OF THE WOUND." THE WOUND WAS DOCUMENTED AS A STAGE 4 WITH MEASUREMENT OF 3 CM X 3 CM X 5.5 CM. THE WOUND BED WAS DOCUMENTED AS HAVING 20 % RED AND 80 % YELLOW SLOUGH AND LARGE AMOUNT OF PURULENT FOUL DRAINAGE. THE RESIDENT WAS ALSO DOCUMENTED AS HAVING A PAIN SCORE OF 10 FROM 1-10 SCALE, 10 BEING THE MOST SEVERE PAIN. THE X-RAY REPORT DATED 11/29/12 REFLECTED THE REASON FOR THE EXAMINATION WAS STATED AS RULE OUT OSTEO[DIAGNOSES REDACTED] OF LEFT HIP. THE CONCLUSION STATEMENT INCLUDED, "PARTIAL LEFT HIP REPLACEMENT WITH INTACT FEMORAL COMPONENT IN ANATOMIC ALIGNMENT, NO RADIOGRAPHIC EVIDENCE OF ACUTE FRACTURE OR DISLOCATION, NO RADIOGRAPHIC EVIDENCE OF LOOSENING OR PARTICLE DISEASE, MILD [MEDICAL CONDITION] AND MILD [MEDICAL CONDITION] ARTHRITIS. THE X-REPORT NEITHER CONFIRMED NOR DENIED THE PRESENCE OF OSTEO[DIAGNOSES REDACTED] (INFLAMMATION OF BONE). THE WOUND (SITE NOT SPECIFIED) CULTURE REPORT DATED 11/27/12 REFLECTED RESIDENT #1 HAD "HEAVY GROWTH OF PROTEUS MIRABILIS, LIGHT GROWTH OF [MEDICATION NAME] FAECALIS." UNDER COMMENT THE REPORT ALSO STATED, "SKIN FLORA ALSO RESENT." ON 12/3/12 AT 1:30 P.M. RESIDENT #1'S ATTENDING PHYSICIAN, (STAFF "Y") WAS INTERVIEWED REGARDING THE CULTURE REPORT. ATTENDING PHYSICIAN "Y" STATED HE WOULD NOT PRESCRIBE ANTIBIOTIC BASED ON THE RESIDENT'S LOW SEDIMENTATION RATE, ELEVATED WITH [MEDICAL CONDITION] AND NECROTIC PROCESS, AT 10 MM/H (NORMAL RANGE: < OR = 20 MM/H) COLLECTED ON 11/30/12, NORMAL WHITE BLOOD CELL COUNT, A LACK OF FEVER AND LIKELY CONTAMINATED SOURCE OF MICROORGANISMS. HOWEVER, IT WAS EXPLAINED TO THE ATTENDING PHYSICIAN "Y" THE RESIDENT'S WOUND CULTURES WERE OBTAINED 5 DAYS AFTER (DUE TO LACK OF RIGHT CULTURE MEDIUM TUBES) WHEN THE WOUND OPENED, HAVING PURULENT DRAINAGE WITH MEASUREMENT OF 2.0 CM X 2.2 CM X 3.7 CM FROM A WOUND WITH 10 % SLOUGH AND 90 % BLACK ESCHAR THE DAY BEFORE, ON 11/22/12. PHYSICIAN "Y" STATED, "I DID NOT KNOW THAT. THEY SHOULD HAVE SENT THE CULTURES IMMEDIATELY. ALSO THEY SHOULD HAVE CHANGED THE DRESSING DAILY." ON 12/3/12 AT 10:00 A.M., RESIDENT #1 WAS OBSERVED SLEEPING IN HIS BED ON HIS RIGHT SIDE. AT 2:15 P.M., ON SAME DAY RESIDENT #1 WAS OBSERVED AWAKE, LYING ON HIS RIGHT SIDE. THE RESIDENT STATED HE WAS TOLD NOT TO BE OUT OF BED UNTIL HIS WOUND ON HIS LEFT BUTTOCK HEALED. THE RESIDENT WAS VERY UNHAPPY AND LOOKED DEPRESSED. NURSE AIDE, (STAFF "N") STATED SHE WAS INSTRUCTED BY BOTH WOUND CARE NURSE "A" AND THE UNIT NURSE, (STAFF "R") THAT THE RESIDENT WAS NOT TO GET OUT OF BED. STAFF "N" DID NOT HAVE WRITTEN TURNING SCHEDULE FOR RESIDENT #1 SHE WAS TURNING THE RESIDENT FROM RIGHT TO HIS BACK ONLY EVERY 2 HOURS. THE "RESIDENT CARE GUIDE," UPDATED 11/30/12 REFLECTED RESIDENT #1 WAS TO BE BEDREST WITH POSITION CHANGES EVERY 2 HOURS BACK TO RIGHT SIDE. ALSO HE WAS TO CHANGE POSITION HOURLY WHEN UP IN CHAIR, HE WAS ENCOURAGED TO BE COOPERATIVE WITH POSITIONING DURING INCONTINENCE CARE. RESIDENT#1'S PLAN OF CARE HAD NOT BEEN UPDATED SINCE 9/20/12. THE CARE PLAN DID NOT ADDRESS ANY ASSESSMENT, INTERVENTIONS OR EVALUATION OF treatment for [REDACTED]. AS A RESULT OF RESIDENT #1'S FACILITY ACQUIRED, PREVENTABLE STAGE 4 PRESSURE ULCER, RESIDENT #1'S CLINICAL CONDTION HAS BEEN COMPROMISED WITH A DECLINE IN THE FOLLOWING AREAS: HE IS NOW RESTRICTED TO BED REST WHEREAS BEFORE HE COULD MOVE AROUND THE FACILITY IN HIS WHEELCHAIR AND HE HAS EXPERIENCED ADDITIONAL PAIN RELATED TOTHE PRESSURE ULCER CITE (IN ADDITION TO THE CHRONIC PAIN FROM HIS [MEDICAL CONDITION] JOINT DISEASE.) ( ) ACCORDING TO HOSPITAL RECORD DATED 9/24/12 RESIDENT #17 WAS A [AGE] year OLD FEMALE WITH PAST MEDICAL HISTORY THAT INCLUDED [MEDICAL CONDITION], HYPERTENSION, DEPRESSION, CHRONIC CONSTIPATION, [MEDICAL CONDITIONS], DIABETES MELLITUS, END STAGE [MEDICAL CONDITION] ON [MEDICAL TREATMENT]. RESIDENT #17 WAS REadmitted to the facility on [DATE]. THE ADMISSION "NURSING COMPREHENSIVE EVALUATION" FORM DATED 9/28/12 REFLECTED RESIDENT #17 WAS ALERT AND ORIENTED TO TIME, PLACE AND PERSON. THE RESIDENT WAS CONTINENT OF BOWEL AND BLADDER. SHE WAS NOT AMBULATORY BUT PROPELLED WHEELCHAIR. THE RESIDENT REQUIRED "HOYER" TO TRANSFER FROM BED TO WHEELCHAIR. UNDER SKIN CONDITION RESIDENT #17 WAS DOCUMENTED AS HAVING ONE SITE MARKED AS [MEDICAL TREATMENT] PORT, ONE SURGICAL SITE ON HER RIGHT FOOT AND [MEDICAL TREATMENT] SHUNT CIRCLED AT LEFT FOREARM. NO OTHER AREAS OF SKIN BREAKDOWN WERE MARKED OR ILLUSTRATED. NURSING CARE PLAN REGARDING SKIN INTEGRITY FIRST INITIATED ON 10/20/11 REFLECTED RESIDENT #17 WAS AT " RISK FOR IMPAIRED SKIN INTEGRITY DUE TO DECREASED MOBILITY DUE TO HER AGE, HISTORY OF MOTOR VEHICLE ACCIDENT AND STROKE. RECEIVED [MEDICAL TREATMENT] AND WAS DIABETIC. [DIAGNOSES REDACTED]." THE ADDED FOCUS DATED 2/20/12 REFLECTED THE RESIDENT WAS NON-COMPLIANT WITH INTERVENTIONS USED TO PROMOTE SKIN INTEGRITY. THE INTERVENTIONS INCLUDED "BODY/SKIN AUDIT WEEKLY, PRESSURE RELIEVING MATTRESS, AIR CELL CUSHION, ASSIST WITH POSITION CHANGES, CALAMIZE PER STANDING ORDER, BRADEN SCALE QUARTERLY, DIETITIAN TO ASSESS AS NEEDED, KEEP LINENS DRY AND WRINKLE FREE, SUPPLEMENTS AND CONSULTS AS NEEDED." THE WOUND CONSULT EVALUATION AND INTERVENTION NOTE DATED 9/25/12 REFLECTED RESIDENT #17 WAS BEING treated for [REDACTED]. THE OBJECTIVE FINDING INCLUDED "HEELS AND BUTTOCK INTACT, DRY SKIN LEFT HEEL." THE "NURSE'S NOTES" DATED 10/11/12 REFLECTED " LATE ENTRY FROM 10/10/12. THIS NURSE (WOUND NURSE) REQUESTED RES. LAY DOWN ON BED TO ASSESS SKIN INTEGRITY ON BUTTOCKS...RES STAYED 'STOP STOP I AM HURTING TOO MUCH..." THE NEXT ENTRY OF WOUND CARE NURSE NOTE DATED 10/12/12 REFLECTED, " ABLE TO INSPECT SKIN ON BUTTOCKS THIS AM. AREA LEFT ISCHIAL SUPERFICIAL PINK 1.0 X 1.2 X < 0.1; RIGHT ISCHIAL SUPERFICIAL 100 % PINK 0.8 X 0.5 X < 0.1. [MEDICATION NAME] CREAM APPLIED..." THE WOUND NURSE'S NEXT ENTRY REGARDING ISCHIAL AREA INSPECTION WAS DATED 10/25/12, " LEFT AREA BARELY DENUDED 100 % PINK 0.3 X 0.4 X < 0.1, RIGHT ISCHIAL 100 % PINK 0.2 X 0.3. COVER WITH [MEDICATION NAME]. THE NEXT ENTRY REGARDING ISCHIAL AREA WAS DATED 11/2/12, " BUTTOCKS/NEAR GLUTEAL FOLDS AREA SMOOTH PINK, DEPIGMENTED SKIN. ALL OTHER SKIN INTACT ALSO." THE NURSE'S NOTES DATED 11/6/12 THROUGH 11/15/12 HAD NO FURTHER ASSESSMENT OF ISCHIAL SKIN CONDITION. THE NURSE'S NOTE DATED 11/15/12 REFLECTED RESIDENT #17 HAD DEVELOPED 2 STAGE 2 PRESSURE ULCERS ON BOTH BUTTOCKS. THE NOTE STATED, " OBSERVED AREA LEFT ISCHIAL STAGE 2 0.7 X 2.2 X < 0.1, 100 % RED; RIGHT ISCHIAL 2 STAGE 2, 0.4 X 0.5 AND 0.5 X 1.0 X < 0.1, RES EXPERIENCING AGITATED AND RESISTIVE BEHAVIOR..." THE NURSE'S NOTE DATED 11/23/12 REFLECTED, " RES AGREED TO BE LAYED DOWN AND ABLE TO INSPECT..LEFT ISCHIAL 2.5 X 4.0 X UD (UNABLE TO DETERMINE), 60 % MOIST BLACK ESCHAR 40 % RED WOUND BED, SMALL AMOUNT OF PURULENT DRAINAGE FROM SLOUGH TISSUE. RIGHT ISCHIAL 2.5 X 4.5 X UD, 50 % YELLOW SLOUGH, 50 % RED MOIST, SMALL PURULENT DRAINAGE..." BOTH WOUNDS HAD SIGNIFICANTLY INCREASED IN SIZE AND DETERIORATED IN CHARACTERISTIC. ON 11/30/12 AT 11:30 A.M., THE WOUND CARE NURSE, (STAFF "A") WAS ASKED WHAT FACTORS MAY HAVE BEEN THE RAPID WORSENING OF RESIDENT #17'S BUTTOCK PRESSURE ULCERS. STAFF "A" STATED RESIDENT #17 HAD GENERAL DECLINE DUE TO SEVERE WEIGHT LOSS, CHRONIC LOWER EXTREMITY [MEDICAL CONDITION], UP MOST OF DAY, BEING SEDATED MOST OF TIME FROM HEAVY USE OF NARCOTIC AND SHE WAS NON-COMPLIANT WITH POSITIONING. HOWEVER, ANY OF THESE ADDED RISK FACTORS WERE NOT UPDATED IN HER CARE PLAN AS A PROBLEM AND APPROPRIATE INTERVENTIONS WERE NOT DEVELOPED ACCORDINGLY. THE " NURSING WEEKLY (HEAD-TO-TOE) SKIN ASSESSMENT" FORM WAS FILLED OUT FOR 2 DAYS ONLY ( 6/1/12 AND 8/29/12). ( ) RESIDENT #3 WAS AN [AGE] year OLD FEMALE ORIGINALLY admitted to the facility on [DATE] AND REadmitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. ACCORDING TO RESIDENT #3'S READMISSION MINIMUM (MDS) data set [DATE] RESIDENT #3 SCORED 3 OUT OF A POSSIBLE 15 POINTS ON THE BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) INDICATING COGNITIVELY IMPAIRED. REVIEW OF RESIDENT #3'S MEDICAL RECORD REFLECTED RESIDENT #3 HAD DEVELOPED 2 PRESSURE ULCERS ACCORDING TO THE FACILITY DOCUMENTS TITLED "INTERDISCIPLINARY CARE PLAN" ONE DATED 11/15/12 REFLECTED AN UNSTAGEABLE WOUND TO LEFT HEEL AND THE OTHER DATED 11/19/12 REFLECTED A STAGE II ON THE LEFT ISCHIAL AREA. THE READMISSION MINIMUM (MDS) data set [DATE] REFLECTED RESIDENT #3 WAS AT RISK FOR DEVELOPING PRESSURE ULCERS AND DID NOT HAVE A PRESSURE ULCER AT THAT TIME. THE LATEST ASSESSMENT WAS COMPLETED WITH USE OF THE BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK IN HOME CARE ON 10/31/12 THAT REFLECTED A SCORE OF 16 OUT OF 18 WITH THE SCORE KEY INDICATING THE RESIDENT IS AT A MILD RISK. THE BRADEN SCALE REFERENCE TOOL HAD LISTED AN INTERVENTION GUIDE FOR RESIDENTS THAT SCORED AS MILD RISK THAT INCLUDED FREQUENT TURNING, MAXIMAL REMOBILIZATION, PRESSURE-REDUCTION SUPPORT SURFACE IF BED OR CHAIR BOUND, PROTECT HEELS, MANAGE FRICTION AND SHEER (THAT INCLUDED PROTECT ELBOWS AND HEELS IF BEING EXPOSED TO FRICTION). A physician progress notes [REDACTED]. (NURSING) REPORT "LEFT POSTERIOR HEEL" FRICTION FROM SHOE..."; ANOTHER physician progress notes [REDACTED]." A FORM UNTITLED DATED 11/9/12 READ "DENUDED BLISTER AREA DEVELOPED DUE TO FRICTION FROM SHOE; POSTERIOR HEEL LEFT FOOT. RESIDENT USES FEET AND LEGS TO PROPEL SELF IN WHEELCHAIR. SHOE REMOVED, FOAM HEEL BOOT (OFF LOAD) PLACED. LAB WORK 10/25/12 TOTAL PROTEIN 6.5 (NORMAL RANGE 6.32 - 8.3); [MEDICATION NAME] 2.8 LOW (NORMAL RANGE 3.6-5.1); BUN 11 CREATININE .58 LOW. WEIGHT STABLE, WEEKLY WEIGHT CURRENTLY. ON 11/28/12 AT 11:30 P.M. THE WOUND NURSE, STAFF "A" DESCRIBED THE UNTITLED FORM WAS UTILIZED WHEN THE INTERDISCIPLINARY TEAM MEETS WHEN CARE ISSUES ARISE FOR RESIDENTS. ON 11/28/12 AT 11:30 A.M. AN INTERVIEW WITH THE WOUND NURSE, STAFF "A" REVEALED THE PRESSURE ULCER ON RESIDENT #3'S LEFT HEEL WAS CAUSED FROM HER SHOE. FURTHER DISCUSSION WITH STAFF "A" REVEALED STAFF "A" REMINDS CERTIFIED NURSING ASSISTANTS THAT WHEN A CNA DRESSES OR UNDRESSES A RESIDENT WHICH INCLUDES APPLYING AND REMOVING SHOES CNAS ARE TO INSPECT THE SKIN. IN ADDITION, A RESIDENT IS TO BE REPOSITIONED IN THEIR WHEELCHAIR EVERY HOUR ESPECIALLY WHEN THEY (REFERRING TO RESIDENT) ARE AT AN INCREASED RISK FOR SKIN BREAKDOWN. REVIEW RESIDENT #3'S MEDICAL RECORD REFLECTED A DOCUMENT TITLED "WOUND/SKIN HEALING RECORD" WITH THE LAST ENTRY DATE OF 11/19/12 THAT DOCUMENTED THE SIZE OF THE LEFT HEEL WOUND TO MEASURE 2.0 X 1.5 CENTIMETERS WITH THE WOUND BED AS ESCHAR. REVIEW RESIDENT #3'S MEDICAL RECORD REFLECTED A DOCUMENT TITLED "WOUND/SKIN HEALING RECORD" WITH THE LAST ENTRY DATE OF 11/26/12 THAT DOCUMENTED THE SIZE OF THE LEFT ISCHIAL WOUND TO MEASURE .5 X .5 CENTIMETERS WITH THE WOUND BED AS BEEFY RED. ON 11/28/12 AT 11:25 A.M. RESIDENT #3 WAS OBSERVED SITTING IN WHEELCHAIR IN THE DAY ROOM WATCHING THE ACTIVITY MOVIE AND WAS POSITIONED WITH LEFT SIDE OF BODY SITTING LOWER THAN THE RIGHT. ON 11/29/12 AT 9:35 A.M. AN OBSERVATION OF THE DRESSING CHANGES TO RESIDENT #3'S LEFT HEEL WOUND AND LEFT ISCHIAL WOUND WAS MADE IN RESIDENT #3'S ROOM WITH WOUND NURSE, STAFF "A". THE LEFT HEEL WOUND MEASURED 1.5 X 2 CENTIMETERS AND ESCHAR WAS NOTED. RESIDENT #3 WHEN ASKED ABOUT PAIN RESPONDED "YES" WITH MILD GRIMACING. THE LEFT ISCHIAL WOUND WAS FOUND TO MEASURE 0.3 X 0.4 CENTIMETERS HOWEVER, A NEW PRESSURE WOUND HAD DEVELOPED SINCE 11/26/12 STATED STAFF "A" ADJACENT TO PREEXISTING LEFT ISCHIAL WOUND THAT MEASURED 0.5 X 0.4 CENTIMETERS AND THE WOUND BED WAS OBSERVED TO HAVE A YELLOW COLORED SLOUGH IN THE CENTER. AT THAT TIME STAFF "A" STATED "THE MOST EFFECTIVE INTERVENTION IS PRESSURE RELIEF, APPARENTLY THE CUSHION SHE HAS ISN'T DOING IT." ON 11/29/12 AT 9:35 A.M. AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA), STAFF "I" CONFIRMED HEELS SHOULD BE CHECKED AFTER REMOVING SHOES. STAFF "I" WAS ASKED IF RESIDENT #3 LAYS DOWN DURING THE DAY AND STATED "SHE NEEDS TO BE WATCHED. SHE TRIES TO GET UP, THAT'S WHAT I WAS TOLD." THERE WAS NO DOCUMENTATION AVAILABLE TO SUPPORT THAT RESIDENT #3'S HEELS WERE ACCURATELY ASSESSED. ON 11/29/12 AT 10:00 A.M. AFTER RESIDENT #3'S DRESSING CHANGE AN INTERVIEW WAS CONDUCTED IN THE HALLWAY OUTSIDE OF RESIDENT #3'S ROOM WITH WOUND NURSE, STAFF "A". STAFF "A" STATED "FROM MY TRAINING UNLESS THERE ARE SEVERE CO-MORBIDITIES WITH FREQUENT ASSESSMENT AND PREVENTATIVE MEASURES PRESSURE ULCERS ARE AVOIDABLE." RESIDENT #25 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. RESIDENT #25 WAS ALERT AND ORIENTED TO PER

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ANSWER CALL LIGHTS TIMELY FOR 5 OF 9 RESIDENTS FROM THE CONFIDENTIAL GROUP INTERVIEW (4 CONFIDENTIAL RESIDENTS AND SAMPLED RESIDENT #16) RESULTING IN NEGLECT WITH VERBALIZATION OF EMBARRASSMENT DUE TO SOILING THEMSELVES FOR 4 OF THE 5 CONFIDENTIAL RESIDENTS AND PSYCHOSOCIAL HARM FOR RESIDENT #16 FROM A TOTAL FACILITY CENSUS OF 111. FINDINGS INCLUDE: ACTIVITY DIRECTOR "Z", WHO IDENTIFIED HERSELF AS BEING IN CHARGE OF HELPING COORDINATE THE RESIDENT COUNCIL GROUP IN THE FACILITY, WAS INTERVIEWED OUTSIDE OF THE "RECREATION ROOM" ON 11/29/12 AT 8:30 AM. ACTIVITY DIRECTOR "Z" AGREED TO ENSURE RESIDENTS WHO WERE COGNITIVELY INTACT AND RELIABLE FOR INFORMATION WOULD ATTEND THE CONFIDENTIAL GROUP INTERVIEW SCHEDULED AT 10:00 AM THAT DAY. THE CONFIDENTIAL GROUP INTERVIEW OCCURRED AT 10:00 AM ON 11/29/12. DURING THE GROUP INTERVIEW, 5 OF THE 9 CONFIDENTIAL RESIDENTS IN ATTENDANCE AGREED THAT TIMELY ANSWERING OF CALL LIGHTS WAS A CONCERN IN THE FACILITY. ONE CONFIDENTIAL RESIDENT STATED, "IT DEPENDS ON WHO IS WORKING" AND THAT CALL LIGHTS CAN TAKE UP TO "A HALF HOUR" TO BE ANSWERED. ANOTHER CONFIDENTIAL RESIDENT STATED THEY HAD WAITED "UP TO 2 HOURS" FOR A CALL LIGHT TO BE ANSWERED. ANOTHER RESIDENT STATED THEY HAD WAITED "45 MINUTES" FOR THEIR CALL LIGHT TO BE ANSWERED AND "THEY WILL COME IN AND SAY THEY ARE BUSY AND WILL BE BACK AND YOU WAIT A LONG TIME". ANOTHER CONFIDENTIAL RESIDENT STATED THAT THEY HAD WAITED UP TO 25 MINUTES FOR THEIR CALL LIGHT TO BE ANSWERED. 4 OF THE 5 CONFIDENTIAL RESIDENTS THAT STATED CALL LIGHT RESPONSE TIME WAS A CONCERN, STATED THEY HAD SOILED THEMSELVES AS A RESULT OF HAVING TO WAIT AND CONFIRMED, "WE WERE EMBARRASSED" AFTER SOILING THEMSELVES. THE ADMINISTRATOR WAS INTERVIEWED IN THE CONFERENCE ROOM ON 11/30/12 AT 10:45 AM, AND REVEALED THE FACILITY DID NOT HAVE A POLICY IN REGARDS TO APPROPRIATE CALL LIGHT RESPONSE TIMES. ( ) RECORD REVIEW OF RESIDENT #16'S ADMISSION RECORD, UNDATED DOCUMENTED THAT RESIDENT #16 WAS admitted to the facility on [DATE] WITH THE FOLLOWING Diagnoses: [REDACTED]. RECORD REVIEW OF RESIDENT #16'S MINIMUM DATE SET, (A RESIDENT ASSESSMENT AND CARE SCREENING TOOL) DATED SEPTEMBER, 2012 DOCUMENTED RESIDENT #16 SCORED A 14 OUT OF 15 ON THE BRIEF INTERVIEW OF MENTAL STATUS TEST, INDICATING THAT RESIDENT #16 WAS FULLY COGNITIVE. ON 11/29/2012 AT 11:50 A.M., RESIDENT #16 WAS INTERVIEWED IN HIS ROOM FOLLOWING THE CONFIDENTIAL RESIDENT GROUP COUNCIL MEETING. AT THAT TIME RESIDENT #16 STATED HE HAD WAITED LONGER THAN 30 MINUTES FOR HIS CALL LIGHT TO BE ANSWERED AND AT ONE TIME HAD TO WAIT LONGER THAN ONE HOUR AND 30 MINUTES BEFORE RECEIVING STAFF ASSISTANCE IN ORDER TO USE THE RESTROOM. RESIDENT #16 ALSO STATED THAT DUE TO THOSE DELAYS HE HAD SOILED HIMSELF REPEATEDLY WHICH COULD HAVE BEEN AVOIDED. AS RESIDENT #16 LOWERED HIS HEAD AND LOOKED AT THE FLOOR AS HE STATED, "THIS WAS VERY EMBARRASSING. I'M TO BIG TO BE DOING THAT". RESIDENT #16 SOUGHT A SURVEYOR TO ENSURE THAT HE WAS HEARD REGARDING BEING LEFT INCONTINENT. HE APPEARED EMBARRASSED AND HUMILIATED AS HE RECALLED THESE INCIDENTS WHICH HAD BEEN OCCURRING FOR SOME TIME. RECORD REVIEW OF THE COMPUTER GENERATED REPORT TITLED, "ADVANCED STATISTICAL CALL ANALYSIS FOR VISION PRO CALL DATA," AND DATED 11/01/2012 TO 11/30/2012, DOCUMENTED RESIDENT #16 HAD CALL LIGHT RESPONSE TIMES AS LONG AS 95:38 MINUTES. THE FOLLOWING IS A SUMMARY OF RESIDENT #16'S DELAYED CALL LIGHT RESPONSE TIMES: 1) 11/01/2012 THE CALL LIGHT WAS ACTIVATED AT 4:14 P.M. WITH A RESPONSE TIME OF 18:22 MINUTES 2) 11/07/2012 THE CALL LIGHT WAS ACTIVATED AT 6:51 P.M. WITH A RESPONSE TIME OF 18:54 MINUTES. 3) 11/07/2012 THE CALL LIGHT WAS ACTIVATED AT 8:25 P.M. WITH A RESPONSE TIME OF 19:59 MINUTES. 4) 11/08/2012 THE CALL LIGHT WAS ACTIVATED AT 5:35 A.M. WITH A RESPONSE TIME OF 42:47 MINUTES. 5) 11/10/2012 THE CALL LIGHT WAS ACTIVATED AT 5:19 A.M. WITH A RESPONSE TIME OF 22:43 MINUTES. 6) 11/11/2012 THE CALL LIGHT WAS ACTIVATED AT 6:47 P.M. WITH A RESPONSE TIME OF 30:16 MINUTES. 7) 11/12/2012 THE CALL LIGHT WAS ACTIVATED AT 6:00 A.M. WITH A RESPONSE TIMES OF 29:29 MINUTES. 8) 11/15/2012 THE CALL LIGHT WAS ACTIVATED AT 8:58 P.M. WITH A RESPONSE TIME OF 95:38 MINUTES. RESIDENT #16'S MEDICAL HISTORY NECESSITATED ASSISTANCE AND THE LONG CALL LIGHT RESPONSE TIMES CAUSED RESIDENT #16 TO BE INCONTINENT. HE EXPERIENCED PSYCHOSOCIAL HARM EXPRESSING ONGOING EMBARRASSMENT AND HUMILIATION AS HE PERCEIVED THESE INCIDENTS WHICH WERE PREVENTABLE AND CLEARLY DO NOT ENHANCE RESIDENT #16'S DIGNITY OR RESPECT FOR HIS INDIVIDUALITY. ( )

This cite pertains to MI 831. Based on observation, interview, and record review the facility failed to prevent resident to resident sexual abuse of 1 of 6 sampled residents (#102), from a total sample of 6 residents, resulting in the sexual abuse of Resident #102 by Resident #101. Findings include: Review of the Care Plan Recent for behaviors dated 12/22/12 revealed Resident #101 had "on return from in-patient psych stay due to angry outbursts, threatening gestures with cane, inappropriate comments and touching of others" was, updated on 4/23/12, which indicated "2 episodes of touching female residents, one on her thigh...2nd episode was inappropriate between her legs." The care plan was updated on 4/23/12 and included "Resident to have 1:1 (1 to 1) during wake hour when up in wheelchair." Review of Care Plan for Behaviors dated 12/22/11 by social worker revealed Resident #101 on 3/5/12 was "...making inappropriate comments to lady residents, telling them he loves them, wants them to sleep with him, and telling them they look good and he wants to put his hands and arms all over them." Review of the Facility Investigation Report dated 4/23/12 at approximately 10:05 AM revealed Resident #102 was sitting in her wheelchair and Resident #112 was seen sitting in his wheelchair perpendicular to Resident #102's wheelchair with his had rubbing between Resident #102's legs. Resident #102 and Resident #101 where seperated and Resident #101 was placed on 1:1 observation. Per the Facility Investigation Report dated 4/30/12 revealed on 4/29/12 between 10:00 - 10:15 A.M. Resident #101 had his hand on the groin area of Resident #102. Resident #101 was removed from the area of Resident #102 and Resident #101 was then taken to the local emergency department for a psychiatric evaluation. Resident #102 was assessed for mental and physical stress from the incident and a skin evaluation revealed no redness to any area and no distress to Resident #102. Review of the 15 Minute Check sheet dated 4/29/12 revealed Resident #101 was out of bed at 9:30 A.M. The 15 Minute Check sheet revealed Licensed Practical Nurse (LPN) #7 had signed the check sheet every 15 minutes from 9:30 A.M. - 11:45 A.M. which indicated he was the 1 to 1 staff with Resident #101. In an interview on 5/9/12 at 12:10 P.M., LPN #7 stated he knew Resident #101 was 1 to 1 and stated he was watching Resident #101. LPN #7 stated he was helping another nurse with a physician's orders [REDACTED]. LPN #7 stated he was trying to do too many jobs that morning and "I realized he (Resident #101) wasn't with me" and "I knew I had really screwed up." LPN #7 stated there was a staff person scheduled to come into the facility to do 1 to 1 care with Resident #101 at 11:00 A.M. In an interview on 5/9/12 at 10 P.M. Housekeeper #9 stated on 4/29/12 she had come out of another residents room and saw Resident #101 holding hands with Resident #102. Housekeeper #9 stated she told RN #18 about what had happened. In an interview on 5/9/12 at 9:30 A.M. RN #18 stated on 4/29/12 she was sitting at the central nurses desk doing paperwork when she was alerted by Housekeeper #9. RN #18 stated she saw Resident #101 with his hand between Resident #102's legs and Resident #102's hands were on Resident #101's hands. RN #18 stated to Resident #101 that his behavior was inappropriate and "he (Resident #101) just dropped his head" and "didn't say anything." RN #18 stated Resident #101 was 1 to 1 supervision while up in his wheelchair. RN #18 stated she did not know who had gotten Resident #101 out of bed but LPN #7 had stated to her Resident #101 had "sneaked away from him." An observation and interview on 5/9/12 at 9:30 A.M. revealed Resident #102 was seated in her wheelchair by the central nursing desk. Resident #102 did not recall the event on 4/29/12 and would smile at Surveyor when asked specific questions of the event on 4/29/12. Review of the Face Sheet revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had a Brief Interview for Mental STatus (BIMS) score of 1 out of 15 which indicated severe cognitive impairment. The MDS revealed Resident #102 required extensive assistance of 1 person for transfers and used a wheelchair for locomotion on the unit. Resident #102 had a guardian placed for decisions of her care. Review of Social Service Progress Notes dated 4/29/12 (un-timed), revealed Resident #102 was assessed by social worker. Social Service Progress Notes revealed Resident #102 was "smiling" and "eating well". Review of Social Service Progress Notes dated 4/30/12 (un-timed), revealed Resident #102 was asked by social worker if she was scared. Resident #102 responded to social worker by "laughing and said 'no'." Review of the Face Sheet revealed Resident #101 was an [AGE] year old male admitted to the facility on [DATE]. The MDS dated [DATE] revealed Resident #101 had a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. The MDS revealed Resident #101 required extensive assistance of 1 person for transfers and used a wheelchair on the unit for locomotion. The MDS revealed Resident #101 had a history of [REDACTED]. Review of the Care Plan regarding activities dated 12/28/11 revealed Resident #101 "ambulates independently in a wheelchair" and, updated on 2/29/12, indicated "over past few months has been seeking out female residents" and "requires monitoring and supervision." The Care Plan intervention for Resident #101 was to not seat resident next to female residents and to monitor and redirect as needed. Review of Behavioral Flow Sheet dated 2/8/12 at 6:45 P.M., revealed Resident #101 had been in Un-sampled Resident #30's room and the resident had complained to staff about the incident. Review of Behavioral Flow Sheet dated 2/9/12 at 6:50 P.M., revealed Resident #101 had stopped Un-sampled Resident #30 outside of his room and stated to her "that he isn't going to jail because he hasn't done anything to her or any other women here." Review of Behavior Management Program notes dated 2/9/12, revealed Resident #101 had continued "to seek out particular female residents" and "tends to want to be with other female residents." Review of Behavioral Flow Sheet dated 2/11/12 at 11:15 A.M., revealed Resident #101 had "approached Un-sampled Resident #31" and was taken away from area. Resident #101 had come "right back a few minutes later to Un-sampled Resident #31 saying, 'how are you Hun'." Resident #101 was removed from the area and "after a few minutes he came back and approached another (female) resident calling her 'hunny'." Review of Behavioral Flow Sheet dated 2/11/12 at 11:32 A.M., revealed Resident #101 had "come back to library activity approached Un-sampled Resident #31" and was redirected to his room. Review of Behavioral Flow Sheet dated 2/13/12 at 1:10 P.M., revealed Resident #101 had approached Un-sampled Resident #30. Review of Behavioral Flow Sheet dated 2/15/12 at 10:00 A.M., revealed Resident #101 had 3 times attempted to talk to Un-sampled Resident #30 during church service. Review of Behavioral Flow Sheet dated 2/19/12 at 10:58 A.M., revealed Resident #101 was found near Un-sampled Resident #31 and at 11:50 A.M. Resident #101 was found near Un-sampled Resident #30. Review of Behavioral Flow Sheet dated 2/29/12 at 3:43 P.M., revealed Resident #101 was found "sitting directly next to Un-sampled Resident #30 in library in wheelchairs." Review of Behavioral Flow Sheet dated 3/2/12 at 3:53 P.M., revealed Resident #101 was found "sitting next to Un-sampled Resident #30 in library" and Un-sampled Resident #30 did not "want him near her." Review of Behavioral Flow Sheet dated 3/14/12 at 4:40 P.M., revealed Resident #101 had "wheeled self to (female resident's) room and was trying to look into room." Review of Incident and Accident Report dated 4/1/12 at 5:30 P.M., revealed Resident #101 had stated to Un-sampled Resident #32 "how are you , honey, what's going on today with touching her thigh twice."

Complaint Intake Number: MI 918 Based on observation, interview, and record review, the Facility failed to monitor anti-coagulation status in 3 of 6 sampled residents (#101, #112 & #113) on anti-coagulant therapy, from a total of 13 sampled residents, resulting in an Immediate Jeopardy when: 1) Resident #101, who was on [MEDICATION NAME] (blood thinner), fell on [DATE] and sustained a 12.0 x 8.0 cm bruise on his hip that was not treated by facility staff; was found unresponsive on 11/8/11 and transferred to the hospital, where it was discovered he had an INR (blood test that measured the coagulation status) level of 15.9 mg/dL (normal 2.0-3.0), multiple bruises, a large abdominal bruise, and blood in his stools, which required treatment with Vitamin K and a blood transfusion; 2) Resident #112, who was readmitted on [DATE] with an order for [REDACTED].#113, who was admitted to the facility on [DATE] with an order for [REDACTED]. This deficient practice placed 13 residents, who were prescribed [MEDICATION NAME], at risk for serious harm, injury, and/or death. Findings include: Resident #101: Per the Hospital Discharge Summary, dated 11/14/11, Resident #101 was admitted to the emergency roiagnom on [DATE] and was diagnosed with [REDACTED].=3.0-4.0). Per the emergency room notes, dated 11/08/11, Resident #101 had a large bruise to his left upper abdomen, bruising to both arms and dark tarry stools which tested positive for blood. Resident #101 received an injection of Vitamin K (to counteract the effect of the [MEDICATION NAME]) and a transfusion of fresh frozen plasma. Per the Face Sheet, dated 11/02/11, Resident #101 was admitted to the facility on [DATE]. Per the Clarification Telephone Order, dated 10/24/11, Resident #101 was prescribed the anti-coagulant [MEDICATION NAME] 7.5 mg daily. In an interview on 3/01/11 at 11:33 a.m., Director of Nursing (DON) #1 stated the admission order for 7.5 mg was misread and Resident #101 received 8.0 mg [MEDICATION NAME] for the first 3 days. Per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Per the 10/2011 MAR, Resident #101 received [MEDICATION NAME] 7.5 mg daily at "21:00" (9:00 p.m.) beginning on 10/25/11 through 10/31/11. Per the 11/2011 MAR, Resident #101 received [MEDICATION NAME] 7.5 mg daily at 21:00 from 11/01/11 through 11/07/11. Per Resident #101's Standing Orders, dated 10/21/11, residents who received [MEDICATION NAME] were to have the coagulation status tested (PT/INR) "One week after any dosage change or upon initiation..." Review of the clinical record revealed no documented evidence that Resident #101's INR level was obtained by the Facility at any time from his admission on 10/21/11 through his discharge to the emergency roiagnom on [DATE]. In an interview on 3/01/12 at 11:33 a.m., DON #1 stated there was an "expectation" that when a person was newly admitted with orders for [MEDICATION NAME], the Standing Order for the PT/INR would followed as the admission order for [MEDICATION NAME] was considered "upon initiation" of the drug. DON #1 confirmed that Resident #101 did not have a INR level drawn at the Facility from his admission on 10/21/11 through his discharge to the emergency roiagnom on [DATE]. Review of Resident #101's 2/2012 physician's orders [REDACTED]. Per the Minimum Data Set, dated dated [DATE], Resident #101's [DIAGNOSES REDACTED]. Resident #101 had identified cognitive deficits (score of 12 out of a possible 15) and required assistance with activities of daily living. In an observation on 2/27/12 at 10:15 a.m. Resident #101 was seated in his wheelchair in his room with supplemental oxygen through a nasal canula from a portable oxygen tank hooked to the back of his wheelchair. Resident #101 had dark purple bruises on the back sides of both hands and on his lower forearms. Resident #101 said he always had bruises on his arms and hands. ( ) Resident #112: Per the Face Sheet, dated 1/27/12, Resident #112 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Per the Minimum Data Set, dated dated [DATE], Resident #112 had significant cognitive impairment (score of 1 out of a possible 15), did not walk, and required extensive-to-total assistance with activities of daily living. Per the Physician admission orders [REDACTED]. Per the Nurses' Notes, dated 2/13/12, Resident #112's oxygen saturation rates dropped to 77% and rose to only 84 % on 4 liters of oxygen. Resident #112 was "sent to ER (emergency room )" where she was diagnosed with [REDACTED]." In an interview on 3/01/12 at 1:00 p.m., DON #1 said when Resident #112 was readmitted to the facility on [DATE], after hospitalization for bilateral [MEDICAL CONDITION] embolism (blood clots that traveled through the blood stream and lodged in the lungs), she was prescribed the anti-coagulant [MEDICATION NAME] and that no INR level had been obtained since 2/18/12. Per the Transfer admission orders [REDACTED]. Per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #112's clinical record revealed no documented evidence that her INR level was obtained since her re-admission on 2/18/12. In an interview on 3/01/12 at 1:00 p.m., DON #1 stated no INR level was obtained for Resident #112 since being readmitted on [DATE] until the concern was brought to the Facility's attention by the Surveyor on 2/29/12. At that time the Facility discovered Resident #112's last recorded INR at the hospital was obtained on 2/16/12 (results 1.5) and the last dose of [MEDICATION NAME] she received at the hospital was 6.0 mg on 2/17/12. Per Resident #112's physician's orders [REDACTED]. Per the laboratory test results, dated 3/01/12, (no time), Resident #112's INR was elevated at 3.9 mg/dL. Review of the physician's orders [REDACTED].#112's [MEDICATION NAME] on 3/01/12 and 3/02/12, resume [MEDICATION NAME] at a lower dose of 2.5 mg on 3/03/12 and obtain PT/INR every Monday and Thursday. Review of Resident #112's medical record revealed the attending Physician was aware of Resident #112's [DIAGNOSES REDACTED].#112 "was in the hospital for [MEDICAL CONDITION] embolism". The Physician further documented that Resident #112's "Chart and medications reviewed" but there was no documented evidence that the Physician noticed the order for a INR blood test every Monday and Thursday on the transfer order sheet, which was not transcribed onto the admission orders [REDACTED]. In an observation on 3/5/12 at 1:40 p.m., Resident #112 was seated in a wheelchair in her room. Resident #112 smiled but did not verbalize answers to questions posed to her. ( & ) Resident #113: Per the admission orders [REDACTED]. Per the Minimum Data Set, dated dated [DATE], Resident #113 had significant cognitive deficits (score of 6 out of a possible 15) and required extensive assistance with activities of daily living including transfers and ambulation. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Per Resident #113's Physician's Standing Orders, dated 2/17/12, a INR level was ordered to be drawn in one week after any dosage change or upon initiation of [MEDICATION NAME]. Review of Resident #113's clinical record revealed no documented evidence that the INR level was obtained one week after admission (on 2/24/12) or at any other time since her admission on 2/17/12. Per the Physician's Progress Note, dated 2/18/12, Resident #113's "Chart and Medications (were) reviewed." Per the Physician's Progress Note "Assessment/Plan", dated 2/28/12, Resident #113 had a [MEDICAL CONDITION] and [MEDICAL CONDITION] (prevention) was part of the treatment plan. There was no documented evidence on the Progress Note of 2/28/12 that the Physician noted the absence of INR monitoring since Resident #113's admission on 2/17/12. In an interview on 3/01/12 at 1:00 p.m., DON #1 stated no INR was obtained for Resident #113 since she was admitted on [DATE] until the concern was brought to the Facility's attention when looking for other information requested by the Surveyor on 2/29/12. Per Resident #113's physician's orders [REDACTED]. Per the laboratory INR report, dated 2/29/12, Resident #113's INR was elevated at 4.1 mg/dL. Review of the Physicians' Order, dated 2/29/12, revealed an order to "Hold (not administer) [MEDICATION NAME] 2/29/12 and 3/01/12" for Resident #113 and resume with a decreased dose of [MEDICATION NAME] 2.5 mg on 3/02/12 and obtain an INR every Monday and Thursday. Per the Physician's Progress Note, dated 3/02/12, Resident #113 "sustained a skin tear on her right lower leg-unable to stop bleeding. Vitamin K 5 mg given...Hold [MEDICATION NAME] 2.5 mg until INR is less than 3. (Draw) daily PT/INR..." In an observation on 3/05/12 at 1:45 p.m., Resident #113 was seated in her wheelchair in the TV lounge. Resident #113 was extremely hard of hearing and answered one question, "How are you?" with the reply, "Oh fine." No further questions were answered. The Administrator was notified on 3/02/11 at 4:10 p.m. of the Immediate Jeopardy that began on 10/28/11 and was identified on 3/01/12 as a result of the facility's failure to monitor residents on anti-coagulant therapy, which resulted in actual serious harm (hemorrhage-bleeding) for Resident #101, who required [MEDICAL CONDITION] and the potential for serious harm (bleeding) for Residents #112 and Resident #113 whose INR levels were not obtained. On 3/05/12, the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. On 12/8/11, Resident #101 was readmitted to the facility and was no longer prescribed anti-coagulant therapy. 2. On 3/1/12, Resident #112 had an INR level drawn and a head-to-toe assessment was done on 3/01/12 with no bruising noted. 3. On 2/29/12, Resident #113 had an INR level drawn on 2/29/12, [MEDICATION NAME] was held for two days and resumed at a lower dose (2.5 mg). INR was ordered every Monday and Thursday. A head-to-toe assessment was done on 3/01/12 with no bruising noted. 4. On 3/01/12, 13 out of 102 residents were identified on [MEDICATION NAME] therapy. The 13 residents on [MEDICATION NAME] therapy were physically assessed for signs of adverse reactions to [MEDICATION NAME] use and none was found. The clinical records of the 13 residents on [MEDICATION NAME] therapy were reviewed to ensure standing lab orders were in place and labs were current with physician's orders [REDACTED]. 5. On 3/01/12, the Physician's Standing Orders for INR monitoring were revised to include "upon admission". 6. On 3/01/12, the Facility's Admission/Readmission Check List was updated with bold print highlighting the instructions to nurses to "check standing order form for medications requiring continued lab monitoring and complete lab order slip. 7. On 3/02/12, the revised Standing Physician Orders, dated 3/01/12, were signed and placed on 102 of 102 residents' charts. 8. On 3/03/12, 32 of 33 nurses attended on-site in-service training regarding expectations of [MEDICATION NAME] monitoring. The remaining nurse was expected for training before reporting for work on 3/05/12. 9. On 3/01/12, the new hire orientation outline was revised to include copies of the Facility's standing orders for INR monitoring and included a copy of the in-service "Anti-coagulation Therapy Monitoring" dated 2/29/12. 10. On 3/02/12, a plan to monitor new admissions for compliance regarding Standing Physician order [REDACTED]. A compliance review of all admissions will be conducted by the management team consisting of Administrator, DON, ADON, Unit Managers, MDS Coordinator, MDS Nurse, Social Workers, Activity Director, Director of Maintenance, Dietary Manager and the Rehab Director at the daily IDT meeting Monday through Friday. 11. On 3/02/12, the Administrator and Nursing IDT team members received in-service education on the audit procedure and need to review the admission audit at the daily IDT meeting, Monday through Friday. Although the Immediate Jeopardy was removed on 3/03/12, the Facility remained out of compliance at a scope of pattern and severity of potential for harm that is not Immediate Jeopardy because not all nurses attended the in-service and sustained compliance had not been verified by the State Agency. ( )

Complaint Intake Number: MI 918 Based on observation, interview, and records review the Facility failed to provide the necessary care and services (nursing assessment of injury and assessment of medical conditions related to cessation of anti-coagulation therapy) to maintain the highest practicable physical well-being for 2 of 7 residents on anti-coagulation therapy (#101 & #111) in the sample of 13 resulting in actual harm for Resident #101 (delay in treatment of [REDACTED]. Findings include: Resident #101 Review of the November 2011 Nurses' Notes and interview with Director of Nursing (DON) #1 on 3/5/12 at 1:55 p.m. revealed no documented evidence that the large bruise that appeared 6 hours after Resident #101 fell on [DATE] was assessed, monitored and evaluated for the cause of the bruise (such as [MEDICAL CONDITION]) or with the understanding he was taking a large dose of [MEDICATION NAME] (blood thinner) daily and his anti-coagulation status was not known as there were no laboratory coagulation test results obtained since his admission. Per Resident #101's Nurses' Notes dated 10/30/11 he was "found on the floor" at 7:40 a.m. and had no injuries. Per Resident #101's Nurses' Notes dated 10/30/11 at "14:00" (2:00 p.m.) Resident #101 had a "12.0 cm x 8.0 cm purple blue bruise noted to right hip related to fall." The only other documentation in the Nurses' Notes regarding the Resident #101's bruise on his right hip was 10/30/11 "21:30" (9:30 p.m.) "bruise to right hip purple in color," 11/01/11 7:30 a.m. "Bruise to right hip," 11/01/11 9:00 a.m. "bruise to right hip continue to monitor." Per interview with the DOn #1 and the Assistant Director of Nursing (ADON) #2 on 3/5/11 at 1:55 p.m. the only other documentation they found regarding the bruise to Resident #101's right hip was an entry on the 24 hour report on 10/30/11. There was no documentation on the 24 hour report that the Physician was informed of the bruise. Although per Resident #101's Medication Administration Records of October and November 2011 he received the anti-coagulant (blood thinner) [MEDICATION NAME] 7.5 mg at bedtime daily and although no INR (blood test that measured the coagulation status) was found on his chart, there was no documented evidence that the Nursing Staff assessed Resident #101 for the possibility of hemorrhage or reported the bruise to the Physician or reminded the Physician that Resident #101 received [MEDICATION NAME], or asked the Physician for an order to check Resident #101's coagulation status. Per the Nurses' Notes dated 11/08/11 he was found slumped over and unresponsive at approximately 7:00 a.m. and sent to the hospital by ambulance. Per the Hospital emergency room notes dated 11/08/11, Resident #101's INR level was critically high at 15.9 (high therapeutic range=3.0-4.0), he had a large bruise on his abdomen, bruises on his arms, and there was blood in his stool and he required an injection of Vitamin K to reverse the effectiveness of the [MEDICATION NAME] and a transfusion of fresh frozen plasma. Per the Hospital Discharge Summary dated 11/14/11, Resident #101 was diagnosed with [REDACTED]. Per the Minimum (MDS) data set [DATE], Resident #101's [DIAGNOSES REDACTED]. In an observation on 2/27/12 at 10:15 a.m. Resident #101 was seated in his wheelchair in his room with supplemental oxygen through a nasal canula from a portable oxygen tank hooked to the back of his wheelchair. Resident #101 had dark purple bruises on the back sides of both hands and on his lower forearms. Resident #101 said he always had bruises on his arms and hands. ( ) Resident #111 Per the Minimum (MDS) data set [DATE], Resident #111 was an [AGE] year old female with [DIAGNOSES REDACTED]. Per the Physician's Admission Order Sheet dated 11/15/11, Resident #111 was prescribed [MEDICATION NAME] Sodium (blood thinning medication) 5,000 units every 12 hours. Per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Per the physician's orders [REDACTED]." Per the Physical Therapy Discharge Summary dated 12/14/11, Resident #111 was able to ambulate 70 feet with contact guard assist and a four wheeled walker however, she only did this 1 time and then refused to do it again. Per the Physical Therapy Discharge Summary "assessment" dated 12/14/11 Resident #111 had made "minimal progress" and exhibited a "lack of consistency with participation in therapy." The Physical Therapy Discharge Summary the "plan" dated 12/14/11 was to discontinue therapy and start Resident #111 on restorative services. Per Resident #111's Facility Functional Maintenance Program dated December 2011, the "interventions" were: "1) ambulate with four wheeled walker 25-50 feet with contact guard assist and follow closely by wheelchair for rest using gait belt", and "2) lower extremity ex's (exercises) on small leg bike for 10-15 minutes." Review of Resident #111's Facility "Functional Maintenance Program Weekly Restorative Aide" documentation dated December 2011 and January 2012 revealed Resident #111's participation in the restorative program consisted of the following: 12-21-11 exercised lower extremities on small foot bike for 15 minutes with 1 rest period. 12-22-11 exercised lower extremities on small foot bike for 15 minutes with 1 rest period. 12-23-11 ambulated 20-25 feet with four wheeled walker. 12-27-11 ambulated from bed to toilet (no distance noted on sheet) with contact guard assist, four wheeled walker and Resident #111 required moderate assistance to transfer to her walker. 12-29-11 ambulated with four wheeled walker, contact guard assistance and followed closely with wheelchair a distance of 12-15 feet. 12-30-12 ambulated from room to shower (no distance noted on sheet). 12-31-12 ambulated 50 feet with 1 rest period at 25 feet. 1-3-12 ambulated 30 feet with four wheeled walker and moderate assistance for transfers. 1-6-12 ambulated 25 feet x 2 with 2 rest periods and seated "ex's 10 x 3 sets." 1-9-12 ambulated 50 feet x 2 with 1 rest period 1-10-12 ambulated 15-20 feet and used a small leg bike 10 minutes. 1-11-12 "declined ex's." 1-12-12 ambulated to the dining room with wheelchair following closely (no distance noted on sheet). 1-14-12 refused to participate in restorative therapy. 1-17-12 ambulated with four wheeled walker 25 feet with 1 rest period. 1-19-12 ambulated 25-30 feet. 1-24-12 ambulated 10 feet. 1-25-12 refused restorative therapy. There was no documented evidence found in the Nurses' Notes or in the Care Plans that Resident #111 was assessed and evaluated by nursing staff for the possibility of development of [MEDICAL CONDITION] after Resident #111's [MEDICATION NAME] was discontinued on 1/13/12 until 1/27/12 when Resident #111 complained of pain behind her left knee and the nurse observed "a series of bruises in the area" and Resident #111 had "a positive Homan's sign" (an early sign of [MEDICAL CONDITION] when pain is felt in the calf with passive dorsiflexion-nurse bending resident's toes/foot toward the head while holding the leg flat). "Any period of relative or prolonged activity or immobility such as prolonged sitting, surgery or bed rest (increased the risk of development of [MEDICAL CONDITIONS] is common in older adults and preventive measures are particularly important for this age group... particularly after surgery...Preventing the incident of [MEDICAL CONDITION] ([MEDICAL CONDITION] is a major nursing concern ...Early ambulation remains the single best preventive measure available, and the nurse needs to explain the rationale for frequent ambulation ...All patients need instruction about the risks associated with prolong sitting ... " (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.). In an interview on 3/05/12 at 3:47 p.m., DON #1 said the Facility's unwritten policy for discontinuation of anti-coagulation therapy was, "when a resident is walking they (the resident) can be taken off [MEDICATION NAME]." Per the Physician's Progress Note dated 1/13/12, Nurse Practitioner (NP) #30 wrote Resident #111 was seated in her wheelchair after returning from removal of a wound vac from her abdomen (a device used to remove pus and debris from a wound). NP #30 said Resident #111 was "in good spirits about her progress in rehab walking." However, per the Physical Therapy Discharge Summary dated 12-14-11 (a month earlier) Resident #111 was discharged from therapy due to a lack of consistency with participation in therapy." In a telephone interview on 3-6-12 at 1:45 P.M., NP #30 stated she wrote the order to discontinue Resident #111's [MEDICATION NAME] on 1/13/12, (a month after Physical Therapy was discontinued) because Resident #111 "was walking in therapy and up in her wheelchair." NP #30 stated she had "no knowledge from others" about Resident #111's ambulation status but "did observe her (Resident #111)." NP #30 stated Resident #111 "got up" for meals then clarified her statement saying Resident #111 did not walk to meals but rather was in her wheelchair for meals. NP #30 asked, "Didn't I put her on anything else?" (meaning another anti-coagulant therapy such as [MEDICATION NAME]). NP #30 reported that sitting in a chair can place a resident at risk for developing a [MEDICAL CONDITION] and "there isn't any difference between sitting in a wheelchair or just sitting in a chair." In a telephone interview on 3/6/12 at 11:35 A.M., RN #29 stated Resident #111's wheelchair was her main mode of transportation within the facility and she was in her wheelchair or in her bedside chair for most of the day. RN #29 stated Resident #111 preferred her wheelchair because "of the seat pad, it was a comfort thing for her." RN #29 stated Resident #111 walked "only with therapy." Review of Resident #111's physician's orders [REDACTED]. In an interview on 3/05/12 at 3:47 p.m. when asked by Surveyor if the staff were to alert the physicians if the residents stopped or decreased the frequency of walking, DON #1 said as a "prudent nurse they should but there is not a policy for this." Per the Physician's Progress Note dated 1/27/12 Resident #111's left calf was painful, tender and ecchymotic (blue/black swelling) and she was sent to the hospital for tests to rule out [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot). Per the History and Physical Report dated 1-27-12, Resident #111 was "evaluated in the ER with ultrasound which shows extensive proximal left leg [MEDICAL CONDITION] ([MEDICAL CONDITION]-clots in the leg)." An observation of Resident #111 on 3-5-12 at 1:36 P.M. revealed Resident #111 was in her wheelchair in the activity room playing a game with other residents. ( & )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE PRESSURE ULCERS DID NOT DEVELOP AND FAILED TO PROMOTE HEALING OF PRESSURE ULCERS IN 3 OF 8 (#1, 4 AND 14,) RESIDENTS REVIEWED FOR PRESSURE ULCER DEVELOPMENT, FROM A TOTAL SAMPLE OF 21 RESIDENTS, RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE STAGE 4 PRESSURE ULCER (FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE) ON RESIDENT #4'S ACHILLES TENDON, AND THE DEVELOPMENT OF AVOIDABLE PRESSURE ULCERS ON THE COLLAR OF RESIDENT (1), AND ON THE HEELS OF RESIDENTS (4 AND 14), RESULTING IN RESIDENTS (1&4) HAVING AN INFECTION AT THE SITE OF THE PRESSURE ULCER, INCREASED RISK OF INFECTION FOR RESIDENTS (#1, 4 AND 14,) AND PAIN. THE BUREAU OF HEALTH SYSTEMS, MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS HAS IDENTIFIED "A SITUATION IN WHICH THE PROVIDER'S NONCOMPLIANCE WITH ONE OR MORE REQUIREMENTS OF PARTICIPATION HAS CAUSED OR IS LIKELY TO CAUSE SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH TO A RESIDENT." (SEE 42 CFR PART 489.3). THE IMMEDIATE JEOPARDY BEGAN ON 01/04/12. WHEN A STAGE II PRESSURE ULCER WAS IDENTIFIED ON THE LEFT LOWER LEG. THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO RELIEVE PRESSURE FROM THE BACK OF RESIDENT #4'S LEFT LOWER LEG AND LEFT HEEL. THE IMMEDIATE JEOPARDY WAS DISCOVERED ON 1/19/12 , AT APPROXIMATELY 9:30 A.M DURING OBSERVATION OF THE DRESSING CHANGE OF RESIDENT #4'S LEFT LOWER LEG AND HEEL. THE ADMINISTRATOR AND DIRECTOR OF NURSING (DON) WERE NOTIFIED OF THE IMMEDIATE JEOPARDY ON 1/19/12 AT APPROXIMATELY 2:50 PM IN THE CONFERENCE ROOM. EVEN THOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 1/20/12 AT APPROXIMATELY 1:50 PM, WHEN THE FACILITY TOOK THE FOLLOWING ACTIONS: 1. RESIDENT #4'S BRADEN SCALE, CARE PLAND AND RESIDENT CARE GUIDE WERE UPDATED. 2. THE FACILITIES NURSE MANAGERS RE-ASSESSED 103 RESIDENT FOR PRESSURE ULCER RISK. 3. THE TREATMENT NURSE WAS GIVEN A 1:1 INSERVICE ON PRESSURE ULCER PREVENTION BY THE DON AND ADMINISTRATOR. 4. EMPLOYEE EDUCATION ON PRESSURE ULCER PREVENTION WAS INITIATED. 5. THE FACILITY DETERMINED THEY WILL INCLUDE PRESSURE ULCER PREVENTION EDUCATION FOR ALL NEW HIRES AS OF 1/20/12 OR AFTER. 6. THE FACILITY DETERMINED THEY WILL HAVE LICENSED NURSES MONITOR RESIDENTS IDENTIFIED AS AT RISK EVERY SHIFT. 7. THE FACILITY DETERMINED THEY WILL IDENTIFY ALL RESIDENTS AT RISK BY PERFORMING AN ASSESSMENT USING THE BRADEN SCALE UPON ADMISSION, DURING THE QUARTERLY ASSESSMENT OR WITH THE SIGNIFICANT CHANGE ASSESSMENT. NONCOMPLIANCE REMAINED AT THE LOWER SCOPE AND SEVERITY OF ISOLATED WITH ACTUAL HARM FOLLOWING THE REMOVAL OF THE IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ACCORDING TO THE PHYSICIAN'S ORDERS FOR JANUARY 2012, RESIDENT #4 WAS readmitted TO THE FACILITY AFTER SURGERY TO CORRECT A FRACTURED LEFT HIP ON 11/23/11. RESIDENT #4'S [DIAGNOSES REDACTED]. RESIDENT #4'S MINIMUM DATA SET ((MDS) dated [DATE], REFLECTED, BASED ON STAFF ASSESSMENT, SHE HAD MODERATE COGNITIVE IMPAIRMENT. THE SAME MDS ASSESSMENT REFLECTED THAT RESIDENT #4 REQUIRED EXTENSIVE ASSISTANCE FROM ONE STAFF MEMBER FOR BED MOBILITY AND REFLECTED RESIDENT #4 WAS AT RISK FOR DEVELOPING PRESSURE SORES. THE ACTING UNIT MANAGER LICENSED PRACTICAL NURSE (LPN) "A" VERIFIED THIS ON 1/20/12 AT APPROXIMATELY 11:30 AM AT THE CENTRAL NURSES STATION AND STATED, "SHE CAN ASSIST STAFF BUT CANNOT MOVE IN BED INDEPENDENTLY." THE BRADEN SCALE (A TOOL USED TO PREDICT THE RISK OF DEVELOPING PRESSURE SORES) FROM THE DOCUMENT "NURSING COMPREHENSIVE EVALUATION" DATED 11/23/11 REFLECTED A SCORE OF 12 OUT OF 23 INDICATING A HIGH RISK OF DEVELOPING PRESSURE SORES (THE LOWER THE SCORE, THE HIGHER THE RISK). THE BODY MAP UNDER THE HEADER "SKIN" FROM THE SAME DOCUMENT REFLECTED NO CONCERNS ON EITHER OF RESIDENT #4'S HEELS. THE DOCUMENT "NUTRITIONAL EVALUATION" DATED 11/29/11 REFLECTED RESIDENT #4 WAS "admitted WITH NO PRESSURE AREAS." RESIDENT #4'S LAB RESULTS FROM BLOOD COLLECTED ON 01/02/ INDICATED A LOW TOTAL PROTEIN LEVEL 5.8 MG/DL (MILLIGRAMS PER DECILITER), AND A LOW [MEDICATION NAME] OF 3.3 MG/DL, (A PRECURSOR TO PROTEIN PRODUCTION), INDICATING A HIGH RISK OF PRESSURE SORE DEVELOPMENT. THE PROGRESS NOTE DATED 1/3/12 LISTED THE CHIEF COMPLAINT AS " F/U PT REPORTS RESIDENT (SIC) C/O MUCH PAIN. RESIDENT (ARROW UP) IN W/C, HOLDING L(EFT) LEG WHIMPERING. IMMOBILIZER REMOVED." THE ASSESSMENT/PLAN NOTED: "[MEDICAL CONDITION] L(EFT) LOWER LEG". [MEDICATION NAME] (ANTIBIOTIC) WAS ORDERED TO BE GIVEN FOR 10 DAYS. THE CARE PLAN FOUND IN RESIDENT #4'S MEDICAL RECORD WITH AN INITIATED DATE OF 8/16/2011 (PRIOR TO RESIDENT #4'S READMISSION) REFLECTED RESIDENT #4 WAS "AT RISK FOR IMPAIRED SKIN INTEGRITY (SIC) DUE TO DECREASED MOBILITY. INTERVENTIONS ON THIS CARE PLAN, THAT WERE TYPED, INCLUDED "DIETICIAN TO ASSESS PRN (AS NEEDED), BRADEN SCALE QUARTERLY AND PRN, BODY/SKIN AUDIT, PRESSURE RELIEVING MATTRESS, SUPPLEMENTS AS ORDERED, ASSIST WITH TOILETTING IN AM BEFORE AND AFTER MEALS AT HS (BEDTIME) AND PRN, PODIATRY CONSULT PRN, KEEP NAILS CUT SHORT AND TRIMMED, NOTIFY MD (PHYSICIAN) OF AN SIGNS OF SYMPTOMS OF INFECTION OR SKIN BREAKDOWN, EXAMINE SKIN DURING CARE FOR RED/OPEN AREAS, KEEP LINENS DRY AND WINKLE (SIC) FREE, TREATMENTS AS ORDERED, CUSHION TO W/C (WHEELCHAIR), ASSIST WITH FREQUENT POSITION CHANGES." INTERVENTIONS THAT WERE HAND WRITTEN WITH NO CORRESPONDING DATE INCLUDED "(L) HEEL BOOT (FOOT), HEELS UP AS TOLERATED." IN AN INTERVIEW ON 1/19/12 AT APPROXIMATELY 9:00 AM IN THE PRIVATE DINING ROOM, THE ACTING UNIT MANAGER LPN "A" CONFIRMED THAT THE INTERVENTION "HEELS UP BEGAN ON 1/4/12", THE DATE A PRESSURE ULCER ON WAS FIRST OBSERVED ON BOTH RESIDENT #4'S LEFT ANKLE AND HER LEFT ACHILLES AREA (JUST ABOVE THE LEFT ANKLE). LPN "A" THEN REVEALED RESIDENT #4 HAD NOT HAD HER HEELS ELEVATED OFF THE BED PRIOR TO 1/4/12 BECAUSE "SHE WAS COMPLIANT WITH STAFF POSITION CHANGES AND SHE HAD A PRESSURE REDUCING MATTRESS." THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, AGENCY FOR HEALTH CARE POLICY AND RESEARCH CONSUMER GUIDE "TREATING PRESSURE SORES," REFLECTS ON PAGE 8, IN REGARDS TO PREVENTING NEW PRESSURE ULCERS, "WHEN LYING ON YOUR BACK, KEEP YOUR HEELS UP OFF THE BED BY PLACING A THIN FOAM PAD OR PILLOW UNDER YOUR LEGS FROM MIDCALF TO ANKLE." IN AN INTERVIEW AT 1/19/12 AT APPROXIMATELY 2:20 PM BY THE CENTRAL NURSES STATION THE DON STATED "DID WE HAVE HER HEELS UP? NO, BUT WE KNOW WHY WE DIDN'T. DO YOU PUT AN IMMOBILIZER ON AND A HEELS UP DEVICE ON SOMEONE WHO DOESN'T DEAL WELL WITH CHANGE?" THE DOCUMENT "WOUND/SKIN HEALING RECORD" WITH DATES OF 1/4/12, 1/11/12, AND 1/17/12, REFLECTED THE WOUND ON RESIDENT #4'S LEFT HEEL WAS FIRST IDENTIFIED BY THE FACILITY ON 1/4/12 WITH DIMENSIONS OF "3.0 CENTIMETERS (CM) X 4.0 CM X UD"(UNDETERMINED) DEPTH. THE WOUND BED WAS DESCRIBED "BLACK/BROWN (ESCHAR)" (THICK, LEATHERY, FREQUENTLY BLACK OR BROWN IN COLOR, NECROTIC (DEAD) TISSUE). THE FACILITY DOCUMENTED THE WOUND "PRESENTS AS UNSTAGEABLE." ON 1/11/12 THE FACILITY DOCUMENTED NO DIFFERENCE IN THE SIZE OR APPEARANCE OF RESIDENT #4'S LEFT HEEL ULCER ON BOTH 1/11/12 AND 1/17/12. ALL WOUND ASSESSMENTS WERE SIGNED BY THE WOUND CARE NURSE LPN "B". THE DOCUMENT "WOUND/SKIN HEALING RECORD" WITH DATES OF 1/5/12, 1/11/12, AND 1/17/12 REFLECTED THE WOUND ON RESIDENT #4'S LEFT ACHILLES AREA WAS FIRST IDENTIFIED BY THE FACILITY ON 1/5/12 WITH THE DIMENSIONS OF "3.0 CM X 3.0 CM X UD" DEPTH. DESCRIPTION OF THE WOUND BED WAS "PRESENTS AS UNSTAGEABLE, PINK/BEEFY RED, SLOUGH (DEAD TISSUE IN THE PROCESS OF SEPARATING FROM THE VIABLE PORTIONS OF THE BODY), BLACK/BROWN ESCHAR, SOFT." THE SAME DESCRIPTION WAS DOCUMENTED FOR THE LEFT ACHILLES WOUND ON 1/11/12. ON 1/17/12, THE FACILITY DOCUMENTED THE LEFT ACHILLES WOUND "PRESENTS AS UNSTAGEABLE, 2.5 CM X 2.5 CM X 0.3 CM" AND DESCRIBED THE WOUND BED AS "PINK/BEEFY RED, SLOUGH, BLACK/BROWN (ESCHAR), SOFT." ALL WOUND ASSESSMENTS WERE SIGNED BY THE WOUND CARE NURSE LPN "B". OBSERVATION OF THE DRESSING CHANGE OF RESIDENT #4'S LEFT HEEL AND LEFT ACHILLES PRESSURE ULCERS OCCURRED IN HER ROOM WITH THE WOUND CARE NURSE LPN "B" AND CERTIFIED NURSES AID (CNA) "C" ON 1/19/12 AT APPROXIMATELY 9:35 AM. CNA "C" HELD RESIDENT #4'S LEFT LEG OFF THE BED WHILE LPN "B" PERFORMED THE DRESSING CHANGE. DURING THE DRESSING CHANGE, THIS SURVEYOR OBSERVED THE OUTER ASPECT RESIDENT #4'S LEFT HEEL TO BE COVERED IN BLACK/BROWN ESCHAR. RESIDENT #4'S LEFT ACHILLES AREA WAS OPEN WITH BEEFY RED TISSUE, WITH A SHINY WHITE STRIP DOWN THE CENTER OF THE WOUND FROM TOP TO BOTTOM. THE RESIDENT STATED "OW, THAT HURTS" DURING DRESSING CHANGED. LPN "B" STATED DURING THE DRESSING CHANGE "NOW THAT THE ESCHAR IS OFF I CAN SEE SOME TENDON. SHE'S GOING TO THE WOUND CLINIC, SO HE'S GONNA STAGE IT FOR ME." AFTER COMPLETING THE ORDERED TREATMENTS AND WRAPPING RESIDENT #4'S LEFT ANKLE AND ACHILLES AREA IN KERLIX, BOTH CNA "C" AND LPN "B" LOWERED RESIDENT #4'S LEG DIRECTLY ONTO THE BED. CNA "C" THEN EXITED THE ROOM. LPN "B" DISCARDED THE THE ITEMS USED DURING THE DRESSING CHANGE, PULLED BACK THE CURTAIN AND BEGAN TO WALK OUT OF RESIDENT #4'S ROOM. THIS SURVEYOR THEN ASKED LPN "B" "ARE YOU FINISHED?" LPN "B" RESPONDED "YES." THIS SURVEYOR THEN ASKED "ARE HER HEELS SUPPOSED TO BE ON THE BED?" LPN "B" WAS THEN OBSERVED REVIEWING THE "RESIDENT CARE GUIDE" HANGING IN RESIDENT #4'S CLOSET AND STATED RESIDENT #4 SHOULD HAVE A "HEALS UP" (IDENTIFIED AS A PILLOW USED TO KEEP A RESIDENT'S HEELS OFF THE BED) DEVICE. NO "HEELS UP" DEVICE WAS FOUND IN RESIDENT #4'S ROOM. THE WOUND CARE NURSE LPN "B" WAS INTERVIEWED ON 1/19/12 AT APPROXIMATELY 10:30 AM OUTSIDE RESIDENT #4'S ROOM. LPN "B" WAS ASKED HOW SHE WOULD STAGE THE WOUND ON RESIDENT #4'S LEFT ACHILLES, AND REPLIED "IF IT WERE UP TO ME IT WOULD HAVE TO BE A STAGE 4. IT'S PRETTY OBVIOUS." REVIEW OF THE NURSES NOTE WRITTEN BY LPN "B" ON 1/19/12 AT 9:45 AM REFLECTED "DRESSING CHANGE TO LEFT ACHILLES SHOWED LOW AMOUNT OF ESCHAR - SMALL ABOUT @ (AT) DISTAL PORTION OF WOUND - OBSERVED WHAT APPEARS TO BE TENDON". THE DON WAS INTERVIEWED IN THE CONFERENCE ROOM ON 1/19/12 AT 3:35 PM REGARDING RESIDENT #4'S LEFT ACHILLES PRESSURE SORE. THE DON STATED "I KNEW OF THE ISSUE WITH (RESIDENT'S NAME), BUT NOT TO THE EXTENT, OBVIOUSLY." THE DON THEN STATED SHE WAS TOLD BY THE WOUND NURSE LPN "B" HAD TOLD HER "THE SCABBED AREA fell OFF ON 1/17/12" REGARDING RESIDENT #4'S LEFT ACHILLES AREA. NO NURSES NOTE COULD BE PROVIDED REGARDING THIS EVENT. THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT A STAGE 4 PRESSURE ULCER ON RESIDENT #4 ' S LEFT ACHILLES, AN ANSTAGEABLE PRESSURE ULCER ON RESIDENT #4 ' S LEFT HEEL, AND FAILED TO FOLLOW INTERVENTIONS ON RESIDENT #4 ' S CARE PLAN AFTER THE DEVELOPMENT OF PRESSURE ULCERS TO PROMOTE HEALING. ( ) ACCORDING TO THE ADMISSION MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], RESIDENT # 1 WAS A [AGE] year OLD FEMALE WITH THE [DIAGNOSES REDACTED]. RESIDENT #1'S NURSING COMPREHENSION EVALUATION, DATED 12/16/11 REVEALED, ON PAGE 5. SECTION K. OF SKIN CONDITIONS NO ABNORMALITIES NOTED IN THE NECK AREA OF THE BODY STRUCTURES. A WRITTEN NOTATION "CERVICAL NECK BRACE WAS NOTED." THE RESIDENT WAS admitted WITH OUT ANY PRESSURE ULCER TO THE COLLAR BONE AREA. RESIDENT #1'S ALTERATION IN SKIN CARE PLAN, DATED 12/29/11 REVEALED, "STAGE II L (LEFT) COLLARBONE .1 X 12.1 X 0.1 (CENTIMETERS) RESIDENT #1'S WOUND SKIN HEALING RECORD DATED 12/29/11, REVEALED (L) COLLAR BONE STAGE II 1.0 X 0.8 X 0.1 SEROUS DRAINAGE. NO OTHER DOCUMENTATION RECORDED ON THE WOUND RECORD. THE CLINICAL RECORD HAD DOCUMENTED DISCREPANCIES OF PRESSURE ULCER WOUND SIZE ON THE SAME DATE. THE WOUND WAS NOT MEASURED AFTER THE INITAL MEASUREMENTS ON 12/29. RESIDENT #1'S WEEKLY SKIN ASSESSMENT WAS REVIEWED, AND REVEALED THE FOLLOWING INFORMATION: 12/22/11 " 0 (NO) NEW SKIN ISSUE,CERVICAL COLLAR IN PLACE " 12/29/11 " 0 S/S INFX TO ST (NO SIGN/SYMPTOM INFECTION TO SITE) " 1/5/12 " DRESSING INTACT, 0 NEW ISSUES " 1/12/12 " DRSG (DRESSING)TO L NECK-BRACE ABRASION, 0 NEW SKIN ISSUES " 1/18/12 " NECK BRACE ON, 0 OTHER ISSUES NOTED " THERE WAS NO MEASUREMENT OR ON GOING ASSESSMENT OF COLLAR BONE PRESSURE ULCER SITE NOTED IN THE CLINICAL RECORD AFTER THE INITIAL MEASUREMENTS DATED 12/29/11. RESIDENT #1'S PHYSICIAN ORDER DATED 1/4/12, REVEALED "KEFLEX 500 MG (MILLIGRAMS) 1 PO (ORALLY) BID ( 2 TIMES A DAY) X (TIMES) 10 DAYS [MEDICAL CONDITION] (L) COLLARBONE)." RESIDENT #1'S PHYSICIAN ORDER DATED 1/7/12, REVEALED, " CLEANSE WITH NA (NORMAL SALINE), APPLY TAO (TRIPLE ANTIBIOTIC OINTMENT) + COVER WITH BAND-AID." ON 1/20/12 AT APPROXIMATELY 8:34 AM NORTH UNIT MANAGER "L" REPORTED THAT RESIDENTS RECEIVE WEEKLY SKIN ASSESSMENTS AND THAT THE SIZE WOULD NOT NECESSARILY BE ON THAT REPORT BUT IT WOULD BE DOCUMENTED ON THE "WOUND LOG." NORTH UNIT MANAGER "L" VERIFIED THAT RESIDENT #1'S "WOUND LOG" HAD NOT BEEN DOCUMENTED ON SINCE 12/29/11 AND VERIFIED THAT THE MEASUREMENTS OF THAT DOCUMENT AND THE CARE PLAN DATED 12/29/11 DID NOT AGREE. NORTH UNIT MANAGER "L" REPORTED THAT WAS THE ONLY DOCUMENTATION AVAILABLE AT THAT TIME. ON 1/20/12 AT APPROXIMATELY 11:00 AM, RESIDENT #1 WAS OBSERVED IN HER ROOM. THE WOUND NURSE "B" WAS OBSERVED AS SHE ENTERED THE ROOM AND APPLIED GLOVES WITHOUT WASHING HER HANDS. WOUND NURSE "B" PROCEEDED TO REMOVE A BAND-AID FROM THE PRESSURE ULCER SITE ON THE LEFT COLLARBONE. THE AREA HAD A SUPERFICIAL SCALE OF SKIN AND WAS NOTED TO BE PINK/RED AND SLIGHTLY SWOLLEN ON THE SURFACE OF THE BASE OF THE COLLARBONE. THE WOUND NURSE "B" REMOVED THE FLAKE OF SKIN. THE SKIN WAS NOT NOTED TO BE OPEN. WOUND NURSE "B" REPORTED SHE WAS NOT GOING TO BE COVERING IT WITH A BAND-AID AND NO TREATMENT WAS APPLIED. THE AREA WAS NOT CLEANSED WITH NORMAL SALINE AS ORDERED. THE FACILITY FAILED FOLLOW THE FACILITY POLICY TO PROVIDE HAND HYGIENE DURING A DRESSING CHANGE OBSERVATION FOR A PRESSURE ULCER, FOLLOW THE PHYSICIan order for [REDACTED]. ON 1/20/12 AT APPROXIMATELY 2:50 PM, THE DIRECTOR OF NURSING, PROVIDED THE POLICY, "WOUND CARE TREATMENT GUIDELINES" DATED AUGUST 2010, REVEALED "VI. HAND HYGIENE MUST BE DONE AS OUTLINED IN THE PROCEDURE." THE FACILITY FAILED TO FOLLOW THEIR POLICY FOR PROVIDING HAND HYGIENE. ON 1/20/12 AT APPROXIMATELY 2:50 PM, THE DON, PROVIDED THE FACILITY POLICY "PROCEDURE FOR CLEAN DRESSING TECHNIQUE" DATED AUGUST 2010, WHICH REVEALED: -6. WASH HANDS -8. WASH HANDS... -9. CLEANSE WOUND WITH SOLUTION ORDERED USE " NO-TOUCH TECHNIQUE. DO NOT DIRECTLY TOUCH ANY ITEM THAT WILL COME IN CONTACT WITH THE WOUND. WASH FROM CENTER OF THE WOUND TO THE PERIPHERY. ALWAYS WASH FROM THE AREA OF LEAS CONTAMINATION TO THE AREA OF MOST CONTAMINATION. -10. OBSERVE THE WOUND FOR SIZE, COLOR, APPEARANCE AND AMOUNT OF DRAINAGE. THIS IS THE BEST TIME TO MEASURE THE AREA, BEFORE ANY MEDICATION IS APPLIED. 14. REMOVE GLOVES AND WASH HANDS. THE FACILITY FAILED TO FOLLOW THEIR POLICY FOR CLEAN DRESSING CHANGE. ( ) RESIDENT #14 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH ACCUMULATIVE [DIAGNOSES REDACTED]. ACCORDING TO THE ADMISSION THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED, "SECTION M. (2) NUMBER OF UNSTAGEABLE PRESSURE ULCERS WITH SUSPECTED DEEP TISSUE INJURY IN EVOLUTION". RESIDENT #14'S "ALTERATION IN SKIN INTEGRITY " CARE PLAN DATED 1/5/12 REVEALED A PRESSURE ULCER, "STAGE II L(LEFT) HEEL 4.0 X 4.0 X 0.0 (CENTIMETER). A SECOND "ALTERATION IN SKIN INTEGRITY " CARE PLAN DATED 1/5/12 REVEALED ANOTHER PRESSURE ULCER, "STAGE II R (RIGHT) HEEL 2.0 X 2.5 X 0.0 (CENTIMETER). THE CARE PLAN WAS NOT UPDATED. RESIDENT #14'S PHYSICIAN ORDER DATED 1/14/11 REVEALED, MOON BOOTS-BOTH FEET, 12% LACHYDRIN LOTION TO BOTH FEET AND ANKLES DAILY." RESIDENT #14'S TREATMENT RECORD DATED 1/15/12 THROUGH 1/16/12 REVEALED, "CLEANSE L (LEFT) HEEL BLISTER WITH NS (NORMAL SALINE) APPLY TOA (TRIPLE ANTIBIOTIC OINTMENT) AND NON ADHERENT PAD - WRAP WITH KERLIX. " TREATMENT RECORD DATED 1/16/11, REVEALED, "CLEANSE L HEEL WOUND WITH NS-APPLY HYDROGEL - COVER WITH XEROFORM -GAUZE- WRAP WITH KERLIX QD (DAILY) AND PRN ( AS NEEDED)." RESIDENT #14'S PHYSICIAN ORDER DATED 1/16/12 (1) DC (DISCONTINUE) L HEEL BLISTER WITH NS APPLY TOA -NON ADHERENT PAD WRAP WITH KERLIX QD. (2) CLEANSE L HEEL WOUND WITH NS APPLY HYDROGEL - COVER WITH XEROFORM - GAUZE - WRAP WITH KERLIX QD AND PRN. THERE WAS NO PHYSICIAN ORDER NOTED IN THE CLINICAL RECORD FOR THE treatment of [REDACTED]. ON 1/20/12 AT APPROXIMATELY 11:20 AM, DURING AN OBSERVATION OF RESIDENT #14'S (2) HEEL PRESSURE ULCERS DRESSING CHANGE, THE FOLLOWING WAS OBSERVED WITH WOUND NURSE. "B": - DRESSING SUPPLIES WERE SET UP ON THE END OF THE RESIDENT #14'S BED. - WOUND NURSE "B WAS OBSERVED TO NOT WASH HER HANDS PRIOR TO APPLYING GLOVES AND REMOVING DRESSINGS TO BOTH HEEL ULCERS FROM BOTH FEET. -NO CHANGE OF GLOVES WAS NOTED BETWEEN FEET . -MEASUREMENTS WERE DONE ON BOTH HEEL WOUNDS. THE SAME MEASURING PAPER WAS USED FOR BOTH WOUNDS . THE LEFT HEEL WAS CLEANSED THEN THE RIGHT HEAL WAS CLEANSED. WOUND NURSE "B" THEN REMOVED HER GLOVES AND WASHED HER HANDS AND APPLIED NEW GLOVES. THE TREATMENT WAS THEN APPLIED TO THE LEFT HEEL WITH GLOVED HAND. -WOUND NURSE "B" THEN REACHED IN TO HER POCKET WITH A SOILED GLOVE ON TO GET A MARKER TO LABEL THE TAPE. - WOUND NURSE "B" CONTINUED ON TO THE RIGHT HEEL AND APPLIED WITH THE TREATMENT WITH THE SAME SOILED GLOVE. -WOUND NURSE "B" THEN REMOVED HER GLOVES AND PLACED TAPE AND ALL PACKAGED SUPPLIES IN HER UNIFORM POCKETS AND SOILED SCISSORS IN HER PANTS POCKET, -PROCEEDED TO BAG UP TRASH AND ASSISTED RESIDENT #14 WITH THE CONTROL FOR THE BED AND -HELD THE TRASH BAG CONTAINING SOILED DRESSING SUPPLIES AGAINST HER UNIFORM TOP WHILE WASHING HER HANDS. WOUND NURSE 'B'" LEFT RESIDENT #14'S ROOM AND RETURNED TO THE TREATMENT CART WHERE WOUND NURSE "B"FOUND THE TRASH RECEPTACLE FULL, - PLACED THE COVER OF THE TRASH RECEPTACLE ON TOP OF THE BARRIER AND GLOVE CONTAINERS, REMOVED THE TRASH CONTAINER OUT ALONG WITH THE TRASH IN HER HAND FROM RESIDENT #14'S ROOM AND WENT TO THE SOILED UTILITY ROOM TO DISCARD. ON 1/20/12 AT APPROXIMATELY 11:35 AM, DURING THE WOUND OBSERVATION IN RESIDENT #14'S ROOM, WOUND NURSE "B" EXPLAINED TO RESIDENT #14 WHEN HE INQUIRED, THAT HIS WOUNDS WERE PROBABLY CAUSED BY FRICTION ON THE BED, HIS HEELS RUBBING MULTIPLE TIMES ACROSS THE BED AND HIS HEELS NOT BEING ELEVATED ON A PILLOW OFF THE BED. ON 1/20/11 AT APPROXIMATELY 11:45 AM, WOUND NURSE "B" REPORTED WHEN INTERVIEWED FOLLOWING THE ABOVE PROCEDURE AND OF POLICY/ NORMAL PRACTICE SHE RESPONDED SHE WOULD "TREAT THE WOUNDS AS SEPARATE WOUNDS, WASH HER HANDS PRIOR TO STARTING AND AFTER THE TREATMENT, LEAVE SUPPLIES IN THE RESIDENT'S ROOM FOLLOWING A RESIDENT'S PROCEDURE OR THROWN IN THE TRASH; CLEAN SCISSORS WITH ALCOHOL FOLLOWING PROCEDURE, NOT PLACE SUPPLIES IN UNIFORM POCKETS, AND NOT PUT SOILED GLOVES IN UNIFORM POCKET DURING PROCEDURE." ON 1/20/12 AT APPROXIMATELY 2:12 PM, IN THE CONFERENCE ROOM, DURING AND INTERVIEW WITH THE DON REGARDING CONCERNS WITH OBSERVATION OF HEEL PRESSURE SORES DRESSING CHANGE, THE DON REPORTED THE FOLLOWING RESPONSES TO CONCERNS IDENTIFIED: -TWO WOUNDS WERE TO CONSIDERED INDIVIDUAL SEPARATE WOUNDS; -SUPPLIES WERE EXPECTED TO BE LEFT IN THE RESIDENT'S ROOM FOLLOWING A RESIDENT'S PROCEDURE OR THROWN IN THE TRASH; -SCISSORS WERE TO BE CLEANED WITH ALCOHOL FOLLOWING PROCEDURES; -NO DRESSING SUPPLIES WERE TO BE PLACED IN NURSE UNIFORM POCKETS, AND FINALLY - SOILED GLOVES WERE NOT TO BE PLACED IN UNIFORM POCKETS DURING PROCEDURES. ON 1/20/12 AT APPROXIMATELY 2:50 PM, THE DIRECTOR OF NURSING, PROVIDED THE POLICY "WOUND CARE TREATMENT GUIDELINES" DATED AUGUST 2010, WHICH DOCUMENTED: - IV (4) SUPPLIES (OTHER THAN THE TRASH BAG ARE NOT TO BE PLACED NON THE BED. -V. (5) SUPPLIES SHOULD BE PLACED ON A CLEAN SURFACE/BARRIER. -VI. (6) HAND HYGIENE MUST BE DONE AS OUTLINED IN THE PROCEDURE. THE FACILITY FAILED TO FOLLOW THEIR POLICY FOR PROVIDING AN APPROPRIATE BARRIER AND HAND HYGIENE. ON 1/20/12 AT APPROXIMATELY 2:50 PM, THE DON, PROVIDED THE FACILITY POLICY "PROCEDURE FOR CLEAN DRESSING TECHNIQUE" DATED AUGUST 2010, WHICH REVEALED: -6. WASH HANDS -8. WASH HANDS... -9. CLEANSE WOUND WITH SOLUTION ORDERED USE " NO-TOUCH TECHNIQUE. DO NOT DIRECTLY TOUCH ANY ITEM THAT WILL COME IN CONTACT WITH THE WOUND. WASH FROM CENTER OF THE WOUND TO THE PERIPHERY. ALWAYS WASH FROM THE AREA OF LEAS CONTAMINATION TO THE AREA OF MOST CONTAMINATION. -10. OBSERVE THE WOUND FOR SIZE, COLOR, APPEARANCE AND AMOUNT OF DRAINAGE. THIS IS THE BEST TIME TO MEASURE THE AREA, BEFORE ANY MEDICATION IS APPLIED. 14. REMOVE GLOVES AND WASH HANDS. THE FACILITY FAILED TO FOLLOW THEIR POLICY FOR HAND WASHING AND MAINTAINING A SEPARATE CLEAN FIELD AND MEASURING AFTER CLEANING THE WOUND ( )