Every finding on record at Schoolcraft Medical Care Facility

Based on interview and record review, the facility failed to ensure physician visits were completed timely following admission for 4 Residents (R5, R11, R33 & R40) of 15 sampled facility residents. This deficient practice resulted in the potential for unidentified and unaddressed medical care needs.Resident #33 (R33) Review of MDS assessment dated [DATE], revealed admission to the facility on 3/24/25, with diagnoses that included: Non-Alzheimer's dementia and anxiety disorder. R33 scored a 5 of 15 on the BIMS assessment reflective of severe cognitive impairment. During an interview on 3/25/26 at 11:35 a.m., NHA reported, The required physician visits were out of compliance. During an interview on 3/25/26 at 3:59 p.m., the NHA reported, the History and Physical were completed by the Medical Doctor (MD) on 3/25/25, the 30 day follow up were completed by the NP C, but no required 60-day physician visit were completed until 6/29/25. Resident #5 (R5) Review of an admission Record revealed Resident #5, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic obstructive pulmonary disease. Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 1/13/2026 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated R5 was cognitively impaired. During an interview on 3/25/26 at 11:26 a.m., when asked about the timeliness of physician visits for R5, the NHA said R5 was also of compliance with the timeliness of physician visits for the months between 7/2025-12/2025. Review of a facility Policy with a review date of 2/2026 read in part: Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Policy Explanation and Compliance Guidelines: 1. The Attending Physician should: a. See residents within 30 days of initial admission to the facility. b. The resident must be seen at least once every 30 calendar days for the first 90 calendar- days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law. c. Review the resident's total program of care including medications and treatments at each visit. d. Date, write and sign a progress note for each visit. Findings include: (R11) Review of R11's Minimum Data Set (MDS) assessment revealed R11 was admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, atrial fibrillation, cancer, renal insufficiency, thyroid disorder, respiratory failure, pulmonary edema, multiple myeloma and local infection of the skin and subcutaneous tissue. R11 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. During an interview with R11 on 3/23/26 at 4:00 p.m., when asked if the Residents' primary Physician had visited R11 since their admission to the facility, R11 said they did not know who their primary physician was and did not recall seeing a physician during their stay in the facility. Review of R11's complete electronic medical record (EMR) revealed post-admission required physician visits were performed as follows: 12/23/25 – History and Physical completed by Physician F. 1/21/26 – 30-Day Follow Up visit completed by Nurse Practitioner (NP) C. 3/22/26 – 30-Day Follow Up visit completed by Physician K 50 days after the 1/21/26 visit. During an interview on 3/24/26 at 3:04 p.m., the Nursing Home Administrator (NHA) acknowledged post-admission regulatory physician visits were completed every 30 days for the first 90 days and then every 60 days after that. The NHA stated, No visit was completed for the second 30-day regulatory visit. The NHA acknowledged 30-day follow up visits were not completed for R11 as required. (R40) Review of R40's MDS assessment revealed R40 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, hypertension, Alzheimer's disease and chronic obstructive pulmonary disease (COPD). R40 scored 9 out of 15 on the BIMS, reflective of moderately impaired cognition. Review of R40's complete EMR on 3/25/26 at 10:28 a.m. revealed post-admission required physician visits were performed as follows: 6/2/25 - History and Physical completed by Physician L. 7/2/25 - 30-Day Follow Up visit completed by NP C. 9/1/25 – 30-Day Follow Up visit completed 61 days after the 7/2/25 visit by Physician F. During an interview on 3/25/26 at 11:26 a.m., when asked about the timeliness of physician visits for R40, the NHA said R40 was definitely out of compliance with the timeliness of physician visits.

This deficiency pertains to Facility Reported Incident (FRI) 2631248Based on observation, interview, and record review, the facility failed to implement interventions and physician recommendations/orders to prevent one Resident (#1) with a known history of elopement of three residents reviewed for elopement from eloping from the facility. This deficient practice resulted in an immediate jeopardy when Resident #1 eloped from the facility and was found 1.2 miles away and was missing for approximately 2 hours, resulting in the likelihood of series injury, harm or death.Findings include:The Immediate Jeopardy began at 12:16 p.m. on 9/28/25 when R1 eloped from the facility undetected and was reported by a facility staff member to be located at a fast-food restaurant, 1.2 miles away at 2:10 pm. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 10/8/25 at 2:10 PM. At that time, an immediacy removal plan was requested from the facility. This surveyor confirmed by observation, interview, and record review that the immediacy was removed on 10/8/25 at 4:06 p.m., however, noncompliance remained at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA).Resident #1 (R1)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/7/25, with active diagnoses that included: Alzheimer's disease and macular degeneration (an eye disease that damages the macula [part of the eye for sharp, central vision], causing blurry or distorted central vision). Further review of MDS Section B1000 Vision revealed R1 vision is severely impaired with no vision or sees only light, colors or shapes; eyes to not appear to follow objects. R1 scored a 4 of 15 on the Brief Interview for Mental Status reflective of severe cognitive impairment.Review of the Facility Reported Incident (FRI) submitted to the SA included an Incident Summary read in part, .R1 was found not to be in the facility.he went out when a family member came into the facility. Investigation Summary/Actions Taken.At approximately 1:13 p.m. on 9/28/25, Administrator was called by charge nurse.who stated that R1 could not be found in the facility.the facility has been checked and R1 was not in the building.at 2:10 p.m. the resident has been found at [fast food restaurant] 1.2 miles away from the facility.the Director of Nursing (DON) and Administrator reviewed the cameras after the event and noticed that the resident was playing with the door code earlier in the day.Views of the camera showed that he waited for a family member to come in the door to sneak out of the facility.he did walk around.before leaving the facility premises.Review of google maps revealed R1 would have crossed multiple streets and likely walked along a busy highway to gain entrance into the fast-food restaurant located next to the highway. The fast-food restaurant is also located near a very large lake with an average surface temperature in late September of approximately 50 degrees Fahrenheit.Review of the Elopement [R1] Incident Timeline dated 9/28/25, read in part .12:16 p.m. a residents family entered the facility in the Northeast entrance. R1 seen them come in and he immediately went to the door and got outside. nobody seen him go out.12:59 p.m. Certified Nurse's Assistant (CNA) went to check on resident and realized he was not there.at 2:10 PM Staff Member D found resident at [fast food restaurant].Review of Incident Report titled Elopement dated 9/28/25, read in part . Nursing Description: Resident waited for a family member enter the building so that he could exit the building.He was seen on [video] camera playing with the door code at 11:35 a.m.No witnesses to that.During an interview on 10/7/25 at 12:28 p.m., the NHA reported I don't know how he made it to the [fast food restaurant], he can't see. I had 40 people looking all over the [city name] looking for him.he wants to get out of here and go to another facility.he does not want to be here, especially since his wife died.she died just before he eloped from here.During a phone interview on 10/7/25 at 1:04 p.m., family member [daughter] A reported He has talked about leaving the facility prior to the elopement.he left that day and he just didn't want to be there since mom died.During an interview on 10/7/25 at 1:15 p.m., CNA B reported He was grieving since his wife passed.he always talked about leaving and going to the city where he used to live [50 miles away].he has gone to the doors before.I worked that day and went to his room to check on him and he was gone.he left the facility and was found a mile or so away.During an observation on 10/7/25 at 1:27 p.m., the Northeast exit door was noted to be across from the dining room.During an observation on 10/7/25 at 1:33 p.m., the NHA replayed the video camera footage which revealed R1 walked out of the dining room and exited the northeast exit door after other visitors entered. R1 walked outside of the fence and then walked across the parking lot towards the street.During an interview on 10/7/25 at 2:40 p.m., R1 stated I wanted to get out of here and I did. I will try again, and they will not find me.I don't want to be here.Review of R1's physician progress notes revealed the following entries:5/21/25, read in part .[R1] Resides in the memory care unit. He greatly benefits from this environment due to poor safety awareness and wandering.6/29/25, read in part .He was admitted to the memory care unit on 4/7/25. He was diagnosed with Alzheimer's disease in March of 2025.Review of R1's progress notes revealed the following entries:7/1/25, read in part .Room change.Reason: resident to move on main nursing floor. The progress note did not indicate R1 did not meet the criteria for being in the memory care unit or the reason why he was taken out of the memory care unit.7/5/25, read in part R1.said he wanted to get out of here.he was very upset and said he wanted to go home. 7/6/25, read in part .Resident went out the south exit door. CNA went out to get him.he came back in the Northeast exit door.Review of document titled Elopement Risk Assessment dated 7/7/25, read in part .total score elopement risk.total score of 21 [out of 24] .if total score is above 10 indicates need for care planning .Review of R1's care plan revealed no care planning was completed regarding elopement risk.During an interview on 10/8/25 at 10:49 a.m., the NHA reported There was no investigation or incident/accident report when R1 exited the facility on 7/6/25.there was no care plan or interventions put in place after he exited facility on 7/6/25. During a follow-up interview at 11:08 a.m., the NHA reported There was no care plan in place after the elopement assessment was completed on 7/7/25.we missed it, and I don't know why.Review of physician progress revealed the following entries: 7/11/25, read in part .Noted to be pacing up and down hall, approaching nurses' station to inquire about.getting back home.He is repetitive with his thoughts and is noted to be wandering/pacing in the halls.7/21/25, read in part .R1 requested to be moved back into the secure memory unit.Review of R1's progress notes revealed the following:7/25/25, read in part ID (interdisciplinary) team met for weekly meeting Admin (NHA), wound care nurse, AD (Activity Director), SWD (Social Worker Designee), RD (Registered Dietician), NP (Nurse Practitioner), and DON (Director of Nursing) in attendance. Resident has been having increased behaviors and exit seeking.8/5/25, read in part .Resident walked out Northeast exit door.During an interview on 10/8/25 at 10:49 a.m., the NHA reported There was no investigation or incident/accident report when R1 exited the facility on 8/5/25.there was no care plan or interventions put in place after he exited the facility on 8/5/26. We did not have a care plan for him regarding elopement or elopement risk until after the elopement on 9/28/25.Review of policy titled Comprehensive Care Plans date reviewed/revised 3/25/25, read in part .It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident.that includes measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs and all services that are identified.and meet professional standards of quality.the comprehensive care plan will be reviewed and revised by the interdisciplinary team.alternative interventions will be documented as needed.Review of policy titled Resident Elopement read in part .It is the policy of this facility that all residents will be assessed for behaviors or conditions that put them at risk for elopement. All resident so identified will have these issues addressed in their individual care plan.Residents at risk for elopement shall be identified and documented in the individual plan of care.Review of R1's social worker notes revealed the following entries: 8/12/25, read in part .left message with residents Durable Power of Attorney (DPOA) related to possibly moving resident to the secured unit. 8/18/25, read in part .spoke with residents DPOA and she gave consent for resident to reside in the memory care unit.related to safety issues, she will sign a new consent if necessary.During an interview on 10/8/25 at 1:43 p.m., the NHA reported The facility did not formally move R1 to the memory care unit after his previous attempts of eloping from the facility.he went back there [to the memory care unit] a couple times to take a break from being with his wife who was declining in health, however he did not meet the criteria to be in the memory care unit.Review of facility document titled [Facility name] Memory Care Unit-Consent Form revealed the DPOA signed the consent form on 4/7/25.Review of policy titled Memory Care Unit read in part .It is the policy of this facility to provide holistic are to those residents affected with.Alzheimer's disease by providing a.safe environment.criteria is identified on the Memory Care Unit Consent Form that is signed on admission.admission Criteria 1. Individual must have diagnosis of .Alzheimer's Disease.2. Individual must be able to .b. be up in a chair.or ambulate.3. Individual must be assessed to have moderate to severe cognitive impairment.4. The individual requires no more support than 1 person assisting with transfers.Review of MDS revealed R1 did meet the criteria to stay in the Memory Care Unit based on the criteria above.Review of social work note dated 9/8/25, read in part .Spoke with the residents DPOA and she believes his dementia is progressing.Review of physician progress note dated 9/26/25, read in part .adjustment disorder with mixed anxiety and depressed mood: R1 wife passed away very recently .He is noted to have some increased sadness and agitation.Review of R1's progress notes revealed the following entries:9/27/25, read in part .He is upset because he is here and is just here to die.9//28/25, read in part .He was in the dining room for lunch and came up missing.staff searched the whole building and outside premises for him. DPOA/daughter was called.DPOA states she figured this would happen because of [wife's] passing.he had $100 dollars in his wallet and he is very [NAME] and is probably on his way to try to get to [hometown city approximately 50 miles away].the DPOA was going to call neighbors and friends.to be on the lookout for him.This nurse went out and walked close by streets to try and find resident. Then this nurse got in her truck and rode around.Review of policy titled Resident Elopement read in part .Definitions.for the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds.all residents shall be reviewed for safety concerns.The Immediate Jeopardy which began on 9/28/25 was removed on 10/8/25 at 4:06 p.m. when the facility took the following actions to remove the immediacy. The Facility Removal Plan read:R #1 is safe and residing in the Memory Care Neighborhood, a secured unit. No physical injury, mental anguish, harm or painR #1 Elopement Assessment has been updated, and a care plan has been developed, with appropriate interventions.All residents have an Elopement Assessment. All were audited to ensure that if they have a score higher than 10, that they will; have a care plan in place with appropriate interventions. All are completed. All staff have reviewed and signed a copy of the Facility Elopement Policy. The Director of Nursing, or designee will audit all new admissions for elopement risk and ensure appropriate interventions are in placeThe Director of Nursing, or designee will audit residents, based on MDS schedule, to ensure Elopement Assessment is completed and appropriate interventions are in place. The Director of Nursing was educated to review Elopement Assessments to ensure that proper care plan interventions are in ace, based on the MDS schedule and admissions. The Northeast door code has been changed and only staff are allowed to have this code. All visitors and staff must enter and exit the facility through the front lobby only. All DPOA's and Emergency contacts will be contacted today to let them now of the change. Signage will also be posted. Staff education has been sent regarding these changes and to ensure they do not give out the cede to the Northeast door and that they all use the front lobby to enter and exit. If they hear the alarm o off, they need to remind the visitor to use the front lobby door, or if they cannot identify who set the alarm off, they need to call a code missing person and start a headcount. All physician orders and physician progress notes have been reviewed for R #1 and have been placed. Resident is utilizing nonpharmacological interventions, residing in the memory care unit, and on antidepressant medications, per Behavioral Care Solutions recommendations. The Director of Nursing and Administrator consulted with [physician name], our Medical Director, who has no concerns at this time that we have not followed any of his recommendations on any other residents. He does not have any concerns at this time with any resident risk of elopement, safety, or wandering.

Based on observation, interview, and record review, the facility failed to implement a comprehensive infection control program to mitigate the spread of Norovirus during an outbreak by failure to: 1. Implement effective disinfection of the facility. 2. Perform outbreak surveillance to track and mitigate the spread of Norovirus. 3. Adhere to Hand Hygiene Infection Control Principles. This deficient practice resulted in a sustained outbreak affecting 18 Residents out of a total facility census of 63 residents who contracted Norovirus. Residents (R26 and R44) were hospitalized from the outbreak. The failure to mitigate the outbreak also resulted in identification of sustained transmission of Norovirus with two additional Residents confirmed by facility staff who tested positive on 1/8/25. Findings include: On 1/1/25, three Residents (#8, #44, & #250), developed symptoms of emesis (vomiting) and diarrhea. Resident #44 (R44) was sent to the hospital on 1/2/25 and was confirmed positive for Norovirus infection and was subsequently admitted to the hospital. The Infection Preventionist (IP)/Registered Nurse (RN) A provided a handwritten note which indicated Resident #26 (R26) developed symptoms of Norovirus on 1/6/25, including diarrhea and vital signs very unstable and was sent to the Emergency Department. R26 was also admitted to the hospital and was admitted with Pneumonia and was on contact precautions at the hospital due to the diarrhea. Testing had not been performed for Norovirus according to the hospital. On 1/7/25 at approximately 1:30 p.m., an unidentified housekeeper was observed in the east hallway wiping down the handrails. This staff member stated to not to lean on the handrails because they were wiping them down with bleach. The unidentified housekeeper then gestured to the white cloth in her hand. This Surveyor observed the cloth and noted it was not completely saturated. The unidentified staff member continued down the hall wiping down the handrails with the same damp cloth. On 1/7/25 at approximately 3:00 p.m., Housekeeping Aide/Staff E stated the facility used bleach water to clean and disinfect using one cup of bleach to every gallon of water. Staff E stated their supervisor told them to use the bleach water to clean high touch areas twice a day. During an interview on 1/8/25 at 10:09 a.m., the Director of Nursing (DON) stated there were two additional cases of resident illnesses consistent with Norovirus today, and confirmed there were currently two residents hospitalized with Norovirus . The facility was asked to provide their surveillance of the outbreak. RN A provided the survey team with a typed summary of events from the outbreak on 1/8/24. However, there was no additional information on education provided, auditing, or monitoring of the outbreak to mitigate the spread. On 1/8/25 at approximately 10:12 a.m., during an interview, RN A stated, The Norovirus started with two Residents on the South wing and one Resident on the [NAME] wing . we were encouraging residents to stay in their rooms . the Norovirus then jumped to the Northeast wing . our team decided not to close down dining or activities . if residents are not symptomatic and their roommate is sick the resident without symptoms can come out for dining . we have 17 residents with the Norovirus currently . RN A was asked to provide their surveillance of the outbreak and any efforts to mitigate the spread. During an interview on 1/8/25 at 11:41 a.m., the NHA stated, We are still having communal dining .I feel that closing dining would not change anything (won't assist in stopping the spread of Norovirus) . During an interview on 1/8/25 at 12:18 p.m., Licensed Practical Nurse (LPN) B stated, I didn't know we could not use hand sanitizer for the Norovirus .it is what I have been using . Review of facility document titled GI Outbreak January 2025, read in part . Wash hands with soap and water as hand sanitizer does not kill the Norovirus . During an interview on 1/8/25 at 12:31 p.m., Housekeeping Supervisor/Staff C stated, We are using bleach to clean due to the Norovirus .we are using a 1 to 10 ratio .bleach to water .we did get a special cleaner to use that would kill the Norovirus but .we decided not to use it .the bleach has a three minute contact time (how long the surface needs to remain visibly wet in order for the disinfectant to be fully effective) .I looked to the CDC website .I educated the housekeeping staff how to use the bleach on the 6th of January . On 1/8/25 at 12:41 p.m., Housekeeping Aide D stated, We use a 1 to 10 ratio (bleach to water) to clean .1 cup of bleach to 10 cups of water and clean high touch areas three times a shift and wring out the cleaning rags so they aren't dripping wet . On 1/8/24 at 11:22 a.m., Supervisor C stated, We went to a spray that kills in one minute . but when we are spraying it on, we felt it didn't cover everything we would like it to cover as it was a spray . that product worked in one-minute. On 1/9/25 at 12:28 p.m., Supervisor C stated this was why they went to a bleach solution because the staff weren't sure of the effectiveness of the spray and didn't like to use it. During a follow-up interview on 1/8/25 at 1:02 p.m., Supervisor C acknowledged the housekeeping staff were not waiting for three minutes to ensure proper contact time of the bleach solution to the surfaces. Supervisor C indicated staff felt pressure from too many other job duties. Indicating staff would only wipe down surfaces, then move on to other job duties and would not leave surface completely wet for the correct time frame. On 1/8/25 at 3:00 p.m., Resident #64 (R64), who was identified as having Norovirus was observed sitting in her wheelchair in the East hallway. R64 attempted to grab this Surveyor's hand while self-propelling. There was no staff noted in the hallway at the time to redirect R64 back to her room. During a follow-up interview on 1/8/24 at 4:06 p.m., RN A acknowledged the facility had 18 residents with Norovirus, two of which were identified during this annual survey, demonstrating the facility was experiencing a sustained outbreak of Norovirus. Review of CDC website on 1/13/25 at 8:41 a.m., titled Norovirus: Explore Topics subtitled: How to Prevent Norovirus .Clean and Disinfect Surfaces, 11/1/24, read in part . Leave bleach disinfectant on the affected area for at least 5 minutes . Review of the CDC website on 1/13/25 at 8:43 a.m., titled Norovirus: Explore Topics subtitled Norovirus Prevention Steps and Strategies, last updated 11/1/24, read in part . clean and disinfect surfaces after someone vomits or has diarrhea .disinfect the area as directed on the product label . Review of facility housekeeping policies found no instructions on how to appropriately disinfect or clean nonporous surfaces using a bleach solution in response to an outbreak of an infectious disease. None of the policies specified surfaces had to remain wet for a minimum contact time as described in the guidance from the CDC in response to mitigating an outbreak of Norovirus. On 1/8/24 at approximately 3:45 p.m., the NHA stated the facility did not stop communal dining or activities during the active outbreak. The NHA did acknowledge Norovirus spreads thru direct contact with the organism from an infected person. Review of facility policy titled Infection Outbreak Response and Investigation last reviewed/revised 3/5/24, read in part . Implementation of infection control measures .staff will be educated on the mode of transmission of the organism, symptoms of infection and isolation or other special procedures this includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines . During a follow up interview on 1/8/25 at 4:06 p.m., RN A acknowledged the outbreak was not posted at the entrance of the facility. RN A stated they did not know how the facility was being disinfected and was not monitoring this activity for staff adherence to proper infection control practices and/or cleaning/disinfection. Review of facility policy titled Infection Prevention and Control Program, last reviewed 1/2/25, read in part . An infection prevention and control program is designed .to help prevent the development and transmission of communicable diseases and infections .the infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .a system of surveillance is utilized for prevention, identifying, reporting, investigation, and controlling infections and communicable diseases . Review of facility document titled Infection Preventionist Job Description read in part . Major duties and responsibilities . develops and implements an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infections .establishes facility wide systems for the prevention, identification, reporting, investigation and control of infections an communicable diseases of residents .overseas resident care activities that increase risk of infection .provides education related to infection prevention and control principles, policies, and procedures to staff, residents and families .collaborates with other departments in fulfilling requirements in relation to occupational health and safety .develops, schedules and directs refresh training as necessary for all personnel .serves as a resource for staff regarding infection prevention and control, including the identification of when a resident needs to be place on transmission based precautions .works with environmental services to prevent cross contamination in the care environment .helps to prevent transmission of infection during care. Review of facility policy titled Isolation Precautions last reviewed 4/2/21, read in part .It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents .transmission based precaution refers to the actions .that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections .contact precautions are measures that are intended to prevent the transmission of infectious agents .which are spread by direct or indirect contact with the resident or the residents environment . Review of facility policy titled Infection Outbreak Response and Investigation last reviewed 1/2/25, read in part .The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission and prevent additional infections .outbreak refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time .recognition of outbreak . a sudden cluster of infections .during a short period of time i.e. three or more cases . Review of Centers for Disease Control and Prevention (CDC) website on 1/13/25 at 8:40 a.m., titled, Norovirus: Explore Topics subtitled Norovirus Prevention Steps and Strategies, last updated 11/1/24, read in part . Wash your hands often with soap and water, hand sanitizer alone does not work well against Norovirus . Review of facility policy titled Hand Hygiene, last reviewed 1/9/25, read in part . Staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .hand hygiene .soap and water .after caring for a person with known or suspected infectious diarrhea . Review of CDC website on 1/13/25 at 8:48 a.m., titled Norovirus: Explore Topics subtitled How Norovirus Spreads last updated 4/24/24, read in part . Norovirus is very contagious .you can get Norovirus by accidentally getting tiny particles of feces or vomit in your mouth from a person infected with Norovirus .Norovirus spreads through sick people and contaminated surfaces when a person with Norovirus touches surfaces with their bare hands .tiny drops of vomit from a person with Norovirus spray through the air landing on surfaces or entering another person's mouth, or a person with Norovirus has diarrhea that splatters onto surfaces . 35103 3. Appropriate Performance of Hand Hygiene On 1/9/25 at approximately 9:00 a.m., RN G administered Azelastine Hydrochloride nasal spray, two puffs, into each nostril of Resident #12 (R12) without the performance of hand hygiene or donning of gloves. On 1/9/25 at approximately 9:05 a.m., RN G was observed as they examined R12's open, what appeared to be a scratched area on their posterior, upper hip. RN G explained the scratched area was new and RN G said she was going to apply barrier cream to the open, scratched skin area. RN G applied barrier cream to R12's open wound without performance of hand hygiene or donning of gloves. On 1/9/25 at approximately 9:07 a.m., RN G was observed as they applied a 4% Lidocaine Transdermal Patch to R12's posterior, right hip. RN G did not don gloves prior to application of the patch to R12's skin. RN G's bare hands were observed to touch R12's bare posterior hip as the patch was smoothed out over the Resident's skin. No hand hygiene was performed after the patch application. RN G then assisted with repositioning R12 in bed, tied up the open garbage bag near the sink and rearranged the linens on R12's bed. No hand hygiene was performed. On 1/9/25 at approximately 9:09 a.m., RN G was observed as they administered Fluticasone Propionate nasal spray, one puff in each nostril without the performance of hand hygiene before or after administration of the nasal spray. RN G held the nasal spray in her bare right hand while activating R12's nasal spray. On 1/9/25 at approximately 9:12 a.m., RN G was observed to pick up a box of tissues R12 had dropped onto the floor, with bare hands, and placed the now dirty box of tissues on top of R12's over bed table. No hand hygiene was performed prior to exit from the room. On 1/9/25 at 9:16 a.m., RN G was asked if they had used gloves during the administration of R12's nasal sprays. RN G stated, No, I did not use gloves at all. When asked about the application of barrier cream to R12's open, scratch wound, RN G acknowledged they had put the cream on the R12's open skin without donning gloves. RN G also confirmed they had not donned gloves prior to application of R12's transdermal patch, nor had they performed hand hygiene following application of R12's transdermal patch. RN G stated, I cannot do patches with gloves. RN G confirmed she had picked up R12's tissue box and placed it on top of R12's over bed table. When asked if the tissue box would be considered clean or dirty, RN G agreed the box from the floor would be dirty when placed on the over bed table. RN G did not perform hand hygiene following picking up the tissue box from the floor. RN G gathered the two nasal spray bottles in her dirty, bare hands as they exited the room. The nasal spray bottles were placed on top of the medication cart, without a barrier, and then placed back into the manufacturer's boxes in the medication cart. During an interview on 1/9/25 at 10:05 a.m., the NHA was informed of observation of ungloved hands during contact with skin and/or body fluids, failure to perform hand hygiene, and potential contamination of environmental surfaces. The NHA stated, What was [RN G] thinking. That is Nursing 101 (to perform hand hygiene). The NHA expressed understanding of the concern with infection control practices, especially during an outbreak of Norovirus within the facility and said RN G would be educated immediately. Review of the [Facility] Hand Hygiene policy, dated 4/2/2021 and reviewed 1/9/25 at 10:35 a.m., revealed the following, in part: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Review of the Hand Hygiene Table, reviewed 1/9/25, revealed hand hygiene should be performed in the following situations, in part: .After caring for a person with known or suspected infectious diarrhea (such as Norovirus), when coming on duty, between resident contacts, after handling contaminated objects .before applying and after removing personal protective equipment (PPE), including gloves, before preparing or handling medications, before and after handling clean or soiled dressings, linens, etc., before performing resident care procedures . After handling items potentially contaminated with blood, body fluids, secretions, or excretions, when, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions, after sneezing, coughing, and/or blowing or wiping nose . When in doubt .

Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 53 residents. Findings include: Review of CMS PBJ Staffing Data Report FY (fiscal year) Quarter 4 2024 (July 1 -September 30) revealed the metric No RN (Registered Nurse) Hours, Excessively Low Weekend Staffing, One Star Staffing Rating, and Failed to have Licensed Nursing Coverage 24 Hours/Day Triggered with the following infraction dates being: No RN hours every day beginning with 7/1/24 through 9/30/24. Failed to have Licensed Nursing Coverage 24/Hours/Day every day beginning with 7/1/24 through 9/30/24 During an interview on 1/9/25 at 9:59 a.m., Human Resource Manager F stated, I input the information for the PBJ report . we switched companies to take our data and convert it and send it to CMS .we did find out that it did not work. During an interview on 1/9/25 at 10:27 a.m., Nursing Home Administrator (NHA) stated, the report was not created correctly., acknowledging the report was not submitted correctly. Facility policy for PBJ reporting was requested from facility but was not given prior to exit.

This citation pertains to intake MI00146197. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the identification and reporting of potential abuse for five Residents (#10, #12, #14, #18 and #20) of six residents reviewed for abuse, resulting in the potential for unidentified abuse and further exposure to abusive situations. Findings include: Resident #10 (R10) R10 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R10's Minimum Data Set (MDS) assessment, dated 8/15/2024, revealed R10 was independent with transfers and ambulation. Further review of the MDS assessment revealed R10 had severe cognitive impairment. Review of R10's electronic medical record (EMR) revealed the following: 6/11/2024 23:02 [11:02 p.m.] Nurses Note. Resident [complained of] hand broken after being redirected from another resident's room . DON [Director of Nursing] notified . 6/12/2024 07:57 [7:57 a.m.] Nurses Note. Writer in the [morning] to assess reports of possible broken hand . 6/12/2024 11:16 [11:16 a.m.] Nurses Note. DPOA [Durable Power of Attorney] notified of incident that occurred last night and [x-ray] orders. Review of R10's incident reports for April 1, 2024 through August 19, 2024, provided by the Nursing Home Administrator (NHA), revealed the following: Injury of Unknown Source . Incident Description: Called into unit, CNA [Certified Nursing Assistant] upset, stated [R10] was in a female resident's bed and that she tried to get him out he punched her in the leg and called her a name. Sent CNA on break and in to assess resident. Resident unable to give description. Skin assessed on hand. ROM [range of motion] assessed and [positive] for pain when making a fist. Call placed to DON, notified of same. Instructions received to obtain x-ray of hand/wrist. CNA instructed to get nurse if residents need redirecting . The Injury of Unknown Origin, checklist attached to the incident report indicated both the DON and NHA were notified of the incident. During a telephone interview on 8/20/2024 at 10:53 a.m., CNA D reported finding R10 in bed with a female resident on 6/11/2024. CNA D stated upon attempting to redirect R10 from the female resident's bed, R10 became combative. CNA D stated she did not remember who the female resident was or how R10 injured his hand. Further review of R10's EMR revealed the following: 7/29/2024 14:02 [2:02 p.m.] Nurses Note. Follow up from CNA behavior charting on 7/26 [7/26/2024]. Resident was found in bed with another male resident. [R10] was naked from the waste [sic] down. Other resident unaffected by this action. CNA immediately intervened with no issues. Review of R10's incident reports revealed no report to correspond with the incident documented in R10's EMR for 7/26/2024. Review of R10's point of care Behavior charting the following, entered by CNA C on 7/26/2024 at 6:55 a.m. Resident took of dry pants and [brief] and layed [sic] in bed with another resident twice. During a telephone interview on 8/20/2024 at 11:57 a.m., CNA C reported on 7/26/2024 she found R10 unclothed and lying in Resident #12's (R12's) bed with R12. CNA C stated she did not know what R10 was doing but she thought R12 was sleeping. When asked if she reported the incident, CNA C stated she alerted the nurse but was unsure if the nurse came in to assess either resident after the incidents were reported. CNA C could not identify the nurse she alerted to R10's behavior on 7/26/2024. CNA C reported R10 was not put on one-to-one supervision following the incident. During a telephone interview on 8/20/2024 at 11:59 a.m., the DON reported she was alerted to the incident involving R10 being found unclothed in bed with R12 by reviewing R10's behavior notes. The DON stated staff did not alert her when the incidents occurred on 7/26/2024. The DON reported she did not initiate an incident report, investigation or report the incident to the NHA or the State Agency (SA) as an allegation of abuse. Resident #14 (R14) Resident 14 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety and anoxic brain injury (brain damage due to lack of oxygen). Review of R14's MDS assessment dated [DATE] revealed was independent with transfers and ambulation. Further review of the MDS assessment revealed R14 had severe cognitive impairment. Review of R14's EMR revealed the following: 6/15/2024 2216 [10:16 p.m.] Nurses Note. Resident (1) was found in resident (2) room laying on top of resident (2) when aid went in to try to get resident (1) off of resident (2), resident (1) tried to hit the aid and kick at her. So, aid got resident (2) out of bed to try to remove resident (1) other resident (3) came in the room and resident (1) tried to hit him, so he turned and tried to hit the aid. The note was entered by Licensed Practical Nurse (LPN) B. Review of R14's incident reports for April 1, 2024, through August 19, 2024, provided by the NHA, revealed no incident report to correspond with the incident documented in R10's EMR on 6/15/2024. During a telephone interview on 8/20/2024 at 11:33 a.m., LPN B she was alerted by a CNA of the incident on 6/15/2024. LPN B stated she was alerted R14 was found lying on top of Resident #18 (R18) in R18's bed. LPN B reported she was unsure of what R14 was doing or if there was a conflict prior to the CNA's attempts to redirect and separate the residents but remembered R20 was involved. LPN B could not recall the CNA who alerted her of the incident. A review of R14's EMR was conducted with the NHA on 8/20/2024 at 2:10 p.m. The NHA confirmed no incident report or investigation was initiated regarding the incident involving R14, R18 and R20 on 6/15/2024. The NHA stated she recognized the incident as an allegation of abuse and that it should have been reported to her and the SA. The NHA reported she was also unaware of the incident between R10 and R12 on 7/26/2024. The NHA stated a diagnoses of dementia and/or when residents state they do not remember an incident does not negate the facility's responsibility to identify allegations of abuse and report such allegations to the SA. Review of the undated facility policy titled Abuse, Prevention and Prohibition Of, revealed the following, in part: The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source . shall immediately report the matter to the facility Administrator and/or the Director of Nursing . The facility Administrator, employee, or agent who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse or neglect, or any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria . Definitions: Abuse means the willful infliction of injury . intimidation . resulting in physical harm, pain or mental anguish . Willful means that individual intended the action . Special Note: A diagnosis of dementia (including Alzheimer's) does not rule out the ability of a person to form intent .

This citation pertains to intake MI00146197. Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for five Residents (#10, #12, #14, #18 and #20) of six residents reviewed for abuse. Findings include: Resident #10 (R10) R10 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R10's Minimum Data Set (MDS) assessment, dated 8/15/2024, revealed R10 was independent with transfers and ambulation. Further review of the MDS assessment revealed R10 had severe cognitive impairment. Review of R10's incident reports for April 1, 2024, through August 19, 2024, provided by the Nursing Home Administrator (NHA), revealed the following: Injury of Unknown Source . Incident Description: Called into unit, CNA [Certified Nursing Assistant] upset, stated [R10] was in a female resident's bed and that she tried to get him out he punched her in the leg and called her a name. Sent CNA on break and in to assess resident. Resident unable to give description. Skin assessed on hand. ROM [range of motion] assessed and [positive] for pain when making a fist. Call placed to DON, notified of same. Instructions received to obtain x-ray of hand/wrist. CNA instructed to get nurse if residents need redirecting . The Injury of Unknown Origin, checklist attached to the incident report indicated both the DON and NHA were notified of the incident. Review of the written statement signed by CNA D and dated 6/11/2024 at 10:15 p.m., revealed the following: [R10] was in bed with another resident. When I went to get him out he swung at me and while I was getting him out of the female resident's bed he punched me in my leg and called me a [expletive]. Finally got him in his own room. It was noted there was no documentation in R10's EMR or in the incident report and witness statement, dated 6/11/2024, as to how R10 injured his hand. During a telephone interview on 8/20/2024 at 10:53 a.m., CNA D reported finding R10 in bed with a female resident on 6/11/2024. CNA D stated upon attempting to redirect R10 from the female resident's bed, R10 became combative. CNA D stated she did not remember who the female resident was or how R10 injured his hand. Further review of R10's EMR revealed the following: 7/29/2024 14:02 [2:02 p.m.] Nurses Note. Follow up from CNA behavior charting on 7/26 [7/26/2024]. Resident was found in bed with another male resident. [R10] was naked from the waste [sic] down. Other resident unaffected by this action. CNA immediately intervened with no issues. Review of R10's incident reports revealed no report to correspond with the incident documented in R10's EMR for 7/26/2024. Review of R10's point of care Behavior charting the following, entered by CNA C on 7/26/2024 at 6:55 a.m. Resident took of dry pants and [brief] and layed [sic] in bed with another resident twice. During a telephone interview on 8/20/2024 at 11:57 a.m., CNA C reported on 7/26/2024 she found R10 unclothed and lying in Resident #12's (R12's) bed with R12. CNA C stated she did not know what R10 was doing but she thought R12 was sleeping. When asked if she reported the incident, CNA C stated she alerted the nurse but was unsure if the nurse came in to assess either resident after the incidents were reported. CNA C could not identify the nurse she alerted to R10's behavior on 7/26/2024. CNA C reported R10 was not put on one-to-one supervision following the incident. Further review of the EMRs for R10 and R12 revealed no documentation of physical or psychosocial assessments by licensed staff following the incidents on 7/26/2024. In addition, no documentation of physical or psychosocial assessments were conducted in relation to the incident involving R10 and R14 on 6/11/2024. During a telephone interview on 8/20/2024 at 11:59 a.m., the DON reported she was alerted to the incident involving R10 being found unclothed in bed with R12 by reviewing R10's behavior notes. The DON stated she interviewed R10 and R12 and found neither Resident recalled the incidents, therefore an investigation was not conducted. The DON reported no physical or psychosocial assessments were completed on R10 and R12 in relation to the incident since they did not remember, and she did not feel any harm was done. Resident #14 (R14) Resident 14 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety and anoxic brain injury (brain damage due to lack of oxygen). Review of R14's MDS assessment dated [DATE] revealed was independent with transfers and ambulation. Further review of the MDS assessment revealed R14 had severe cognitive impairment. Review of R14's EMR revealed the following: 6/15/2024 2216 [10:16 p.m.] Nurses Note. Resident (1) was found in resident (2) room laying on top of resident (2) when aid went in to try to get resident (1) off of resident (2), resident (1) tried to hit the aid and kick at her. So, aid got resident (2) out of bed to try to remove resident (1) other resident (3) came in the room and resident (1) tried to hit him, so he turned and tried to hit the aid. The note was entered by Licensed Practical Nurse (LPN) B. Review of R14's incident reports for April 1, 2024, through August 19, 2024, provided by the NHA, revealed no incident report to correspond with the incident documented in R10's EMR on 6/15/2024. During a telephone interview on 8/20/2024 at 11:33 a.m., LPN B she was alerted by a CNA of the incident on 6/15/2024. LPN B stated she was alerted R14 was found lying on top of Resident #18 (R18) in R18's bed. LPN B reported she was unsure of what R14 was doing or if there was a conflict prior to the CNA's attempts to redirect and separate the residents but remembered R20 was involved. LPN B could not recall the CNA who alerted her of the incident. A review of R14's EMR was conducted with the NHA on 8/20/2024 at 2:10 p.m. The NHA confirmed no incident report or investigation was initiated regarding the incident involving R14, R18 and R20 on 6/15/2024. The NHA stated the incident should have been investigated as an allegation of abuse. The NHA reported she was also unaware of the incident between R10 and R12 on 7/26/2024. The NHA stated a diagnosis of dementia and/or when residents state they do not remember an incident does not negate the facility's responsibility to identify and investigate allegations of abuse. Review of the undated facility policy titled Abuse, Prevention and Prohibition Of, revealed the following, in part: Resident abuse must be reported immediately to the Director of Nursing . and the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action . Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Employees will be interviewed who were working on the specific hall/wing . If the resident is not interviewable, question the roommate and any family or friends who visit frequently to assist with completion of a questionnaire. Follow-up counseling should be made available . Definitions: Abuse means the willful infliction of injury . intimidation . resulting in physical harm, pain or mental anguish . Willful means that individual intended the action . Special Note: A diagnosis of dementia (including Alzheimer's) does not rule out the ability of a person to form intent .

Based on interview and record review, the facility failed to provide comprehensive diabetic management for one Resident (R60) of one resident reviewed for diabetic care. This deficient practice resulted in harm when R60 was hospitalized in the intensive care unit (ICU). Finding include: On 10/4/23, R60 was hospitalized with severe hyperglycemia (high blood glucose levels) and encephalopathy (brain dysfunction that can appear as confusion, memory loss personality changes and/or coma) due to hyperosmolar hyperglycemic state [HHS] (a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, and altered consciousness.) Review of R60's Minimum Data Set (MDS) admission assessment, dated 6/14/23, revealed R60 was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15 of 15, reflective of intact cognition. R60 was responsible for her own medical decisions, and was documented with clear speech, the ability to understand others and be understood in making their needs known. No behaviors were documented on the MDS admission assessment. Review of R60's MDS assessment, dated 9/14/23 (prior to hospitalization for HHS), revealed a BIMS score of 9 of 15, reflective of moderate cognitive impairment. R60 was again documented with clear speech, clear comprehension, and understood by others with no behaviors noted. Review of R60's MDS assessment, dated 10/17/23, following hospitalization for HHS revealed a BIMS score of 6 of 15, reflective of severe cognitive impairment, with clear speech, sometimes understood, and sometimes able to understand. No behaviors were noted on the 10/17/23 MDS assessment for R60. Review of R60's Progress Notes revealed the following, in part: - 8/20/23 02:58 (2:58 a.m.), .Resident stated [they] had been feeling dizzy and weak . Blood sugar checked with result of 252 . No physician order was in place at this time for the blood glucose monitoring of R60. - 9/6/23 14:13 (2:13 p.m.), .Resident alert to self this am, increasing confusion, increasing lethargic . - 9/8/23 19:53 (7:53 p.m.), .[R60] does not have a UTI (urinary tract infection) per culture. - 9/25/23 04:27 (4:27 a.m.), .Resident (R60) out of bed at HS (hour of sleep), acute confusion, calling out for [Name] . Calmer but confusion remains. Does not appear to recognize surroundings or staff . - 10/4/23 04:01 (4:01 a.m.), .Resident has been awake most of the night . Resident continues to have difficulty finding words and is easily frustrated. Can say 2-3 words at times, other times unable to form any intelligible word. Balance very poor with walker tonight . - 10/4/23 13:57 (1:57 p.m.), Resident alert and oriented to self. Needing assistance with meals . Resident not able to verbalize needs appropriately. Word salad verbally. Res (Resident) unable to focus on tasks, appearing distracted and unable to follow at times. Increasing confusion. - 10/4/23 15:02 (3:02 p.m.), Res CBG (Capillary Blood Glucose), measured with a glucometer) 'HI' (over the number the glucometer is able to measure), tremors, shaking, warm to touch. Call placed to provider. Orders eval (evaluation) and treat [local acute care hospital] . - 10/5/23 14:27 (2:27 p.m.), Resident (R60) currently in [Regional Hospital] ICU (Intensive Care Unit). - 10/9/23 11:56 a.m., . Spoke with [Regional Hospital staff] resident (R60) was moved (out of ICU). - 10/12/23 14:42 (2:42 p.m.), .Alert to person and place. She was well aware she was coming back from [Regional Hospital city] and wanting to go to her home . Very pleasant mood with staff. Big smiles and happy to be back . Diagnosis at discharge of acute metabolic encephalopathy due to hyperosmolar hyperglycemic state without coma . - 10/17/23 10:23 a.m., [R60] is readmitted to facility after hospital stay for hyperglycemia with a BG (blood glucose via blood draw in the hospital) 966 and HgbA1C (Hemoglobin A1C, measures blood glucose levels over time) 11.6. [They were] fed thru a N/G (nasogastric) tube initially but later progress to a dysphagia diabetic diet with insulin and coverage . seems to forget to eat and needs cueing often . - 11/14/23 12:42 p.m., Resident (R60) extremely jittery/shaking, vitals charted, high blood sugar. Unable to answer simple questions, slurred speech. Right sided weakness. Unable to follow commands . Called EMS . Review of Physician Orders as documented in R60's Medication Administration Records (MARs) for June through November of 2023, revealed the absence of a physician order for any capillary blood glucose monitoring from the date of admission into the facility on [DATE] until 10/4/23 when R60 presented symptoms of acute encephalopathy due to HHS. Review of R60's Physician Order Summary report for all physician orders between 6/9/23 and 11/22/23, revealed the following admission orders which were initiated by Physician J: Diabetes S. O. (Standing Order): If blood sugar is < (less than) 60 and the resident is symptomatic and does not respond to oral Intervention Glucose Gel within 15 minutes, administered 1 mg (1 unit) of IM (intramuscular) glucagon from the emergency kit and call the physician for no response within 10-15 minutes, Blood sugars greater than 400 call the Nurse Practitioner/Physician as needed for diabetes, Order date: 6/9/23, Start Date: 6/9/23. Januvia Oral Tablet, 50 mg (milligrams), Give 50 mg by mouth one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY. Order Date: 6/9/23, Start Date: 6/10/23. Review of the facility Standing Orders provided by the Director of Nursing (DON) on 2/14/24 at 10:52 a.m., revealed the only diabetic standing order was the was one previously identified on R60's Physician Order Summary. No standing orders were present for any CBG monitoring should resident symptoms be identified related to adverse diabetic outcomes. During an interview on 2/14/24 at 7:52 a.m., when asked about R60's hospital blood glucose level of 966, the DON confirmed that CBG orders were put in place after she returned from the hospital and the diagnosis of HHS. The DON confirmed R60 was having some seizure-like activity, and she was transferred to [a Regional Medical Center] and ended up in the ICU. The DON stated, When [R60] came back from the hospital, she never came back (to baseline functional status). During an interview on 2/14/24 at 8:05 a.m., Licensed Practical Nurse (LPN) H said she had frequently provided care for R60. LPN H stated, [R60] came in post-surgical for her shoulder and she wanted to rehab and go home. LPN H did recall that R60 did have a blood glucose level of 966 in the hospital, and stated, I don't think I got a reading (numerical value on the glucometer). It (glucometer) just read 'HI'. During an interview on 2/14/24 at 10:26 a.m., the DON reviewed R60's Physician Order History report and the Telephone/Verbal Order Signature Detail report with this Surveyor and acknowledged there was no order for any blood glucose monitoring for R60 prior to their hospitalization on [DATE] with encephalopathy related to HHS. The DON said she talked to Physician K the previous week, and Physician K said that we (the facility) have to have a way to monitor CBGs for two weeks with diabetics who come into the facility. The DON was asked to provide a copy of any diabetic management policies related to resident care in the facility. During an interview on 2/14/24 at 10:52 a.m., the DON returned with a copy of the facility Standing Orders and the Physician Orders signed by Physician J upon R60's admission and Physician K beginning 10/4/23. The DON said the facility did not have any diabetic management policies for resident care in the facility. No Physician Standing Order was present for blood glucose monitoring for residents with diabetes residing in the facility. The DON said there was no standardized monitoring for diabetic blood glucose levels upon their admission. The blood glucose monitoring would only be performed based upon physician orders. The DON agreed there were no physician orders for blood glucose monitoring for R60, and that the facility did need a physician order for any blood glucose monitoring because it was an invasive procedure. When asked if the DON would be surprised if the concern related to lack of diabetic management and blood glucose monitoring may rise to the level of harm the DON stated, Yes, I would be surprised. I don't believe the high blood sugar caused her death. She had many other co-morbidities. This Surveyor acknowledged R60's comorbidities and asked if the lack of diabetic blood glucose monitoring, and the lack of facility processes for management of diabetic residents resulted in the absence of blood glucose monitoring for R60 from the time of admission, resulted in her intensive care hospitalization for treatment of encephalopathy which resulted from a hyperosmolar hyperglycemia state with an extremely high blood glucose level of 966. The DON stated, Now that you say it like that, I would agree with you. The resident was transferred (to the hospital) because of the results of an unmonitored high blood sugar. During a telephone interview on 2/14/24 at 1:24 p.m., Physician K was asked about R60's lack of blood glucose monitoring upon admission to the facility. Physician K said that they began working at the facility on September 1st, and they were not aware that all residents in the facility who were diabetic were not having their blood glucose measured upon admission. When asked about the lack of a diabetic management program within the facility, Physician K stated, I really like taking care of diabetic patients .The main issue is that residents weren't getting their blood sugars checked. Physician K said they were very surprised at how high R60's blood sugars were when [R60] was transferred to theER on [DATE]. When asked what the expectation would be regarding monitoring new admission residents (diabetic) blood sugars, Physician K said they would want every diabetic newly admitted to the facility to have their blood glucose checked twice daily until seen by the physician. Physician K would then evaluate the blood glucose numbers and write orders to meet each resident's needs. When asked about the complete lack of physician orders to monitor a new resident's blood glucose, Physician K stated, It would be completely unacceptable to me.

Based on observation, interview, and record review, the facility failed to maintain adequate resident and employee infection surveillance based on current professional standards for Infection Control (IC). This deficient practice had the potential to contribute to a facility COVID-19 infection outbreak, and the potential for ongoing infection spread, with the potential to affect all 58 facility residents. Findings include: Review of the November 2023, Infection Surveillance Monthly Report, showed 25 residents had respiratory infections, with 23 HAI's (Health Associated Infections - obtained in a health care facility after admission). The infection column showed 22 COVID-19 infections marked. When each column was followed to the right to the comments section, to show 21 residents tested positive for COVID, with infections resolved. There was no infection visual location mapping provided, which showed trends/clusters, locations of residents (rooms) with infections, or the potential for contact tracing. The monthly report yielded no narrative monthly summary, to show how the facility responded to contain the spread, i.e. education, audits, or other methods to contain and stop the COVID-19 infection spread. There was no separate Outbreak surveillance log for the COVID-19 outbreak, or outbreak investigation found. Review of the October 2023, Infection Surveillance Monthly Report, showed 20 residents had respiratory infections, with 16 HAI's. The infection column showed 17 COVID-19 infections, with 16 residents testing positive in the facility. There was no visual mapping for distinguishing patterns of infection spread, consistent contact tracing, outbreak surveillance, outbreak investigation, or monthly summary of the outbreak and actions taken to prevent spread. Review of the September 2023, Infection Surveillance Monthly Report, showed 59 respiratory infections, with 7 HAI's. The log showed 57 COVID infections in the infection column. Review of the August 2023, Infection Surveillance Monthly Report, showed 56 respiratory infections, and 6 HAI's. The log showed 54 COVID infections in the infection column. During an interview on 2/13/2023 at 3:13 p.m., the Infection Preventionist, Registered Nurse (RN) D, and the Director of Nursing (DON) were asked about the 57 COVID infections in September 2023, and the 56 COVID infection in August 2023, and what had been done to stop the outbreaks. Both reviewed the August 2023, and September 2023 resident infection facility surveillance logs (line listings). Neither could answer, as both reported they were not employed in the facility at that time. RN D reported they could not explain the data and high incidence of COVID-19 in the facility during these months. Surveyor asked if some of the infections could have been carried over from the month prior. Both reported they were unaware, as there had been another IP nurse in the facility at that time, and they could not tell this from the surveillance logs. Neither could confirm COVID-19 outbreak months with certainty, as they reported they were not employed during the entire outbreak time period. Further review of the November 2023 line listing revealed 17 of these infections were carried over from October 2023, by showing an infection onset date during October (2023). Thus, there were 5 new onset COVID infections in November 2023, however this was unclear from the general surveillance line listing for all facility resident infections, which appeared to show 22 residents were COVID-19 positive during the month of November 2023. Further review of the October 2023 line listing revealed the surveillance line listing was an accurate representation of COVID-19 positive residents in the facility, which showed 17 residents. Further review of the September 2023 log showed there were 3 new COVID-19 infections for the month of September, and 4 COVID 19 infections on the log carried over from August 2023. The 52 other infections in the infection column were residents tested for COVID-19 due to facility outbreak, who were negative. This showed the log reflected inaccurate data. Further review of the August 2023 log showed there were 4 new COVID-19 infections for the month of August, and 3 COVID 19 infections on the log which showed positive tests in September 2023. The 52 other infections in the infection column were residents tested for COVID-19 due to facility outbreak, who were negative. It was unclear why the August 2023 log had testing results in the comments section from September 2023, if the August infection log was completed in August. Due to the three-month COVID-19 outbreak, other resident surveillance logs were reviewed to confirm the date of the outbreak inception, and month the outbreak ended, both prior and post these three months. Review of these reports showed the resident COVID-19 facility outbreak started in August 2023. Review of these reports showed the resident COVID-19 facility outbreak ended in November 2023. Post review of facility surveillance logs, it was confirmed by RN D and Surveyor review the COVID-19 outbreak started in August 2023, with a resident positive. When asked what hall the outbreak started on, RN D reported they were unaware. During further interview on 2/13/24 at 3:30 p.m., RN D and the DON were asked if they would have expected to see a separate COVID-19 outbreak line listing (separate surveillance logs), an outbreak investigation, and a narrative monthly summary describing what was done about the COVID-19 outbreak to prevent spread. Both affirmed this would be the expectation per Infection Control standards and could find no evidence in the facility surveillance records. Both understood the need to correlate data between months and an accurate representation of COVID-19 infections was imperative to prevent the spread, including the need for visual location mapping to trace and contain outbreaks. Both acknowledged there was no evidence of education or audits found during the outbreaks which also could help prevent infection spread and contain outbreaks. Regarding testing, both were asked what criteria or resident symptoms indicated a need to test for COVID-19, such as when residents had respiratory symptoms, i.e. given pneumonia and COVID-19 and other infections may have similar symptoms and were unable to reference a specific criterion the facility used to differentiate. Record review of resident surveillance revealed the COVID outbreak occurred from August 2023, through November 2023. After the interview, the Nursing Home Administrator (NHA) was asked for a list of COVID + residents, since the monthly surveillance logs had carryover/crossover residents in each month, and it was unclear the total number of residents who were COVID-19 positive during the outbreak. Moreover, there was no COVID or outbreak surveillance log which would have had this data, which the NHA confirmed. Surveyor requested clarification for the COVID-19 residents, due to no COVID-19 line listing. The NHA provided separate pages for each of 26 COVID-19 positive residents during the facility outbreak, with the first resident positive on 8/27/23. There was no separate line listing for these residents provided by survey exit. Review of the employee infection tracking binder, provided by RN D, revealed separate pages which showed each staff call-off date, and reason, including symptoms, such as having a fever. There were no employee tracking surveillance sheets which would show staff infections on a log, common symptoms, COVID 19 tracking, and when testing was done. RN D confirmed they had not been tracking employee infections on a surveillance log or line list, including COVID-19, and had not found any history of any employee surveillance logs. During an interview on 2/13/24 at 4:32 p.m., the Infection Surveillance, Infection tracking, and COVID-19 outbreak concerns were reviewed with the NHA, who reported they understood each concern. The NHA confirmed they understood some of the current infection surveillance logs contained inaccurate data, and an inaccurate reflection of facility resident and staff infections. Review of the policy, Infection Surveillance, reviewed annually, received from the Nursing Home Administrator (NHA), revealed, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infection and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infection. Infection Surveillance refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data .The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .6. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. All resident infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated. Employee, volunteer, and contract employee infections will be tracked, as appropriate .Data to be used in surveillance activities may include, but are not limited to .e. Skills validations for hand hygiene, PPE, and/or high-risk procedures . Review of the policy, Infection Outbreak Response and Investigation, reviewed annually, provided by the NHA, revealed, The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. Some infections are so rare that a single case would constitute and outbreak .Policy Explanation and Compliance Guidelines: 1. Prompt recognition of outbreak: a. Changes in condition and/or signs and symptoms of infection will be reported according to procedures for infection reporting. b. The following triggers shall prompt an investigation as to whether an outbreak exists: i. An increase over a baseline infection rate (i.e. ten percent or more increase). ii. A sudden cluster of infections on a unit or during a short period of time. (i.e. three or more cases). iii. A single case of a rare or serious infection .c. An outbreak will be defined according to the characteristics of a given organism. Current definitions used by local and state health departments will help guide the determination. d. An outbreak will be reported to the local and/or state health department .2. Implementation of infection control measures. a. Symptomatic residents will be considered potentially infected, assessed for immediate needs, and placed on empiric precautions while awaiting physician orders. b. Symptomatic employees will be screened by the Infection Preventionist, or designee, and referred to the appropriate medical provider. c. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism. d. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. e. Surveillance activities will increase to daily for the duration of the outbreak. 3. Outbreak investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. the Infection Preventionist will be responsible for coordinating all investigation activities .c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include i. Person - key characteristics the patients (or staff) share in common. ii. Place - the location associated with the outbreak. iii. Time - period of time associated with illness onset for the cases under investigation. iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough. d. A line list about each person affected by the outbreak will be maintained. e. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved. F. A summary of the investigation will be documented and reported to QAA committee and health department, if indicated. Review of the policy, COVID-19 Prevention, Response, and Reporting, dated 9/25/2023, revealed, It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance .Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility. a. No current risk .b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures. 2. Staff will be alert to signs of COVID-19 and notify the resident's physician/practitioner if evident: a. fever and chills. b. cough. c. shortness of breath or difficulty breathing. d. fatigue. e. muscle or body aches. f. headache. g. new loss of taste of smell. h. sore throat. i. congestion or runny nose. j. nausea or vomiting. k. diarrhea .5. The facility will instruct HCP [health care personnel] to report any of the 3 above criteria to the Infection Preventionist or designee for proper management .21. Responding to a newly identified SARS-Co-V-2 infected HCP [health care practitioner] or resident: b. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. c. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach (e.g. unit, floor, or other specific area(s) of the facility) is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. d. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. 22. The Infection Preventionist, or designee, will monitor and track COVID-19 related information to include, but not limited to: a. The number of residents and staff who exhibit signs and symptoms of COVID-19. b. The number of residents and staff who have suspected or confirmed COVID-19 and date of confirmation. c. Staff and resident vaccination status. d. Employee compliance with hand hygiene. e. Employee compliance with standard and transmission-based precautions. f. Employee compliance with cleaning and disinfection policies and procedures. g. Supply of personal protective equipment, cleaning/disinfection supplies, alcohol-based hand rub, and other relevant supplies. h. other information as per federal, state, and/or local guidance . Centers for Disease Control (CDC), Mapping Public Health, https://www.cdc.gov/museum/pdf/cdcm-[NAME]-stem-mapping-public-health-lesson.pdf, accessed 2/22/2024, revealed, Maps are used in public health to plan health interventions, monitor outbreaks, identify vulnerable populations, and communicate health data. They are invaluable visualization and analysis tools that scientists and researchers use to address health problems .

This citation relates to Intake #MI00142455. Based on interview and record review, the facility failed to prevent employee to resident abuse for two Residents (R3, R22) of three residents reviewed for abuse. This deficient practice resulted in the abuse of R22, and the potential for ongoing abuse of R3 and other facility residents. Findings include: Review of R22's Minimum Data Set (MDS) assessment, dated 1/25/24, revealed R22 was admitted on [DATE], with diagnoses including stroke and depression. R22 required one-person assistance with transfers and bed mobility and was independent with toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 11/15, which showed R22 had moderate cognitive impairment. Review of R3's MDS assessment, dated 12/14/23, revealed R3 was admitted to the facility on [DATE], with diagnoses including diabetes, thyroid disorder, arthritis, depression, and anxiety. R3 was independent with bed mobility and transfers and required moderate assistance for toileting. The BIMS assessment revealed a score of 15/15, which showed R22 had no cognitive impairment. Review of R3's profile revealed she had a guardian as her responsible party. Review of R22's Investigation report, dated 1/31/24 at 2:21 p.m., revealed, It was discovered on 1/28/24 a CNA [Certified Nurse Aide B] was doing cares on [R22] and found bruising on resident's arm. The CNA [B] asked [R22] what happened, and she said it was from a CNA [H], that she feels doesn't like her and is rough with her. The CNA [B] immediately got the nurse [Licensed Practical Nurse - LPN A] who assessed the resident and it did look like fingerprints on the bruising . The report confirmed R22 was her own responsible party. The report further revealed the Nursing Home Administrator (NHA) and the Director of Nursing (DON) went to talk to R22 on 1/29/24 at 9:00 a.m . when [R22] immediately started crying .The DON assessed bruising on resident's arms and they did look like fingerprints. [The] DON asked what happened and R22 said a CNA [H] was rough with her and that she obviously wasn't moving fast enough for the CNA's liking, so she pulled her to turn her in bed. [R22] said the CNA is not nice, doesn't seem to like her job or care about her, and has been rough with her before. [R22] said she never reported it to anyone before until the CNA [B] asked her about it. [R22] then identified the aide as [CNA H] , who is a day shift CNA. [R22] was very tearful when talking to use about the CNA's behaviors .Writer asked [R22] if she feels safe here and she stated, When she's not here [CNA H]. The report confirmed R22 was her own responsible party. The report further revealed, Other residents interviewed [for potential abuse]; one resident said she is crabby, and another resident [R3] did say she would rather [CNA H] not take care of her, as she hollers and points her finger at her. [R3] said she feels safe here but does not want [CNA H] to take care of her if she can help it .After reviewing the statements and the facts, [CNA H] was terminated. The police were called as a potential abuse .case was created. The officer came and talked with [R22] . Review of R22's Accident and Incident report, dated 1/28/24 at 18:20 p.m. (6:20 p.m.), by Licensed Practical Nurse (LPN) A revealed, [LPN A] asked to go to resident's room [R22]. Upon getting to room, [R22] was on toilet with arms bare, getting evening cares done. I was shown by CNA [B] bruises on left and right upper arms. Discussed with [R22] how these were obtained. Resident is fearful; she does not want trouble. Encouraged to let us know what happened. [R22] proceeded to tell that CNA is rough .'She grabs my arm tight and puts me to bed roughly.' [R22] continues to say, 'CNA is gruff at times', when she brings my food trays, she throws them on the bedside table and does not help me. I do not think she likes me.' Review of R22's police report, dated 1/29/24 at 12:04 p.m., revealed the incident [employee to resident abuse towards R22] occurred on 1/24/24 between 4:00 p.m. and 10:00 p.m., and was reported on 1/29/24 at 12:00 p.m .The report showed, [Local police] dispatched to [facility] for report of Elder Abuse, reported by staff. Upon arrival, contact made with [NHA] who stated [R22] told staff she was abused by caregiver, later identified as [CNA H] .[Police Officer] made contact with [R22] who shared the incident .[R22] said when staff was assisting her rolling over in bed that she was just too aggressive and that's how she bruised her INJURIES: Injuries noted on [R22] appeared as hand prints on both arms from over gripping . It was later clarified by the NHA the date of the incident was not 1/24/24, and occurred on 1/28/24. Review of R22's, Report of Alleged Resident Abuse, dated 1/29/24, revealed, Evidence of Injury, marked Yes, described as bruising on both arms found by CNA during cares . The category, Types of Abuse was marked with an X as follows: Physical, Verbal/emotional/psychological, and Staff to Resident . The report concluded, Abuse is still substantiated d/t [due to] CNA's [H] verbal outbursts towards residents and the fact that residents say she is not nice to them [Two resident statements attached]. Staff have had to intervene and educate CNA [H] on how to talk to residents .[CNA H] terminated . Review of R3's abuse interview witness statement revealed, .[CNA H] hollers, points fingers at me. I don't want her taking care of me if I can help it . During an interview on 2/12/24 at 3:16 p.m., LPN C was asked about any abuse concerns on R22's hall. LPN C reported they had seen marks on R22's arms which looked like fingerprints, and R22 had reported being treated roughly. LPN C reported they believed it occurred, as they had seen the bruises, and found R22 to be a reliable reporter. During an interview on 2/12/24 at 3:19 p.m., R22 was interviewed and stated her care is good now. R22 was fully oriented and was interviewable. When asked if she felt safe at the facility, R22 stated, [CNA H] just didn't like her job; she yelled at me one day in the bathroom, and I said, 'I can't wipe myself', and she said, 'Lose the attitude' .Her name was [CNA H]. [CNA H] was rough with me. When she came in here, I was incontinent, and she came to change my brief and told me to roll over and I grabbed my left rail and she grabbed me hard over the arm. R22 showed Surveyor how CNA H grabbed her hard by both arms in the bed to turn her, and how she still had a couple bruises. A faded yellow dime-sized bruise was observed on the front of her left arm, just below the shoulder, and the right arm appeared to have a small older bruise in the same location. R22 denied pain, and stated, [CNA H] didn't want to do anything for you. I just came in a couple weeks [after admission to the facility] when it happened. I knew she hurt me and my CNA [CNA B] saw it. When asked if she feared CNA H, R22 affirmed, stating, A little bit, as I didn't know what to expect of her after that, and a couple days before she yelled at me in the bathroom .[CNA H] was mad I wasn't moving fast enough . During a phone interview on 2/14/24 at 9:32 a.m., LPN A was asked about the incident. LPN A stated, I was brought in by a CNA [B] when they were doing bedtime cares. When I got there, [R22] was on the toilet and she had bruises on both of her arms. I asked her what happened. and she said, 'Someone was rough with her and she didn't want to get in trouble'. [R22] said it was an employee, one of the CNAs, and described the employee to her. LPN A stated there were bruises on both of R22's arms, almost identical, and it looked like a handprint, as there was a thumb print in front and the back was fingers. Surveyor asked about any pain, and LPN A said R22 did not want them to touch the bruises and described the bruises as looking a couple days old. LPN A stated they presented as yellowing, with some very noticeable bluish purple bruises. LPN A confirmed the employee was CNA H, and reported R22 was fearful of her, and stated, I don't want her in my room anymore, as it had happened during cares more than once. LPN A reported there was no lasting psychosocial change for R22. During further interview on 2/14/24 at approximately 9:40 a.m., LPN A was asked if she had any concerns with CNA H prior, as she worked on their hall. LPN A reported, A week or so before [the incident with R22] CNA H was observed hollering at a resident, and I said, 'You do not treat our residents like that.' And she grinned .It was [R3]. When asked if there was any psychosocial affect for R3, LPN B reported she had her head down, which was not typical for R3. LPN B reported she should have reported the incident and understood after education it was abuse. During an interview on 2/14/24 at 9:59 a.m., CNA B was asked about their care of R22. CNA B reported they noticed bruises all over her and said, I asked [R22] where she got the bruises and she said, It was one of the CNAs, and I told her to be gentle with me. R22 clarified this CNA was rough with her. CNA B stated, [R22] had multiple bruises on her upper arms and on her left arm; it looked to be a handprint, and it didn't look like regular bruises, to me they looked like fingerprints, with a thumb in front and fingers on her left arm and random little bruises. I would suspect the resident [R22] was right and the aide was being rough with her, [CNA H]. I had noticed .[CNA H] was more aggressive than she needed to be on the floor, and they [the residents] seemed borderline nervous around her. I had mentioned it to a nurse [could not recall who] and I was trying to see if there was something more substantial [before substantiating it was abusive treatment.] I wasn't sure what was going on, as no residents had said anything, and clarified they did not regularly work on R22's hall or with CNA H very often. LPN A's and CNA B's witness statements were reviewed and corroborated their interviews. During a follow up phone interview on 2/14/24 at approximatley 2:00 p.m., LPN A was asked to clarify during the call if the incident between R3 and CNA H was verbal abuse, and stated, Yes. LPN A described CNA H arguing with R3, and stated, None of them [residents] should be treated that way in their home .It was gruff . During an interview on 2/14/24 at 2:11 p.m, the DON was asked about their findings related to abuse or potential abuse of R22 and R3. The DON reported when they and the NHA walked into R22's room, R22 immediately started to cry and said the aide [CNA H] did not like her, and stated, She's rough with me when she's around, and she plops her food tray down and doesn't set it up. The DON reported they observed R22's bruises under her arms and one arm had a thumbprint which was green and yellow, and up to 4 days old. The DON added the other bruises appeared a couple days old, with a newer bruise which was purple, with the edges turning green and yellow. The DON reported they suspected it was physical abuse more than likely because of the location, and they could not explain how the bruises would be there. The DON brought pictures of the bruises, taken by LPN A, and showed how it appeared R22 was grabbed by their arms as if to pull them up, and pointed out an apparent thumb print and bruising under the arms. The DON clarified the bruises would not be bruises from a medication or diabetic care, and confirmed R22 was a credible resident and reporter. The DON concluded, We substantiated emotional abuse 100%, as it was emotional abuse . During an interview on 2/14/24 at approximately 2:25 p.m., the DON was asked about R3 and their description of LPN H yelling at them, and confirmed this verbal abuse incident should also have been reported, as they and the NHA were unaware until the abuse audits were completed, after the abuse was discovered towards R22 on 1/28/24. During a phone interview on 2/14/24 at approximately 4:15 p.m. with R3's responsible party, Guardian F, confirmed R3 reported to them a staff member had been mean to her, and R3 had asked they not work with her again. The staff member was later confirmed to be CNA H. During an interview on 2/14/24 at 4:26 p.m., the NHA was asked about the abuse incidents towards R22 and R3, perpetrated by CNA H. The NHA confirmed they had substantiated abuse towards both residents, suspended CNA H pending investigation, and terminated their employment. The facility requested past noncompliance. Review of the policy, Abuse, Prevention, and Prohibition of, dated 10/31/22, provided by the NHA, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility will not use emotional, verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, employees, the medical director, consultants, and volunteers .Policy: This policy prohibits mistreatment, neglect, or abuse of residents .This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone .4. Identification: The facility will identify residents whose personal histories render them at risk for abusing other residents through the prescreening process. The nursing staff is responsible for reporting the appearance of bruises, lacerations, skin tears or other abnormalities as they occur .The Director of Nursing (DON) is responsible for their evaluation and assessment. If the source of the injuries is unknown, a UKO [Unknown Origin] injury investigation must be completed. An abuse investigation may also be conducted based on the investigation findings. Investigation: Resident abuse must be reported immediately to the Director of Nursing (or Nurse Manager on call) and the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress .Implement steps to prevent further potential abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the state agency and law enforcement if there is reasonable suspicion of a crime or serious bodily harm .Complete a report of alleged resident abuse within required timelines .A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted .Complete a thorough investigation .Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. b. Employee Allegations. When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending outcome of the facility investigation, prosecution, or disciplinary action against the employee .Reporting/Response: The facility employee or agent who becomes aware of abuse, neglect, exploitation, or mistreatment, including injuries of unknow source or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator and/or the Director of Nursing regardless of whether serious bodily injury occurred. The facility Administrator, and/or the Director of Nursing, who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse, neglect, exploitation, or mistreatment or any allegation of such shall report or cause a report to be made to the mandated State Agency per reporting criteria immediately: but no later than 2 hours after an allegation is made if the allegations involve abuse or result in serious bodily injury .such reports may be made to the local law enforcement agency in the same manner . Review of facility Past Non-Compliance (PNC) document, dated 2/01/24, revealed: This plan of correction is submitted as the facility's credible allegation of compliance. 1. Immediate action(s) taken for the resident(s) found to have been affected include: A thorough investigation was conducted by Director of Nursing Services and the facility Administrator regarding the allegations made by Resident #1 [R22]. Facility ensures residents safety, residents has been given 1:1 activity staff, the Social Services Designee has been checking on resident, she is working with therapy, and a BCS (Behavioral Care Solutions) referral has been made. Resident stated she felt safe the night the incident was identified. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All staff, besides those on a LOA, have been in-serviced on the facility's abuse policy. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will be conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that they feel safety and have no concerns with any of the staff members. The Director of Nursing Services, or designee, will conduct a random audit of five (5) staff members weekly for four (4) consecutive weeks. These staff will be assessed and interviewed to ensure that they have not failed to report any suspected abuse to the facility's Abuse Coordinator. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 2/1/2024. Attached education 1/29/24 included education in the types of abuse, abuse reporting, and staff abuse audits. It was verified onsight the residents were protected from further abuse. The facility ensured their safety and psychosocial well-being. Resident abuse interviews were completed to ensure no ongoing abuse. Staff educations and audits verified substantial compliance following the incidents. The facilty determined CNA H was responsible for their behavior and was terminated from employment at the facility. All elements of the PNC were met and accepted by the State Agency.

This citation relates to Intake #MI00142455. Based on interview and record review, the facility failed to follow their abuse policy and report abuse to prevent employee to resident abuse for two Residents (R3, R22) of three residents reviewed for abuse. Findings include: Review of R22's Investigation report, dated 1/31/24 at 2:21 p.m., revealed Certified Nurse Aide (CNA) B discovered bruising on R22's arms and notified Licensed Practical Nurse (LPN) A. R22 was tearful when interviewed and reported a CNA (identified as CNA H) was rough with her during cares and she did not feel safe when CNA H was working with her. LPN A observed the bruising appeared to be fingerprints on R22's upper arms. The report showed other residents were interviewed for potential abuse. R3 reported CNA H hollered at her and pointed her finger at her and stated she did not want CNA H to work with her. Review of R22's police report, dated 1/29/24 at 12:04 p.m., described how R22 said when a staff person was assisting her rolling over in bed, CNA H was too aggressive and bruised her. The Officer reported they observed handprints on both of R22's arms from over gripping. Review of R22's, Report of Alleged Resident Abuse, dated 1/29/24, revealed, Evidence of Injury, marked Yes, described as bruising on both arms found by CNA during cares . The category, Types of Abuse was marked with an X as follows: Physical, Verbal/emotional/psychological, and Staff to Resident. Summary of interview with resident described the incident as [R22] was very upset. Didn't want to report at first. Stated CNA [H] is rough with her . The NHA conveyed, .Abuse is still substantiated d/t [due to] CNA's [H] verbal outbursts towards residents, and the fact that residents say she is not nice to them [Two resident statements .]. Staff have had to intervene and educate CNA [H] on how to talk to residents .[CNA H] terminated . Review of R3's abuse interview revealed, .[CNA H] hollers, points fingers at me. I don't want her taking care of me if I can help it . During an interview on 2/12/24 at 3:16 p.m., LPN C was asked about any abuse concerns on R22's hall. LPN C reported they had seen marks on R22's arms which looked like fingerprints on her arms, and R22 had reported being treated roughly. LPN C reported they believed it occurred, as they had seen the bruises, and found R22 to be a reliable reporter. During an interview on 2/12/24 at 3:19 p.m., R22 was interviewed regarding their care at the facility, and confirmed CNA H was verbally and emotionally abusive to them and provided rough treatment. During a phone interview on 2/14/24 at 9:32 a.m., LPN A was asked about the incident. LPN A confirmed R22 reported rough treatment by CNA H towards her, emotional abuse, and expressed feelings of fearfulness. During further interview on 2/14/24 at approximately 9:40 a.m., LPN A was asked if she had any concerns with CNA H prior, as she worked on their hall. LPN A reported, A week or so before [the incident with R22], CNA H was observed hollering at a resident, and I said, 'You do not treat our residents like that.' And she grinned .It was [R3]. When asked if there was any psychosocial affect for R3, LPN B reported she had her head down, which was not typical for R3. LPN B reported she should have reported the incident and understood after education it was abuse. During an interview on 2/14/24 at 2:11 p.m, the DON was asked about their observations of R22's bruises and affect, and their findings related to abuse or potential abuse of R22 and R3. The DON reported when they and the NHA walked into R22's room, R22 immediately started to cry and said the aide [CNA H] did not like her, and stated, She's rough with me when she's around, and she plops my food tray down and doesn't set it up. The DON reported they observed R22's bruises under her arms and one arm had a thumbprint which was green and yellow, and up to 4 days old. The DON clarified the other bruises appeared a couple days old, with a newer bruise which was purple, with the edges turning green and yellow. The DON reported they suspected it was physical abuse more than likely because of the location, and they could not explain how the bruises would be there. The DON brought pictures of the bruises, taken by LPN A, and showed how it appeared R22 was grabbed by their arms as if to pull them up, and pointed out an apparent thumb print and bruising under the arms. The DON clarified the bruises would not be bruises from a medication or diabetic care, and confirmed R22 was a credible resident and reporter, and they believed them. During an interview on 2/14/24 at 2:20 p.m., the DON concluded, We substantiated emotional abuse 100%, as it was emotional abuse .[R22] described to them, [CNA H] is very rough with me when she turns me. The tray [setting it down hard] was verbal abuse .when R22 said, '[CNA H] is very short with me.' During an interview on 2/14/24 at approximately 2:25 p.m., the DON was asked about R3 and their description of LPN H yelling at them. The DON confirmed this verbal abuse incident should also have been reported, as they and the NHA were unaware until the abuse audits were completed, after the abuse was discovered towards R22 on 1/28/24. During an interview on 2/14/24 at 4:26 p.m., the NHA was asked about the abuse incidents towards R22 and R3, perpetrated by CNA H. The NHA confirmed they had substantiated abuse towards both residents, suspended CNA H pending investigation, and terminated their employment. Review of the policy, Abuse, Prevention, and Prohibition of, dated 10/31/22, provided by the NHA, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility will not use emotional, verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, employees, the medical director, consultants, and volunteers .Policy: This policy prohibits mistreatment, neglect, or abuse of residents .This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone .4. Identification: The facility will identify residents whose personal histories render them at risk for abusing other residents through the prescreening process. The nursing staff is responsible for reporting the appearance of bruises, lacerations, skin tears or other abnormalities as they occur .The Director of Nursing (DON) is responsible for their evaluation and assessment. If the source of the injuries is unknown, a UKO [Unknown Origin] injury investigation must be completed. An abuse investigation may also be conducted based on the investigation findings. Investigation: Resident abuse must be reported immediately to the Director of Nursing (or Nurse Manager on call) and the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress .Implement steps to prevent further potential abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the state agency and law enforcement if there is reasonable suspicion of a crime or serious bodily harm .Complete a report of alleged resident abuse within required timelines .A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted .Complete a thorough investigation .Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. b. Employee Allegations. When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending outcome of the facility investigation, prosecution, or disciplinary action against the employee .Reporting/Response: The facility employee or agent who becomes aware of abuse, neglect, exploitation, or mistreatment, including injuries of unknow source or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator and/or the Director of Nursing regardless of whether serious bodily injury occurred. The facility Administrator, and/or the Director of Nursing, who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse, neglect, exploitation, or mistreatment or any allegation of such shall report or cause a report to be made to the mandated State Agency per reporting criteria immediately: but no later than 2 hours after an allegation is made if the allegations involve abuse or result in serious bodily injury .such reports may be made to the local law enforcement agency in the same manner . Review of facility Past Non-Compliance (PNC) document, dated 2/01/24, revealed: This plan of correction is submitted as the facility's credible allegation of compliance. 1. Immediate action(s) taken for the resident(s) found to have been affected include: A thorough investigation was conducted by Director of Nursing Services and the facility Administrator regarding the allegations made by Resident #1 [R22]. Facility ensures residents safety, residents has been given 1:1 activity staff, the Social Services Designee has been checking on resident, she is working with therapy, and a BCS (Behavioral Care Solutions) referral has been made. Resident stated she felt safe the night the incident was identified. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All staff, besides those on a LOA, have been in-serviced on the facility's abuse policy. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will be conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that they feel safety and have no concerns with any of the staff members. The Director of Nursing Services, or designee, will conduct a random audit of five (5) staff members weekly for four (4) consecutive weeks. These staff will be assessed and interviewed to ensure that they have not failed to report any suspected abuse to the facility's Abuse Coordinator. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 2/1/2024. Attached education 1/29/24 included education in the types of abuse, abuse reporting, and staff abuse audits. It was verified onsight the residents were protected from further abuse. The facility ensured their safety and psychosocial well-being. Resident abuse interviews were completed to ensure staff followed their policy to report all types of abuse and allegations of abuse. Staff educations and audits verified substantial compliance following the incidents. All elements of the PNC were met and accepted by the State Agency. All elements of PNC were met and accepted by the State Agency.

Based on interview and record review the facility failed to ensure Physician's orders were obtained and communication/documentation occurred for coordination of care for hospice services provided to two Residents (R6 and R13) of two Residents reviewed for hospice services. This deficient practice resulted in the potential for a lack of coordination of comprehensive services and unmet needs. Findings include: Resident #6 (R6) A review of the medical record for R6 revealed an admitted [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] indicated R6 was receiving hospice services. The Resident Roster printed on 2/12/24 denoted R6 was on hospice. During an interview on 2/12/24 at approximately 12:05 PM, Family Member L stated R6 started on hospice services in December 2023. The Electronic Medical Record (EMR) was reviewed and there was not a Physician order for Hospice Services. On 02/14/24 at 12:17 PM, the hospice resident folder in R6's room did not include calendar entries for January or February indicating a schedule for planned visits. Both months were blank. No documentation by any hospice personnel was in this folder. The unit hospice folder found in the nurse's station had two names of other residents on hospice and did not include a section for R6 or any hospice documentation of visits or care plans for R6. Resident #13 (R13) A review of the medical record for R13 revealed an admitted [DATE]. The Minimum Data Set (MDS) assessments dated 11/09/23 and 2/1/24 indicated R13 was receiving hospice services. The Resident Roster printed on 2/12/24 denoted R13 was on hospice. The EMR was reviewed and there was not a Physician order for Hospice Services. The care plan for R13 included a focus of (R13) is receiving Hospice services. The goal included: Hospice Binder in (R13's) room, with Hospice information. During an interview on 2/14/24 at 12:16 PM Registered Nurse (RN) M stated the hospice staff speaks to the facility staff and gives a progress report, but she was not sure where any documentation was. RN M said there should be a folder in the hospice resident's room with information. The room for R13 was accessed and a Hospice folder was observed. The folder contained: - An October 2023 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank. One day - October 31 had a name written in and the word admit. - A November 2023 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank. - A December 2023 calendar which had the name of the hospice and a line designating Patient Name:_____________ which was blank. There were two dates on the calendar 12/5/23 and 12/7/23 which had a name written on each day. All other dates were blank. - A January 2024 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank. - A February 2024 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank. - A Vital Signs Record with R13's name and one set of vitals recorded for 11/7 The remainder of the log was blank. - There was one Volunteer Assignment sheet filled out and signed on 11/15/23. - There was no other documentation indicating hospice personnel such as hospice nurses, hospice aides, hospice social workers or hospice chaplains had been in to serve R13. During an interview on 2/14/24 at 12:19 PM, the Director of Nursing (DON) explained the process used for obtaining hospice services. The DON stated the physician would review the resident to determine if that resident was eligible and if the resident was accepted to hospice the facility would obtain a physician order. The DON reviewed the EMR and confirmed there had not been a physician order for R6 or R13 to receive hospice services. The EMR also did not contain documented communication from hospice personnel. The DON stated, the facility did not have documented communication from the hospice staff, but she was able to access it online. When asked if the information had been printed out or available to any of the floor staff the DON stated it was not. During an interview on 2/14/24 at 1:10 PM, RN N stated there was not a calendar to indicate when the hospice personnel were scheduled to visit or what services they would be providing. RN N stated, It is very hard to plan. The facility policy titled, Coordination of Hospice Services and dated as implemented on 9/1/23, read in part, The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility . The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure the mechanical dish machine was properly sanitizing food contact surfaces, including plates, glasses, flatware and cooking utensils. 2. Failing to ensure food service staff properly washed their hands following contamination and returning to food related tasks. 3. Failing to ensure all food staff properly had their hair restrained. This deficient practice has the potential to result in food borne illness among any or all 46 residents in the facility. Findings include: 1. On 1/31/23 at approximately 1:30 PM, observations of the mechanical dish machine were made and determined the machine was a high temperature sanitizing type with a conveyor mechanism. This type of machine requires a series of cycles of hot water to ensure that food contact surfaces are properly sanitized by the surface reaching a minimum temperature of 160 F. Dietary Aide (DA) I was conducting dish washing activities by placing soiled dishes, plates, cups, glasses and utensils on the cassettes and pushing them into the machine. Three cycles were observed during the wash rinse and sanitize cycle, which included the final rinse registering 197 F on the machine's temperature gauge. Two DishTemp irreversible maximum registering thermometers (one facility and one surveyor's) were placed on the cassette and allowed to measure a complete cycle of washing, rinsing and sanitizing. Upon exit from the machine, the DishTemp thermometers read 154 F and 156 F respectively. At 1:45 PM an interview was conducted with Dietary Manager (DM) A at this time and asked if this reading on the maximum registering thermometer was acceptable, who then replied No. The interview continued related to the monitoring of the dish machine temperature. A log was located hanging on the wall in the dish room labeled Dish Machine Temperatures was for January 2023. A column on the log was labeled Thermo-Works temp and was used to document the readings from the DishTemp irreversible maximum registering thermometer used by the facility. On 13 occasions from 1/1/23 through 1/30/23 the documented temperatures were below 160 F, indicating improper sanitizing of food contact surfaces by the machine. DM A acknowledged she did not review the logs. DM A acknowledged the facility did not have a back up system (e.g.: heat sensitive strips) or quality assurance system to confirm the accuracy of the thermometer. The proper temperature for sanitizing was not present on the form, nor was any corrective action requirement when the machine failed to meet the proper parameters. The FDA Food Code 2017 states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing: (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature 4-302.13 Temperature Measuring Devices, Manual Warewashing. Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C(160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C(160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). 2. On 1/31/23 at approximately 11:45 AM, observations were made during the noon meal preparation and service. Dietary Cook (DC) J was observed to wash her hands, dry her hands with a paper towel, lift the lid to a 45 gallon garbage can, dispose of the towel, replace the lid and return to the preparation work counter. At 12:10 PM DA I was observed to do the same, at a different garbage can in the kitchen, then again at 12:15 PM DC J did the same. An interview was conducted with DC J at 12:15 PM related to the use of the garbage can versus simply disposing of paper towels in the open trash can below the sink. DC J stated I don't know why I did that. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 3. On 1/31/22 at 10:00 AM, during the initial tour of the kitchen, DM A was observed with a hair restraint on, but with large amounts of loose hair extending below the restraint. During subsequent observations during the noon meal and dish washing observations on 1/31/23, (11;15 AM to 3:00 PM) then again on 2/1/23 at approximately 7:30 AM during the morning meal preparation and service this same condition of unrestrained hair was observed. DA K was observed at this same time with an excessive amount of hair extending below her hair bouffant. On 2/1/23 at approximately 8:00 AM an interview was conducted with DM A related to the unrestrained hair. DM A stated she was not aware her hair was hanging below the hair restraint. The FDA Food Code 2017 states: Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, 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;

Based on observation, interview and record review, the facility failed to develop comprehensive, person-centered care plans for four Residents (#9, #29, #37 and #44) of 14 residents reviewed for care planning. This deficient practice resulted in the potential for unidentified and unmet care needs. Findings include: Resident #9 A review of Resident #9's Minimum Data Set (MDS) assessment, dated 12/02/2022, revealed she was admitted to the facility on [DATE] and had diagnoses including heart failure and chronic pain syndrome. Further review the MDS assessment revealed in the five days prior to the assessment, Resident #9 received scheduled and as needed (prn) pain medication, and non-medication interventions to treat pain. The MDS assessment also revealed Resident #9 experienced Shortness of breath or trouble breathing with exertion during the assessment lookback period. Resident #9 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. An observation on 1/31/2023 at 4:05 p.m., revealed Resident #9 sitting up in her bed wearing a nasal cannula with tubing attached to a portable oxygen concentrator running at 2.5 L (two- and one-half liters) per minute. During an interview at the time of the observation, Resident #9 reported she no longer got out of bed due to being short of breath and having severe pain in her left knee. Resident #9 stated she often had pain in her left knee and lower back that worsened when standing. The Resident reported she was particular about administration of her scheduled pain medication and stated she needed to have the medication during the scheduled timeframe's, or the pain was difficult to catch up with. When asked how often she required the use of supplemental oxygen, Resident #9 stated she used oxygen continuously due to ongoing trouble with breathing and being short of breath. A review of Resident #9's physician orders on 2/02/2023 at approximately 8:00 a.m., with Licensed Practical Nurse (LPN) D revealed the following: Hydrocodone-acetaminophen Tablet 10-325 MG (milligram), Give 1 tablet by mouth four times a day for chronic pain, give every 6 hours. Order date: 1/16/2023 1206 (12:06 p.m.). Further review of the order revealed scheduled times for administration of 5:00 a.m., 10:00 a.m., 3:00 p.m. and 8:00 p.m. During an interview at the time of the record review. LPN D reported Resident #9's pain medication administration times were recently changed due to the Resident wishing not to be awakened in the night for medication administration. LPN D stated Resident #9 preferred to stay in bed due to increased pain when transferring and ambulating. When asked what non-pharmacological interventions were in place to manage Resident #9's pain, LPN D stated staff had attempted to use ice for pain control but Resident #9 often refused. LPN D was unsure what other interventions were attempted or why the Resident refused the care. A review of Resident #9's care plan revealed no focus area, goals or interventions related to the Resident's chronic pain. Further review revealed no focus area, goals or interventions related to Resident #9's congestive heart failure, shortness of breath and trouble breathing or the Resident's use of continuous oxygen. During an interview on 2/02/2023 at 2:10 p.m., the Director of Nursing (DON) reported she would expect care plans to accurately reflect resident's conditions and include interventions needed to appropriately provide care based on each resident's specific needs. The DON stated there was a possibility of unmet care needs when care plans were incomplete. Resident #29 A review of Resident #29's MDS assessment, dated 12/09/2022 revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder (mood disorder characterized by extreme shifts in mood from mania to depression). Further review of the assessment revealed Resident #29 was administered an antipsychotic medication on all days of the seven-day lookback period. A review of Resident #29's hospital discharge summary, dated 6/08/2022, revealed Resident #29 was previously hospitalized related to signs and symptoms of bipolar disorder. A review of Resident #29 Medication Administration Record (MAR) for January and February 2023 revealed she was ordered and administered the following: Olanzapine (antipsychotic medication used to treat signs and symptoms of mood disorders) and (name brand) (an antidepressant medication]. A review of Resident #29's care plan revealed the following: Need: (Resident #29) is prescribed psychotropic medication (related to) her (diagnosis) of bipolar. Date Initiated: 6/09/2022. Goal: (Resident #29) will be free from discomfort or adverse reactions related to medication therapy through the review dated. Date Initiated: 6/09/2022. Interventions: Give antidepressant medications ordered by physician. Observe and report to (physician) for side effects and effectiveness. Date Initiated: 6/09/2022. The care plan revealed no target behaviors or non-pharmacological interventions listed related to Resident #29's bipolar disorder, depression and anxiety, as listed on the 12/09/2022 MDS assessment and as evidenced by Resident #29's administration of antipsychotic and antidepressant medications. A review of the facility policy titled Care Planning - Resident Participation, provided by the Assistant Administrator, Staff L, and dated 11/17/2022, revealed the following, in part: The care planning process will include an assessment of the resident's strengths and needs . On 2/02/2022 at approximately 2:30 p.m., Staff L was asked if the facility had a policy related to how care plans were developed and what care plans were to include. Staff L stated the facility had no policy related to initial development of comprehensive care plans to include criteria for development of the care plan. 40330 Resident #37 Review of the MDS assessment, dated 12/29/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive neurological condition of movement which often causes stiffness, incoordination, and tremors), coronary artery disease (narrowing of the heart blood vessels), congestive heart failure (a progressive heart disease causing fatigue and shortness of breath), acute respiratory failure with hypoxia (lack of oxygen), and hearing loss. Resident #37 required extensive two-person assistance for transfers and toileting, and extensive one-person assistance for bed mobility, dressing, and personal hygiene. The BIMS assessment revealed a score of 13/15, which showed Resident #37 had intact cognition. During an observation on 01/31/23 at 12:16 p.m., Resident #37 was observed in their room sitting upright in their manual wheelchair, reading. Resident #37 was receiving oxygen via a nasal canula running at 2L (liters), and the oxygen concentrator tubing extending from the concentrator to their nose was undated. During an interview on 01/31/23 at approximately 12:22 p.m., Certified Nurse Aide (CNA) Q was asked why Resident #37 was wearing the oxygen. CNA Q reported, [Resident #37] is [medically] declining. Review of Resident #37's Care Plan, accessed 02/02/23 at 3:14 p.m., revealed, [Resident #37] has a dx [diagnosis] of heart disease; she has a pacemaker .Revision on: 06/14/2021. Administer medication as ordered. Date initiated: 04/21/2020 There was no mention of respiratory compromise or oxygen administration, including PRN. During an interview on 02/02/23 at 8:15 a.m., the DON reviewed the Electronic Medical Record (EMR) and concurred there was no mention of the oxygen use or care in Resident #37's Care Plan. The DON reported the care planning may have been missed as Resident #37 returned recently from the emergency room (ER) wearing oxygen. The DON clarified despite Resident #37 wearing oxygen as needed, it should have been documented in the Care Plan and on the TAR (Treatment Administration Record). The DON confirmed Resident #37 was needing oxygen PRN recently due to cardiac diagnoses, including progression of congestive heart failure, and medical/respiratory decline. During an interview with the Nursing Home Administrator (NHA) on 02/01/23 at 1:48 p.m., they reported they understood the concern regarding oxygen use and care not being reflected in Resident #37's Care Plan. 38328 Resident #44 A review of the care plan section of the Electronic Medical Record (EMR) for Resident #44 revealed no evidence of dementia or behavioral care planning. A review of the Medication Orders in the EMR revealed the following: (Brand name) [antipsychotic medication] Oral Tablet 0.5 MG [milligrams] (Risperidone) Give 1 tablet by mouth at bedtime related to VASCULAR DEMENTIA, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F01.B0) (Brand name) [antidepressant medication] HCl [hydrochloride] Tablet 25 MG Give 1 tablet by mouth one time a day related to VASCULAR DEMENTIA, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F01.B0) A review of the 9/6/22 admission Minimum Data Set (MDS) assessment for Resident #44, revealed a PHQ-9 (depression assessment) of 3 (depression severity none) and no hallucinations or delusions noted in the behaviors section of the MDS. Resident #44 scored 10 on the Brief Interview for Mental Status (BIMS) assessment, indicating there was moderately impaired cognition present. A review of the 12/7/22 quarterly MDS for Resident #44, revealed a PHQ-9 of 0 and no hallucinations or delusions noted in the behaviors section of the MDS. Resident #44 scored 8 out of 15 on the BIMS assessment indicating a decline in cognition from the previous assessment. A review of September 2022 through December 2022 behavior logs which were present in the EMR, revealed behavior tracking, but no behavioral interventions were identified for staff to implement in the event of behaviors. A review of 9/30/22, 10/21/22 and 12/2/22 effective dates for physician progress notes revealed no evidence of consideration for Gradual Dose Reduction (GDR) consideration for any of his psychotropic medications. A review of the face sheet for Resident #44 revealed admission to the facility on [DATE], with diagnoses including vascular dementia with agitation, depression, and anxiety. There was no evidence of consents found in the EMR to approve the use of psychotropics or antipsychotics for Resident #44. A review of the care plan on 2/2/23 at 11:30 a.m., revealed minimal care planning in place for Resident #44. The care plan was reviewed by the Nursing Home Administrator (NHA) and this surveyor. The NHA stated she recognized care planning has been an issue and the facility has been continuing to work on them as residents come up for clinical review and MDS assessments. The NHA stated the facility recognized care planning had improvements which still needed to be made. The care plans for Resident #44 were noted to be revised by Activities Director (AD) S on 2/2/21 after the facility was informed of the concern regarding lack of dementia care planning.

Based on observation, interview and record review, the facility failed to ensure staff were properly donning and doffing Personal Protective Equipment (PPE) while entering and exiting COVID-19 isolation rooms. This deficient practice resulted in the potential for further spread of COVID-19 to the entire facility population. Findings include: On 1/31/23 at 12:35 p.m., Certified Nurse Aide (CNA) T was observed entering and exiting rooms during meal tray delivery service on the COVID-19 and Influenza unit. CNA T was observed entering and exiting room [ROOM NUMBER] (Resident #39) on the SNU (resident unit designation) unit, who was positive for COVID-19, with only the upper strap of the N95 (Direct Supply-Brand Name) secured, the bottom strap was hanging loose in front of the mask. On 1/31/23 at 12:40 p.m., CNA T then entered and exited room [ROOM NUMBER] (Resident #24) on the SNU unit with a different N95 (Makrite-Brand Name) and failed to ensure the metal nose stay (bendable metal strip) was formed to the face. A gap was visualized between the mask and the face of CNA T between the cheek bone and nose on both sides. On 1/31/23 at 12:42 p.m., CNA T failed to perform hand hygiene between removal of an N95 used to enter and exit COVID-19 positive room [ROOM NUMBER] (Resident #28) and donning a new N95 mask. CNA T contaminated her face. CNA T again did not ensure the metal nose stay was form fitted to the face (Makrite). On 1/31/23 at 12:45 p.m., CNA T was observed entering and exiting room [ROOM NUMBER] (Resident #47) on the SNU unit without ensuring the metal nose stay was form fitted to her face. (Makrite) On 1/31/23 at 12:47 p.m., CNA T changed her N95 mask without performing hand hygiene between removing the old mask and donning a new mask and contaminated her face. On 1/31/23 at 12:55 p.m., CNA T went from room [ROOM NUMBER] (Resident #10) to room [ROOM NUMBER] (Resident #47) on the SNU unit without changing the N95 mask and no face shield or outer mask was worn over the N95 mask. On 1/31/23 at 12:58 p.m. CNA T doffed an N95 mask and donned a new N95 mask and failed to perform hand hygiene, contaminating her face. On 1/31/23 at 1:01 p.m., CNA U doffed an N95 mask and failed to perform hand hygiene before donning a new N95 mask. During an interview on 2/1/23 at 8:20 a.m., CNA V stated CNA T was responsible for the south and west halls (non-COVID-19 area) and CNA V stated she was assigned to the COVID-19 unit. On 2/1/23 at 8:40 a.m., the breakfast tray cart for the SNU unit arrived and CNA V brought the cart onto the unit, leaving one of the doors open to the remainder of the facility. On 2/1/23 at 8:50 a.m., an unknown staff member passed by and closed the door between the COVID-19 unit and the remainder of the facility. A Simultaneous observation of CNA V was conducted for proper PPE usage. CNA V delivered a meal tray to room [ROOM NUMBER] (Resident #39) on the SNU unit and performed a setup of the tray, touching the environment of the COVID-19 positive room. CNA V preformed doffing of her PPE starting with her gown and gloves, then failed to perform hand hygiene before removing the surgical mask covering her N95 mask and contaminated her N95 mask and face. On 2/1/23 at 9:00 a.m., CNA V delivered a meal tray for room [ROOM NUMBER] (Resident #10) and provided set-up, including handing of food items and touched the environment. CNA V doffed gown and gloves and then failed to perform hand hygiene before removing an outer mask covering her N95 and contaminated her N95 and face. During an interview on 2/1/23 at 2:30 p.m., CNA T verbalized understanding when concerns brought up regarding hand hygiene between doffing gown and gloves and before removing an N95 mask and putting on a new N95 mask. CNA T also acknowledged the concern with not forming the metal stay to her nasal area for the (Makrite) N95. When asked if fully vaccinated, CNA T stated she was fully vaccinated,. When asked if she had a COVID-19 infection, CNA T stated she had COVID-19 in January or February of 2022. On 2/2/23 at approximately 9:50 a.m., the infection control concerns were brought to the attention of the Director of Nursing (DON). When asked about the concerns with hand hygiene observed during the survey for CNA T, U, and V, the DON agreed the lack of hand hygiene before bring hands to their face was a breach of infection control and acknowledged hand hygiene should have been performed between doffing gown and gloves before doffing any face mask. The DON also confirmed N95 masks should be conformed to the user's face before entering a room and both straps should be in place. The DON confirmed the door to the COVID-19 unit should be closed when not in use to go on or off the unit. A review of the Makrite N95 instructions on the box read as follows: Step 1 Hold the respirator in had with the nosepiece at your fingertips, allowing the head bands to hang freely below your hand. Step 2 Press the respirator firmly against your face with the nosepiece on the bridge of your nose. Step 3 Stretch and position the top band high on the back of the head. Stretch the bottom band over the head and position below your ears. Step 4 Using both hands, mold the nosepiece to the shape of your nose. Step 5 To test fit: a) Cup both hands over the respirator being careful not to distrub (sic) position, and b) inhale vigorously. If air leaks around the edges, reposition the straps or adjust strap tension for better fit. Please carefully follow these instructions during each use to achieve proper fit. A review of the Direct Supply N95 instructions on the box read as follows: Step 1 Hold the respirator in hand with the nosepiece at your fingertips, allowing the head bands to hang freely below your hand. Step 2 Press the respirator firmly against your face with the nosepiece on the bridge of your nose. Step 3 Stretch and position the top band high on the back of the head. Stretch the bottom band over the head and position below your ears. Step 4 Using both hands, mold the nosepiece to the shape of your nose. Step 5 To test fit: Cup both hands over the respirator while careful not to disturb placement, then inhale deeply. If air leaks around the edges, reposition the straps or adjust trap (sic) tension for better fit. Follow these fitting instructions during each use to achieve proper fit. A review of the facility hand hygiene policy, no date, read in part: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . . 6. Additional considerations: a. The use of glove does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Hand Hygiene Table: . After handling contaminated objects . . Before applying and after removing personal protective equipment (PPE), including gloves . . Before and after providing resident care to residents in isolation .

Based on interview and record review, the facility failed to notify the resident or the resident representative, in writing, of the reason for a transfer out of the facility to the hospital and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for 2 Residents (#9 and #40) of 3 residents reviewed for notice of transfer. This deficient practice resulted in the potential for residents and their representatives being uninformed of the reason for transfer and unnecessary or undesired transfers. Findings include: Resident #9 A review of Resident #9's Minimum Data Set (MDS) assessment, dated 11/20/2022, revealed a discharge date of [DATE] with the discharge status listed as the Acute hospital. Further review of Resident #9's MDS assessments revealed a reentry to the facility on [DATE] from the Acute hospital. A review of Resident #9's Electronic Medical Record (EMR) and paper chart revealed no written notification of transfer or discharge for the Resident's hospitalization on [DATE]. On 1/31/2023 at 1:37 p.m., a review of the listing sent to the representative of the Office of the State Long-term Care Ombudsman, provided by the Administrator Assistant, Staff L and notifying the Ombudsman of residents transferred or discharged from the facility in November 2022, revealed Resident #9's transfer and hospitalization on [DATE] was not included on the notification list. Resident #40 A review of Resident #40's MDS assessment, dated 12/18/2022, revealed a discharge date of [DATE] with the discharge status listed as the Acute hospital. Further review of Resident #40's MDS assessments revealed a reentry to the facility on [DATE] from the Acute hospital. A review of Resident #40's EMR and paper chart revealed no written notification of transfer or discharge for the Resident's hospitalization on [DATE]. On 1/31/2023 at 1:37 p.m., a review of the listing sent to the representative of the Office of the State Long-term Care Ombudsman, provided by the Administrator Assistant, Staff L and notifying the Ombudsman of residents transferred or discharged from the facility in December 2022, revealed Resident #40's transfer and hospitalization on [DATE] was not included on the notification list. During an interview on 2/02/2023 at approximately 1:30 p.m., Staff L stated there were no written notifications of transfer or discharge completed for Resident #9's hospitalization on [DATE] or Resident #40's hospitalization on [DATE]. Staff L confirmed Resident #9 was not listed on the Ombudsman's notification list for residents transferred and discharged in November 2022 nor was Resident #40 listed on the December 2022 notification list as being discharged on [DATE]. Staff L stated she was unsure why Resident #9's and Resident #40's hospitalization s were overlooked.

Based on observation, interview, and record review, the facility failed to provide adequate grooming for one Resident (#44) of two residents reviewed for activities of daily living. This deficient practice resulted in Resident #44 having long fingernails and long facial hair stubble, appearing unshaven. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 12/07/22, revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including kidney disease, septicemia (systemic infection), dementia, depression, anxiety disorder, muscle weakness, and palliative care (specialized care for people living with serious illness). Resident #44 required extensive two-person assistance for transfers, toileting, and extensive one-person assistance for bed mobility, dressing, and personal hygiene (which included combing hair, brushing teeth, and shaving). The Brief Interview for Mental Status (BIMS) assessment revealed a score of 08/15, which showed Resident #15 had moderate cognitive impairment. During an observation on 01/31/23 at 11:08 a.m., Resident #44 was observed in their bed wearing a hospital gown, with their hair disheveled, and long facial hairs above their lip, and covering their chin, 1/4 in length. Resident #44 was asked about his facial hair stubble, and stated he did not like his facial hair this long. Resident #44 reported he liked to be cleanly shaven, and needed assistance to shave. Resident #44's fingernails of both hands were observed with dirt and residue under the nail edges, which extended 1/8 to 1/4 in length beyond the nail body. Resident #44 was asked about his longer fingernails, and explained it bothered him. During an observation on 02/01/23 at 8:58 a.m., Resident #44 was observed again with some long facial hairs, and stubble under his lip. When asked about his facial hair, Resident #44 stated, Shave it off,, and explained he was not happy with being partly shaven. Resident #44's nails remained 1/8 to 1/4 long at the nail edges. Resident #44 stated, I wish they were trimmed. During an observation on 02/02/23 at 8:40 a.m.,with the Director of Nursing (DON), Resident #44 appeared partially and unevenly shaven, with the left side of his face showing long facial stubble. Resident #44's fingernails of both hands remained 1/8 to 1/4 in length, at the nail edges, with dirt and residue remaining underneath their fingernails. The DON nodded in apparent understanding during the observation, then left the room, and did not comment. Review of Resident #44's tasks, accessed 02/02/23 at 10:11 a.m., in the Electronic Medical Record (EMR), revealed personal hygiene (which included brushing teeth, shaving .and washing and drying hands) was to be completed at least once daily with one-person assistance. The 30-day look back revealed Resident #44 was marked as having personal hygiene completed daily, one to three times per day. There was no separate delineation to show how often shaving was completed. Review of Resident #44's last two skin assessments dated 01/23/22 and 01/29/22, accessed from the EMR on 02/02/22 at 10:11 and 10:13 a.m., showed Resident #44's nails were marked as not needing to be trimmed on those dates. During an interview on 02/02/23 at 11:26 a.m., Certified Nurse Aide (CNA) P was asked about Resident #44's long nails and untrimmed facial hair stubble. CNA P reported they observed (on 02/02/23) Resident #44 needed to be shaven, and stated they would assist him. CNA P reported residents' nails were trimmed twice a week during showers. They stated, They [fingernails] may not be getting done [trimmed]. They will get done [trimmed] today. During an interview on 02/02/23 at 1:37 p.m., the Nursing Home Administrator (NHA) reported they understood the concern, per Surveyor description of observations. During an interview on 02/02/23 at approximately 2:15 p.m., the Administrative Assistant, Staff L, reported there was no policy respective to resident activities of daily living care, including for shaving.

Based on observation, interview and record review, the facility failed to 1) ensure use of safe transfer techniques for one Resident (#12) and, 2) failed to ensure an environment free of hazards for one Resident (#10) of two Residents reviewed for accidents and hazards. This deficient practice resulted in the potential for injury. Finding include: Resident #12 A review of Resident #12's Minimum Data Set (MDS) assessment, dated 12/07/2022, revealed the Resident was admitted to the facility on [DATE] and had diagnoses including dementia, renal insufficiency and respiratory failure. A review of the assessment Section G - Functional Status revealed Resident #12 required extensive, two-person physical assistance with transfers and the Resident's Balance During Transitions and Walking was assessed as Not steady, only able to stabilize with human assistance. Resident #12 scored three out of 15 on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive impairment. An observation on 1/31/2023 at 12:30 p.m., revealed Certified Nurse Aide (CNA) M and Registered Nurse (RN) N preparing Resident #12 to transfer from her bed to a wheelchair. Resident #12 was seated on the left side of her bed with her feet on the floor. CNA M positioned the wheelchair parallel to the bed to the right of the seated Resident and proceeded to position himself facing Resident #12 while RN N stood with the wheelchair between her and the Resident. CNA M was observed placing his hands under the Resident's arms and pulling the Resident up to her feet. Resident #12 did not straighten her legs upon standing and remained in a seated position with her knees bent at approximately 70 degrees and her buttocks pointing out. All of Resident #12's weight was observed to be supported by CNA M holding the resident up with his hands placed under her arms and pulling up to lift the resident up under her shoulders. During the observation Resident #12 called out don't let me fall. An observation on 1/31/2023 at 12:44 p.m., revealed CNA M and RN N preparing Resident #12 to transfer from the toilet to a wheelchair positioned in the bathroom facing the toilet. CNA M placed his hands under the Resident's arms and instructed Resident #12 to hold the metal grab bar attached to the wall on the right side of the toilet. Further observation revealed the Resident holding the grab bar while CNA M lifted the Resident to standing position by pulling the Resident up with his hands placed under the Resident's arms. Resident #12 did not straighten her legs upon standing and remained in a seated position while RN M grabbed the back waistband of the Resident's pants and pulled the Resident's buttocks toward the wheelchair seat. CNA M then lowered the Resident down onto the seat with his hands remaining under Resident #12's arms. RN N and CNA M did not use a gait belt (assistive device used to help Residents with gait and balance issues to safely transfer) to aid in stabilizing the Resident during either of the observed transfers. At the time of the transfers, a tan-colored gait belt was observed to be hanging near a glove rack attached to the wall to the left of the Resident's bathroom door. During an interview immediately following the observation, RN N was queried regarding the use of gait belts during transfers. RN N stated she believed gait belt use was only required for specific residents and was unsure if Resident #12 required the use of a gait belt during transfers. During an interview on 1/31/2023 at 12:53 p.m., CNA M was queried regarding the use of a gait belt while transferring residents. CNA M reported he was trained in the use of gait belts and should have used a gait belt when transferring Resident #12. CNA M stated he was aware of the gait belt hanging on the wall in Resident #12's room. On 2/01/2023 at 5:09 p.m., the Assistant Administrator, Staff L reported the facility did not have a policy related to safe transfers or gait belt use. During an interview on 2/02/2023 at 2:10 p.m., the Director of Nursing (DON) reported the facility required use of gait belts during transfers for all residents requiring assistance. The DON acknowledge the potential for injury related to unnecessarily pulling on Resident's arms during transfer and a risk of falls when gaits belts were not utilized. During an interview on 2/02/2023 at 3:00 p.m., Occupational Therapist (OT) O reported the use of gait belts while transferring residents was a standard of practice for safe transfers. 38328 Resident #10 On 1/31/23 at 10:56 a.m., Resident #10's room had a fall mat observed in place on the floor next to the bed. Resident #10 was sitting in a wheelchair and the fall mat was between Resident #10 and the bed. During this observation, Resident #10 moved around in the wheelchair almost constantly with her legs. A pommel (cushion with raised area between the legs) cushion was observed in place, which was suggestive of Resident #10 making attempts to rise from the wheelchair unassisted. The floor mat appeared to be a hazard to Resident #10 if she were to rise and attempt to ambulate to the bed or attempt to propel toward the bed in her wheelchair. The wheelchair did not have anti-tip bars in place for the front of the wheelchair. Resident #10 made attempts to get to the bed propelling in her wheelchair during the observation. On 1/31/23 at 1:59 p.m., during a review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had two or more falls. On 2/1/23 at 3:00 p.m., a review of the falls sustained by Resident #10, provided by the facility, revealed no injuries over four falls dated 10/22/22, 11/1/22, 12/9/22, and 1/4/23. Review of Falls Incident Reports: 1/4/23 fall at 2:30 p.m. with no injuries at the time. Resident #10 was found sitting on the activities floor. Resident #10 was in the activities room coloring. Resident #10 was sitting on her buttocks and legs outstretched in front of sink. The fall was unwitnessed and reported by Activities Director AD S. 11/1/22 fall at 9:30 p.m. with no injuries. Resident #10 was observed two minutes prior out in the common area and then was found on the floor by staff at 9:20 p.m. 12/9/22 fall at 5:15 a.m. and Resident #10 was in her wheelchair. The fall was unwitnessed and per the report, Resident #10 appeared to be sitting on a couch in the common area and was found in that area on the floor. 10/22/22 fall (time cut off) where Resident #10 was found with no injury in the hallway on the floor at 8:50 p.m., and was unwitnessed. 9/10/22 fall (time cut off) where Resident #10 was visualized sleeping by several staff before waking up and she spontaneously fell . She was observed next to a recliner in the room. During an interview on 2/2/23 at approximately 11:30 a.m., Assistant Administrator (AA) L stated she disagreed with the fall mat being a tripping hazard because it had a beveled edge. AA was informed of the observation of Resident #10 attempting to propel toward her bed, but could not do so because of the floor mat in place.

Based on observation, interview, and record review, the facility failed to date, label, and change out oxygen tubing for one Resident (#37) of one resident reviewed for oxygen services. This deficient practice resulted in the potential for infection, and deterioration of the tubing. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 12/29/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive neurological condition of movement which often causes stiffness, incoordination, and tremors), coronary artery disease (narrowing of the heart blood vessels), congestive heart failure (a progressive heart disease causing fatigue and shortness of breath), acute respiratory failure with hypoxia (lack of oxygen), and hearing loss. Resident #37 required extensive two-person assistance for transfers and toileting, and extensive one-person assistance for bed mobility, dressing, and personal hygiene. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15, which showed Resident #13 had intact cognition. During an observation on 01/31/23 at 12:16 p.m., Resident #37 was observed in their room sitting upright in their manual wheelchair, reading. Resident #37 was receiving oxygen via a nasal canula running at 2L (Liters), and the oxygen concentrator tubing extending from the concentrator to their nose was undated. Resident #37 appeared comfortable and did not appear to be in respiratory distress. During an interview on 01/31/23 at approximately 12:22 p.m., Certified Nurse Aide (CNA) Q was asked why Resident #37 was wearing the oxygen. CNA Q reported, [Resident #37] is [medically] declining. Review of Resident #37's physician orders revealed, .Respiratory Distress .: Check oxygen saturation PRN (as needed), start oxygen at 2L per minute per nasal canula. Recheck oxygen saturation PRN and titrate [continuously measure and adjust the balance of] oxygen to maintain saturation >90%. Notify Nurse Practitioner/Physician PRN . Review of Resident #37's Care Plan, accessed 02/02/23 at 3:14 p.m., revealed, [Resident #37] has a dx [diagnosis] of heart disease; she has a pacemaker .Revision on: 06/14/2021. Administer medication as ordered. Date initiated: 04/21/2020 There was no mention of recent respiratory compromise requiring oxygen administration, or dating, labeling, or changing out oxygen tubing weekly. During an observation on 02/01/23 at approximately 9:40 a.m., CNA R was asked if they saw a date on the Resident #37's oxygen tubing. CNA R reported they did not see a date on the tubing, but saw a flattened area in the tubing, so they would replace the tubing for Resident #37. CNA R reported Resident #37 only wore the oxygen as needed, and the tubing was changed weekly. During an observation on 02/02/23 at 8:11 a.m., the Director of Nursing (DON) was asked to observe Resident #37's oxygen tubing with Surveyor. Both observed there was no date on the tubing. The DON reported, There should be a sticker [label] on it .every Sunday [it was changed]. During an interview on 0202/23 at 8:15 a.m., the DON reviewed the Electronic Medical Record (EMR) and concurred there was no mention of the oxygen use or care in Resident #37's Care Plan. The DON reported Resident #37's oxygen orders were standing orders and indicated the oxygen tubing labeling and care planning may have been missed as Resident #37 returned recently from the emergency room (ER) wearing oxygen. The DON confirmed there was no order to change the oxygen tubing in the nursing tasks, i.e., on the Medication Administration Record (MAR) or on the Treatment Administration Record (TAR) as well. The DON clarified despite Resident #37 wearing oxygen as needed, oxygen use should have been documented in Resident #37's Care Plan and on their TAR. The DON showed Surveyor bright orange mailing labels where the nurses documented the dates the oxygen was changed, which was weekly. The DON reported the labels slipped off easily, and this may have been why the tubing was not labeled and dated. The DON explained Resident #37 was needing oxygen PRN recently due to cardiac diagnoses, including progression of congestive heart failure, and medical/respiratory decline. During an interview with the Nursing Home Administrator (NHA) on 02/01/23 at 1:45 p.m., they reported they understood the concern, and going forward medical tape would be labeled, dated, and secured to the oxygen tubing for any facility resident wearing oxygen. Review of the policy, [Facility Name], Policy and Procedure For: Cleaning and Changing Oxygen Supplies, undated, received from the Administrative Assistant on 02/02/23, Staff L, revealed, Policy: It is the Policy of [Facility Name] to maintain clean oxygen equipment for residents who receive continuous or intermittent oxygen. Procedure: 1. The oxygen .connecting tubing and cannula or mask will be changed weekly. 2. The .oxygen tubing and nebulizer tubing will have the resident's initials, date, and be initialed by the nurse changing them .All oxygen equipment will be changed weekly whether it has been used or not. Oxygen concentrator filters are to be taken out, cleansed, dried and placed back in concentrator weekly.

Based on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for 2 of 2 residents reviewed for therapeutic diets (Resident #2 and Resident #14). This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications. Findings include: Resident #2 The Electronic Medical Record (EMR) revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including diverticulitis (infection or inflammation in the intestine), gastroesophageal reflux disease (GERD), hypertension, anxiety disorder and depression. The Physician orders listed a diet order of: Regular, Diver diet, Soft foods texture, Thin consistency for Bland diet as tolerated for diverticulitis. Active 10/17/2022 A Registered Dietitian (RD) progress note on 10/25/2022 read in part: (Resident #2) was readmitted to facility after hospitalization for diverticulitis . She is provided with a Regular diet- bland with diver (diverticulitis) features, small portions . An RD progress note of 11/8/2022 read in part: Resident's weight is up 2 lbs (pounds) this week. She is on a bland diet. Intake is 50-75% . The EMR for Resident #2 included a Care Plan with a focus of . at risk for alteration of nutritional status r/t (related to) multiple dx (diagnoses) . Interventions for this focus included, Provide and serve diet as ordered: Regular, bland, diver features, small portions. Lunch was observed on 01/31/23 at 12:15 PM, Resident # 2 received her meal which included a tray card indicating the following diet was to be served: Regular, Sm (small) Portions, Finger Fd (food), Diver. Breakfast was observed on 02/01/23 at 8:45 AM. The tray card listed Resident # 2 was to receive the following diet: Regular, Sm Portions, Finger Fd, Diver. Resident #14 The EMR revealed Resident #14 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] indicated active diagnoses included anxiety, depression, and pulmonary concerns. The Physician orders listed a diet order of: Dysphagia Mechanic diet Soft foods texture, Nectar consistency Start Date: 10/3/22. An RD progress note of 10/4/2022 read in part: (Resident #14) is alert and able to make needs known. She is provided with a Dysphagia Mechanical diet with nectar thick liquids, no straws per speech, diver features, small portions . An RD progress note of 11/11/2022 read in part: Per Speech, the elder will remain on a Mech Soft diet, nectar thick liquids. Straws are now ok and nosey cups will be used per the request of the elder. On 02/02/23 the Care Plan for Resident #14 was reviewed and included a focus of: (Resident #14) is at risk for alteration of nutritional status r/t multiple dx including Schizophrenia, Depression, Anxiety, and GERD, h/o GI hemorrhage (history of bleeding stomach/intestines), Diverticulosis . This focus included interventions of: Provide and serve diet as ordered. Dysphagia mechanical, nectar thick liquids, straws ok (per speech. Diver features, Small portions. Lunch was observed on 01/31/23 at 12:15 PM. Resident # 14 received a meal which included a tray card indicating the following diet was to be served: Mech Soft, Diver, Nectar/Mild Sm Portions. Breakfast was observed on 2/01/23 at 9:20 AM. Resident # 14 received a meal which included a tray card indicating the following diet was to be served: Mech Soft, Diver, Nectar/Mild Sm Portions. During an interview on 2/01/23 at 2:00 PM, Dietary Aide (Staff) K stated a diver diet was one without seeds, nuts, or skins. During an interview on 2/01/23 at 2:02 PM, Dietary Manager (DM) A stated a diver diet was used With people with diverticulitis - no seeds nuts, skins . but if they want strawberries for instance they can have them. DM A said this therapeutic diet was served daily to four residents and she had a list of foods to avoid on a diver diet but this diet was not found in the facility diet manuals available in her office. DM A confirmed Resident #2 was served a Regular, Sm Portions, Finger Fd, Diver diet. The Physician's diet order for Resident #2 also included a bland and a soft restriction. DM A stated a bland diet excluded spicey foods but she did not know Resident #2 was on this restriction. The facility diet manuals did not define bland or soft foods restrictions and this portion of the order was not followed. DM A confirmed Resident #14 received a Mechanical Soft, Diver, Nectar/Mild Small Portions diet. The Physician's diet order for Resident #14 did not include a diver restriction but did include a soft food restriction. The facility diet manuals did not define soft foods restriction and this portion of the order was not followed. During an interview on 2/02/23 at 10:12 AM, DM A stated there was a diet manual on line. This manual was reviewed and did not define a diver diet, a bland diet, or a soft diet.

Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for three Residents (#2, #43, and #44) of three residents reviewed for dining assisstive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss. Findings include: Resident #2 The Electronic Medical Record (EMR) revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including diverticulitis (infection or inflammation in the intestine), gastroesophageal reflux disease (GERD), hypertension, anxiety disorder and depression. The facility Registered Dietitian (RD) progress note of 10/25/2022 read in part: (Resident #2) was readmitted to facility after hospitalization for diverticulitis . Finger foods are provided as able also to help with her independence with meals as vision is extremely limited and she does well with finger foods . She does need assist and cueing at meals due to vision- colored lip plate, suction bowls and colored utensils are provided . A further facility RD progress note of 11/28/2022 read in part: Residents weight has slowly increased since admission . She is provided with a colored lip plate, suction bowls and colored utensils at meals to help promote self feeding as she has very limited vision . The Care Plan for Resident #2 as reviewed on 2/1/23 read in part: (Resident #2) has very limited vision in left eye and is blind in right eye. She needs assistance with meal set up- placement cueing using clock method and assist with meals as needed. Please offer her more finger food options .Provide and serve diet as ordered: Regular, bland, diver features, small portions. Colored lip plate, suction bowl, and colored utensils at all meals. Lunch was observed on 01/31/23 at 12:15 PM. Resident # 2 received her meal, but her tray did not include a colored lip plate, or colored utensils and had no suction bowl. (All of these adaptive pieces of equipment were listed as needed on Resident #2's tray card.) Resident #2 received disposable plates and utensils with regular mugs and was not on transmission-based precautions (quarantine) for infection. Breakfast was observed on 02/01/23 at 8:45 AM. Resident # 2 had her chocolate supplement poured into her disposable Styrofoam bowl containing oatmeal. The supplement was also spilled into the to-go container under the bowl. Resident #2 stated, We have to have these dishes because we have COVID in the building, but I do not have it. During an interview on 2/01/23 at 9:00 AM, Dietary Manager (DM) A stated, Everyone is on disposables. DM A investigated the spilled supplement and Styrofoam containers in Resident #2's room and she stated, You will not see that again. Resident #43 The EMR revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), epilepsy, hypertension, anxiety disorder and dementia. During breakfast observations on 02/01/23 at 8:40 AM, Resident # 43 was in his room in bed struggling to feed himself. He was not on transmission-based precautions (quarantine) for an infection. His meal tray card indicated he needed Built-Up Utensil 1 each, and Inner Lip Plate 1 each. These items were not present. When Resident #43 was asked if he did better with his built-up adaptive equipment, Resident #43 replied, yes, he did. During an interview on 2/01/23 at 8:45 AM, Certified Nurse Aide (CNA) H confirmed Resident #43 should have received adaptive utensils. The EMR for Resident #43 had a Care Plan with a focus of . at risk for alteration of nutritional status r/t (related to) multiple dx (diagnoses) including Epilepsy . Interventions for this focus included, Provide and serve diet as ordered . Built up utensils and lip plate at meals. During an interview on 2/01/23 at 8:55 AM, Dietary Aide (Staff) I stated, We have been under construction and in COVID outbreak . we have not been putting special equipment on trays. During an interview on 2/01/23 at 5:22 PM, DM A stated there was not a policy or guidelines for adaptive meal equipment. 40330 Resident #44 Review of the Minimum Data Set (MDS) assessment, dated 12/07/22, revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including kidney disease, septicemia (systemic infection), dementia, depression, anxiety disorder, muscle weakness, and palliative care (specialized care for people living with serious illness). Resident #44 needed one-person assistance for feeding. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 08/15, which showed Resident #15 had moderate cognitive impairment. During an observation on 01/31/23 at 11:08 a.m., Resident #44 was observed in their bed with wearing a hospital gown. Resident #44 was attempting to hold his Styrofoam (lightweight, unstable) coffee cup with a removeable plastic lid, however, demonstrated bradykinesia (impaired and slow movements) as he attempted to pick up the coffee cup on the tray table in front of him. Resident #44 was hunched forward due to cervical spine curvature and was struggling to lift their arm up to the height of the tray table. It appeared Resident #44 was going to spill the coffee on himself, as he reached unsteadily and the cup was shaking when he attempted to pick it up. Resident #44 was covered with one white hand towel, which the hot coffee could have easily permeated. Surveyor intervened and called CNA Q to assist; they provided Resident #44 with a straw, and began to leave the room. Surveyor intervened a second time to clarify the safety concern regarding Resident #44 drinking hot coffee from a Styrofoam coffee cup, without supervision and assistance as needed, or a waterproof protective barrier. CNA Q then assisted Resident #44. CNA Q reported residents on their hall were all solely using Styrofoam dinnerware due to COVID (transmissible viral infection) outbreak on Resident #44's hall. CNA Q reported prior to COVID outbreak in the facility, Resident #44 used a large brown lidded plastic coffee cup for drinking his coffee, a sippy cup (a cup with a lid and a spout, for safe drinking to prevent any spillage). Resident #44 agreed they needed assistance to drink their coffee during this observation, and understood the concern. During an interview on 01/31/23 at approximately 11:20 a.m., CNA R was asked if Resident #44 was typically able to feed himself. CNA R clarified Resident #44 could feed himself, mainly finger foods, and required set-up and assistance with feeding to begin the task, and some days needed additional assistance for self-feeding, due to weakness. When asked about Resident #44 drinking coffee from a Styrofoam cup, CNA R confirmed Resident #44 used a brown lidded spillproof plastic mug prior to the COVID outbreak on their hall. During a second observation on 02/01/23 at 8:58 a.m., Resident #44 was observed dressed and sitting up in their wheelchair. Resident #44 did not have a coffee initially and asked for an aide (unnamed) to bring them a hot coffee. The aide delivered the hot coffee and left the room. Resident #44 began drinking their hot coffee from a Styrofoam cup with lightweight plastic lid, without spillage, however, they were not wearing a waterproof protective barrier. An unnamed CNA was called to supervise/assist, per Resident #44's Care Plan requiring supervision and assistance as needed with drinking hot liquids. Surveyor shared the additional safety concern with the lack of a waterproof protective barrier when Resident #44 was observed drinking hot coffee. Review of Resident #44's Care Plan, accessed 02/02/23, revealed, [Resident #44] has deficit in performing ADL's (activities of daily living tasks) due to his physical condition [unspecified]. Date initiated: 09/10/2022 .Staff will set up and assist as needed for eating, oral care .Date initiated: 09/10/2022 .[Resident 44] has the potential/actual impairment to skin integrity related to burns from hot foods/hot liquids due to decreased safety awareness related to dx of dementia. Date initiated: 09/25/2022 .[Resident #44] is not able to have hot beverages or soups in his room with-out supervision. All hot beverages must have sip lid [spill proof lid with spout] .Revision on : 09/25/2022 . Review of Resident #44's Electronic Medical Record (EMR) on 02/02/23 at 10:42 a.m., including assessments and miscellaneous documents showed Resident #44 had no hot liquid assessment. During an interview on 02/01/23 at 11:14 a.m., the Director of Nursing (DON) was asked about Resident #44's safety during the observations of Resident #44 using Styrofoam (lightweight unstable) cups for drinking hot coffee without supervision or assistance. The DON reported they understood the concern and verified with the Nursing Home Administrator (NHA) (via phone during the interview) Resident #44 should have had a plastic lidded (spill prevention) cup for hot coffee. The DON called the dietary department during the interview, to address the concern for the next meal, to ensure Resident #44 received their coffee in the adaptive mug, and would update their Care Plan. Soon after, the DON showed Surveyor a laminated sign which showed Resident #44 should not drink hot coffee in a regular cup, and planned to update further with verbiage, and post as a visual reminder for Resident #44's nursing staff. During an interview on 02/02/23 at approximately 11:35 a.m., the Rehabilitation Director, Occupational Therapist (OT) O, was asked about Resident #44's ability to self-feed, and the concern with drinking hot coffee from a Styrofoam cup, including in bed (during first observation).OT O understood the concerns, and reported Resident #44 would have the most success and optimal positioning and safety with self-feeding positioned upright in their wheelchair. OT O clarified this was due in part to marked range of motion impairment of their right shoulder and cervical spine. OT O reported they would address self-feeding with Resident #44 by picking them up on their caseload. During an interview on 02/02/23 at 1:42 p.m., the NHA was asked about the concern regarding Resident #44 drinking hot coffee from Styrofoam cups. The NHA confirmed they understood the concern, and the facility had addressed during the survey. During an interview on 02/02/23 at approximately 2:00 p.m., the Administrative Assistant, Staff L, reported there was no policy addressing the provision of adaptive feeding equipment or regarding activities of daily living including self-feeding.

Based on interview and record review, the facility failed to ensure that a tube feeding dependent resident (R14) received nutrition and hydration to meet her estimated needs. This deficient practice resulted in an immediate jeopardy when: 1) R14's tube feeding was discontinued for 33 days, 21 days of which she received only a supplement (providing only 200 calories and 30 grams of protein) and the remaining 12 days she received no nutrition; 2) R14 continued to receive 1350 mL (mililiters) of free water flushes for the first 11 of the 33 days, but the remaining 22 days she received only 600 mL of free water; 3) R14 was restarted on a tube feeding regimen on [DATE] at 7:00 p.m., and at approximately 11:00 pm (4 hours later) she was found unresponsive and was sent to the emergency room (ER); 4) R14 was found with abnormal and critical labs and was found without a pulse on [DATE] at 10:35 a.m. Findings include: A review of R14's medical record revealed she admitted to the facility on [DATE] with diagnoses including cerebral palsy, epilepsy, profound intellectual difficulties, and GERD (gastro-esophageal reflux disease). A review of her [DATE] Minimum Data Set (MDS) assessment revealed she was assessed by staff to be severely cognitively impaired and received only tube feeding via a PEG (Percutaneous endoscopic gastrostomy - feeding tube) tube to meet her nutrition and hydration needs. A review of the [DATE] Significant Change MDS assessment revealed that the tube feeding was only providing 25% or less of her required calories. A review a progress notes for R14 from January to February 2022 revealed the following: [DATE] (Name of R14) is tube fed, NPO (nothing by mouth) . TF (tube feeding) is meeting her estimated needs. She is tolerating TF well - doing much better since back on prevacid (medication that reduces stomach acid) . [DATE] Resident skin is red surrounding peg opening with new small pale green flat beds . [DATE] notified (Family of R14) DPOA (durable power of attorney) of planned ER transfer for (Name of R14)/ increased abdominal pain, increased gastric acid and burning of skin . A review of the hospital discharge note dated [DATE] revealed, .Dressing changes (to PEG site) every ,d+[DATE] hours as needed to keep skin dry . Follow up with wound care regarding skin around G tube. With specialist . 5. The patient still has stomach contents leaking form around gastrostomy (PEG) tube under the skin . I did attempt to contact (name of Surgeon N) twice this past Friday and did not get any return calls . I did speak with (Name of Hospital Physician L) this morning concerning this patient. He is (sic) seen her and stated that replacing the G-tube with a larger tube was not a cure for the irritation around the area where the G tube enters. He stated that the only answer to that (concern) is to change the dressings and keep the area dry every hour to as needed. Also we have been using some zinc oxide (treatment) and that seems to help as well. There (sic) is starting to look slightly better . 8. Acid Reflux . Patient will continue on pantoprazole (medication to reduce stomach acid similar to prevacid) down the tube . 11. Peristomal dermatitis (skin condition/irritation around the PEG site) associated with moisture . We will continue treating the area around the gastrostomy tube until we can get a referral for someone to see her . A review of R14's [DATE] progress notes revealed the following: [DATE] .leakage around peg tube remains . continue to try different medications re (regarding) wound care to abdomen . [DATE] Peg tube site red and excoriated with some amount of dark brown discharge. Old drain sponge 100% + saturated . [DATE] .Residents peg tube site continues to improve. Gauze 50% saturated with clear drainage . [DATE] Per NP. hold tube feeding tonight only. [DATE] Tonight 10PM Start tube feeding at 50cc per hour for 4 hours then complete at 200cc and flush with water . [DATE] Resident awoke around 0130 (1:30 a.m.), went to perform flush and residents' gown, and sheet was completely saturated with yellowish fluid. Drain sponge was 100% saturated with yellowish fluid . [DATE] .did decrease tube feeding and weight is still increasing. Noted recent ileus (lack of movement in bowels/blockage) and tube feeding was restarted recently- recommendations to decrease volume of tube feed. Will decrease tube feeding to help prevent further weight gain- goal is for some weight loss at this time . Will increase water flushes to 225 ml with each flush and increase Prosource protein to BID (twice per day). This will provide 1341 kcals (calories), 82g protein, 2118 ml water . NP ordered labs for next week to closely monitor . A review of the NP/DON's provider note dated [DATE] revealed, . orders [DATE] for skin care . Pharm D recommendation for decrease in prevacid will attempt GDR (gradual dose reduction) . Skin: PEG tube site with saturated Aquacel one layer in place (nurse reports for just one hour) drainage mild not flowing, light green, tan no infectious concerns. PEG tube is pulled taut to securement. Peritubo (skin around PEG site) area with improvement noted. No bleeding . peristomal dermatitis improved . Plan note: Decrease prevacid . to every other day x 2 weeks then discontinue . Despite hospital recommendations and R14's history of doing well with the prevacid in place, the NP/DON reduced the prevacid twice per day order and fully discontinued it on [DATE]. A review of NP/DON's [DATE] provider note revealed in part, .reports no increase in drainage around PEG (which is vastly improved and skin is almost healed) . A review of R14's [DATE] notes revealed the following: [DATE] Elder is not tolerating tube feeding per NP, noted increase in amounts of drainage from tube site after feeding for last few days . Labs on [DATE] were mostly WNL (within normal limits), Ca (calcium) is now WNL, Na (sodium) and K+ (potassium) were WNL, lactic acid was 4.3 (normal is less than 2). Per np, will decrease tube feeding x (times) 3 days to allow GI (gastrointestinal) rest and then will work on increasing TF slowly back to her goal of previous order. NP recommended to go to 50 ml/hr x 4 hours for a total of 200 ml and will re-evaluate tolerance to TF on [DATE]. Will increase water flushes to 350 ml every 4 hours . Will closely monitor her tolerance to TF and adjust if needed. Goal is to return to full feeds slowly to prevent GI distress . [DATE] Resident is having increase drainage at peg tube site. Yellow-green in color. Every 2 hours gauze is 100% saturated along with towel and gown being saturated . [DATE] Resident's PEG tube dressing, gown, and sheet saturated with dark green drainage . writer gently cleansed and skin very red and irritated looking. Open area with 0.2 cm (centimeter) depth at the 11 o'clock position in relation to PEG tube . [DATE] Per NP continue tube feeding at 50 ml/hr x 4 hours for total of 200 ml. She continues to have some drainage but has improved per nsg (nursing) notes. Will re-evaluate per NP on [DATE] . [DATE] No new orders obtained today for tube feeding. Staff report good tolerance of water flushes, she is content and no s/s (signs or symptoms) of distress or dehydration. She is tolerating TF and continues to have some drainage but decreased from previous days. Will follow up tomorrow to see if tube feeding can be increased . [DATE] Spoke with MD (Physician G) on this date about tube feeding and patient's tolerance of tube feeding and bile drainage. Per MD, increase tube feeding today to 50 ml/hr x 14 hours and then if tolerated, continue to increase to goal . Lab orders obtained also to recheck electrolyte status and lactic acid. He did state possibility of switching to 2cal formula (dense tube feeding formula of 2 calories per mililiter) for less volume to help her tolerate better, did ask about possibility to change to specialty formula for GI related issues and he did state that was ok also. Will see how pt tolerates current tube feeding and re-evaluate need for 2cal or speciality (sic) formula. Adjusted water flushes also due to increase in tube feeding. Will re-evaluate after tube feeding tomorrow morning and lab results . [DATE] Resident has had a lot of drainage-greenish/yellowish today . Did review of medications and prevacid was decreased in February to 30 mg once daily and again in March to 30mg every other day and to d/c on [DATE]. In past when she had decreases in prevacid she also had a lot of green drainage. Will check into med changes as this may be a factor in her tolerance of tube feeding . Labs today . Na 126L (low), K 3.6, BUN (blood urea nitrogen) 41H, Gluc (glucose)113H, Creat (creatinine) 0.7 . Ca 7.9L, lactic acid 2.8H . [DATE] Resident didn't tolerate last flush/med administration very well . Gauze, sheet, and cloth was 100% saturated with yellow/green discharge. Stat lock was replaced due to stomach being so distended. [DATE] .Prevacid daily was added today . will increase TF to 60 ml/hr x 12 hours. Adjusted water flushes to 250ml every 4 hours due to increase in TF and lower Na level on last lab draw . obtain 2cal formula for Resident so volume amount will be less to help with tolerance of tube feeding. Anticipate less drainage with the addition of prevacid daily . [DATE] Resident not tolerating tube feeding increase well . continues with drainage- greenish from tube site. She did tolerate the 50ml/hr x 14 hours better, will decrease TF back to 50ml/hr x 14 hours and see if she is able to tolerate better. Continues with low residuals. Will increase water flushes to 275 ml . [DATE] Per nsg (nursing) Elder is tolerating TF, continues with drainage but much less than last week. Skin is also improving, resident is less agitated than last week also . [DATE] Resident switched over to 2cal formula . Water flushes at 275 ml six times a day. TF is meeting needs and is less overall volume to help her tolerate TF better. She is having less drainage and less agitation, she is tolerating TF much better since prevacid was added daily . Will recommend labs in the next few weeks to monitor electrolytes and lactic acid . [DATE] Writer spoke via phone to (Name of RD A) this AM re (regarding) 7p Nurse report resident was gagging last night, resident had started new Formula and writer wanted to rule out this as possible problem, informed Dietitian resident has been calm today sleeping off/on . Dietitian did not feel the gagging was related to the new formula . [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] notes written by Licensed Practical Nurse (LPN) C noted that R14 was gagging. [DATE] Spoke with midnight RN (Registered Nurse) this morning, she reported no gagging with tube feeding, tolerated tube feeding well . [DATE] Resident slept through 0200 (2:00 a.m.) water flush, at that time PEG tube dressing and towel covering dressing 100% saturated with clear drainage. [DATE] .Per nsg (nursing), less drainage also, skin is improving with less redness/excoriation. No changes at this time, will continue to monitor . [DATE] .Residents peg tube site - every flush/med administration from 7p - 7a:100% saturated gauze 100% saturated towel 25% saturated gown The saturated fluid is tan in color and appears to be the feed formula . I had to change resident's shirt/top every flush/med administration. Resident currently has only one top left that is clean . [DATE] .will hold feeding tonight and give frequent water and flushes with medications. NP will f/u with RD and plan face to face visit [DATE] . A review of R14's MAR (Medication Administration Record) for [DATE], her tube feeding orders were changed 9 times, and her water flushes were changed six times. The orders for flushes ranged from 250 mL to 350 mL's every 4 hours (six times per day), ranging from 1500 mL to 2100 mL of water per day, in addition to the free water provided by the tube feeding. Due to the numerous changes in the tube feeding and lack of staff documenting on the MAR, it is unclear how many mL of water and how many total mL of total fluid was given to R14 each day. Per the documentation, the flushes were given as boluses (all at once) and the tube feeding pump system was not used to slowly administer the water throughout the day, which would have allowed for less volume of fluid in the stomach at a time. A review of R14's progress notes for [DATE] revealed the following in part: [DATE] .Formula was shooting out like a faucet from peg tube site (hole) for about 2 minutes straight .(written by LPN C) [DATE] NP/DON provider note . nursing notes reviewed related to ongoing gagging with tube feedings and intolerance with drainage to skin Exam: General appearance: no acute distress, well nourished, well hydrated, well developed, interactive during exam, poor historian, obese . Plan: Interim orders written and provided: IVT (intravenous fluids) D5NS.9% (fluid with sodium and glucose) to run at 100cc/hr ongoing. Lab: [DATE] CBC (complete blood count), BMP (basic metabolic panel), Dx (diagnosis) hyponatremia, elevated BUN. Collaboration with RD (RD A) who wishes to keep tube feeding at current caloric intake and volume, will monitor . A review of Lab work for R14 dated [DATE] revealed the following: Sodium 126 L, Potassium 2.9 low, BUN 102 critical high, glucose 212 high. [DATE] .Lab notified writer this AM (morning) of critical BUN 117, writer notified NP. [DATE] NP call to DPOA re labs received with sodium low and BUN high will start bag of IV fluids today at facility and recheck labs on ,d+[DATE] in the AM. [DATE] 22G IV catheter inserted in Right Hand. Running D5NS 0.9% at 100cc/hr ongoing. [DATE] Labs returned, some labs not WNL, sodium was low and BUN high- NP ordered IV fluids, 5% dextrose NS, 100ml/hr with repeat labs in AM. Tube feeding not adjusted at this time as she is at the very low end of estimated needs factoring in for weight loss. Will decrease water flushes to 225 ml due to IV fluids and will re-evaluate after labs in AM. Per nsg skin is healing well and she tolerated water flushes today . [DATE] IV fluids 950ml infused . Lungs are clear, no infiltration, no s/s of CHF. Resident tolerating . [DATE] NP phoned (name of FM F) . discussed failed IV fluid resuscitation (sic) and non absorption with gagging and skin damage from tube feedings at lowest volume and dosing. Comfort Care started. No IVF, No ER visits, No blood or radiolgy (sic) tests. No tube feedings, continue to flush tube at this time per NP orders. [DATE] .Orders from (Name of NP/DON) to D/C (discontinue) tube feeding and IV fluids. PEG tube flushes and medications to continue. Patient does not appear to be in any pain at this time. No discomfort noted . [DATE] . After medication administration large amount of drainage that appeared watery and orange noted from PEG tube site. Smelled like protein supplement . [DATE] 0200 (2:00 a.m.) flush gauze was dry. Once I flushed peg tube, most of the water came back out of the peg tube site and saturated gauze 100%. Cleansed, dried, applied . [DATE] CNA alerted nurse around 0100 (1:00 a.m.) that resident was crying. When approaching the room I could hear her yelling with a cry like voice . Repositioned resident and administered Tylenol as ordered [DATE] .Will d/c weekly weights as she is comfort cares. [DATE] .Tongue was very cracked, dry and white. I swabbed residents mouth with wet swab and resident was sucking on the swab, enjoyed having mouth cleansed . [DATE] .Resident was saying what sounded like I want breakfast. Then asked resident are you hungry (name of R14)? Resident responded I am hungry 2x (two times). I swabbed her mouth to moisturize it and resident was sucking it and seemed to enjoy it. Cleansed mouth, tongue doesn't appear to be so dry and white in color at this time. [DATE] New orders received from NP to (name of LPN C) last night. A review of the [DATE] order revealed it was restarting the Prosource supplement twice per day, that had been discontinued on [DATE]. A review of the [DATE] MAR revealed that two shifts of documentation were missing for the IV fluid administration. A comparison of the order, the MAR, and the progress notes was completed and a total amount of fluids dispensed could not be calculated due to lack of documentation. A review of the [DATE] Nutrition Risk Assessment completed by RD A calculated R14's fluid needs 2550 mL per day. R14's calculated caloric needs were between ,d+[DATE] calories per day. A review of the [DATE] MAR revealed that R14 was receiving fluids far above her daily requirements. On [DATE], R14 was received per the MAR documentation 3815 mL of fluid (455 mL free water from tube feeding, 140 ml post tube feeding flush, 480 mL flush/potassium medication mix, 180 mL with prosource and flush, 1350 mL from the normal flush orders (225 mL every 4 hrs), and 1200 mL from the normal saline (marked as only running for 12 hours). This much fluid was provided despite R14 having low sodium and low potassium. [DATE] Writer notified NP of residents symptoms. Resident unable to be aroused. Seems to be declining but comfortable . [DATE] Writer notified NP re resident starting to mottle at hands and feet, skin cool to touch, awake and making soft noises .T93.5 (temperature 93.5 degrees Fahrenheit - very low body temperature) . [DATE] .Patient cold to touch on BLE (bilateral lower extremities - legs), BUE (bilateral upper extremities - arms), and forehead. [NAME] stokes respirations noted, brief periods of apnea. Does not appear to be in any pain, no guarding or grimacing noted . [DATE] This writer called and spoke with the resident's guardian to see if he has updated guardianship paperwork as it expired at the end of 2021. The guardian stated he was under the impression that the facility would have the guardianship transferred from (previous county of residence) . This writer informed him that the facility would not initiate and that it would be up to him to do so. Also, this writer informed the guardian that due to the fact that the resident's guardianship is for a mentally incapacitated individual it needs to be amended to allow him to make end-of-life decisions. That at this point the resident would be considered a full code until revised and updated guardianship papers were received. Also, informed the guardian that per the medical director they were going to slowly reintroduced tube feedings to see if the resident would tolerate them. The Resident's guardian voiced his understanding. [DATE] Spoke with (Name of Physician G) regarding tube feeding restart. Verbal order given to restart 2 cal HN (tube feeding) at 20ml per hour x 24 hours (continuous) and see how she tolerates tube feeding and will work on slowly increasing to meet her needs as tolerated. She is currently receiving 100ml water flushes six times daily and continues on prosource BID. Discussed bile drainage previously and MD stated he would increase prevacid to BID. No recent weights as they were d/c'd per comfort cares previously. Will request new weight as able. Tube feeding will provide a total of 960 kcals, 480 ml total, 40 g protein (with prosource will provide additional 30 g protein and 120 kcals) and 336 ml free water. At this time will keep water flushes as ordered temporarily to see how she tolerates tube feeding this evening . [DATE] As night nurse was leaving this AM he reported that just in past hour (R14) seemed to be having discomfort. The day LPN and myself went into assess (R14). She is in bed with HOB (head of bed) elevated, tube feeding running and grimacing (sic). she moans out when I press stethocope (sic) to right upper quadrant which is slightly distended. she is fidgeting with her hands and continues to grimace with forehead frowns. there is no saturation of PEG tube dressing or noted drainage on skin from PEG site. tymmpanny (sic) sounds with bowel percussion increased from a few hours ago . [DATE] . tube feedings restarted and it appears she may not tolerate them as she is showing abdominal distention, discomfort . labs were requested in early May which showed electrolyte imbalances and IV fluids and medication changes were done, (R14) began to third space (fluids going into other body cavities inappropriately) those fluids and was pulling out IVS, discussions with family were held and IV fluids stopped and when she wasn't tolerating tube feedings with multiple adjustments family had asked for her to be comfort care without tube feedings, NG (nasogastric) feedings were declined related to them reporting her past history of not allowing anything on her face and pulling tubes. in March local surgeon had met with (FM F) and decision had been made to do no surgical type procedures. water flushes for hyddration (sic) and protein supplements along with medications have continued until yesterday . (written by NP/DON). [DATE] Resident crying out/moaning. Held resident's hand and spoke softly offering reassurance. Resident has furrowed brow, opened eyes briefly, and eventually stopped moaning. [DATE] Resident presenting tracheal rattle, tachypnea (rapid breathing), low BP (blood pressure), low O2 sat (oxygen saturation), flaccid and unresponsive. Called for additional floor nurse to witness my assessment. While assessing resident, resident's VS (vital signs) worsened. Call to NP for status update. [DATE] Verbal order received from (Name of NP/DON), to send resident via ambulance to (name of hospital) for treatment and evaluation related to low BP, tachypnea, and abdominal distress. Administrator, (Name of Administrator) notified that order was received. Attempted notification to DPOA, DPOA is unavailable by phone this evening. Resident left facility via ambulance at 12:02 AM. [DATE] Received phone call from (name of hospital) to verify resident's code status. Informed ER nurse that resident is FULL CODE. Nurse requested advanced directive paperwork, informed nurse I do not have the updated paperwork at this time . [DATE] Received phone call from (Name of ER Physician H) regarding resident's newly reinstated tube feeding. Explained to Dr that (R14's) tube feeding was reinstated by (Name of Physician G) due to the guardianship expiring end of year 2021. Shared with (Physician H) the scenario as recorded by (Name of Administrator) . [DATE] This writer received a phone call from local ER physician (Physician H) in regard to Resident's current medical condition. (Physician H) needed clarification on the status of the guardianship papers that were provided by (name of FM F). This writer explained that (FM F) essentially provided a copy of the same guardianship paperwork that the facility already had on file. (FM F) was told by this writer as well as by the Assistant Administrator (Staff M) that the guardianship still needed to be amended by the courts to give him expressed authority to make end-of-life decisions for the resident. The resident's guardianship was for a medically incapacitated individual. Since the resident has been incapacitated since birth the guardianship is handled differently per legal counsel than a normal guardianship . In the physician's (Physician Hs) opinion, he felt like the resident's current medical condition would not allow her to tolerate tube feedings. Due to her critical labs, he felt the resident was nearing the end of life and should be a DNR however, understood the issues with the current status of the guardianship papers. It was decided that the resident would be kept under observation at the hospital on comfort measures until Monday at which time perhaps the court could be approached to modify or amend the current guardianship status. On [DATE] at 12:21 p.m., an interview was conducted with RD A. When asked why the tube feeding was discontinued in [DATE], RD A reported it was due to R14 not tolerating the tube feeding and that there were some ultrasounds that showed issues with her internal organs. RD A was asked to provide the ultrasounds that she was referring to. RD A was asked to clarify what she meant when she said the resident wasn't tolerating the tube feedings. RD A stated, More of the bile discharge, also abdominal distention . Kinda wasn't tolerating the whole process. When asked about which types of specialty formulas were tried, RD A reported the facility had tried Jevity 1.5 and 2CalHN. RD A reported she had made recommendations to try a fiber formula, but it was never put in place. When asked about the prevacid being discontinued, RD A confirmed that it had been decreased and that the NP/DON was very involved with the medication changes. RD A reported that the gastroenterologist suggested for R14 to slow down the feedings to a slower rate but even with a different formula at a lower rate the formula wasn't being .digested . When asked to clarify if the formula wasn't being digested, or if it was coming through the opening around the PEG tube due to the excoriation, RD A reported it was coming from around the PEG tube site. When asked if there was an interdisciplinary team discussion about sending R14 out in [DATE] to be evaluated, RD A stated, the NP (Name of NP/DON) was doing a lot of it . She had communicated with the hospital about the findings (from [DATE]) . RD A was asked if she had recommended the decrease in water flushes during the time the tube feeding was stopped from 1300 to 600 mL, but RD A reported the recommendation and order came from the NP/DON. When asked about R14 being NPO and not getting the Prosource from [DATE] through [DATE] RD A reported the Prosource was only discontinued for a day because the NP/DON wanted to keep her on that. RD A was then asked if she had any concerns about the restarting of R14's tube feeding, and stated, Yes, I was concerned how she was going to tolerate it. For being off (of it for) that amount of time . He (Physician G) started it off very slow, at a slow rate and small amount . RD A was asked what was in place to monitor R14 for refeeding syndrome (acute, life threatening condition that can occur when patients who have not been receiving adequate or any nutrition and are restarted on feeding too rapidly and causes electrolyte shifts). RD A stated, Yes . we were watching her very closely to see if she was tolerating it . RD A reported she was unaware if any labs were drawn before or after starting R14's tube feeding. When asked if there had been an IDT discussion about sending R14 to the hospital instead of the facility restarting the tube feeding there, RD A reported there was no discussion that she was aware of. RD A was asked if R14 had ever shown signs of hunger or thirst and stated, Not that I'm aware of. When asked what comfort was being provided for R14 who's tube feeding was discontinued for comfort care, RD A stated, Making sure they are free from any signs of hunger or thirst. Keeping her hydrated per the orders . RD A was then asked what she would have recommended if R14 had reported or shown signs of hunger/thirst and stated, I would talk to the medical staff and voice concerns about that. On [DATE] at 1:13 p.m., a phone interview was conducted with Family Member F. When asked who he had discussions with about R14's tube feeding, FM F reported it was mostly with the NP/DON. When asked why the tube feeding was stopped, FM F stated, They (the facility) stopped it because it was leaking around the tube. From previous years they figured it was scar tissue (around the peg tube site) and wasn't healing around the tube. When asked if he had discussed the transition to comfort care for R14 with the Physician G, RD A, or the IDT team, FM F stated, It was mostly the nurse practitioner. FM F confirmed that he had not been able to get updated guardianship paperwork for R14 prior to her expiring. On [DATE] at 2:01 p.m., an interview was conducted with the NP/DON. The NP/DON was first asked about why R14's tube feeding was stopped in [DATE] and reported that the facility had sent her out one time and the hospital got ahold of the surgeon who had placed the tube originally to see about replacing the Peg tube and got imaging done. The NP/DON reported that R14 was . not someone you could send out easily. This was her home. (She was) childlike . When asked about the hospital's recommendations in [DATE], the NP/DON reported that they were trying different things and . we were trying to heal the skin . When asked about why the tube feeding was discontinued in [DATE], the NP/DON reported she had discussed with FM F a list of the benefits or the risks. NP/DON was asked about the note she had written when the tube feeding was discontinued and about R14's . failed IV resuscitation . The NP/DON stated, You fail it (IV resuscitqation) when it makes the electrolytes go worse . you get third spacing. We didn't send her out because some people tolerate going out and some people don't . we had to change the fluids I believe because it was difficult . When asked why the IV was started in the first place, the NP/DON stated, When you are chasing critical labs, there are pathways (you follow). Have we found everything? What more? The findings are driving the care. Once something is sclerosed, there's nothing you cand do. The NP/DON was asked to provide documentation of the imaging and sclerosis of the PEG site. When asked if there was discussion of sending R14 to the hospital for evaluation in [DATE] after continued issues with the PEG, the NP/DON stated, No, because of the decisions of the findings . He (hospital Physician) was not going to do a new tube. He was reaching out to see who might. When asked if the hospital orders for the wound care and a wound care referral were completed, the NP/DON reported that she was wound certified and that she . had no reason to double it wasn't happening . The NP/DON was asked about the RN and LPN competencies for tube feeding, and specifically that LPN C did not have tube feeding reviewed on hire. The NP/DON stated, We have to hands on teach . I would have just done it (observation) the one time . I know (name of LPN C) had the training cause I did it. The NP/DON was asked about LPN C consistently documenting that R14 was gagging during her shifts and stated, There was a concern on what gagging and coughing was. She was the night nurse, that's when we hung this tube feeding. Yes she would have seen it more than others. When asked if R14 was aspirating and if the coughing was related to the tube feeding, the NP/DON stated, No. We didn't have any further coughing. No tearing (of the eyes) . When asked about why she went to FM F to discuss the tube feeding being discontinued, the NP/DON stated, I always go by what's on the top of the facesheet . The NP/DON continued on to say that the social worker is the one who sets up the facesheet contact info. When asked if Physician G was involved in the discussion to discontinue the tube feeding, the NP/DON stated, He did not talk to them (family) himself. The NP/DON was asked what the reason for the prosource being discontinued and then restarted after being off for 12 days, the NP/DON reported they felt they needed to give her nutrient-wise what she could tolerate without it . coming back up . When asked if she was aware of R14 showing signs of hunger or stating she was hungry, the NP/DON reported she had not heard that before, but if she had, she would have said, . I gotta send you out because we gotta try a whole new ball game because there wasn't something more we could do . When asked for the reason the tube feeding was

Based on interview and record review, the facility failed to ensure that code status and advanced directives were developed with the appropriate Resident Advocate and were reviewed periodically for appropriateness for one Resident (#14) out of five reviewed for advanced directives. This deficient practice resulted in no documentation of life-sustaining treatment wishes and an expired guardian making life-sustaining treatment decisions. Findings include: A review of R14's medical record revealed she admitted to the facility on [DATE] with diagnoses including cerebral palsy, epilepsy, profound intellectual difficulties, and GERD (gastro-esophageal reflux disease). A review of her [DATE] Minimum Data Set (MDS) assessment revealed she was assessed by staff to be severely cognitively impaired and received only tube feeding via a PEG tube to meet her nutrition and hydration needs. A review of the [DATE] Significant Change MDS assessment revealed that the tube feeding was only providing 25% or less of her required calories. A review of R14's medical record revealed a Do-Not-Resuscitate Decision form signed by Family Member (FM) F dated ,d+[DATE]. A review of the only Guardianship papers in R14's chart noted FM F as the primary guardian, but the letters of Guardianship expired on [DATE]. No new guardianship documentation was in R14's closed hard chart or electronic medical record. A review of a progress note dated [DATE] revealed, This writer called and spoke with the resident's guardian to see if he has updated guardianship paperwork as it expired at the end of 2021. The guardian stated he was under the impression that the facility would have the guardianship transferred from (Name of previous county) county to (Name of current county of residence) county. This writer informed him that the facility would not initiate and that it would be up to him to do so. Also, this writer informed the guardian that due to the fact that the resident's guardianship is for a mentally incapacitated individual it needs to be amended to allow him to make end-of-life decisions. That at this point the resident would be considered a full code until revised and updated guardianship papers were received. Also, informed the guardian that per the medical director they were going to slowly reintroduced tube feedings to see if the resident would tolerate them. The Resident's guardian voiced his understanding. A review of a progress note dated [DATE] revealed, Received phone call from (emergency room ) to verify resident's code status. Informed ER nurse that resident is FULL CODE. Nurse requested advanced directive paperwork, informed nurse I do not have the updated paperwork at this time. Nurse replied she might just call (name of R14's attending physician) myself. Apologized for any inconvenience. A review of another [DATE] progress note revealed, This writer received a phone call from local ER physician (Physician H) in regard to Resident's current medical condition. (Physician H) needed clarification on the status of the guardianship papers that were provided by the resident's nephew (Family Member (FM) F). This writer explained that (FM F) essentially provided a copy of the same guardianship paperwork that the facility already had on file. (FM F) was told by this writer as well as by the Assistant Administrator (Staff M) that the guardianship still needed to be amended by the courts to give him expressed authority to make end-of-life decisions for the resident. The resident's guardianship was for a medically incapacitated individual. Since the resident has been incapacitated since birth the guardianship is handled differently per legal counsel than a normal guardianship. This writer and the physician then discussed the best course of care for this resident. In the physician's opinion, he felt like the resident's current medical condition would not allow her to tolerate tube feedings. Due to her critical labs, he felt the resident was nearing the end of life and should be a DNR however, understood the issues with the current status of the guardianship papers . On [DATE] at 12:53 p.m., an interview was conducted with Social Work Assistant/Staff E. When asked about where R14's treatment decisions about hospitalization , IV hydration, or other life-saving treatments, Staff E stated, I don't think we have that. When asked to confirm then that the facilities' Advanced Directives were limited to just full code resuscitation or no-code Do-Not-Resuscitate, Staff E stated, That's all we do. When asked if she had the updated Guardianship paperwork for R14, Staff E reported she believed that it was in process of getting updated when R14 passed away. Staff E confirmed she did not have any updated guardianship paperwork for R14. When asked how often code status and guardianship/responsible party paperwork was reviewed and updated, Staff E stated, It gets reviewed every quarter if they come to the care conferences. Otherwise its during the annual review. When asked if she was a part of the discussion about R14's life-sustaining treatments being discontinued, Staff E reported she was not. Staff E could not say why FM F's guardianship papers expiring was missed. A review of R14's record revealed a [DATE] care conference assessment, but there was no documentation of care conferences after the [DATE] conference through her transfer out of the building on [DATE]. A review of the [DATE] Interdisciplinary Care Conference Documentation revealed social services, activities, and the Authorized Representative attended, the review of the code status was left blank. On ,d+[DATE] at 12:42 p.m., a phone interview was conducted with Staff E. When asked about R14 not having any care conferences between January and her death in [DATE], Staff E acknowledged that care conferences had .fallen through the cracks . and that some IDT notes may not have been documented. On [DATE] at 11:41 p.m., the facility provided a policy titled, Policy and Procedure for Notifying Residents of their Rights Regarding Advance Directives and for Implementing Advance Directives which was undated. This document revealed, It is the policy of the (name of facility) to provide a consistent and orderly method of notifying residents of their rights under Michigan law to make decisions concerning their medical care, including the right to accept or refuse medical treatment, and to formulate advance directives .1. The (name of facility) share inquire of each resident at the time of admission and periodically thereafter, whether or not the resident has executed an advance directive . 5. Before following the instructions of the Resident Advocate, staff shall determine whether the instructions are within the authority granted by the Resident Advocate document . On [DATE] at 11:41 a.m., an email from the Assistant Administrator/Staff M revealed, . We do not have a job description for (Name of Social Services Assistant/Staff E) . On [DATE] at 1:33 p.m. an email was sent by Staff M in response to a query of who was doing which social services, if there was no job description for Staff E. Staff E replied, .she helps assist with setting up appointments, discharges, get to know you at admission, does the BIMS and PHQ9 (depression assessment), and other parts of the policies that state designee, (Name of Staff E) takes care of that stuff as well . Also, related to the social services policies . We do not have a policy that specifically states Social Services Policy . The facility failed to recognize the expired document and allowed withdrawel of tubefeeding leading to the death of R14. A review of the facility policy titled, Policy and Procedure for Notifying Residents of their rights Regarding Advanced Directives and for implementing Advanced Directives (undated) revealed, .1. The (Name of facility) share inquire of each resident, at the time of admission and periodically thereafter, whether or not the resident has executed an advance directive. The (name of Facility) shall document in the resident's medical record whether or not the resident has executed an advance directive. 2. Each resident shall be provided the opportunity to participate in the planning and acceptance of his/her own plan of care to the extent he/she is capable of being involved . 5. Before following the instructions of the Resident Advocate, staff shall determine whether the instructions are within the authority granted by the resident advocate designation document . 7. Staff shall not be bound by the decision of a Resident Advocated under the following circumstances: .b. Where the Resident Advocated has instructed staff to withhold or withdraw treatment which would allow the resident to die, and staff has actual knowledge that the resident has not authorized the Resident Advocate to make such a decision .

Based on interview and record review, the facility failed to ensure that quality of care for one Resident (#14) regarding tube feeding, medications, Intravenous hydration, labwork, monitoring and assessment. This deficient practice resulted in R14's lab results not being reviewed or addressed timely, lack of accurate documentation of medications, tube feeding, and IV Fluid administration, and lack of appropriate nutrition and hydration orders to prevent malnutrition, dehydration, and death. Findings include: A review of R14's medical record revealed she admitted to the facility on [DATE] with diagnoses including cerebral palsy, epilepsy, profound intellectual difficulties, and GERD (gastro-esophageal reflux disease). A review of her [DATE] Minimum Data Set (MDS) assessment revealed she was assessed by staff to be severely cognitively impaired and received only tube feeding via a PEG tube to meet her nutrition and hydration needs. A review of the [DATE] Significant Change MDS assessment revealed that the tube feeding was only providing 25% or less of her required calories. A review a progress notes for R14 from January to February 2022 revealed the following: [DATE] (Name of R14) is tube fed, NPO (nothing by mouth) . TF is meeting her estimated needs. She is tolerating TF well - doing much better since back on prevacid . [DATE] Resident skin is red surrounding peg opening with new small pale green flat beds . A review of the hospital discharge note dated [DATE] revealed, .Dressing changes (to PEG site) every ,d+[DATE] hours as needed to keep skin dry . Follow up with wound care regarding skin around G tube. With specialist . 5. The patient still has stomach contents leaking form around gastrostomy tube under the skin . I did attempt to contact (name of Surgeon N) twice this past Friday and did not get any return calls . I did speak with (Name of Hospital Physician L) this morning concerning this patient. He is (sic) seen her and stated that replacing the G-tube with a larger tube was not a cure for the irritation around the area where the G tube enters. He stated that the only answer to that (concern) is to change the dressings and keep the area dry every hour to as needed. Also we have been using some zinc oxide and that seems to help as well. There (sic) is starting to look slightly better . 8. Acid Reflux . Patient will continue on pantoprazole (medication to reduce stomach acid) down the tube . 11. Peristomal dermatitis associated with moisture . We will continue treating the area around the gastrostomy tube until we can get a referral for someone to see her . A review of R14's [DATE] progress notes revealed the following: [DATE] .leakage around peg tube remains . continue to try different medications re (regarding) wound care to abdomen . [DATE] Peg tube site red and excoriated with some amount of dark brown discharge. Old drain sponge 100% + saturated. Area cleansed, dried, stoma powder and zinc paste applied with new drain sponge . [DATE] .: Residents peg tube site continues to improve. Gauze 50% saturated with clear drainage . [DATE] .did decrease tube feeding and weight is still increasing. Noted recent ileus and tube feeding was restarted recently- recommendations to decrease volume of tube feed. Will decrease tube feeding to help prevent further weight gain- goal is for some weight loss at this time . Will increase water flushes to 225 ml with each flush and increase Prosource protein to BID. This will provide 1341 kcals, 82g protein, 2118 ml water . NP ordered labs for next week to closely monitor. Will keep on weekly weights to monitor her closely . A review of NP/DON's provider note dated [DATE] revealed, . orders [DATE] for skin care . Pharm D recommendation for decrease in prevacid will attempt GDR (gradual dose reduction) . peristomal dermatitis improved .Decrease prevacid solutab 30mg to every other day x 2 weeks then discontinue . Despite hospital recommendations and R14's history of doing well with the prevacid in place, the NP/DON reduced the prevacid twice per day order and fully discontinued it on [DATE]. A review of NP/DON's [DATE] provider note revealed in part, .reports no increase in drainage around PEG (which is vastly improved and skin is almost healed) . A review of R14's [DATE] notes revealed the following: [DATE] Elder is not tolerating tube feeding per NP, noted increase in amounts of drainage from tube site after feeding for last few days . Labs on [DATE] were mostly WNL, Ca is now WNL, Na and K+ were WNL, lactic acid was 4.3H. Per np, will decrease tube feeding x 3 days to allow GI rest and then will work on increasing TF slowly back to her goal of previous order . [DATE] Resident is having increase drainage at peg tube site. Yellow-green in color. Every 2 hours gauze is 100% saturated along with towel and gown being saturated . [DATE] Resident's PEG tube dressing, gown, and sheet saturated with dark green drainage . writer gently cleansed and skin very red and irritated looking. Open area with 0.2cm depth at the 11 o'clock position in relation to PEG tube, tube is secured away from this open area at this time . [DATE] Per NP continue tube feeding at 50 ml/hr x 4 hours for total of 200 ml. She continues to have some drainage but has improved per nsg (nursing) notes. Will re-evaluate per NP on [DATE] . [DATE] . Lab orders obtained also to recheck electrolyte status and lactic acid . [DATE] Resident has had a lot of drainage-greenish/yellowish today . Did review of medications and prevacid was decreased in February to 30 mg once daily and again in March to 30mg every other day and to d/c on [DATE]. In past when she had decreases in prevacid she also had a lot of green drainage. Will check into med changes as this may be a factor in her tolerance of tube feeding . Labs today HGB 12.9, HCT 38.2, Na 126L, K 3.6, BUN 41H, Gluc 113H, Creat 0.7, GFR >60, Ca 7.9L, lactic acid 2.8H . [DATE] Resident didn't tolerate last flush/med administration very well . Gauze, sheet, and cloth was 100% saturated with yellow/green discharge. Stat lock was replaced due to stomach being so distended. [DATE] .Prevacid daily was added today . will increase TF to 60 ml/hr x 12 hours. Adjusted water flushes to 250ml every 4 hours due to increase in TF and lower Na level on last lab draw . obtain 2cal formula for Resident so volume amount will be less to help with tolerance of tube feeding. Anticipate less drainage with the addition of prevacid daily . [DATE] Per nsg (nursing) Elder is tolerating TF, continues with drainage but much less than last week. Skin is also improving, resident is less agitated than last week also . [DATE] Resident switched over to 2cal formula . Water flushes at 275 ml six times a day. TF is meeting needs and is less overall volume to help her tolerate TF better. She is having less drainage and less agitation, she is tolerating TF much better since prevacid was added daily . Will recommend labs in the next few weeks to monitor electrolytes and lactic acid . [DATE] .Per nsg (nursing), less drainage also, skin is improving with less redness/excoriation. No changes at this time, will continue to monitor . [DATE] .will hold feeding tonight and give frequent water and flushes with medications. NP will f/u with RD and plan face to face visit [DATE] . A review of R14's MAR for [DATE], her tube feeding orders were changed 9 times, and her water flushes were changed six times. The orders for flushes ranged from 250 mL to 350 mL's every 4 hours (six times per day), ranging from 1500 mL to 2100 mL of water per day, in addition to the free water provided by the tube feeding. Due to the numerous changes in the tube feeding and lack of staff documenting on the MAR, it is unclear how many mL of water and how many total mL of total fluid was given to R14 each day. Per the documentation, the flushes were given as boluses (all at once) and the tube feeding pump system was not used to slowly administer the water throughout the day, which would have allowed for less volume of fluid in the stomach at a time. A review of R14's progress notes for [DATE] revealed the following in part: [DATE] .Formula was shooting out like a faucet from peg tube site (hole) for about 2 minutes straight .(LPN C) [DATE] NP/DON provider note . nursing notes reviewed related to ongoing gagging with tube feedings and intolerance with drainage to skin Exam: General appearance: no acute distress, well nourished, well hydrated, well developed, interactive during exam, poor historian, obese . Plan: Interim orders written and provided: IVT (intravenous fluids) D5NS.9% to run at 100cc/hr ongoing. Lab: [DATE] CBC, BMP, Dx hyponatremia, elevated BUN. Collaboration with RD (RD A) who wishes to keep tube feeding at current caloric intake and volume, will monitor . A review of Lab work for R14 dated [DATE] revealed the following: Sodium 126 low, Potassium 2.9 low, BUN 102 critical high, glucose 212 high. [DATE] .Lab notified writer this AM (morning) of critical BUN 117, writer notified NP. [DATE] . labs received with sodium low and BUN high will start bag of IV fluids today at facility and recheck labs on ,d+[DATE] in the AM. [DATE] 22G IV catheter inserted in Right Hand. Running D5 (dextrose) NS (normal saline) 0.9% at 100cc/hr ongoing. [DATE] Labs returned, some labs not WNL, sodium was low and BUN high- NP ordered IV fluids, 5% dextrose NS, 100ml/hr with repeat labs in AM . Will decrease water flushes to 225 ml due to IV fluids and will re-evaluate after labs in AM. Per nsg skin is healing well and she tolerated water flushes today . [DATE] IV fluids 950ml infused . Lungs are clear, no infiltration, no s/s of CHF. Resident tolerating . [DATE] NP phoned (name of FM F) . discussed failed IV fluid resuscitation (sic) and non absorption with gagging and skin damage from tube feedings at lowest volume and dosing. Comfort Care started. No IVF, No ER visits, No blood or radiolgy (sic) tests. No tube feedings, continue to flush tube at this time per NP orders. There was no indication that FM F was offered to have R14 sent to the hospital for further evaluation before nutrition was withheld. [DATE] .Orders from (Name of NP/DON) to D/C (discontinue) tube feeding and IV fluids. PEG tube flushes and medications to continue. Patient does not appear to be in any pain at this time. No discomfort noted . [DATE] .Tongue was very cracked, dry and white. I swabbed residents mouth with wet swab and resident was sucking on the swab, enjoyed having mouth cleansed . [DATE] .Resident was saying what sounded like I want breakfast. Then asked resident are you hungry (name of R14)? Resident responded I am hungry 2x (two times). I swabbed her mouth to moisturize it and resident was sucking it and seemed to enjoy it. Cleansed mouth, tongue doesn't appear to be so dry and white in color at this time. [DATE] New orders received from NP to (name of LPN C) last night. A review of the [DATE] order revealed it was restarting the Prosource supplement twice per day, that had been discontinued on [DATE]. A review of the [DATE] MAR revealed that two shifts of documentation were missing for the IV fluid administration. A comparison of the order, the MAR, and the progress notes was completed and a total amount of fluids dispensed could not be calculated due to lack of documentation. A review of the [DATE] Nutrition Risk Assessment completed by RD A calculated R14's fluid needs 2550 mL per day. R14's calculated caloric needs were between ,d+[DATE] calories per day. A review of the [DATE] MAR revealed that R14 was receiving fluids far above her daily requirements. On [DATE], R14 was received per the MAR documentation 3815 mL of fluid (455 mL free water from tube feeding, 140 ml post tube feeding flush, 480 mL flush/potassium medication mix, 180 mL with prosource and flush, 1350 mL from the normal flush orders (225 mL every 4 hrs), and 1200 mL from the normal saline (marked as only running for 12 hours). This much fluid was provided despite R14 having low sodium and low potassium. Review of R 14's EMR progress revealed: [DATE] Writer notified NP of residents symptoms. Resident unable to be aroused. Seems to be declining but comfortable . [DATE] Writer notified NP re resident starting to mottle at hands and feet, skin cool to touch, awake and making soft noises .T93.5 (temperature 93.5 degrees Fahrenheit) . [DATE] .Patient cold to touch on BLE, BUE, and forehead. [NAME] stokes respirations noted, brief periods of apnea. Does not appear to be in any pain, no guarding or grimacing noted . [DATE] .this writer informed the guardian (FM F) that due to the fact that the resident's guardianship is for a mentally incapacitated individual it needs to be amended to allow him to make end-of-life decisions. That at this point the resident would be considered a full code until revised and updated guardianship papers were received. Also, informed the guardian that per the medical director they were going to slowly reintroduced tube feedings to see if the resident would tolerate them . [DATE] Spoke with (Name of Physician G) regarding tube feeding restart. Verbal order given to restart 2 cal HN at 20ml per hour x 24 hours (continuous) . No recent weights as they were d/c'd per comfort cares previously. Will request new weight as able. Tube feeding will provide a total of 960 kcals, 480 ml total, 40 g protein (with prosource will provide additional 30 g protein and 120 kcals) and 336 ml free water. At this time will keep water flushes as ordered temporarily to see how she tolerates tube feeding this evening . [DATE] As night nurse was leaving this AM he reported that just in past hour (R14) seemed to be having discomfort. the day LPN and myself went into assess (R14). She is in bed with HOB elevated, tube feeding running and grimacing (sic). she moans out when I press stethocope (sic) to right upper quadrant which is slightly distended. she is fidgeting with her hands and continues to grimace with forehead frowns. there is no saturation of PEG tube dressing or noted drainage on skin from PEG site. tymmpanny (sic) sounds with bowel percussion increased from a few hours ago . [DATE] . tube feedings restarted and it appears she may not tolerate them as she is showing abdominal distention, discomfort . labs were requested in early May which showed electrolyte imbalances and IV fluids and medication changes were done, (R14) began to third space those fluids and was pulling out IVS, discussions with family were held and IV fluids stopped and when she wasn't tolerating tube feedings with multiple adjustments family had asked for her to be comfort care without tube feedings, NG feedings were declined related to them reporting her past history of not allowing anything on her face and pulling tubes. in March local surgeon had met with (FM F) and decision had been made to do no surgical type procedures. water flushes for hyddration (sic) and protein supplements along with medications have continued until yesterday . (written by NP/DON). [DATE] Resident crying out/moaning. Held resident's hand and spoke softly offering reassurance. Resident has furrowed brow, opened eyes briefly, and eventually stopped moaning. [DATE] Resident presenting tracheal rattle, tachypnea, low BP, low O2 sat (oxygen saturation), flaccid and unresponsive. Called for additional floor nurse to witness my assessment. While assessing resident, resident's VS (vital signs) worsened. Call to NP for status update. [DATE] Verbal order received from (Name of NP/DON), to send resident via ambulance to (name of hospital) for treatment and evaluation related to low BP, tachypnea, and abdominal distress. Administrator, (Name of Administrator) notified that order was received. Attempted notification to DPOA, DPOA is unavailable by phone this evening. Resident left facility via ambulance at 12:02 AM. [DATE] Received phone call from (name of hospital) to verify resident's code status. Informed ER nurse that resident is FULL CODE. Nurse requested advanced directive paperwork, informed nurse I do not have the updated paperwork at this time . [DATE] Received phone call from (Name of ER Physician H) regarding resident's newly reinstated tube feeding. Explained to Dr that (R14's) tube feeding was reinstated by (Name of Physician G) due to the guardianship expiring end of year 2021. Shared with (Physician H) the scenario as recorded by (Name of Administrator) . [DATE] This writer received a phone call from local ER physician (Physician H) in regard to Resident's current medical condition. (Physician H) needed clarification on the status of the guardianship papers that were provided by (name of FM F . In the physician's (Physician Hs) opinion, he felt like the resident's current medical condition would not allow her to tolerate tube feedings. Due to her critical labs, he felt the resident was nearing the end of life and should be a DNR however, understood the issues with the current status of the guardianship papers . On [DATE] at 12:21 p.m., an interview was conducted with RD A. When asked about the Prevacid being discontinued, RD A confirmed that it had been decreased and that the NP/DON was very involved with the medication changes. RD A reported that the gastroenterologist suggested R14 to slow down the feedings to a slower rate but even with a different formula at a lower rate the formula wasn't being .digested . When asked to clarify if the formula wasn't being digested, or if it was coming through the opening around the PEG tube, RD A reported it was coming from around the PEG tube site. When asked if there was an IDT discussion about sending R14 out in [DATE] to be evaluated, RD A stated, the NP (Name of NP/DON) was doing a lot of it . She had communicated with the hospital about the findings (from [DATE]) . RD A was asked if she had recommended for decrease in water flushes during the time the tube feeding was stopped from 1300 to 600 mL, but RD A reported the recommendation and order came from the NP/DON. RD A reported the Prosource was only discontinued for a day because the NP/DON wanted to keep her on that. RD A was then asked if she had any concerns about the restarting of R14's tube feeding, and stated, Yes, I was concerned how she was going to tolerate it. For being off (of it for) that amount of time . He (Physician G) started it off very slow, at a slow rate and small amount . RD A was asked what was in place to monitor R14 for refeeding syndrome (acute, life threatening condition that can occur when patients who have not been receiving adequate or any nutrition are restarted on feeding too rapidly and causes electrolyte shifts). RD A stated, Yes . we were watching her very closely to see if she was tolerating it . RD A reported she was unaware if any labs were drawn before or after starting R14's tube feeding. When asked if there had been an IDT discussion about sending R14 to the hospital instead of the facility restarting the tube feeding there, RD A reported there was no discussion that she was aware of. RD A was asked if R14 had ever shown signs of hunger or thirst and stated, Not that I'm aware of. When asked what comfort was being provided for R14 who's tube feeding was discontinued for comfort care, RD A stated, Making sure they are free from any signs of hunger or thirst. Keeping her hydrated per the orders . RD A was then asked what she would have recommended if R14 had reported or shown signs of hunger/thirst and stated, I would talk to the medical staff and voice concerns about that. On [DATE] at 1:13 p.m., a phone interview was conducted with Family Member F. When asked who he had discussions with about R14's tube feeding, FM F reported it was mostly with the NP/DON. When asked why the tube feeding was stopped, FM F stated, They (the facility) stopped it because it was leaking around the tube. From previous years they figured it was scar tissue (around the peg tube site) and wasn't healing around the tube. When asked if he had discussed the transition to comfort care for R14 with the Physician G, RD A, or the IDT team, FM F stated, It was mostly the nurse practitioner. FM F confirmed that he had not been able to get updated guardianship paperwork for R14 prior to her expiring. On [DATE] at 2:01 p.m., an interview was conducted with the NP/DON. The NP/DON was asked about why R14's tube feeding was stopped in [DATE], and the NP/DON reported that the facility had sent her (R14) out one time and the hospital got ahold of the surgeon who had placed the tube originally to see about replacing the Peg tube and got imaging done. The NP/DON reported that R14 was . not someone you could send out easily. This was her home. (She was) childlike. When asked about why the tube feeding was discontinued in [DATE], the NP/DON reported she had discussed with FM F a list of the benefits or the risks. NP/DON was asked about the note she had written when the tube feeding was discontinued and about R14's . failed IV resuscitation . The NP/DON stated, You fail it (IV resuscitation) when it makes the electrolytes go worse . you get third spacing. We didn't send her out because some people tolerate going out and some people don't . When asked why the IV was started in the first place, the NP/DON stated, When you are chasing critical labs, there are pathways. Have we found everything? What more? The findings are driving the care. Once something is sclerosed, there's nothing you can do . When asked if Physician G was involved in the discussion to discontinue the tube feeding, the NP/DON stated, He did not talk to them (family) himself. The NP/DON was asked what the reason for the prosource being discontinued and then restarted after being off for 12 days, the NP/DON reported they felt they needed to give her nutrient-wise what she could tolerate without it . coming back up . When asked if she was aware of R14 showing signs of hunger or stating she was hungry, the NP/DON reported she had not heard that before, but if she had, she would have said, . I gotta send you out because we gotta try a whole new ball game because there wasn't something more we could do . On [DATE] at 3:21 p.m., a phone interview was conducted with Physician G. When asked if he recalled R14, Physician G reported he vaguely remembered her, that she was sent to the hospital at one point and her tube wasn't able to be replaced for some reason, that there were issues with her guardianship and whether he was able to make those medical decisions. When asked why R14 was getting just the 200 calories of protein on some of the days she was off the tube feeding, Physician G stated, I think they were trying to keep her comfortable by giving the protein and water and I think they felt it was better than starving her. On [DATE] at 4:00 p.m., the NP/DON reported that she was mistaken and that imaging was not done in March of 2022 which showed issues with gastric organs that made R14 not tolerate or digest the tube feeding. The NP/DON also reported that per a review of the hospital notes from [DATE], the physicians there were not able to get in contact with the surgeon who placed it, but that they didn't think it was an option at the time. On [DATE] at 3:26 p.m., a phone interview was conducted with the Hospital Physician H. Physician H reported he had called the facility because he was frustrated that they suddenly made a DNR resident a full code and . then they (R14) decline and at the last minute call (EMS) when they (R14) are basically dying and send them (to the ER) . Physician H reported he spoke with the Administrator who reported that due to R14 being chronically intellectually disabled they (the facility) didn't feel FM F was able to make R14 a DNR. When asked about the condition R14 arrived in, Physician H reported her PEG tube looked good but her mucous membranes were dry, which suggested dehydration. Per Physician H, R14's sodium was noted to be extremely high but previously had been really low, suggesting R14 was really dehydrated. Physician H also reported that looking at her labs the high hemoglobin and critically high creatinine could suggest renal failure as well. Physician G was asked about her nutritional status and stated, Obviously if she (R14) is not getting the tube feeding and she's nothing by mouth (NPO) she's starving. On [DATE] at 1:40 p.m., a follow up interview was conducted with the NP/DON. The NP/DON was asked why she had discontinued the Prevacid despite indication for use and recommendations from hospital to continue it and stated, Many times those things (recommendations) are done related to PharmD (pharamcists') recommendations. When asked if discontinuing the med potentially resulted in the worsening of the bile secretions and skin irritation of the PEG site, the NP/DON stated, In theory it could, but it would be minimal because of her not absorbing it (the tubefeeding). When asked to clarify why R14 wasn't absorbing the tube feeding, the NP/DON reported that she meant that R14 wasn't tolerating the tube feeding in general. The NP/DON was asked about the [DATE] labs that were not addressed until [DATE] and reported she signs all things that she reviews and that it was a misstep in an otherwise pretty good system. The NP/DON confirmed that the facility did not have the normal saline in stock and did not know why that was. The NP/DON was asked why she wrote that R14 failed the IV resuscitation again, and stated it was due to R14 third spacing. When asked how she knew this, she reported that the resident had more generalized edema and by how she looked and turgor changes. When informed that there was no documentation in the record of any of those physical signs, the NP/DON stated in part, . I crossed over and made a medical diagnosis. Its more visual. If you don't find it (in the record then) I didn't document the signs or symptoms. The NP/DON was asked about the amount of fluids that R14 was receiving in bolus flushes and whether or not that had been reviewed regarding the amount of fluids in her stomach and the leaking peg site. The NP/DON reported that with the type of pump they had they would have had to obtain water to hang up and that they were using a type of gravity free flow. The NP/DON reported that the flush volumes were not discussed as a potential concern. When asked why the IV fluids were ordered if R14 was already receiving water flushes above her needs, the NP/DON reported it was because . Her electrolytes were out of balance, so we wanted to add fluids .I was concerned about dehydration . When asked how she had calculated R14's fluid needs, the NP/DON reported she relied on the Registered Dietitian to calculate them. The NP/DON was asked about there being no intake/output (I/O) documentation on R14 but only stated that the staff were doing them but had not documented it anywhere in the record. Lastly, the NP/DON was asked if R14's labs had been reviewed to rule out other conditions that could affect her electrolytes and BUN, like renal failure or kidney disease, but the DON could not say that it had been ruled out. A review of R14's death certificate revealed the following, her death on [DATE] was related to pneumonia, non stemi (heart attack), and acute renal failure. A review of the facility Resident's Bill of Rights (undated) revealed, . (p.26) 25. Policy: Each health facility resident shall be provided with meals which meet the recommended dietary allowances for that resident's age and sex and which may be modified according to special dietary needs or ability to chew . A review of the facility policy titled, Hydration (undated) revealed, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .1. The facility will utilize a system approach to optimize the resident's hydration status; . c . developing and consistently implementing pertinent approaches. D. Monitoring the effectiveness of interventions and revising them as necessary . b. the dietitian shall use data gathered from the nutritional assessment to (sic) resident's fluid needs and whether intake is adequate to meet those needs . 5. Monitoring/revision Signs and symptoms of dehydration including, but not limited to: .abnormal laboratory values (elevated hemoglobin/hematocrit, potassium, chloride, sodium .a. Record observations pertinent to the resident's hydration status in the nurses' notes . c. Record output in designation locations . d. Record fluid intake via tube or IV on MAR or designated intake record .

This citation has two deficient practice practice statements, A. and B. A. Based on observation, interview, and record review, the facility failed to provide adequate supervision to assure resident safety, failed to ensure safe operation of an air mattress per manufacturer's recommendations, and failed to appropriately assess bed and bed rails to prevent bed entrapment for one Resident (#57). This deficient practice resulted in Resident #57's entrapment between the mattress and side rail on two separate occasions, potential for serious harm and death, with no actions taken by the facility to prevent further incidents, resulting in immediate jeopardy. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility received acceptance of and began an ACTION PLAN for IJ Abatement that included: 1. An entire facility audit is being conducted. A list of all beds with siderails or attached assistive devices will be entered. Those with air mattresses will be marked on the audit. 2. All air mattresses will be checked in the audit for proper inflation parameters. 3. Inflatable mattresses will be assessed to determine alternate plans of action in the event of a power outage. This includes obtaining manufacturer verification that in the event of power outages, the mattresses hold at the inflated state to prevent potential injuries to residents. 4. Informed consent will be obtained for all residents utilizing a side rail or mobility handle. 5. Care plans are updated to include those residents with side rails including any precautions. 6. All residents with siderails or attached assistive devices will have measurements done for gaps, using the FDA guidelines. 7. Any noted gaps will result in stoppage of use of the rail until corrections can be made. 8. All those residents with air mattresses will have checks done and documented every shift for proper inflation. 9. Signs will be placed in the resident room of those using air mattresses to give location of CPR valve during an emergency. 10. Audits by the nursing staff will be conducted to ensure the above measures are completed. 11. The QA Committee will determine on-going methods to ensure compliance. Noncompliance remained until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident safety, including bed and bed rail entrapment, has been completed. Findings include: The immediate jeopardy began on [DATE] at 11:00 p.m. when Resident #57 was found entrapped in the bed rail, and the immediate jeopardy was identified on [DATE]. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy at 1:20 p.m. on [DATE]. The immediate jeopardy was removed on [DATE] at 5:29 p.m. but noncompliance remained at the lower scope and severity level of the potential for harm that is not immediate jeopardy. Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #57 score 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment, had unclear speech, and was usually understood and usually able to understand. Resident #57 required extensive, two-person assistance with bed mobility. Review of Resident #57's Incident Reports documented the following bed rail entrapments: 1. Sunday [DATE] 23:00 (11:00 p.m.) .The resident was wedged in between his mattress and the side rail on his bed. staff assisted x2 (two staff members) back into bed and turned .air mattress back on. Redness to his face, BL (bilateral) ribs, L (left) forearm, BL knees, and on his L thumb .When asked if his air mattress deflated when the power went out he stated yah .found him in between bed and arm rail/feet on the floor, arms wedged in between arm rail and bed, head to the side .Last check was on 2nd shift (unknown time before 10:00 p.m.). power went out during this time. N/A (not applicable) was noted for General Follow up Procedures that included Conclusion, Root Cause, Factual description of incident added to nurse note, Report and investigation completed in full, Notifications completed and documented in nurse note, and Care plan updated . 2. Sunday [DATE] 02:20 (2:20 a.m.) .abrasion .left forehead .(Registered Nurse (RN) U) spoke with administrator about the possibility of mattress malfunction and the possibility of removing the side rail that is against the wall so that there is no gap there in the future .Witness Statement (by Certified Nurse Aide (CNA) T) .: went to (Resident #57's) room and found him b/t (between) wall and bed, last check was between 1230 - 1 am found him at 0220 am. N/A was again the documentation in the General Follow up Procedures as listed above. On [DATE] at 10:10 a.m. the Nursing Home Administrator (NHA) was asked for any investigation files for Resident #57's two bed rail entrapments on [DATE] and [DATE]. Documents provided by the NHA on [DATE] included Nursing Progress Notes for the timeframe of the entrapments, and two Witness Statements completed by RN U and CNA T for Resident #57's [DATE] entrapment. No Witness Statements were provided for the [DATE] entrapment and no other documentation was provided by the facility. Resident #57's fall care plan was reviewed with no new interventions initiated following Resident #57's [DATE] and [DATE] bed/side rail entrapments. On [DATE] at 5:17 p.m. Resident #57's bed was observed with a (Name Brand) Alternating Pressure Low Air Loss Mattress on the bed. Mobility bars (side rails) were observed on both sides of the bed, with the rail on the right side (when looking at the mattress from the foot of the bed) extending out approximately six inches from the mattress. The side rail on the left was next to the wall. The mattress was plugged into a regular power outlet - not an emergency power outlet. The bed was positioned along the west bathroom wall inside Resident #57's room. During an interview on [DATE] at 10:20 a.m. the Director of Nursing (DON1) was asked if Resident #57's care plan was updated following the [DATE] and [DATE] bed rail entrapments. DON1 stated, .Absolutely we should have done these things (interventions to prevent future entrapment) after the first incident. We are a very young team that basically have no idea what we are doing . When asked what was not being done in the facility (due to being a young team) DON1 stated, Bed rails, policies . DON1 confirmed there was no bed rail policy. On [DATE] at 10:57 a.m. DON1 observed Resident #57's exit side bed rail with this Surveyor and confirmed a six to eight-inch gap between the side of the mattress and the mobility side rail. On [DATE] at 10:16 a.m. DON1 was asked what the facility did to prevent further entrapment for Resident #57 after the [DATE] and [DATE] bed entrapments. DON1 stated, We didn't do anything for him. There is nothing in his care plan .I had no idea you could move a grab bar .Of course then you would be doing measurements to make sure it fit properly .We haven't done it (measured side rails) for about two and a half years. On [DATE] at 3:25 p.m. Resident #57's bed was observed with Maintenance Supervisor K, who agreed the mobility side rail was approximately 6 inches from the bed frame/mattress and could have the potential for resident entrapment. When asked if the bed frame was compatible with the mattress and the side rails, Maintenance Supervisor K stated, No, I don't know if they are appropriate - the bed or mattress or grab bar. When asked for the manufacturer's recommendations for use for Resident #57's mattress, bed frame, and side rails Maintenance Supervisor K reported he did not have them. Review of the (Brand Name) User Manual for the Alternating Pressure Low Air Loss mattress on Resident #57's bed, retrieved from http://www.(Brand Name).com/doc_files/ 37.pdf, accessed during the survey, revealed the following, in part: WARNING! To avoid risk of death, injury or damage from product misuse or entrapment: .The (Name Brand) mattress MUST fit firmly against the bed frame AND bed side rails to prevent patient entrapment. Follow the manufacturer's product instructions . During an interview on [DATE] at 10:35 a.m. when asked what occurred with Resident #57's bed on [DATE] LPN C stated, It (mattress) did deflate after the power outage. There was no safety feature on that mattress. LPN C said the [DATE] entrapment was due to a mattress malfunction. LPN C stated, It was the same older mattress .I think it was finally at its end. When asked who decides which rails go on which bed, LPN C stated, I have no idea who measures the bed rails (to assure an appropriate fit). LPN C could not confirm or show documentation that side rail and/or bed measurements had been completed by any facility staff prior to or following Resident #57's bed rail entrapments on [DATE] and [DATE]. When asked for LPN C's understanding of the risk posed by Resident #57's mobility bar extending six inches out from his mattress, LPN C stated, .(Resident #57) Getting stuck in there (between side rail and mattress/bed. On [DATE] at 12:40 p.m. Registered Nurse (RN) U, regarding Resident #57's [DATE] and [DATE] entrapment stated, I don't think they (facility staff) did anything to the bed after the first entrapment. I told (NHA) to look into the matter because (Resident #57) had an alternating air mattress and if he was too far to one side, the mattress filled up with air on the other side and basically booted him out of the bed . RN U confirmed Resident #57's bed had always been on the wall adjoining the rooms bathroom (west wall), which was not within reach of the emergency power outlet. On [DATE] at 4:58 p.m. former CNA T was interviewed by telephone regarding Resident #57's bed entrapments that occurred on CNA T's scheduled night shifts. CNA T confirmed there were two entrapment occurrences: .The first time something went wrong with the mattress (Power) outage came just before my night shift (10:00 p.m.) The second time (Resident #57) got stuck between the bed and the grab bar . CNA T said he resigned his job (at facility), and stated, I don't believe we had enough staff for resident safety. B. Based on observation, interview and record review, the facility failed to prevent repeated falls for five Residents (#19, 55, 56, 60 and 67) of 7 reviewed for falls. This deficient practice resulted in repeated falls, some with minor injury, for these residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #19 was moderately cognitively impaired, with [DIAGNOSES REDACTED]. Incident reports reviewed revealed Resident #19 experienced falls on [DATE] at 10:00 a.m., [DATE] at 1:15 a.m., [DATE] at 6:00 a.m., [DATE] at 9:52 a.m., [DATE] at 8:29 a.m. and on [DATE] at 12:25 a.m. The incident report for the fall on [DATE] revealed the care plan was updated. Review of the care plan revealed there was no update on or around [DATE]. The incident reports for all the other falls did not reflect any care plan updates, to prevent further falls. The care plan also did not reflect any further updates. The incident reports for the falls on all dates except [DATE], were marked N/A (not applicable) in the section General Follow up Procedures including Conclusion, Root Cause, Report and investigation completed in full, and Care plan updated. According to the MDS assessment dated [DATE], Resident #55 was severely cognitively impaired, with [DIAGNOSES REDACTED]. Incident reports reviewed revealed Resident #55 experienced falls on [DATE] at 10:00 p.m., [DATE] at 1:45 a.m., [DATE] at 8:20 a.m., [DATE] at 9:20 p.m., [DATE] at midnight, [DATE] at 10:40 p.m., [DATE] at 9:45 p.m., and [DATE] at 1:00 a.m. The incident reports were marked N/A (not applicable) in the section General Follow up Procedures including Conclusion, Root Cause, Report and investigation completed in full, and Care plan updated. According to the MDS assessment dated [DATE], Resident #56 was moderately cognitively impaired with [DIAGNOSES REDACTED]. On [DATE] at 12:49 p.m., Resident #56 was observed in the dining room on the secured unit with old facial bruising, yellow and green in color, to the right eye and face. A nursing progress note, dated [DATE], revealed a fall on [DATE] at 9:15 p.m. with a right eye laceration. This same progress noted Resident #56 had previous right facial bruising present prior to the fall on [DATE] at 9:15 p.m. The care plan revealed falls with the above dates and injury noted with the fall on [DATE]. The incident report for the fall on [DATE] revealed Resident #56 was sent to emergency department for lacerations to the face. No care plan updates were documented or seen in the care plan. Incident reports reviewed revealed Resident #56 experienced falls on [DATE] at 9:15 p.m., [DATE] at 7:25 a.m., and [DATE] at 9:15 p.m . The incident reports for the falls on [DATE] and [DATE] were marked N/A (not applicable) in the section General Follow up Procedures including Conclusion, Root Cause, Report and investigation completed in full, and Care plan updated. The incident report for the fall on [DATE] revealed, .care plan was reviewed and updated . No new care plan interventions were noted on or around this date, to the care plan. According to the MDS assessment dated [DATE], Resident #60 was moderately cognitively impaired, with [DIAGNOSES REDACTED]. During an interview on [DATE] at 9:37 a.m., Family Member (FM) I was asked if the facility contacted her regarding Resident #60's fall, and responded, Yes, but we're concerned (Resident #60) has so many falls. They call but do not explain why she falls or how they are preventing them. Falling is not good for the elderly. Incident reports reviewed revealed Resident #60 experienced falls on [DATE] at 4:30 p.m., [DATE] at 4:25 p.m., [DATE], [DATE] at 1:40 a.m., [DATE] at 1:50 a.m., [DATE] at 9:00 p.m., [DATE] at 12:30 a.m., [DATE] at 4:25 a.m. The incident report for the fall on [DATE] revealed the care plan was updated. The care plan revealed a floor mat was placed on [DATE], five days after the fall. the incident report for the fall on [DATE] revealed the care plan was updated, but there were no updates on or around that date, in the care plan. The incident reports for the falls on [DATE], [DATE], [DATE], [DATE], and [DATE] were marked N/A (not applicable) in the section General Follow up Procedures including Conclusion, Root Cause, Report and investigation completed in full, and Care plan updated. The incident report for Resident #60's fall on [DATE] revealed, .Nurses note of what happened written by (RN H) .I assisted resident to use her bathroom. Elder is independent with toileting so I left them to attend to another resident. Approximately 5 min(utes) later, (Certified Nurse Aide (CNA)) called from room that elder was on the floor . During a phone interview on [DATE] at 7:02 a.m., RN H was asked about Resident #60's fall on [DATE], and could not remember the specifics of the incident. RN H did say she remembered assisting Resident #60 to the bathroom and asking a CNA in the hallway if Resident #60 was safe to leave on the toilet and was told, 'She's OK, but you have to stay close and watch her.' RN H stated, I don't know these residents very well, they have me (working) all over. I don't have one regular assignment. Resident #60 had three fall assessments performed since admission on [DATE]. Fall Assessments dated [DATE], [DATE] and [DATE] revealed high risk, low risk (not completed) and high risk, respectively. The document Fall Protocol, not dated, signed or on letterhead, revealed, .On admission and re-admission, a Fall Risk Assessment is completed .done again quarterly and with significant changes .depending on the nature of the fall, additional or change in careplan interventions may be implemented . During an interview on [DATE] at 7:35 a.m., RN J was asked about the incident report for the fall on [DATE], as it revealed the care plan was updated. RN J stated, There may not have been an update, but it was definitely reviewed. When asked what was meant on the incident report, when it documented that the care plan was updated, RN J stated, I put in her most recent falls. Other than that, I just reviewed it. When asked about the fall on [DATE], and whether RN J noted the nurse report that Resident #60 was independent, when the care plan said she required assistance of one staff, RN J stated, No, I guess I did not. When asked if there was any follow up to the event with RN H or other staff, RN J said there was not. According to the incident report dated [DATE], Resident #60 was confused and asked why staff changed her bed around, following a fall. RN J was asked about that fall, which occured shortly after Resident #60 had a room change, and whether there was documentation of acclimating Resident #60 to her new room. RN J stated, I'm not sure. I understand that. I don't disagree with you. When asked about the fall on [DATE], RN J stated, I can't tell you right now. I haven't even gotten to do that investigation yet. When asked about other falls on ,[DATE] and ,[DATE], RN J stated, I'm very far behind on my (incident investigations). I've had to fill in on the floor because we're so short. RN J then asked this Surveyor how she should be doing the fall investigations. According to the MDS assessment dated [DATE], Resident #67 was moderately cognitively impaired, with [DIAGNOSES REDACTED]. Incident reports reviewed revealed Resident #67 experienced falls on [DATE] at 12:45 p.m., [DATE] at 11:15 a.m., [DATE] at 11:15 a.m., [DATE] at 12:45 a.m., [DATE] at 9:15 a.m., [DATE] at 11:15 p.m., [DATE] at 12:50 a.m., [DATE] at 11:40 p.m., [DATE] at 1:15 a.m., [DATE], [DATE] and [DATE]. All incident reports were marked N/A (not applicable) in the section General Follow up Procedures including Conclusion, Root Cause, Report and investigation completed in full, and Care plan updated. During an interview on [DATE] at 7:35 a.m., Registered Nurse (RN) J was asked about updates to the care plan to prevent further falls, and responded, I'm behind on my (incidents). During an interview on [DATE] at 4:37 p.m., RN J was asked if she performed any root cause analysis or investigative tasks regarding the above falls, and replied, I do have some (staff)statements, but I don't do anything else. Should I do something else? All other documents regarding the above falls were requested from RN J and received on [DATE] at 5:23 p.m. RN J stated at that time, I don't think I have anything else. The documents provided included some staff statements of the events, and some fall committee notes, all of which were unremarkable and provided no evidence of care plan updates or interdisciplinary root cause analysis of falls to prevent further falls. During an interview on [DATE] at 2:01 p.m., RN J was asked about the quality assurance (QA) process she performs following falls, and said she gets report from floor nurses, reviews the progress notes and incident reports, then verifies the incident reports with the charting. RN J said she had to go into various places for charting as she did not get automatic notices regarding incidents. RN J stated, Some new nurses may forget to complete an incident report, so I may not get one. RN J said she ensures appropriate notifications were made and follows up with any hospitalization s and makes sure the care plan is updated. When asked how she determines which interventions to update the care plan with, RN J stated, It depends on what's already there. It could be that all interventions are already there. RN J said she obtained witness statements for all falls, as a matter of routine, not policy, and then the Director of Nursing (DON) and Administrator (NHA) review the incident. When asked how far behind she is on falls investigations, RN J stated, A couple of months. During an interview on [DATE] at 9:11 a.m., the DON2 (now working in place of DON1 who was no longer employed at the facility) was asked what the expectation was in the aftermath of a fall. DON2 responded, I would hope there's some kind of critical thinking involved, figuring out what happened, what can we do to prevent it from happening again. There should be an interdisciplinary (IDT) huddle. I'm going to be introducing huddles. They work wonderfully with every fall regardless of injury, I would want QA to follow up with a root cause analysis (RCA) and new interventions. Hopefully it's on the 24 hour report, as well. When asked if the falls investigation process was part of a policy, the DON2 stated, I don't know if there is a full set of policies and procedures. During an interview on [DATE] at 9:47 a.m., when asked about the falls process the NHA said following care for the resident, the floor nurse puts an intervention in the care plan, but sometimes they don't always put an appropriate intervention in place. The NHA confirmed RN J should have done an RCA with the IDT. The NHA stated, That's the part that we're not real good about is the (incident report) part. She's (RN J) behind on that. The NHA confirmed the falls committee notes were all the facility had in the way of RCAs for falls, and the weekly meetings of the Falls Committee began ,[DATE] months prior to the survey date. Falls Committee meeting notes were requested, and notes were provided from two meetings.

Based on observation, interview, and record review, the facility failed to ensure correct installation, use, and maintenance of bed rails, including failure to measure bed dimensions, resulting in the potential for serious harm and death for one Resident (#57), out of one resident reviewed for entrapment. This deficient practice resulted in Resident #57's entrapment, on two separate occasions, between the mattress and side rail with redness to face, ribs, left forearm, knees and left thumb, left head abrasion, and the potential for emotional distress, asphyxiation and death. The facility failed to take necessary action to prevent further such incidents, which had the potential to affect all 73 facility residents, resulting in immediate jeopardy. The immediate jeopardy began on [DATE] at 11:00 p.m. when Resident #57 was found entrapped in the bed rail, and the immediate jeopardy was identified on [DATE]. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy at 1:20 p.m. on [DATE]. The immediate jeopardy was removed on [DATE] at 5:29 p.m. but noncompliance remained at the lower scope and severity level of the potential for harm that is not immediate jeopardy. Findings include: Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #57 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment, had unclear speech, and was usually understood and usually able to understand. Resident #57 required extensive, two-person assistance with bed mobility. Review of Resident #57's Incident Reports documented the following bed rail entrapments: 1. Sunday [DATE] 23:00 (11:00 p.m.) .The resident was wedged in between his mattress and the side rail on his bed. staff assisted x2 (two staff members) back into bed and turned his air mattress back on. Redness to his face, BL (bilateral) ribs, L (left) forearm, BL knees, and on his L thumb .When asked if his air mattress deflated when the power went out he stated yah .found him in between bed and arm rail/feet on the floor, arms wedged in between arm rail and bed, head to the side .Last check was on 2nd shift (unknown time before 10:00 p.m.). power went out during this time. N/A (not applicable) was noted for all General Follow up Procedures that included Conclusion, Root Cause, Factual description of incident added to nurse note, Report and investigation completed in full, Notifications completed and documented in nurse note, and Care plan updated . 2. Sunday [DATE] 02:20 (2:20 a.m.) .abrasion .left forehead .(Registered Nurse (RN) U) spoke with administrator about the possibility of mattress malfunction and the possibility of removing the side rail that is against the wall so that there is no gap there in the future .Witness Statement (by Certified Nurse Aide (CNA) T) .: went to (Resident #57's) room and found him b/t (between) wall and bed, last check was between 1230 - 1 am found him at 0220 (2:20 a.m.) am. N/A was again the documentation all of the General Follow up Procedures as listed above. On [DATE] at 10:10 a.m. the Nursing Home Administrator (NHA) was asked for any investigation files for Resident #57's two bed rail entrapments on [DATE] and [DATE]. Documents provided by the NHA on [DATE] included Nursing Progress Notes for the timeframe of the entrapments, and two Witness Statements completed by RN U and CNA T for Resident #57's [DATE] entrapment. No Witness Statements were provided for the [DATE] entrapment and no other documentation was provided by the facility. Review of Nursing Progress Notes revealed the following, in part: [DATE] 16:16 (4:16 p.m.) .Air mattress removed from room and new mattress on bed. (Triple Antibiotic Ointment) applied to left side of head . (Licensed Practical Nurse (LPN) GG) No documentation to show side rails were measured and determined compatible with the new mattress was found, or provided by the facility. Resident #57's fall care plan was reviewed with no new interventions initiated or present following the [DATE] and the [DATE] side rail entrapments, and no interventions present related to the presence of mobility bars on Resident #57's bed. On [DATE] at 5:17 p.m. Resident #57's bed was observed with a (Name Brand) Alternating Pressure Low Air Loss Mattress on the bed. Mobility bars (side rails) were observed on both sides of the bed, with the rail on the right side (when looking at the mattress from the foot of the bed) extending out approximately six inches from the mattress. The side rail on the left was next to the wall. The mattress was not plugged into an emergency power outlet. The bed was positioned along the west bathroom wall inside Resident #57's room. When asked if there was an emergency power outlet in Resident #57's room, Licensed Practical Nurse (LPN) V stated, There is no red (emergency) power outlet connected to the generator in this room. On [DATE] at 5:42 p.m. LPN V reported there was an emergency power outlet in Resident #57's room, but it was not within reach of Resident #57's bed. During an interview on [DATE] at 10:20 a.m. the Director of Nursing (DON1) was asked if Resident #57's care plan was updated following the [DATE] and [DATE] bed rail entrapments. DON1 stated, .Absolutely we should have done these things (interventions to prevent further bed entrapments) after the first incident. We are a very young team that basically have no idea what we are doing . When asked what was not being done in the facility DON1 stated, Bed rails, policies . On [DATE] at 10:57 a.m. DON1 observed Resident #57's exit side bed rail with this Surveyor and confirmed a six to eight-inch gap between the side of the bed/mattress and the mobility side rail. On [DATE] at 10:16 a.m. DON1 was asked what the facility did to prevent further entrapment for Resident #57. DON1 stated, We didn't do anything for him. There is nothing in his care plan .Maintenance is the muscle. They (maintenance staff) basically put them on and remove them (side rails) .I think LPN C measures the bed. She is the one who orders the mattresses .When we saw that (mobility bar extended out from mattress/frame of Resident #57's bed) yesterday I was surprised. I had no idea you could move a grab bar .Of course then you (facility staff) would be doing measurements to make sure it fit properly .We haven't done it (measured side rails) for about two and a half years. DON1 confirmed there was no bed rail policy. On [DATE] at 3:25 p.m. Resident #57's bed was observed with Maintenance Supervisor K, who agreed the mobility side rail was approximately 6 inches from the bed frame/mattress and could have the potential for resident entrapment. Maintenance Supervisor K said the gap between the mattress and the mobility bar was never brought to our (maintenance department staff) attention. Maintenance Supervisor K said Resident #57's mattress was replaced last week. When asked for documentation of when the mattress was changed stated, I didn't write it down. Maintenance Supervisor K stated, The nurses pick the mattress. When asked who measures the bed frame and bed rails, Maintenance Supervisor K stated, We have enough to do other than measure bed rails. That is nursing's responsibility. I don't do it. When asked if the bed frame was compatible with the mattress and the side rails, Maintenance Supervisor K stated, No, I don't know if they are appropriate - the bed or mattress or grab bar. When asked for the manufacturer's information to show compatibility of the bed components, Maintenance Supervisor K said he did not have those and directed this Surveyor to LPN C (who orders the mattresses). Review of the (Brand Name) User Manual for the Alternating Pressure Low Air Loss mattress (observed on Resident #57's bed), retrieved during the survey, from http://www.(Brand Name).com/doc_files/ 37.pdf, revealed the following, in part: Entrapment DANGER! Risk of Death, Injury or Damage. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of entrapment .WARNING! To avoid risk of death, injury or damage from product misuse or entrapment: Read and understand the User Manual prior to using this product .Refer to user manuals for beds and rails for additional product safety information. Proper patient assessment and monitoring is required .The (Name Brand) mattress MUST fit firmly against the bed frame AND bed side rails to prevent patient entrapment. Follow the manufacturer's product instructions . During an interview on [DATE] at 10:35 a.m. LPN C confirmed a new alternating pressure low air loss mattress was put on Resident #57's bed but had no documentation of the date it was replaced. When asked what occurred with Resident #57's bed on [DATE] LPN C stated, It (mattress) did deflate after the power outage. There was no safety feature on that mattress. LPN C said the [DATE] entrapment was due to a mattress malfunction. LPN C stated, It was the same older mattress .I think it was finally at its end. LPN C stated, I usually ask the DON for bed rail approval. When asked who decides which rails go on which bed, LPN C stated, I have no idea. I call my DON and ask her when in doubt .I usually don't decide which mattress/bed/rail combination to use. I let them (maintenance) know what mattress that we need. I have no idea who measures the bed rails (to assure an appropriate fit). LPN C could not confirm or show documentation that side rail measurements had been completed by any facility staff. When asked for her understanding of the concern posed by Resident #57's mobility bar that extended out from his bed LPN C stated, Getting stuck in there. LPN C stated, Nobody is really in charge of that (bed assessment and measuring). We used to have a small handout about bed rails, but I haven't seen that for a while. I don't do measurements. I believe maintenance keeps the manufacturer's recommendations because they do the assembling .I know we talked about the deflations (leading to Resident #57's entrapments) but I don't recall what we said. During an interview on [DATE] at 10:49 a.m. Human Resources E was asked for job descriptions/duties for Maintenance Supervisor K, LPN C, Assistant Director of Nursing, and the DON. Brief job descriptions and position postings were reviewed, with no reference or documentation found to show what staff member was responsible for bed and bed rail measurements and ensuring compatibility between side rails, mattresses, and bed frames. During an interview on [DATE] Registered Nurse (RN)/QA (Quality Assurance) J stated, I have not measured bed rails. RN J after confirming she had completed new resident assessments, was asked how the bed was determined to be appropriate for the resident being admitted . RN J stated, More than likely there is a bed there (in the room) . It might have a grab bar and a side rail. I don't know who assesses that. I don't think I have ever done side rail measurements here (approximately one year). On [DATE] at 12:40 p.m. RN U, regarding Resident #57's [DATE] entrapment stated, I don't think they (facility staff) did anything to the bed after the first entrapment. I told (NHA) to look into the matter because he had an alternating air mattress and if he was too far to one side the mattress filled up with air on the other side and basically booted him out of the bed . On [DATE] at 4:00 p.m. RN/QA J and Nurse Consultant G were asked if Resident #57 had a signed consent for the side rails (mobility bars) observed by this Surveyor during the survey. Nurse Consultant G stated, I would say no as she reviewed the medical record. RN/QA J also said she would say no. Nurse Consultant G found no signed consent for side rails for Resident #57 in the electronic medical record. This Surveyor discussed the observation of the mobility bar extending out from Resident #57's bed, to which Nurse Consultant G replied, That is what they (facility staff) told me - that it was sticking out too far from the bed. At 4:30 p.m. RN/QA J reported that there was not an informed consent regarding Resident #57's mobility bar in the hard (paper) chart. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility submitted and received acceptance of an ACTION PLAN for IJ Abatement that included: 1. An entire facility audit is being conducted. A list of all beds with siderails or attached assistive devices will be entered. Those with air mattresses will be marked on the audit. 2. All air mattresses will be checked in the audit for proper inflation parameters. 3. Inflatable mattresses will be assessed to determine alternate plans of action in the event of a power outage. This includes obtaining manufacturer verification that in the event of power outages, the mattresses hold at the inflated state to prevent potential injuries to residents. 4. Informed consent will be obtained for all residents utilizing a side rail or mobility handle. 5. Care plans are updated to include those residents with side rails including any precautions. 6. All residents with siderails or attached assistive devices will have measurements done for gaps, using the FDA guidelines. 7. Any noted gaps will result in stoppage of use of the rail until corrections can be made. 8. All those residents with air mattresses will have checks done and documented every shift for proper inflation. 9. Signs will be placed in the resident room of those using air mattresses to give location of CPR valve during an emergency. 10. Audits by the nursing staff will be conducted to ensure the above measures are completed. 11. The QA Committee will determine on-going methods to ensure compliance. The noncompliance remained until confirmation of the abatement plan, verification of a functioning facility process to ensure resident safety, including bed and bed rail entrapment has been completed, and staff responsibility for bed and bed rail assessment has been formally established.

Based on observation, interview, and record review, the facility failed to perform regular bed frame, mattress, and bed rail inspection and maintenance, resulting in the risk of serious harm and death for one Resident (#57), out of one resident reviewed for entrapment. This deficient practice resulted in Resident #57's entrapment on [DATE] and [DATE], and continued risk of injury and entrapment from potential bed frame, rail, and mattress incompatibility, and failure to follow manufacturer instructions. The facility failed to take actions to prevent further such incidents, which had the potential to affect all 73 facility residents, resulting in immediate jeopardy. The immediate jeopardy began on [DATE] at 11:00 p.m. when Resident #57 was found entrapped in the bed rail, and the immediate jeopardy was identified on [DATE]. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on [DATE] at 1:20 p.m The immediate jeopardy was removed on [DATE] at 5:29 p.m. but noncompliance remained at the lower scope and severity level of widespread potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #57 scored ,[DATE] on the Brief Interview for Mental Status (BIMS), reflective of moderate cognitive impairment and required extensive, two-person assistance with bed mobility. Review of Resident #57's Incident Reports documented the following bed rail entrapments: 1. Sunday [DATE] 23:00 (11:00 p.m.) .The resident was wedged in between his mattress and the side rail on his bed. staff assisted x2 back into bed and turned his air mattress back on .When asked if his air mattress deflated when the power went out he stated yah .found him in between bed and arm rail/feet on the floor, arms wedged in between arm rail and bed, head to the side .power went out during this time. 2. Sunday [DATE] 02:20 (2:20 a.m.) .abrasion .left forehead .(Registered Nurse (RN) U) spoke with administrator about the possibility of mattress malfunction and the possibility of removing the side rail that is against the wall so that there is no gap there in the future .Witness Statement (by Certified Nurse Aide (CNA) T) .: went to (Resident #57's) room and found him b/t (between) wall and bed, last check was between 1230 - 1 am found him at 0220 (2:20 a.m.) a.m. On [DATE] at 5:17 p.m. Resident #57's bed was observed with a (Name Brand) Alternating Pressure Low Air Loss Mattress on the bed. Mobility bars (side rails) were observed on both sides of the bed, with the rail on the right side (when looking at the mattress from the foot of the bed) extending out approximately 6 inches from the mattress. The side rail on the left was next to the wall. During an interview on [DATE] at 10:14 a.m. the Director of Nursing (DON1) was asked about facility bed rails. DON1 stated, We do not have a system in place to monitor bed rails .The ball just keeps getting dropped. The grab bars don't have to be measured per the previous DON. As far as our most recent bed rail assessment, it has probably been years . On [DATE] at 10:57 a.m. DON1 observed Resident #57's exit side bed rail and confirmed a six to eight-inch gap between the side of the bed/mattress and the mobility side rail. On [DATE] at 10:16 a.m. DON1 was asked about facility bed assessment, measurement, and compatibility between frames, mattresses and side rails. DON1 stated, Maintenance is the muscle. They (maintenance staff) basically put them on and remove them (side rails) .I think LPN C measures the bed. She is the one who orders the mattresses .When we saw that bed (Resident #57's) yesterday I was surprised. I had no idea you could move a grab bar .Of course then you would be doing measurements to make sure it fit properly .We haven't done it (measured side rails) for about two and a half years. DON1 confirmed that there was no bed rail policy. On [DATE] at 3:25 p.m. Resident #57's bed was observed with Maintenance Supervisor K, who agreed the mobility side rail was approximately 6 inches from the bed frame/mattress and could have the potential for resident entrapment. Maintenance Supervisor K said the gap between the mattress and the mobility bar was never brought to our (maintenance department staff) attention. When asked who measures the bed frame and bed rails, Maintenance Supervisor K stated, We (maintenance) have enough to do, other than measure bed rails. That is nursing's responsibility. I don't do it. When asked if the bed frame was compatible with the mattress and the side rails, Maintenance Supervisor K stated, .I don't know if they are appropriate - the bed or mattress or grab bar. When asked for the manufacturer's information to show compatibility of the bed components, Maintenance Supervisor K said he did not have those and directed this Surveyor to LPN C as a possible place to find the information. Review of the (Brand Name) User Manual for the Alternating Pressure Low Air Loss mattress, retrieved from http://www.(Brand Name).com/doc_files/ 37.pdf, observed on Resident #57's bed revealed the following, in part: Entrapment DANGER! Risk of Death, Injury or Damage. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of entrapment .WARNING! To avoid risk of death, injury or damage from product misuse or entrapment: Read and understand the User Manual prior to using this product .Refer to user manuals for beds and rails for additional product safety information. Proper patient assessment and monitoring is required .The (Name Brand) mattress MUST fit firmly against the bed frame AND bed side rails to prevent patient entrapment. Follow the manufacturer's product instructions . During an interview on [DATE] at 10:35 a.m. LPN C was asked who decides which rails go on which bed. LPN C stated, I have no idea. I call my DON and ask her when in doubt .I usually don't decide which mattress/bed/rail combination to use. I let them (maintenance) know what mattress we need. I have no idea who measures the bed rails (to assure an appropriate fit). LPN C could not confirm or show documentation of side rail measurements completed by facility staff. When asked for her understanding of the concern posed by Resident #57's mobility bar that extended out from his bed LPN C stated, Getting stuck in there. LPN C stated, Nobody is really in charge of that (bed assessment and measuring). We used to have a small handout about bed rails but I haven't seen that for a while. I don't do measurements. I believe maintenance keeps the manufacturer's recommendations because they do the assembling . During an interview on [DATE] at 10:49 a.m. Human Resources E was asked for job descriptions/duties for Maintenance Supervisor K, LPN C, Assistant Director of Nursing, and the DON (DON1 and DON2). Brief job descriptions and position postings were reviewed, with no reference or documentation found to show what staff member was responsible for bed and bed rail measurements and ensuring compatibility between siderails, mattresses, and bed frames. During an interview on [DATE] at 7:20 a.m. Registered Nurse (RN)/QA (Quality Assurance) J stated, I have not measured bed rails. RN J after confirming she had completed admission assessments for new residents, was asked how the bed is determined to be appropriate for residents new to the facility. RN J stated, More than likely there is a bed there (in the room) .It might have a grab bar and a side rail. I don't know who assesses that. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility submitted and received acceptance of an ACTION PLAN for IJ Abatement that included: 1. An entire facility audit is being conducted. A list of all beds with siderails or attached assistive devices will be entered. Those with air mattresses will be marked on the audit. 2. All air mattresses will be checked in the audit for proper inflation parameters. 3. Inflatable mattresses will be assessed to determine alternate plans of action in the event of a power outage. This includes obtaining manufacturer verification that in the event of power outages, the mattresses hold at the inflated state to prevent potential injuries to residents. 4. Informed consent will be obtained for all residents utilizing a side rail or mobility handle. 5. Care plans are updated to include those residents with side rails including any precautions. 6. All residents with siderails or attached assistive devices will have measurements done for gaps, using the FDA guidelines. 7. Any noted gaps will result in stoppage of use of the rail until corrections can be made. 8. All those residents with air mattresses will have checks done and documented every shift for proper inflation. 9. Signs will be placed in the resident room of those using air mattresses to give location of CPR valve during an emergency. 10. Audits by the nursing staff will be conducted to ensure the above measures are completed. 11. The QA Committee will determine on-going methods to ensure compliance. The noncompliance remained at lower widespread level of no harm with potential for more than minimal harm until completion of the abatement plan has been confirmed, verification of a functional facility process to ensure resident safety related to regular bed frame, mattress, and siderail inspection and maintenance has been completed, and staff responsibility for bed and bed rail assessment has been formally established. During an interview on [DATE] at 1:25 p.m., the Nursing Home Administrator (NHA) said Resident #57's bed was changed. When asked if the bed rail, mattress and bed frame were assessed for compatibility, the NHA could not confirm.

Based on observation, interview, and record review, the facility failed to prevent the development of new, and re-occurring pressure ulcers and failed to provide adequate care to heal facility acquired pressure ulcers for one Resident (#57), resulting in harm, and for two other Residents (#21, and #67), from four reviewed for pressure ulcers. This deficient practice resulted in the new development and recurrence of two pressure ulcers for Resident #57, and the potential for delayed healing for Residents #21, #57 and #67. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #21 was severely cognitively impaired, with [DIAGNOSES REDACTED]. According to the Admission Record, printed 10/23/18, the facility acquired stage 3 pressure ulcer to the left heel began 1/28/18. Resident #21's care plan revealed, .is at risk for bruising, skin tears, pressure ulcers, and other skin impairment related to fragile skin with history of multiple pressure ulcers, [DIAGNOSES REDACTED].(risk assessment) score is 16 placing her a low risk pressure ulcer formation, however, related to her current pressure ulcer she is at high risk for pressure ulcer formation. 5/17/17 Left heel with facility acquire pressure ulcer stage (3) During an interview on 10/23/18 at 11:08 a.m. LPN C was asked about Resident #21's pressure ulcer being present for so long, and responded, The Nurse Practitioner, ((NP) S) saw the wound and called it pressure, but she did not say when. When asked how much time is expected to pass before contacting the physician, LPN C stated, Usually if it worsens I just put in a request to assess in (NP S's) wound folder. LPN C stated NP S was at the facility daily Monday through Friday. When asked when she would contact the doctor when a wound is unchanged for a period of time, LPN C stated, I just use my judgment. LPN C said there was no policy specifying any time frames for physician contact related to wounds. At this time, LPN C was asked for any and all documentation regarding Resident #21 and #67's pressure ulcers. Documentation was received at approximately 4:00 p.m. on 10/24/18, with confirmation from Nurse Consultant (NC) G that the documentation received contained all available information regarding pressure ulcers for Residents #21 and 67. The documentation contained no physician progress notes [REDACTED]. Wound Round Reports provided on 10/24/18, revealed documentation on 10/22/18, with the pressure ulcer acquisition date of 5/17/17, as an unavoidable pressure ulcer without rationalization. Physician notification was documented as, in rounds book for the Nurse Practitioner (NP), not the primary physician. Other Wound Round Reports were documented on 10/5/18, with no wound assessment or measurements, and 9/28/18, all alerting the NP, not the primary physician. Nursing progress notes revealed the last measurement note regarding Resident #21's pressure ulcer was on 9/21/18, three and a half weeks prior to the survey entrance. physician progress notes [REDACTED].#21's pressure ulcer. The document Wound Log for the month of (MONTH) (YEAR) revealed, a left heel stage 3 pressure ulcer, a risk assessment completion date of 8/28/18, and the following: .Date of Admission: 5/3/17 .Facility acquired: Yes (circled) .Date Acquired: 5/17/17 Wound type: (pressure ulcer) .Week 1 Date: 10/5/18 (LPN C initial), (Measurements) 0.9 (by) 0.8 (by) 0.2 (centimeters (cm)) .Week 2 Date; 10/22/18 (LPN C initials), (Measurements) 1 (by) 1.8 (by) 0.2 (cm). The document Resident Skin Assessments revealed the following: 6/1/18, (no measurements of left heel ulcer), .6/8/18 .left heel pressure 0.5 (by) 0.6 (by) 0.4 (stage 3) .6/22/18 .left heel .0.4 (by) 0.5 (by) 0.5 (cm) .6/26/18 .(no left heel notation) .7/10/18 .left heel .0.6 (by) 0.1 .7/13/18 .left heel .0.6 (by) 0.6 (cm) .7/17/18 .left heel .1.1 (by) 0.6 (by) 0.3 (cm) .7/27/18 .left heel 1.1 (by) 0.8 (by) 0.4 (cm) .8/28/18 .left heel .1.1 (by) 1.1 (by) 0.4 (cm) . During an interview on 10/17/18 at 10:35 a.m., Licensed Practical Nurse (LPN) C confirmed she was the wound nurse. LPN C was asked about the wound program and process and stated, To be honest with you I'm behind on them right now. When asked if she is the only person to provide wound care for residents, LPN C said she does the care when she can, but when she doesn't, the floor nurses do the care. LPN C stated she performs the weekly rounding which includes measurements, weekly charting, and wound assessments. When asked about wound documentation, LPN C said if she wasn't in the building the floor nurse would do the assessment. LPN C stated, Sometimes they put it in nurses notes, sometimes in a wound/skin note. When asked how LPN C monitors the care with nursing documentation in different areas, LPN C stated, I just view all the notes and scroll through. When asked if that made it difficult to track and monitor wounds, LPN C stated, It does. It does. We've been trying to get a better system going. When asked how the care plan gets updated related to wounds, LPN C said floor nurses didn't do anything with the care plans, adding, I go in and do that the next time I'm in the building. According to the MDS assessment dated [DATE], Resident #67 was moderately cognitively impaired, with [DIAGNOSES REDACTED]. On 10/18/18 at 9:27 a.m., Licensed Practical Nurse (LPN) V was observed providing care for Resident #67's right heel pressure ulcer. There was an approximately 2 cm by 2 cm round, unstageable area of pressure to the bottom of the right heel, which appeared to have a regular smooth continuous border, with light eschar (scab-like deadened area) in the center. LPN V performed hand hygiene, then cleansed the wound and applied dimethicone cream directly to the area of eschar, replaced a sock and pressure relieving bootie. Resident #67's physician orders [REDACTED]. A nursing progress note, dated 9/21/18, noted the first discovery of Resident #67's pressure ulcer. The Wound Log for (MONTH) (YEAR) for Resident #67 revealed a facility acquired pressure ulcer on 9/21/18, with the first assessment documented on 10/5/18 by LPN C, and no further documentation. During an interview on 10/23/18 at 11:02 a.m., LPN C was asked about Resident #67's pressure ulcer the and the first assessment of it, LPN C stated, I did not assess that right away. I just didn't get to it, I got caught up with other things and didn't make it down there. When asked if there was a physician order [REDACTED]. Yeah, like it's our standard lotion that we put on everybody's skin. When asked if there should be an order for [REDACTED]. When asked if a new risk assessment was performed for Resident #67 upon discovering the pressure ulcer, LPN C stated, I don't believe so, no. Resident #67's care plan revealed, Apply dimethicone skin protectant . bilateral heels and body twice daily with cares and as needed for skin protection . During an interview on 10/24/18 at 7:33 a.m., Nurse Practitioner (NP) S confirmed she was in the building almost every day, in the morning between 5:00 and 8:00 a.m. When asked about her role in the wound management program, NP S stated, It comes out of my role working with (provider name). NP S said she was made aware of wounds only if the information came through the rounds book or the wound nurse. When asked if there was an order for [REDACTED]. The policy Pressure Injury and Wound Prevention and Management, Updated: (MONTH) (YEAR), revealed, It is the policy .to provide the best possible care to prevent and manage wounds and avoidable pressure ulcers Interdisciplinary Team (IDT) will consider complications, evaluate care and behavior that may influence or contribute to the development or healing of a pressure ulcer or other ulcer and will adjust care plan as needed .A physician's orders [REDACTED].A wound assessment to be completed by the floor nurse upon initial finding. A skin/wound progress note is to be entered with measurements, and wound description along with all parties that have been notified . The primary care physician will function as part of the IDT team to provide orders for treatment and prevention interventions as needed. Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #57 scored 8 of 15 on the Brief Interview for Mental Status (BIMS), reflective of moderate cognitive impairment. Resident #57 required extensive, two-person assistance with bed mobility. Three Stage II pressure ulcers were noted on the 9/17/18 MDS Assessment, with two being present upon admission/reentry, and two of the Stage II pressure ulcers documented as not present or at a lesser stage on the previous MDS assessment. Resident #57's 7/17/18 MDS Assessment documented two stage II pressure ulcers, with one being present upon admission/reentry. Review of Resident #57's Care Plans revealed the following, in part: (Resident #57) has potential/actual impairment to skin integrity related to fragile skin, [DIAGNOSES REDACTED]. (Resident #57) has a Braden Score of 12 placing him at high risk for pressure ulcer formation. Stage II Left buttock - community acquired 4/9/18. Stage II Right buttock - Community Acquired 4/9/18. 9/14/18 Stage II pressure ulcer left heel, worsened to Unstageable pressure ulcer, 10/5/18 able to stage Unstageable to two DTI (deep tissue injuries). 10/5/18 Stage II right distal gluteal facility acquired reoccurring. Initiated 1/4/18, Revision on 10/11/18 by Licensed Practical Nurse (LPN)/Wound Nurse C. Interventions included, in part: Nurse to monitor and document daily on bilateral buttock wounds, and left heel, Revision on 9/27/18. Review of Wound Logs completed by LPN C included the following (MONTH) (YEAR) entries: Lt (left) Buttock, Stage II, Weekly Measurements 9/4/18 5 x 2.0 x 0.1 (centimeters), 9/26/18 100% [MEDICATION NAME], Pink, blanch(blanchable), intact, Braden Score 13 (high risk). Rt (right) Buttock, Stage II, Weekly Measurements: 9/4/18, 5 x 4 x 0.1, 9/26/18 100% [MEDICATION NAME], pink, no blanch. Rt Gluteal, Stage II, Weekly Measurements 9/4/18 1.9 x 0.2 x 0.1, 9/26/18 100% [MEDICATION NAME], pink blanch, resolved. Lt Heel, Stage II Pressure Ulcer, Facility Acquired: Yes, Date Acquired: 9/14/18, Weekly Measurements 9/17/18 6.8 x 9.4, 9/26/18 5.5 x 9.0, Dark - unstageable, boggy, firm outer skin . October (YEAR) Wound Log Documentation included: Lt Buttock, Stage II Pressure Ulcer, Weekly Measurements: 10/5/18 [MEDICATION NAME], 10/17/18 4 x 0.2 x 0.1 and 2 x 0.2 x < (less than) 0.1, beefy red open area, scant drainage .purple peri wound, blanch. Rt Glut (gluteal) distal, Stage II Pressure Ulcer, reoccurring, Date Acquired: 10/5/18, Weekly Measurements 10/5/18 3.0 x 1.8 x <0.1, 100% gran (granulation) beefy red peri wound no blanch, 10/17/18 2.4 x 1.0 x <0.1 Lt Heel, Wound Type: PU (pressure ulcer), Date Acquired 9/14/18, Unstageable 10/5/18 DTI, Weekly Measurements: 10/5/18 1.8 x 0.3, and 10/17/18 1.5 x 0.2. Review of Progress Notes for Resident #57's pressure ulcers revealed the following, in part: 9/22/18 18:54 (6:54 p.m.) Elders bottom and coccyx area is free of any skin breakdown, left heel continues with dark intake blister heel protector on, Transcriber: (Registered Nurse (RN) X) 9/27/18 .Excoriated/open area on lower right buttocks, no open area on coccyx .Left heel callused from blister that was previously there . 10/19/18 09:49 (9:49 a.m.) Tx (treatment) performed to buttocks and right gluteal crease. Open area on right gluteal crease and right buttocks by coccyx, dime size amount of blood on attend before treatment performed . Review of Skin/Wound Notes for Resident #57 included the following, in part: 9/23/18 09:41 (9:41 a.m.) residents' buttock and coccyx area is free of any skin breakdown. Left heel continues with dark blister heel . 10/15/18 .Small open spot <1 cm (centimeter) long on right buttock. Small open area approx. 2 cm long near coccyx. Cleaned. Powder and cream applied. Wound nurse aware . Review of the facility 10/5/18 Wound Round Report completed by Wound Care LPN C read, in part: Acquired: Right and Left Stage II both acquired on admission, Right distal gluteal: facility acquired - New, Left heel: Facility acquired . On 10/18/18 at 11:05 a.m. wound care for Resident #57's was observed by LPN GG assisted by Certified Nurse Aide (CNA) P. Resident #57 was positioned on his right side in bed by CNA P and LPN GG. When Resident #57's brief was removed, a large, soft, yellow-brown bowel movement was found stuck to his rectal/perineal area. LPN GG used a foam skin cleanser to remove the stool on Resident #57's skin, but a line of yellow/brown stool was present in the intergluteal cleft (groove between the buttocks). LPN GG did not clean the residual stool from this area, which included a small coccyx opening and right gluteal fold. Resident #57 then urinated a large volume onto the pad directly below. The urine was cleansed from where it had come into direct contact with Resident #57's body, but the gluteal cleft was not cleansed. Gloves donned and used by LPN G, to remove stool and urine from Resident #57 were not changed prior to handling and applying the [MEDICATION NAME] spray and stoma adhesive powder to the documented pressure injuries on Resident #57's coccyx and right gluteal fold. LPN GG used the same dirty gloves to handle the treatment medications and replace them in a box. LPN GG's dirty gloves were removed and new gloves donned to assist Resident #57 out of bed. No hand hygiene was observed during wound care. CNA P removed her gloves and left the room with no hand hygiene. LPN GG tied the dirty laundry bag closed, removed her right-hand glove and carried the dirty laundry out into the hall with her left hand. No hand hygiene was performed until both CNA P and LPN GG returned to the room. During an interview on 10/19/18 at 3:46 p.m., Wound Care LPN C reported Resident #57 had the following pressure ulcers: Stage II right buttock, Stage II left buttock, and Stage II right gluteal crease. LPN C reported staff had not informed her of the coccyx wound. Wound Logs, Wound Round Reports, Progress Notes, and Wound Assessments were reviewed with LPN C to determine when Resident #57 acquired the pressure ulcers after being documented as clear of all pressure ulcers in the 9/22/18 and 9/23/18 nurse progress notes. LPN C reported the Stage II left buttock and Stage II right distal gluteal opened on 10/5/18, and the Stage II coccyx opening was first documented on 10/15/18, with documentation first on 10/17/18 as a left buttock Stage II, proximal to coccyx. When asked about LPN C's report that she was unaware of the coccyx wound, LPN C stated, It has been a busy month, and everything is overlapping. When asked about incomplete stool removal during wound care, LPN C agreed continued contamination of fecal matter would contribute to delayed healing and increase the risk for infection for Resident #57. LPN C agreed that weekly documentation on the Wound Log was not completed fully for Resident #57, and the exact location of the wounds were difficult to determine. During an interview on 10/23/18 at 11:45 a.m., Director of Nursing (DON2) reviewed the Wound Log Acquired dates of Resident #57's current pressure ulcers. DON2 stated, We should be listing them (pressure ulcers) as acquired on the date they reopened. It looks like (LPN C) is just continuing them, even after they were healed .They are ours (facility acquired) now . During an interview on 10/23/18 at 3:00 p.m. NP S confirmed she was not aware Resident #57 was having multiple episodes of fecal incontinence daily. NP S stated, I was not aware that he was having those (incontinence episodes). When asked if knowledge of Resident #57's repeated daily episodes of fecal incontinence would have changed the course of treatment for [REDACTED].

Based on interview and record review, the facility failed to correctly implement a pummel cushion device for one (Resident #100) of four Residents reviewed for falls, from a total sample of five Residents. This deficient practice resulted in incorrectly securing a pummel cushion in the wheelchair and subsequent fall with nasal fracture, for Resident #100. Findings include: A facility reported incident to the State Agency (SA), revealed Resident #100 sustained a nasal bone fracture from a fall on 12/12/17. According to the Minimum Data Set (MDS) assessment, Resident #100 was a severely cognitively impaired non-verbal [AGE] year old with [DIAGNOSES REDACTED]. A nursing note dated 5/14/17 at 2:40 p.m. revealed, .Elder was on floor .call placed to DON .A special seat cushion with a prop between the legs was located and may assist Elder from sliding himself out of (wheelchair). Per DON (Director of Nursing), if (representative) approves, have MDS care plan the seat cushion and have therapy evaluate this cushion and Elder to be sure it is appropriate for him . The Resident Occurrence report, dated 5/14/17 revealed, Immediate action taken .Found a specialized (wheelchair) cushion with a wedge between legs to aid prevention of sliding out of (wheelchair) during attempts to self transfer .call placed to MDS .Therapy communication to assess Elder and this cushion for appropriate use. Resident #100's careplan, initiated 4/27/17 revealed in part, .Pummel cushion to (wheelchair) for safety. Date initiated 5/22/17 .Anti rollbacks placed on (wheelchair due to) fall from (wheelchair) in room on 4/26/17 .Complete fall risk assessment at least quarterly, following each falling incident, and with any significant change in functional status .Educate my family/caregivers about safety reminders and what to do if a fall occurs .(physical therapy) evaluate and treat as ordered or (as needed). Date initiated 4/27/17 . During a phone interview on 12/27/17 at 10:10 a.m., Physical Therapist (PT) E was asked about the process following falls. PT E said the therapy department gets a hand written referral form from nursing. Therapy then conducts a screening of the Resident issue and recommends any appropriate device, applies the device and inservices floor staff on its use. PT E said nursing then updates the Resident care plan. During an interview on 12/27/17 at 11:15 a.m., Staff F was asked about therapy referrals for Resident #100 and stated, I know for a fact we never got any request to screen a pummel cushion. We never got any screens for (Resident #100) since (his) admission. During an interview on 12/26/17 at 12:30 p.m., at the northeast nursing station, Licensed Practical Nurse (LPN) A was asked about Resident #100's fall on 12/12/17. LPN A said she was at the nursing station on 12/12/17, with Resident #100 about 20 feet from her in the TV area, rocking in his wheelchair, a frequent behavior, when she witnessed Resident #100 fall forward onto the floor, landing on his face. After assessing Resident #100, LPN A said she examined the wheelchair and noticed the pummel cushion (for positioning) had slid from the chair about 6 inches. LPN A went on to say she knew right away the cushion was incorrectly secured to the chair. The facility investigation summary, hand dated 12/19/17, revealed, The investigation into the fall for (Resident #100) was completed. The QA (Quality Assurance) nurse assessed the wheelchair and the pummel cushion in the residents wheel chair. The cushion had moved position in the wheel chair (related to) the resident rocking in his wheel chair. The clasps on the cushion were secured on the top bilateral bars when the proper positioning should have been to secure on the underside of the wheel chair. The positioning of the clasps and the resident rocking in the wheelchair caused the cushion to move forward with the resident and resident falling forward onto the floor .Injuries noted minimal displaced fractures of left and right nasal bones , skin tear to left wrist, small laceration to left ear (related to) glasses . The Diagnostic Radiology report, completed 12/12/17 revealed, .There are minimally displaced bilateral nasal bone fractures with diffuse overlying soft tissue swelling about the nose. There is also a prominent hematoma overlying the right frontal calvarium . The Occurrence Report, dated 12/12/17, revealed, .Details swelling to right orbit, bridge of nose, upper lip, Bleeding noted to upper lip, nose, and behind left ear. Laceration to left ear from glasses . During an interview on 12/26/17 at 12:23 p.m., Certified Nurse Aide (CNA) B was asked about Resident #100's wheelchair and pummel cushion. CNA B stated Resident #100 was usually gotten up and dressed by the midnight staff, who cleans and returns wheelchair cushions. Three attempts were made to contact CNA C (Resident #100's primary CNA on the night shift) on 12/27/17 at 9:30 a.m., 10:51 a.m., and 1:29 p.m., all unsuccessfully. During an interview by phone, on 12/27/17 at 2:00 p.m., Registered Nurse (RN) D confirmed she was the chair of the Falls Committee and did participate in the investigation of Resident #100's fall on 12/12/17. RN D said CNA C was not interviewed as part of the investigation. RN D also said she conducted staff inservices following Resident #100's fall on 12/12/17, which included therapy staff. RN D confirmed there was no referral made to therapy following this fall. RN D confirmed the protocol was to complete a therapy referral form. During an interview on 12/27/17 at 10:30 a.m., the DON and Nursing Home Administrator (NHA) confirmed the protocol following falls, includes a referral to therapy. During an interview on 12/27/17 at 11:25 a.m., the NHA was asked for a policy regarding therapy and referrals, and stated, There is no written policy for therapy or device referrals. It's just understood that we refer to therapy. During an interview on 12/27/17 at 11:40 a.m., RN G was asked about the process when a resident needs a positioning device. RN G said she would assess the resident, the wheelchair, then fill out the therapy referral form, write a nursing note, put the information on the 24 hour report and communicate the incident during nurse shift change report. The following one page document was hanging at the northeast nursing station on 12/27/17: Procedure for when a fall occurs .Once resident has been stabilized: .complete a Fall Risk Assessment. Fill out a PT/OT (occupational therapy) screening form and place under the door of the therapy room. (This is to be done for ALL falls) .(handwritten date) posted 11/28/17 (initials) Resident #100's medical record was absent any therapy referral since admission, and absent any Fall Risk Assessment later than 10/27/17. On 12/27/17 at 2:00 p.m. the facility fall policy was requested from the DON. At 2:30 p.m. that same day, the DON said, regarding the policy, Nobody can find one. At approximately 1:30 p.m. on 12/27/17, the NHA was informed if there was any other documentation pertinent to the investigation the facility wished to include, it should be revealed within the next 60-90 minutes as the investigation was coming to a conclusion. At 2:10 p.m. on that same day, the NHA told this Surveyor, I have nothing more to offer for this (investigation).

Based on observation, interview and record review, the facility failed to provide necessary treatment to prevent development of multiple pressure ulcers for four Residents (#1, #4, #6 and #7) of 11 residents reviewed for risk of pressure ulcers, from a total sample of 17 residents. This deficient practice resulted in the development of multiple, avoidable Stage 2 pressure ulcers with increased pain and risk of infection. Findings include: A review of Resident #6's Admission Record dated 11/15/16 shows a [AGE] year old with the following major Diagnoses: [REDACTED]. A review of Resident #6's Comprehensive Level II Evaluation (dated 10/23/13) for mental illness and intellectual disabilities/developmental disability read in part, .History of Presenting Problems: .Psychological testing over the years continues to produce scores indicating Borderline Intellectual Functioning (IQ 80), slightly above Mild Mental [MEDICAL CONDITION] . A review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE], revealed revealed she was admitted to the facility on [DATE]. According to the MDS assessment, Resident #6 required extensive, two plus persons physical assist with bed mobility and one person physical assist with toilet use (bed pan). Resident #6 was frequently incontinent of urine and occasionally incontinent of bowels. Resident #6's MDS assessment revealed she was 65 inches and weighed 277 pounds and was identified as being at risk for pressure ulcer development without the presence of any pressure ulcers. During Initial Tour on 11/15/16 at approximately 9:15 a.m., Licensed Practical Nurse (LPN) T stated, (Resident #6) had developed pressure sores because she liked to sit on the bedpan for an hour and now we are limiting her to 15 minutes. She is cared planned for it . On 11/15/16 at 2:18 p.m., Resident #6 was observed during pericare performed by Certified Nursing Assistant (CNA) U, CNA V and LPN T. The areas of skin breakdown had no dressings applied. The right, posterior thigh showed dark red, blistered skin and the left buttocks appeared dark red. Resident #6 was asked if she felt any pain to her bottom. Resident #6 responded, Yeah . LPN T instructed the CNAs to put barrier cream on the two wounds and stated, The nurse practitioner will be here tomorrow. She'll take a look at them. Review of Resident #6's Nursing Progress Note dated 11/9/16 read, Resident has Stage II to left upper posterior thigh, where a blister has opened up. Measures 3.6 cm (centimeter)x 2.8 cm. Site cleansed with NaCl (normal saline) and covered with [MEDICATION NAME] per standing orders. Review of Resident #6's Nursing Progress Note dated 11/11/16 read, .CENA reports RN notified of open sores to elder posterior thigh and left buttocks region . Review of Resident #6's Skin/Wound Note dated 11/11/16 read, Bilateral buttocks and thighs assessed and measured. Excoriated areas on the left buttock and one on right upper thigh. These areas had been filled and have opened, removing the top layer of skin. Resident spoke with D.O.N. (Director of Nursing) and agreed upon shorter stays on the bedpan. Has been compliant. During an interview regarding Resident #6's skin breakdown on 11/16/16 at 9:36 a.m., the DON stated (Resident #6) had, shearing. When the DON was asked what interventions had been put into place, the DON stated, We've tried to position her but she won't adhere to it. She's set in her ways. She refuses. There's nothing more you can do. It's her choice . When asked if the physician and legal representative had been notified of the wounds, the DON responded, No, they just developed. When asked about the progress notes which revealed the cause of the skin breakdown was related to the prolonged time Resident #6 was allowed to stay on the bedpan, the DON stated, I agree with that. Review of facility's Wound Log dated 11/11/16 for Resident #6 read, 1 (first wound) 4.5 (length) x2 (width) x<0.1 (depth) in centimeters, dark pink, L (left) buttock 2 (second wound) 2 (length) x3 (width) x0.1 (depth) in centimeters R (right) upper thigh. The facility's Wound Log was incomplete of the following data: Date of Admission, admitted with or Aquired Ulcer, Anatomical Site, Stage, Braden Scale, Pain Management, Brief Description of Treatment and Frequency, Pressure relief device bed/chair, Tx (Treatment), Care Plan, Nurses Notes, Dietary Consult, Supplements and MD (medical doctor) aware/orders. Review of facility provided, Pressure Ulcers/Skin Breakdown undated policy/procedure read, Assessment and Recognition-The nursing staff will assess and document an individual's significant risk factors for developing pressure sores using the Braden Scale. In addition, the nurse shall describe and document/report the following: 1. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates .; 2. Pain assessment; 3. Resident's mobility status; 4. Current treatments . Review of Resident #6's Behavior Note revealed the following: 1. 10/3/16: .refused to get off the bed pan and sitting for long periods of time and swearing at staff. Unable to redirect . 2. 10/18/16: .refusing to get off the bed pan and on it for long periods of time. 3. 10/24/16: .Continues to refused to get off the bed pan and staying on for long periods of time. 4. 11/1/16: .has had increased refusing to get off the bed pan this week .Unable to redirect. 5. 11/8/16 at 2:03 (a.m.): .has refused multiple times to get off the bed pan this evening and has been on since 10 pm . 6. 11/15/16: has been refusing to get off the bed pan for long periods of time . Review of Resident #6's Behavior Observation Sheet (dated 11/7/16) read, 3-11 p.m. shift refused to get off bedpan .nurse aware .11 p.m.-7 a.m. shift Elder refuses to get off the bed pan .nurse aware . An interview was conducted on 11/16/16 at 9:00 a.m. with Social Worker (SW) ,Registered Nurse (RN) P and Social Worker Assistant Q. This Surveyor asked if there were any concerns regarding (Resident #6) that were being addressed from Social Services. Both RN P and SW Assistant stated they were both very new and not very familiar with (Resident #6). RN P stated she was aware (Resident #6) fixated being placed on the bedpan for long periods of time because she (RN P) thought Resident #6 was anxious about having an accident. When RN P was asked when and how often the Interdiciplinary Team met to discuss resident specific behaviors/interventions/outcomes. SW P responded, No, we don't have a specific meeting to discuss just behaviors . Review of Resident #6's skin care plan (revised 8/4/16) read, .has high potential for impairment to skin integrity r/t (related to) previous severe pressure ulcer . Interventions read in part, .take pressure off areas .(revision 1/17/13) .if .adamant about staying on the bedpan for extended periods of time, notify charge nurse (initiated 8/4/16) .Notify physician/NP (nurse practitioner) of any changes in skin condition or worsening conditions (initiated 2/12/15) . Record review of Resident #6's November 2016's Medication Administration Record [REDACTED]. Resident #7 According to the MDS assessment dated [DATE], Resident #7 is a [AGE] year old admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. The same MDS showed risk for pressure sore development. Resident #7 scored a 14 on the Brief Interview of Mental Status, which reflected intact cognition; Resident #7 required one person physical assist for bed mobility and toilet use and was occasionally incontinent of urine. During Initial Tour on 11/15/16 at approximately 9:20 a.m., Licensed Practical Nurse (LPN) T stated, (Resident #7) had developed pressure sores and had a specialty, air mattress. Resident #7's Weekly Skin Assessment dated 10/11 and 10/18/16 was coded a C-Clear intact skin, no new finding. The CENA Skin Report dated 11/12/16 (and signed by the nurse) read, Nothing new, old open areas. The Report did not indicate the location of the old open areas and the diagram was left blank. LPN C was asked where Resident #7's Weekly Skin Assessment for November 2016 was located. LPN C responded, It would be there (indicating the skin assessment binder). The binder contained only one skin assessment for October for Resident #7 and none for November 2016. When the missing documentation was pointed out by this Surveyor, LPN C shrugged shoulders up and down without further comment. Resident #7's care plan (dated 9/1/16) read, I am at risk for ., pressure ulcers, .and skin complications. I have poor mobility strength. I receive diuretic therapy daily .and occasionally incontinent of bladder. I frequently slide down in my bed causing shearing .Interventions .Do not use medi-pads per NP use a folded sheet under her for positioning. Medi-pad too thick and hinders the purpose of the air mattress .Weekly skin assessments on shower days and daily visual checks with cares (initiated 3/16/15) Notify charge nurse of any changes in skin conditions .When head of bed up also place feet up to decrease sliding which causes shearing to her buttocks (initiated 9/1/16) . An observation of Resident #7's skin to bilateral (sacrum) buttocks was performed on 11/16/16 at 3:30 p.m. by NP N, RN O, RN J and this Surveyor. RN J stated, It looks completely different today. Yesterday it was hard and crusty but today it's wet looking. NP N stated, She has maceration (prolonged exposure to urine and/or feces that may cause skin breakdown and moisture may make skin more vulnerable to damage from friction and shearing during position changes.) that we tackled last winter. The blanket loses the benefit of the air mattress. NP N asked Resident #7, Does it hurt? Resident #7 responded, Yes. ( ) Resident #3 Review of the most recent Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/16, revealed an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, Section C for Cognitive Patterns, documented Resident #3 as having a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. Section M for Skin Conditions documents Resident #3 as being at risk of developing pressure ulcers. An observation and interview was conducted on 11/16/16 at 4 p.m. with Registered Nurse (RN) J of Resident #3's facility aquired pressure ulcer on her right heel. The actual wound bed was black/brown in color with no slough or drainage. The area was approximately dime size with a large tennis ball size area of redness surrounding it. RN J stated, I cannot speak for the other nurses when asked about charting on skin issues, I found out when it (Resident #3's pressure ulcer) was a blister. The nurse (Licensed Practical Nurse (LPN) W) who found it on the 16th (of October, a month prior) is no longer here. I let the nurse practitioner know and she sees the resident on her rounds, I do get orders when I call. I guess they (nursing staff) didn't document it when they found it . An interview was conducted on 11/16/16 at 4:25 p.m. with RN B in which she stated, I was aware of (Resident #3)'s sore on her foot heel. It was flat. It wasn't a blister. I made a note on it (10/23/16) and let (RN J wound care nurse) know right away. In discussing the facility's weekly skin assessment forms RN B stated, We haven't done those in a long time. RN B provided the October 2016 CENA Skin Report dated 10/23/16 and the Weekly Skin Assessment for October 2016 (which was blank). There were no November CENA forms or Weekly Skin Assessment forms in the Skin Assessment folder on the unit. An interview was conducted on 11/17/16 at 10:05 a.m. with CNAs L and M. They stated the Resident skin assessment sheets/forms are done on the residents' bath day. They said nursing checks the residents while in tub room as well, then both the CNA and nurse sign the form. Record review on Resident #3 documented the entry on 10/16/16 by LPN W as: .Her R (right) foot hurts she yelled out when I applied lotion (heels are dry) . No further documentation about Resident #3's right heel was noted until 10/23/16, when RN B charted, .(right) heel dark/purple discoloration area . (Nurse Practitioner (NP) N) aware . stated to keep pressure off, place up on pillow, monitor each shift . A progress note dated 10/29/16, with no signature, under DIAGNOSIS/STATUS/UPDATE/PLAN/ORDER states, Please monitor RT (right) heel OFF surfaces Q (every) 4 hours. The Certified Nurses Aide (CNA) Kardex on Resident #3, printed 11/16/16, on resident care specifies under Bathing: Weekly skin assessments on shower days and daily visual checks with ADL's (Activities of Daily Living). Notify charge nurse of any changes in skin condition. On 11/16/16 there were no November CENA forms in the Skin Assessment folder on the unit. There were no interventions listed on Resident #3's Kardex according to the NP N orders to keep pressure off, place up on pillow, monitor each shift . related to Resident #3's right heel pressure ulcer, nor to monitor every 4 hours to ensure right heel was off surfaces. Review of Resident #3's Face Sheet showed a [DIAGNOSES REDACTED]. The current pressure ulcer on Resident #3's right heel was not listed. ( ) Resident #1 According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had multiple [DIAGNOSES REDACTED]. Nursing progress notes dated 11/4/16 revealed Resident #1 sustained a [MEDICAL CONDITION] arm. Resident #1's mobility care plan revised on 11/9/16 reads, Transferring: 11/9/16-Per Physical Therapy: -Maximum Assist of 2 Staff Lying to Sitting Position -Maximum Assist of 2 Staff Seat to Seat Transfers. According to progress notes and an earlier MDS assessment dated [DATE] resident had been independent with walking and required assist of one to transfer or stand. Review of Resident #1's care plan for skin breakdown (revised 11/14/16) did not address Resident #1's fractured arm and subsequent reduced mobility, nor did this care plan identify interventions to prevent wounds resulting from pressure. An observation of Resident #1's coccyx area on 11/15/16 at 4:45 p.m. revealed two open, stage II areas. At this time Certified Nurse Aide (CNA) I stated, It (coccyx wound) has gotten worse. She has been unsteady and not walking since she fractured her arm. The following observations were made of Resident #1: On 11/15/16 at 11:50 a.m. sitting in recliner with feet elevated, no pressure reduction device On 11/15/16 at 2:50 p.m. lying in bed on back, no pressure reduction device On 11/16/16 at 7:26 a.m. lying in bed on back no pressure reduction device On 11/16/16 at 8:45 a.m. sitting in recliner with feet elevated, no pressure reduction device On 11/16/16 at 11:06 a.m. sitting in recliner with feet elevated, no pressure reduction device. Review of Resident #1's Weekly Skin Assessment, completed by the nurses on 11/16/16 revealed the following: 11/2/16 0 (indicating no skin concerns) 11/9/16 Unable to shower There was no Weekly Skin Assessment for 11/16/16. Review of CNA Skin Report dated 11/2/16 read, Nothing new. There was no CNA Skin Report for 11/9/16 or 11/16/16. The CNA care plan reads, Weekly skin assessment on shower days and daily visual skin checks with ADL's (activities of daily living) and PRN (as needed). Notify charge nurse of any changes in skin condition. During an interview on 11/16/16 at 8:20 a.m. CNA H stated, (CNA's) report (skin concerns) to nurse, it can be reported as it occurs, or every week with showers there is a full skin assessment done with the nurse. On 11/17/16 at 7:15 a.m., during an interview regarding reporting skin concerns, the Administrator stated, The CNA tells the nurse and the nurse reports to the wound care nurse. The Administrator was unable to find documentation regarding Resident #1's open areas on coccyx, she stated, (There is) Nothing after reviewing skin assessments, progress notes, and 24 hour reports for Resident #1. On 11/17/16 (two days after this Surveyor visualized skin breakdown on Resident #1's coccyx) at 7:20 a.m., Registered Nurse F stated, I checked (Resident #1's) skin at 6:30 a.m. this morning .it (skin breakdown) was not there Sunday (11/13/16). On 11/17/16 at 10:40 a.m. the Administrator and Director of Nursing (DON) confirmed there was no facility wound reporting policy and procedure. The DON stated, We have just always put it (wounds) on the 24 hour report. ( )

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents according to plan of care for two Residents (#5 & #8) of 6 residents reviewed for falls and supervision from a total sample of 16 residents. This deficient practice resulted in a fall and subsequent fracture to the femur, causing harm to Resident #8, and lack of supervision with the potential of falls for Resident #5. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8 received an 11/15 on the Brief Interview for Mental Status (BIMS) score, indicating moderate cognitive impairment. The MDS showed she could be understood by others and demonstrated understanding when spoken to, with adequate vision and hearing. Resident #8's Activity of Daily Living (ADL) Care Plan dated 10/1/15 read, Toilet Use: require extensive assist of 1 staff participation to use toilet. Resident #8's Fall Care Plan dated 8/17/15 with revision on 9/10/15 read, .moderate risk for falls . Transferring: extensive assist 1 staff/gait belt-additional assist as needed. Review of Resident #8's Occurrence Report dated 11/19/15, showed Resident #8 had an unwitnessed fall, and was found by staff near her bed with a bedside commode tipped sideways over her. The report read, Resident (#8) stated, 'I was trying to go to the bathroom. I grabbed on this (pointing to the bedside commode handle) and I fell .' Hematoma forming on left medial side of head. Complaining to pain to left lower middle back and to left hip/leg/knee. The report also indicated Resident #8 had fallen while transferring and no staff were present. Resident #8 was sent to the emergency department by ambulance at 3:55 p.m. and diagnosed with [REDACTED]. An interview was conducted with Resident #8 on 12/8/15 at 10:15 a.m. When asked about the fall on 11/19/15, Resident #8 said she had self transferred from bed to bedside commode that day stating, I have always transferred myself to the commode. An interview took place with the Director of Nursing on 12/08/15 at 10:30 a.m. When asked about the care plan for Resident #8 and her need for assistance with transfers, the DON stated she did not know it and stated the Certified Nurse Aides (CNA) were marking Resident #8 as independent with transfers to the toilet. An interview was conducted with Certified Nurse Aide (CNA) H on 12/8/15 at approximately 11:30 a.m. CNA H stated, I have never helped (Resident #8) get to the commode, (Resident #8) is independent in transfers. An interview was conducted with CNA K on 12/8/15 at approximately 5:30 p.m. CNA K stated that Resident #8 was independent in transfers to the commode. Review of Resident #8's Therapist Progress and Discharge Summary dated 7/22/15 showed a goal had been set for Resident #8 to safely transfer to toilet/commode. This 'End of Goal Status as of 07/22/2015' was checked as Goal Not Met and Occupation Therapist (OT) J wrote, (Resident #8) is able to transfer to toilet/commode requiring CGA (contact guard assist). A phone interview was conducted with OT J on 12/8/15 at 5:12 p.m. confirming that Resident #8 still required physical assistance with transfers to and from toilet/commode at the time of the incident on 11/19/15. ( ) Resident #5 is a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current MDS quarterly assessment dated [DATE], identified Resident #5's cognition as severely impaired, as assessed by staff. A Brief Interview for Mental Status was unable to be completed. A fall risk assessment dated [DATE] was scored at 16.0, demonstrating a HIGH risk for falls. Given this high risk for falls, a care plan was developed on 9/22/15 which read: Resident (#5) is not to be left unattended in room in wheelchair. On 12/8/15 at 8:00 a.m. and again on this date at 1:55 p.m., observations were made by this Surveyor of Resident #5 left alone in his wheelchair in his room. No staff were observed in attendance. The plan of care clearly showed Resident #5 was not to be left alone in his room unattended while up in the wheelchair, because of a high risk for falls. ( ) --