Every finding on record at Sheffield Manor Nursing & Rehabilitation Center

This citation pertains to intake #2792770. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from psychosocial harm for one resident (R102) of three residents reviewed for abuse by Social Worker B. Findings include:On 02/16/2026, an alleged resident-to-resident abuse allegation was reported to the State Agency. The alleged incident occurred on 02/15/2026. Record review revealed on 02/15/2026 at approximately 01:30 P.M., it was alleged that R102 was hit in the face by R101. Incident summary revealed: R102 was sitting in the hall when R101 rolled past in a wheelchair, stopped and hit R102 in the face. R102 screamed, the staff immediately responded. R102 and R101 were separated. Record review of progress note dated 02/15/2026 by Nurse A revealed, . R102 sitting in hallway peacefully, R101 rolling by punched this resident in the face unprovoked, on the left side. On 05/06/26 at 12:20 P.M., Nurse A was interviewed and stated, I was sitting at my desk and heard (R102) yell out He hit me. I assessed (R102) with no harm and ensured (R101) was no longer within reach. Nurse A said she reported this incident to the Nursing Home Administrator (NHA). Nurse A stated, The staff tries to keep the males and females separated on the floor for safety. On 05/06/2026 at 1:00 P.M., R102 was interviewed in her room during lunch time. R102 was well groomed and was able to recall the alleged incident. R102 stated, (R101) hit me. R102 also stated, (R101) hit me before too. Queried as to previous physical interactions with R101, R102 said this isn't the first time R101 has hit her. R102 said that R101 tries to come into R102's room. R102 stated, I scream and pushing the call light when (R101) tries to come into my room. R102 stated, I'm afraid (R101) will hit me again. Queried as to the most recent incident and feelings of safety, R102 stated, (R101) socked me in the face and No. I don't feel safe because he keeps hitting me! Queried as to the response of staff after the incident, R102 stated, The nurse checked on me after (R101) hit me. Queried as to a follow-up visit with a Social Worker (SW) after the incident, R102 reported the SW did not assess safety after the incidents. Queried as to how these incidents make R102 feel, R102 stated, I don't feel safe. R102 stated, I eat in my room so I can stay away from him. R102 reports plans to talk to her guardian about a transfer due to lack of safety. When asked, how R102 felt today, R102 stated, I feel safe today as long as (R101) isn't anywhere around me. On 05/06/2026 at 12:40 P.M., Social Worker (SW) B was interviewed and said SW B was made aware of the alleged incident between R101 and R102 shortly after it occurred. SW B stated, I followed up with R102 to ensure R102 felt safe afterwards. At this time, a request for documentation of the SW follow-up after the incident due to feelings of lack of safety was made. Record review revealed no documentation in the Electronic Health Record (EHR) regarding a follow up or an assessment after the alleged resident to resident abuse allegation. Queried SW B about expectations of a safety assessment after an allegation of abuse, SW B stated, The Social Services Department is supposed to do a safety assessment after an allegation, we did and we should have documented that this was done. I just forgot to document it. Queried as to whether SW B was aware of R102's reports of fearfulness of R101. SW B said he was not aware of R102's safety concerns. On 05/06/2026 at 1:50 P.M., the Director of Nursing (DON) was interviewed to discuss expectations of a psychosocial assessment after an allegation of abuse has been reported. The DON stated, Social Service is supposed to complete a safety assessment of the resident when abuse is reported. SW B said he did it but didn't document it. When queried about previous reports of abuse between R101 and R102, the DON discussed a previously reported incident dated 08/05/2025 where R101 physically assaulted R102. Queried as to documentation of a Social Services Assessment following the previously reported incident, the DON was unable to locate Social Services documentation of an assessment to rule out psychosocial harm. Record review determined no documentation of a Social Work follow up visit and/or assessment completed after the current or previously reported resident to resident abuse allegation. At this time, queried the DON regarding R102 not feeling safe within the facility due to fear of R101. The DON stated, I didn't know (R102) felt that way. She recants her feelings based on who she is talking to. During this interview, the DON was informed of the concern of the lack of a safety assessment for R102 by the Social Services Department on multiple occasions after allegations of abuse are reported and R102's report of not feeling safe due to R101 hitting R101 on multiple occasions. Record review revealed R102 has a Brief Interview of Mental Health Status score of 15 (Cognitively Intact) according to the Minimum Data Set, dated [DATE]. Review of the facility policy, last revised on 09/09/2022 and entitled, Abuse Prohibition Policy, read in part: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Social Services will provide follow -up counseling with the resident if abuse occurred.

Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 97 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include:On 2/24/2026 at 9:00 A.M. during a tour of the kitchen the air vent covers and adjacent ceiling tiles over the tray line were heavily soiled with visible dust, fuzz strings and lint. The ceiling tile strips had areas of rust and corrosion over the steam table and dish room area. The Bakers pride convection (stove) was soiled with burnt ash and food residue. Both glass doors of the convection stove were soiled with yellowish colored stains and food residue that blocked visibility into the stove. The window panels and legs of the stove were soiled with splattered grease and collected food particles. The deep fat fryer needed cleaning and the grease needed changing. The grease was dark in color and had floating debris. The water drains under the three-compartment sink was soiled and discolored. The floors throughout the kitchen and dish room area needed deep cleaning. The crevasses and edges of the cracked tile in the cooking area were embedded with a visible collection of crumbs, grease and food preparation liquids. On 2/26/26 at 12:40 P.M. during an interview with Dietary Manager (DM) I concerning the cleaning of the kitchen equipment and environment, DM I stated, The department had a cleaning schedule and staff should be cleaning as they worked. The floor should be cleaned at least twice a day, but we are making adjustment in the staff responsibilities, and it may not be done as it has in the past. DM I acknowledged recently the dietary and housekeeping department had agreed to share their cleaning machine, but the dietary department could only use the cleaning machine when housekeeping allowed them to. The cleaning person previously assigned to do the cleaning is no longer here and we are trying to reassign those duties and address the cleaning. The 2002 FDA Model Food Code section 6-501.12 states: Physical facilities shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. On 2/26/2026 at 8:43 AM, a tour of the laundry facility was conducted with Maintenance Director (MD) L. The following was noted. -Peeling floor paint on concrete flooring in front of washing machines estimated four feet by eight feet, an approximate 10-inch by 1/4 inch crack in the concrete floor directly in front of the washing machines. -Soiled flooring on the sides and behind the washing machines. -Five cracked floor tiles in the clean linen room. -Four broken/cracked floor tiles in dirty laundry room. MD L said the flooring should be repaired and repainted and the cracked/broken floor tiles should be replaced. MD L agreed the floor could not be effectively cleaned due to the damaged flooring. On 2/26/2026 at 10:15 AM, the Nursing Home Administrator (NHA) was interviewed and agreed that the laundry room floor needed to be repaired and repainted. On 2/26/2026 at 10:45 AM, clean and sanitary environment and floor care policies were requested and not provided by the end of the survey.

Based on observation, interview and record review the facility failed to utilize safe food practices, provide a safe and sanitary kitchen for food storage, preparation service affecting 90 residents, resulting in the potential for food borne illnesses.Findings include:On 2/24/26 at 8:50 A.M. during observation of the tray line the ambience room temperature exceeded 100 degrees Fahrenheit. Three of the four employees on the tray line were observed with soaked perspired uniforms and facial masks. One employee was observed perspiring profusely as sweat trickled down her face, commenting, I need some air in here. During this observation a large clear container of raw chicken was stored on the counter approximately 20 minutes. The air conditioning units for the kitchen were observed off or not working.On 2/25/26 at 8:30 A.M., during observation of the tray line a colander of diced turkey cubes were thawing in the first sink of the three-compartment sink.At 12:20 P.M. a local vendor delivered 21 (assorted boxes of food) both frozen and staple supplies were stored on the floor without a pellet. Approximately 30 minutes later DM (Dietary Manager) I was observed labeling the boxes and placing them where the items belong. DM I was interviewed concerning who was responsible for putting up the items. DM I responded, this is one of the things we are trying to figure out. I don't have a stock person. I have one position that's not filled so I will put the stock away.At 1:30 P.M. during observation of the three-compartment sink, Dietary Aide O could not correctly identify the immersion time frame for sanitizing pot/pans in the sink.On 2/26/26 at 10:00 A.M. while observing the room temperature in the kitchen, 6-7 Rolls of ground beef was observed thawing in standing water in the cook's sink. DM I observed the observation and commented, .we normally defrost the frozen meat in the refrigerator, but the P.M. cook forgot to take it out of the freezer.The 2005 Food Code section 3-501.13 (Thawing) potentially hazardous foods shall be thawed (A) under refrigeration that maintains the food temperature at 5 degrees centigrade (41 degrees Fahrenheit) or less at 7 degrees centigrade (45 degrees Fahrenheit) or less. completely submerged under running water. (B) Completely submerged under running water. (C). Microwave- thawed food in a microwave oven if it is cooked just after thawing.When frozen food is thawed and exposed to the temperature danger zone, any pathogens in the food will begin to grow. To reduce this growth, never thaw food at room temperature.On 2/26 at 9:00 A.M. and on 2/26/26 at 1:00 P.M. employee personal clothing (hat/coat) was hanging in the kitchen from a storage rack among food supplies. During the observation D.M. I was queried concerning employee lockers for staff. D.M. I stated: the employees have lockers. Their personal coats, hats . should not be left in the kitchenOn 2/26/26 at 1:20 P.M. during an interview with the Administrator, Director of Nursing and Registered Dietitian, the Administrator explained the Dietary department was in the process of changing and addressing the concerns presented. A policy was requested and provided. The facility's policy dated 11/12/2021 titled Dietary Cleaning and Sanitation did not specifically address the aforementioned deficiencies. ,

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the timely reporting to the state agency suspicion of a sexually transmitted disease for one vulnerable resident (R64) of three residents reviewed for abuse.Findings include:A review of R64's electronic medical record (EMR) revealed an admission to the facility on [DATE] with the diagnosis of Vascular Dementia with Agitation, Depressive disorder, and Chronic Obstructive Pulmonary Disease. A review of R64's Brief Interview for Mental Status (BIMS) disclosed a score of 00 (score of 00 indicates severe cognitive impairment).A review of R64's diagnosis list did not note a Herpes virus diagnosis nor a review of R64's previous medical record from another facility.Registered Nurse (RN H) documented the following on 8/15/25 at 3:00 PM: Resident (R64) with white bumps on her vaginal labia (skin folds (inner and outer lips) surrounding the vaginal opening), multiple whitish raised bumps. Labia appeared swollen. No complaints of pain or itching.RN H documented on 8/15/25 at 5:53 PM: Called (Doctor K) ordered to start acyclovir (prescription antiviral medication used to treat and manage herpes virus infections).for 7 days.A review of R64's laboratory order created by Nurse Manager M on 8/19/2025, noted testing for Sexually Transmitted Disease (STD):Results revealed R64's positive Herpes Simplex Virus (HSV) Type 1 and Type 2 on 9/2/2026.On 02/25/2026 at 2:49 PM, the Director of Nursing (DON) and Nurse Manager M were interviewed and reported they did not report the STD incident regarding R64 to the Abuse Coordinator. Nurse Manager M stated, No. I did not think nothing of it.On 02/26/2026 at 09:45am, the Nursing Home Administrator (NHA)/Abuse Coordinator was interviewed regarding not investigating and not reporting an unexplained STD. The NHA stated, This is not a case of abuse. there was no reason to report to the State Agency. The Abuse Coordinator stated that the labs proved that R64 had antibodies to the Herpes so there was no need to report or investigate. It was shared with the Abuse Coordinator that the physician started R64 on an antiviral medication on 8/15/25 used to treat herpes viruses, and R64 tested positive for Herpes on 9/2/25. However, the Abuse Coordinator was unable to explain why the suspicious incident was not reported to the State Agency at the time it occurred, followed by an investigation.

Based on observation, interview, and record review the facility failed to treat one (R72) of three residents reviewed for resident rights, with dignity and respect during incontinence and routine activities of daily living care resulting in mistrust and discomfort, with the potential for mistreatment.Findings include:On 2/26/2026 at 11:30 a.m. R72 was observed in the hall, going to an activity, and wanted the interview to be held at the nurse's station. R72 was alert, oriented to person, place, and situation, and able to recall the incident that was alleged on 12/17/25. R72 said CNA D became upset because she needed to be changed. R72 stated, (CNA D) said why did you wait so long to be changed. You're always doing this. While we were in the bathroom, and I was on the toilet, she tossed the brief at me. I got mad because the aide (CNA D) had been good to me before this. What she did to me hurt my feelings, so I started to curse at her (CNA D). Although the aid apologized and I accepted it, I still didn't have a good feeling about what happened. The trust was gone. The aid (CNA D) would still come into the room, walk pass me without speaking and give care to my roommate. I would just leave the room every time she came in. R72 said they were uncertain why CNA D was still allowed to come into the room after what occurred and bothered them. R72 said the concern was expressed to the Social Worker. On 2/25/25 at 2:00 p.m. an attempt to contact CNA D was made via telephone. Review of clinical record revealed R72 was admitted into the facility on 8/13/16 with diagnoses that included Parkinson's disease with dyskinesia, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, vascular dementia, major depressive disorder, hemiplegia, and cerebral infarction. According to the quarterly Minimum Data Set assessment dated [DATE], R72 was cognitively intact (BIMS-15), and required extensive one-person assistance with most activity of daily living. Review of the Social Service progress note dated 12/22/2025, documented in part the following: I was able to talk to (R72) about the incident with one of the CNAs throwing pamper at her. She mentioned that she is not sure what's going to happen to her. She just feels like she doesn't want to be around her anymore. On 02/26/2026 at 1:24 p.m. review of Daily Assignment forms, CNA D was assigned to R72's room on 1/17/26, 1/18/26 and 1/28/26. On 2/26/26 at 1:38 p.m. the Nursing Home Administrator (NHA) was interviewed about R72 allegation against CNA D and being assigned to R72's room. The NHA said the Abuse Coordinator (NHA) was responsible for ensuring the nurse aide's assignment was away from R72. The NHA said they were unaware CNA D continued to have contact with R72 and have the right to feel comfortable in the bedroom. The aide should have been removed from the unit and R72 should have never been made to feel uncomfortable by CNA D. The NHA informed SA, CNA D was terminated on 2/24/26 for an unrelated incident. There was no return communication from CNA D by the end of the survey. Review of the facility's policy titled Resident Rights, revision date of 5/14/24 documented the following in part: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety.

Based on observation, interview, and record review, the facility failed to investigate the suspicion of a sexually transmitted disease for one vulnerable resident (R64) of three residents reviewed for abuse.Findings include:On 02/24/2026 at 11:30 AM, R64 was observed in bed, wearing a gown, with their eyes closed. R64 did not respond to name being called.A review of R64's electronic medical record (EMR) revealed an admission to the facility on [DATE] with the diagnosis of Vascular Dementia with Agitation, Depressive disorder, and Chronic Obstructive Pulmonary Disease. A review of R64's Brief Interview for Mental Status (BIMS) disclosed a score of 00 (score of 00 indicates severe cognitive impairment). There was no diagnosis of Herpes Simplex Virus Type 1 or 2.A review of R64's Care plan revealed the following: Focus Goal Interventions: (R64) is at risk for impaired skin integrity/pressure injury R/T (related to): Incontinence and debility Date Initiated: 10/30/2024 Created on: 10/30/2024. There was no update to the Skin integrity care plan.Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 10/30/2024 Created on: 10/30/2024.Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated: 10/31/2024 Created on: 10/31/2024.(R64) is at risk for decline in cognition and has impaired cognitive function or impaired thought processes R/T: Dementia, Inability to recall current season, location of room, staff names and faces, placement in nursing home. Date Initiated: 08/18/2025.Ambulation/Walking: Resident is unable to ambulate and requires a Geri chair for locomotion. Resident need to be pushed to desired locations. Date Initiated: 10/31/2024Revision on: 11/19/2025.A review of R64's progress notes noted the following:Registered Nurse (RN H) documented on 8/15/25 at 3:00 PM: Resident (R64) with white bumps on her vaginal labia (skin folds (inner and outer lips) surrounding the vaginal opening), multiple whitish raised bumps. Labia appeared swollen. No complaints of pain or itching.RN H documented on 8/15/25 at 5:53 PM: Called (Doctor K) ordered to start acyclovir (prescription antiviral medication used to treat and manage herpes virus infections).for 7 days.A review of R64's laboratory order created by Nurse Manager M on 8/19/2025, noted testing for Sexually Transmitted Disease (STD): Testing included the following:Herpes simplex virus (HSV)-1 (typically causes oral herpes)HSV-2 (genital herpes through sexual contact)Human immunodeficiency virus (HIV) AntibodySyphilis Antibody, Chlamydia and Gonorrhea (detected using a urine sample).Results revealed R64 positive for Herpes Simplex Virus (HSV) Type 1 and Type 2 on 9/2/2026.The order for the STD was signed in the EMR by Doctor K on 9/6/2025 at 6:54PM.*A Sexually Transmitted Disease panel test is a comprehensive, single-session screening that checks for multiple sexually transmitted infections.A review of R64's EMR revealed the following:- RN H observed R64 with white bumps on (their) vaginal labia, multiple whitish raised bumps, labia appeared swollen on 8/15/2025.-Doctor K was notified and ordered to start acyclovir on 8/15/2025.-Labs for STD were entered on 8/19/2025.-Labs for STD were collected by an outside agency on 8/29/2025.According to the Genital Herpes CDC -Fact Sheet, Herpes simplex virus (HSV) can infect many different parts of your body, most commonly your mouth area (oral herpes) and genitals (genital herpes). HSV causes fluid-filled blisters that break open and crust over wherever the infection is. This is known as a herpes outbreak. *A positive HSV IgG test indicates exposure to the Herpes Simplex Virus and has developed antibodies.On 02/25/2026 at 2:49 PM, the Director of Nursing (DON) and Nurse Manager M were interviewed about RN H documentation of R64's with white raised bumps on the vaginal labia, the appearance of swollen labia, and Doctor K labs and treatment ordered for Herpes Simplex Virus. The DON said she did not remember that occurrence. Nurse Manager M also said that she did not remember that incident. At this time, Nurse Manager M was reminded that she entered the laboratory order in R64's EMR on 8/19/25 and explained that she did not think anything of the STD labs and did not question the reason for the labs. Nurse Manager M was queried if there was a suspicion of possible sexual abuse being that R64 was over [AGE] years old, with impaired cognitive function, and the fluid-filled blisters on R64's vaginal area. Nurse Manager M said she did not consider the thought of sexual abuse. Nurse Manager M said she did discuss R64's condition with the DON or the Abuse Coordinator (Nursing Home Administration-NHA).On 02/26/2026 at 09:45 AM, the NHA was asked if he was aware of R64's vaginal blisters, acyclovir medication, lab orders for STDs, and not investigating an unexplained STD. The NHA stated, This is not a case of abuse.we did not investigate it because there was no reason to investigate. The NHA stated that the labs (from 9/2/2025) proved that R64 had antibodies to Herpes so there was no need to investigate. The NHA was informed that the EMR revealed R64 was treated for the herpes virus and positive Herpes lab results were noted on 9/2/25. The NHA stated, The antibodies are proof that (R64) had it (herpes) before. The NHA did not respond to why the facility did not investigate at the time of R64's herpes diagnosis. The NHA was informed that the facility's EMR and R64's previous facility's notes did not reveal a previous Herpes diagnosis or outbreak.According to CDC Screening for genital herpes.*A positive HSV-2 IgG test indicates antibodies to the herpes simplex virus type 2, suggesting a past or current infection.*A positive IgG result cannot distinguish between a recent or distant infection.*The test detects IgG antibodies, meaning infected at some point in the past (weeks, months, or years ago).On 02/26/2026 at 10:43 AM, the DON was queried if an investigation was initiated related to R64 testing positive for Herpes Simplex Virus (HSV) Type 1 and Type 2. The DON stated, It should have been investigated. I don't know how this got passed me. The DON said she did not remember the incident and was not sure if she knew about the positive Herpes test.On 2/26/26 at 10:17AM, an attempt to contact RN H was unsuccessful. A voice message was left. On 2/26/26 at 10:21am, an attempt to contact Doctor K was unsuccessful. A voice message was left. A review of the facility's Abuse Prohibition Policy dated 9/9/2022 revealed the following: Allegations of resident abuse, exploitation, neglect.adverse event or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies.References: References:Centers for Disease Control and Prevention. Screening for genital herpes.Centers for Disease Control and Prevention (CDC). Genital herpes - CDC fact sheet.[NAME], L., Fan, M., [NAME], X. et al. Herpesvirus-associated diseases: biomarkers and advancements in clinical research. Virol J 22, 177 (2025). https://doi.org/10.1186/s12985-025-02795-7Mody, P. H., [NAME], S., [NAME], L. K., & [NAME], J. V. (2020). Herpes Simplex Virus: A Versatile Tool for Insights Into Evolution, [NAME] Delivery, and Tumor Immunotherapy. Virology : research and treatment, 1178122X20913274. https://doi.org/10.1177/1178122X20913274

Based on observation, interview, and record review, the facility failed to ensure a bottle of hydrogen peroxide was not stored at bedside for one resident (R29) out of three residents reviewed for accidents.Findings include: On 2/24/2026 at 10:10 AM, a bottle of hydrogen peroxide was observed from R29's doorway stored on a bedside table in front of a container with R29's name written on it. When R29 was asked about the bottle, R29 said the bottle was hers but could not state the reason for the hydrogen peroxide. R29 was observed in a wheelchair and was able to self-propel and able to reach for items on her bedside table. R29 was alert and oriented times two and was difficult to understand.On 2/25/2026 at 9:00 AM, a bottle of hydrogen peroxide was observed on R29's bedside table.On 2/25/2026 at 9:15 AM, Registered Nurse E was observed entering R29's room and made R29's bed.On 2/25/2026 at 9:37 AM, a bottle of hydrogen peroxide was observed on R29's bedside table with Licensed Practical Nurse (LPN) F. LPN F was interviewed and said R29 should not have the hydrogen peroxide at bedside. LPN F stated, It's a potential accident due to her behaviors. LPN F said R29 has a history of spitting, hitting other residents and staff.On 2/26/2026 at10:30 AM, The Director of Nursing (DON) was interviewed and stated, The hydrogen peroxide should not be at bedside. It is a hazardous material. The DON further said R29 had a history of behaviors and resided on the lockdown unit because she needed increased supervision. Record review of R29's Electronic Health Record (EHR) revealed R29 admitted to the facility on [DATE] with pertinent diagnoses of Schizophrenia, Adjustment disorder with mixed anxiety and depressed mood, Dysphagia, and Violent behavior. There were no orders allowing self-administration of medications or an order for hydrogen peroxide. There was no evidence in the electronic medical record of an interdisciplinary team assessment for self-administration of medications. Review of the care plan did not reveal any interventions for self-administration of medications. Review of the facility policy titled Medication Administration revised 10/17/2023 revealed in part.Resident medications are administered in an accurate, safe, timely, and sanitary manner. Self-Administration-residents are allowed to self-administer medications when specifically authorized by the attending physician in accordance with the guidelines for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administering process. Self-administering of medication will be reflected in the resident care plan along with any special considerations.

Based on observation, interview and record review, the facility failed to ensure adequate supportive personnel to consistently maintain the sanitation in the kitchen and ensure food safety practices were performed. This deficient practice had the potential to affect 90 of the 96 residents that consumed meals from the kitchen.Findings include:On 2/25/at 12:25 P.M. during observation of the sanitation in the kitchen Dietary Manager (DM) I stated, I am only budgeted for 9 employees a day Monday through Friday, that includes (Fine Dining for lunch), I cannot do any overtime. DM I was queried concerning the exact number of hours each employee worked a day. The manager explained about three weeks ago, an employee (stock person) had to be let go. DM I explained the stock person helped with the cleaning of the kitchen equipment, rotated stock and ensured the floors were cleaned and other things in the kitchen. Since that employee's vacancy all the staff, including the Dietary Manager, pitch in to complete the tasks normally performed by the stock person. DM I added that any further questions concerning replacement hours used for (call ins, vacation relief, and replacement of the stock person) should be referred to the Dietitian and or Administrator.On 2/26/26 at 1:00 P.M. during an interview with the Administrator, Director of Nursing and Registered Dietitian concerning the sanitation in the kitchen, the Administrator confirmed the number of budgeted employees (9) presently allocated but did not provide the exact budgeted hours or the basis for reference for the 9 employees. The Administrator indicated DM I was a Working supervisor and the allotted hours should be sufficient. The staffing schedule indicated the following schedule (A.M. shift) 1 cook, 3 aides, 1 porter 7 days a week), P.M. Shift (1 cook, 2 Aides, 1 porter 7 days a week). The Administrator reviewed proposed future changes in staffing by the end of the month; however, no actual numbers or other details were provided concerning the department's lack of personnel to perform and maintain sanitation in the department.On 2/26/26 at approximately 4:00 P.M the Administrator provided no additional information pertaining to the actual budgeted work hours per day for the department or the per patient day (PPD) amount used to calculate budgeted hours for the facility.

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis for one (R64) of six residents reviewed for infection control. Findings include:On 02/24/2026 at 11:30 AM, R64 was observed in bed, wearing a gown, with their eyes closed. R64 did not respond to name called.A review of R64's electronic medical record (EMR) revealed an admission to the facility on [DATE] with the diagnosis of Vascular Dementia with Agitation, Depressive disorder, and Chronic Obstructive Pulmonary Disease. A review of R64's Brief Interview for Mental Status (BIMS) disclosed a score of 00 (score of 00 indicates severe cognitive impairment).A review of R64's Care plan revealed the following:Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated: 10/31/2024 Created on: 10/31/2024.A review of R64's progress notes revealed the following:Registered Nurse (RN H) documented on 8/15/25 at 3:00 PM: Resident (R64) with white bumps on her vaginal labia (skin folds (inner and outer lips) surrounding the vaginal opening), multiple whitish raised bumps. Labia appeared swollen. No complaints of pain or itching.RN H documented on 8/15/25 at 5:53 PM: Called (Doctor K) ordered to start acyclovir (prescription antiviral medication used to treat and manage herpes virus infections).for 7 days.A review of R64's laboratory order created by Nurse Manager M on 8/19/2025, noted testing for Sexually Transmitted Disease (STD):Herpes simplex virus (HSV)-1 (typically causes oral herpes)HSV-2 (genital herpes through sexual contact)Human immunodeficiency virus (HIV) AntibodySyphilis Antibody, Chlamydia and Gonorrhea (detected using a urine sample).Results revealed R64's positive Herpes Simplex Virus (HSV) Type 1 and Type 2 on 9/2/2026.The order for the STD was signed in the EMR by Doctor K on 9/6/2025 at 6:54PM.On 02/25/2026 at 2:49 PM, the Director of Nursing (DON) and Nurse Manager M were Interviewed about RN B observation of R64 with white raised bumps on R64's vaginal labia, and the appearance of a swollen labia. In addition, Doctor K ordered acyclovir on 8/15/2025, and labs ordered on 8/19/25 for STD. The DON said she did not remember that occurrence. Nurse Manager M also said that she did not remember that incident. Nurse Manager M was reminded that she entered the laboratory order in R64's EMR on 8/19/25. Nurse Manager M stated, I was helping someone with entering the orders. Nurse Manager M added that she did not think anything of the STD labs and did not question the reason for the labs. Nurse Manager M was queried if there was suspicion of possible sexual abuse being that R64 was over [AGE] years old, impaired cognitive function, and the fluid-filled blisters on R64's vaginal area. Nurse Manager M said she did not consider the thought of sexual abuse. Nurse Manager M was asked if the vaginal blisters, immediate order for acyclovir, and personally entering the order for STD labs were discussed with the DON. The DON and Nurse Manager M stated, No. Nurse Manager M was queried if the vaginal blisters, acyclovir, and STD labs were discussed with the Abuse Coordinator. Nurse Manager M answered, No. I did not think nothing of it.On 02/26/2026 at 09:05 AM the Infection Preventionist N was interviewed and queried about R64 white raised bumps labia, and Doctor K ordered acyclovir on 8/15/2025. Infection Preventionist N said she did receive R64 being started on Acyclovir on her dashboard. Infection Preventionist N was asked if she implemented a surveillance plan for tracking, monitoring communicable diseases including R64's Herpes diagnosis. Infection Preventionist N stated, the physician (Doctor K) ordered the antiviral and that was it. (R64) did not need to be monitor.On 02/26/2026 at 09:45am, the Nursing Home Administrator (NHA) was interviewed and asked if he was the facility's Abuse Coordinator. The NHA answered Yes. The NHA was asked if he was aware of R64 vaginal blisters, acyclovir medication, lab orders for STDs, and not reporting an unexplained STD. The NHA said that the lab results proved that R64 had antibodies to the Herpes so there was no need to report or investigate. The NHA said that Doctor K told him and the DON on 02/26/2026 that R64 had antibodies. The NHA stated, The scientific proof is in the lab results.*A positive HSV-2 IgG test indicates antibodies to the herpes simplex virus type 2, suggesting a past or current infection.*A positive IgG result cannot distinguish between a recent or distant infection.*The test detects IgG antibodies, meaning infected at some point in the past (weeks, months, or years ago).References:Centers for Disease Control and Prevention. Screening for genital herpes.Centers for Disease Control and Prevention (CDC). Genital herpes - CDC fact sheet.On 02/26/2026 at 10:43 AM, The DON was queried if they reported R64's unexplained positive for Herpes Simplex Virus (HSV) Type 1 and Type 2. The [NAME] stated, It should have been reported and investigated. I don't know how this got passed me. The DON said she did not remember the incident and was not sure if she knew about the positive Herpes test. The DON was asked if it was their process to update the care plan and diagnosis list of the Herpes diagnosis. The DON said the care plan and diagnosis list should have been updated.On 2/26/26 at 10:17AM, an attempt to contact RN B was unsuccessful. A voice message was left. On 2/26/26 at 10:21am, an attempt to contact Doctor K was unsuccessful. A voice message was left. A review of the facility's Infection Prevention Program Policy dated 10/11/2023 revealed the following: Resident Infection cases are monitored by the Infection Preventionist. The Infection Preventionist completes the infection Surveillance Tracking Tool in Infection Watch and:Reports to the Infection Prevention CommitteeProvides feedback to staff as needed.Reports notifiable diseases to the local health department as directed.Infection Preventionist responsibilities may include:-Collection, analyzing, and providing infection data and trends to nursing staff and healthcare providers.-Consulting on infection risk assessment, prevention, and control strategies.-Compliance with Infection Prevention practice is monitored and documented by the Infection Preventionist through surveillance and observation.

Based on interview and record review, the facility failed to maintain an effective Antibiotic Stewardship program when protocols for appropriate antibiotic administration were not implemented and infection criteria was not met for thre residents (R3, R60, and R71.) This had the ability to affect residents that were prescribed and administered antibiotics while residing at the facility. Findings include: On 1/23/25 at 11:23 AM the facility's Antibiotic Stewardship Program was reviewed with the Director of Nursing (DON). The DON said that the facility had recently hired an Infection Control Nurse, Registered Nurse (RN) E but RN E was not in the facility at the time of infection control program review. The DON said she is an Infection Preventionist and had been responsible for the facility's Infection Prevention Program including Antibiotic Stewardship prior to the hiring of RN E. The facility's Infection Prevention Program was reviewed and indicated that the facility follows McGeer's Criteria (a surveillance tool used to ensure definitive criteria has been met to identify true infections) when prescribing antibiotics and utilized a form; McGeer Criteria for Infection Surveillance Checklist (MCISC). Review of the facility's December 2024's Antibiotic Administration Report revealed the following: R3 According to the Antibiotic Administration Report (line listing), R3 had been prescribed the antibiotic Cipro 500 milligram (mg). There was no start or stop date on the report. There is a note that reads; do repeat urinalysis (UA). There was no Infection Report, MCISC, or UA included in that report. The DON reviewed R3's Electronic Health Record (EHR). There was no MCISC. The UA results from 12/10/24 indicated no culture and sensitivity report was done because there were not enough bacteria present. The Infection Screening Evaluation indicated the resident had only one symptom, pain in bladder area. The DON said, There is a concern with this. It did not appear to meet the criteria for a urinary tract infection. Further review of R3's EHR revealed the resident was diagnosed with bladder cancer and had frequent pain in that area. R60 According to the Antibiotic Administration Report (line listing), R60 had been prescribed the antibiotic Keflex 500 mg for skin infection. There was no start or stop date or signs and symptoms of infection in the report. There was no Infection Screening Evaluation or MCISC form included in the report. The DON said, The start and stop dates should be in this report. I'll look in the resident's record. The DON reviewed R60's Electronic Health Record (EHR) and revealed there was no MICSC. A progress note written by the Nurse Practitioner on 12/20/24 indicated the resident did not have any drainage from the surgical site. The DON said, This is not following McGeer's protocol. There should have been a follow-up to explain why the resident was prescribed antibiotics. R71 According to the Antibiotic Administration Report (line listing), R71 had been prescribed the antibiotic Gentamycin external topical ointment 0.1% for a respiratory infection. The DON said, This is a mistake. Gentamycin external topical ointment is not a treatment for a respiratory infection. No other antibiotics were listed for R71 on the report. A review of R71's EHR revealed three antibiotics had been prescribed for the resident. R71 had been prescribed Gentamycin ointment for a right heel skin infection from 12/18/24 - 1/3/25. Not a respiratory infection. On 12/18/24 R71 had also been diagnosed with pneumonia and prescribed Zithromax 250 mg for 7 days, and Doxycycline 100 mg twice a day for 7 days (12/18/24 - 12/25/24). On 1/23/25 at 1:45 PM the Nursing Home Administrator (NHA) was interviewed and said the facility had three different Infection Control Nurses since April of 2024 (9 months). The NHA said, We have just hired a new Infection Control nurse, and we hope this works out. It's been difficult maintaining someone in this position. According to the facility's Antibiotic Stewardship program effective 10/14/22 in part reads; Protocols will be developed and followed that promote health & wellness through responsible use of antimicrobials in an effort to prevent unnecessary treatment and resultant antibiotic resistance. Current literature stresses that it is important to treat active infections, not asymptomatic colonization in older adults as the emergences of drug resistant infections are rapidly outpacing the development of new antibiotic therapies. Efforts to improve antibiotic stewardship should include education and steps to address the social and behavioral factors that drive the demand for and inappropriate prescribing of antibiotics. The CDC has supported efforts to educate guests/residents and the general public regarding the threat of antibiotic resistance related to the inappropriate use of antibiotics such as for the treatment of viral infections. 1. The program will encourage appropriate prescribing; and reduce adverse effects which often include gastrointestinal problems, C. Difficile diarrhea, yeast infections and antibiotic resistance in aging adults. 2. The medical director and director of nursing will use his/her influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. 3. The Infection Preventionist will be responsible for promoting and overseeing antibiotic stewardship activities in the facility. Responsibilities include educating employees about the importance of antibiotic stewardship, and adhering to programs that prevent the spread of infection and improve antibiotic use. 4. The medical director, primary care providers and pharmacy consultants will be utilized for their drug expertise and/or training in improving antibiotic use. This includes the selection, dosing, appropriate route, of administration and days of therapy 9. Healthcare acquired (nosocomial) infections and use of antimicrobial agents will be tracked and trended. Infection surveillance and trending of infections will be a key component of our QAPI process. The facility has adopted the McGeer's criteria for infection surveillance definitions. The McGeer Criteria for Infection Surveillance Checklist (MCISC) was identified.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions (EBP- personal protective equipment used to prevent the spread of infections) were worn during the administration of medications via a gastric tube for one resident (R6) out of three residents reviewed for infection control practices. Findings include: On 1/22/25 at 8:55 AM, signage was observed on R6's door reminding staff that EBP should be worn when providing care. Licensed Practical Nurse (LPN) D was observed entering R6's room to administer medications via the resident's gastric tube. LPN D did not apply a gown before administering medications. Review of R6's electronic medical record (EMR) documented an original admission into the facility on [DATE] with a pertinent diagnosis of gastrostomy status (gastric tube). Review of Minimum Data Set (MDS) dated [DATE], R6 required substantial/maximal assistance with most Activities of Daily Living (ADLS). Review of Brief Interview for Mental Status (BIMS) dated 4/10/24, R6 scored 14 out of 15 (intact cognition). Record review of R6's ADL Care plan created on 10/14/24 documented Substantial / Maximal Assistance (Enhanced Barrier Precautions). An interview was conducted on 1/22/25 at 11:16 AM, LPN D reported that when administering medications to residents with a gastric tube, a gown and gloves should be worn by nursing staff. On 1/22/25 at 3:30 PM an interview with Director of Nursing (DON) was conducted and revealed that LPN D should have applied EBP before administering the medication to R6 via the gastric tube. It was further reported that those precautions should help to prevent the spread of infections in the facility. Review of facility's policy Enhanced Barrier Precautions (EBP) dated 3/26/24, the following was documented: It is the intent of this facility to use Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for preventing the transmission of CDC (Centers for Disease Control and Prevention) targeted multidrug-resistant organisms (MDROs). Enhanced Barrier Precautions are indicated for residents with any of the following: 1) infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or 2) a wound or medical device, even if the resident is not known to be infected or colonized with a MDRO and should remain in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk.

This citation pertains to intake MI00148780. Based on observation, interview, and record review, the facility failed to ensure (1) safe positioning in a geri-chair, (2) implement appropriate interventions to prevent falls from a geri-chair, and (3) implement appropriate post-fall interventions for one resident (R303) of three residents reviewed for falls, resulting in a fall causing a laceration to the forehead and transfer to the emergency room for imaging studies. Findings include: A complaint received by the State Agency alleged the resident fell and sustained an injury. On 12/17/24 at 11:39 AM, R303 was observed in their room with their eyes closed making some slightly restless movements with their arms and hands. An attempt to get R303's attention by speaking to them was not ackowledged by R303. At the bedside, a geri-chair was observed with two large, thick cushions in the seat. The cushions were made of a shiny black material that appeared slippery and were approimately six and eight inches thick. A review of R303's clinical record revealed they most recently readmitted to the facility on [DATE] and begun hospice services. R303's diagnoses included: protein calorie malnutrition, traumatic subdural hemorrhage, dementia, duslusional disorder, failure to thrive, and seizures. R303's most recent completed Minimum Data Set (MDS) assessment revealed they had severely impaired cognition and needed substantial/maximal assistance for most activities of daily living including transferring and needed partial/moderate assistance for rolling their body from left to right. R303's most recent re-admission nursing assessment dated [DATE] was reviewed and indicated they were At Risk for falls. A review of R303's Kardex (care guide) was conducted and did not indicate R303 used a geri-chair. R303's progress notes were reviewed and revealed the following: A note entered into the record by Nurse 'A' dated 12/5/24 at 11:43 AM indicated R303 was discovered on the floor near their geri-chair with their positioning pillow and a sheet near them with a laceration above their right eye. A note entered into thre record by Nurse 'B' dated 12/6/24 at 9:20 AM indicated the resident had a fall on 12/5/24 resulting in a laceration above their right eye and they (Nurse 'B') transferred R303 to the emergency room per the Nurse Practitioner's order. At that time, R303's care plans were reviewed and did not include any care plans for the use of a geri-chair and/or positioning cushions, or any care plans with interventions for falls at the time the fall occurred on 12/5/24. A review of a facility provided incident report completed by Nurse 'A' indicated the following: R303 resident slid out of the their geri-chair, they were oriented to person, there were no predisposing environmental factors that contributed to the accident, there were no predisposing situation factors that contributed to the accident, and listed confusion, impaired memory, and gait imbalance as predisposing physiological factors to the accident. A review of a facility provided document titled, Post Fall Evaluation last revised July 2014 was reviewed and read, Factors observed at time of fall .Equipment malfunction (specify): Extra padding on gerichair .Were there any changes in the resident's normal routine? (a box marked 'yes') If yes, explain: Res (resident) has a new gerichair cushion, will adjust to sit lower while resident utilizes it . A second review of R303's care plans for falls was conducted and revealed the first fall care plan for R303 was implemented on 12/6/24 by MDS Nurse 'C', the day after the actual fall. The focus read, (R303) is at risk for fall related injury and falls R/T (related to): Confusion, Decondition, Fear of Falling .hx (history) of falls . The interventions on the plan included the following: anticipate the resident's needs, assess the fall risk level, do not leave resident unattended in bathroom, education resident/family/caregivers about safety, appropriate footwear, observe for fatigue and offer rest, obtain labs, provide activities, call light in reach, and revieweing information on past falls to determine root cause. It was noted the care plan did not include any interventions about the geri-chair, the cushions, or increased supervision. On 12/17/24 at 2:04 PM, a phone call was placed for an interview to Nurse 'A', and a voicemail was left, however; the call was not returned. On 12/17/24 at 2:06 PM, a phone call was placed to Nurse 'B' and a voicemail was left, however; the call was not returned. On 12/17/24 at 2:15 PM, an interview was conducted with the facility's Director of Nursing. They were asked how the resident fell from the geri-chair and said they slipped out of the chair because of the very thick cushions that were in the chair at the time. They were then asked why R303 did not have any care plans for falls prior to the fall and said they were going to locate them, however; no evidence of an active fall care plan prior to 12/6/24 was provided by the end of the survey. Finally, the DON was asked why none of the current care plan interventions implemented on 12/6/24 addressed the use of the geri-chair and the cushions and they had no response, but indicated their understanding the care planned interventions in place were not all appropriate for R303 in light of the root cause of the fall on 12/5/24. A review of a facility provided policy titled, Fall Management revised 9/22/23 was conducted and read, The facility will identify hazards and resident risk foactors and implement interventions to minimize falls and risk of injury related to falls .When a fall occurs .4. The licensed nurse will complete: .Review and or revise care plan and link to the resident kardex (care guide) .

This citation pertains to Intake MI142329. Based on observation, interview, and record review the failed to submit the 5-Day investigation to the State Agency for an allegation of resident-to-resident abuse in the required time which involved two residents (R101 and R102) of four residents reviewed for resident- to- resident abuse resulting in an unreported allegation of abuse and the potential for more allegations of abuse to go unreported. Findings include: On 2/7/24 at 10:50 a.m. the Director of Nursing provided the FRI (facility reported incident) and other pertinent documentation regarding the reported incident that occurred on 1/1/24 at 1:00 pm. R102 alleged receiving a fracture because of being rammed with a wheelchair by R101. The facility submitted the incident report (Incident Summary) to the State Agency on 1/3/24 at 4:18 pm. However, the facility did not submit the 5-Day Investigation until 1/17/24 at 3:46 pm (10 days later). On 2/7/24 at 3:05 p.m. the Nursing Home Administrator (NHA) who also identified as the Abuse Coordinator was interviewed and said the Director of Nursing (DON) was getting interviews for the investigation and the NHA was responsible for completing everything else, however it was forgotten and submitted late. The DON was unavailable to participate in an interview. Review of the clinical record documented R101 was admitted into the facility on [DATE] with diagnoses that included delusional disorder, anxiety disorder, and schizoaffective disorder. According to the quarterly Minimum Data Set (MDS) dated [DATE], R101 was cognitively intact and required supervision with set up with activities of daily living. Review of the clinical record documented R102 was admitted into the facility on [DATE] with diagnoses that included major depressive disorder, adjustment disorder, and anxiety disorder. According to quarterly MDS assessment dated [DATE], R102 was cognitively intact and required maximum assistance with activities of daily living. Review of the facility's policy titled Abuse Prohibition Policy dated 9/9/22 documented: .Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies .The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegations or serious injury; all others not later than 24 hours). At the conclusion of the investigation, and no later than 5 working days of the incident .

Based on observation, interview, and record review the failed to identify a reportable allegation of resident-to-resident abuse to the Nursing Home Administrator or the State Agency in the required time for one resident (R18) of 8 sampled residents reviewed for abuse resulting in an unreported allegation of abuse and the potential for more allegations of abuse to go unreported and feelings of not being protected or safe within the facility. Findings include: On 11/28/23 at 1:12 p.m. R18 was observed resting in bed, awake, and alert. During the resident interview, R18 said there was an injury to the breast which occurred about a week ago (11/21/23). R18 pulled the gown up and exposed a dressing that was applied to the right underside of the breast in which the skin was visible through. The breast had a blackened area that was approximately two inches and caused discomfort to the resident. R18 said the blackened area was burned with a cigarette lighter by another resident (R88). The resident said there was no memory of the burn occurring however overheard the other resident speaking and laughing about it. On 11/28/23 at 11:07 a.m. Nurse C was interviewed and asked the awareness of the allegation made by R18. Nurse C acknowledged being aware of the allegation but did not report it because there was no evidence of the incident occurring. On 11/28/23 at 11:19 a.m. the Nursing Home Administrator (NHA) was interviewed and said the resident had a history of reporting many incidents which have been proven to be untrue. Review of the incident report documented the alleged incident occurred on 11/21/23, the Administrator was notified on 11/27/23, and reported and investigated on 11/28/23. On 11/29/23 9:31 a.m. review of the electronic clinical record documented R18 was admitted into the facility on [DATE] with diagnoses that included schizoaffective disorder, anxiety disorder, and congestive heart failure. According to the quarterly Minimum Data Set assessment dated [DATE], R18 was cognitively intact (BIMS score of 15) and required supervision with set up assistance with most activities of daily living. Review of the Physician Assistant's progress note dated 11/26/23 at 21:58 (11:58 pm) documented the following: .seen and examined at patient's behest for right breast redness and wound. Exam chaperoned with nurse (nurse's name). Patient states that resident (R68) came to her room at night and burnt her on her right breast with cigarette lighter. She stated that this happened couple days ago and did not tell anyone. On 11/30/23 at 10:57 a.m. the Physician's Assistant (PA) was interviewed about the allegation that was documented in the progress note dated 11/26/23 in which the PA verified seeing R18 at the bedside and was accompanied by a nurse to examine the resident's right breast. The PA said R18 reported the breast was burned with a lighter and the incident was reported previously to a nurse a couple of days ago. The PA also said the Director of the Nurse's (DON) was notified the next day about the allegation. The incident was not reported immediately by the PA under the assumption it was already reported by the nurse couple of days ago, If I was the first to see it, I would have reported immediately. I know it was known because there was a 2x2 dressing in place. On 11/30/23 at 2:42 p.m. the DON was interviewed and verified the NHA was the Abuse Coordinator, and the DON is the designated Abuse Coordinator. They were both notified of the incident on 11/27/23. They were notified by the Social Worker and the PA. The DON acknowledged the allegation should have been reported immediately by nursing and the PA. On 11/30/23 at 3:13 p.m. the NHA was interviewed and verified being the Abuse Coordinator. The NHA acknowledged the reporting of the allegation was not done in a timely manner and the issue will be addressed with staff. Review of the facility's policy titled Abuse Prohibition Policy dated 9/9/22 documented: .Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies .The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegations or serious injury; all others not later than 24 hours). At the conclusion of the investigation, and no later than 5 working days of the incident .

This citation pertains to intake 139933. Based on interview and record review, the facility failed to review and revise a fall care plan for one resident (R47) of four residents reviewed for accidents, resulting in falls with injury and the potential for reoccurring falls. Findings include: A review of R47 EMR (Electronic Medical Record) revealed R47 was admitted to the facility on [DATE] and discharged from the facility 11/18/23. R47 had medical diagnoses that included Dementia, Osteoarthritis (arthritis of the bone), Psychosis, and Disorders of Bone Density and Structure. A review of R47's MDS (Minimum Data Set), dated 8/1/23, revealed R47 had a BIMS (Brief Interview of Mental Status) score of 0/15 (severely cognitively impaired). R47 required one person limited assistance with bed mobility and transfer. R47 was independent with set up only for walking in her room and the corridor. An incident report dated 9/8/23 revealed R47 had an unwitnessed fall when her translator left the room to get an CNA (Certified Nurse Assistant) to assist R47 to the restroom. R47 sustained no injuries and neuro checks were initiated. R47's predisposing situation factor was documented as ambulating without assistance. An incident report dated 10/1/23 revealed R47 had an unwitnessed fall. A CNA was rounding and found R47 lying on the floor next to her bed on her left side. R47 sustained a gash to the left eyebrow. R47 was transported to the hospital per Physician order. An incident report dated 11/1/23 revealed R47 had an unwitnessed fall. A CNA observed R47 lying on a blanket on the floor next to her bed. R47 had sustained a bruise to the left side of her forehead. Neurological checks were initiated, a skull x ray was ordered, and ice was given to R47 for her bruising. R47's predisposing situation factor was documented as ambulating without assistance. A review of R47's care plan dated 4/18/22 revealed the following: Focus-(R47) is at risk for fall related injury and falls related to new admission, dementia with behaviors and psychosis history (with revision date of 4/20/22) .Goal-will be free from injury related to falls through the review date (with a revision date of 11/1/23) .Interventions- anticipate and meet needs as needed (created 4/19/22), complete fall risk per protocol (created 4/19/22), (R47) is known for sleeping in the fetal position, ensure she is positioned in the center of the bed to avoid slips/falls (created 5/10/22). The only revision made to the fall care plan was for R47's goal dated 11/1/23. There was no evidence R47 had new interventions put in place related to her three falls within a three-month period. On 11/30/23 at 9:59 AM, during an interview with the DON (Director of Nursing), the DON was queried regarding the revision of R47's care plan after R47 experienced three unwitnessed falls. The DON verified that she did not see in the EMR (Electronic Medical Record) where R47's care plan had been updated. The DON said her expectation is care plans should be reviewed to make sure that they are appropriate. A review of the facilities policy titled Care Planning, with an effective date of 6/24/21 revealed in part, The care plan and resident kardex will be updated on Admission, Quarterly, Annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable as needed.

Based on interview and record review, the facility failed to ensure that wound care treatments for pressure ulcers (damage to skin from prolonged pressure to skin) were consistently provided for one resident (R42) of three residents reviewed for wound care, resulting in the potential for worsening of pressure ulcers. Findings include: Review of an Admission Record revealed, Resident #42 (R42) originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Pressure Ulcer of Sacral Region Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). Review of a Minimum Data Set (MDS) assessment, with a reference date of 9/20/23 revealed R42 had severe cognitive impairment with a Brief interview for Mental Status (BIMS) score of 00, out of a total possible score of 15. R42 required total dependence of two persons with bed mobility. Review of Physician orders revealed, R42 had treatment orders for Calcium Alginate-Silver External Pad 2X2 (used for moderate to heavily draining wounds) and Triad Hydrophilic paste (used to protect skin from draining wounds) to the coccyx. Review of a Treatment Administration Record (TAR) from September through November 2023 revealed wound care not documented on 9/11, 9/12, 9/13, 9/14, 9/23, 10/2, 10/9, 10/30, 11/19, 11/20, and 11/23/23. In an interview on 11/30/23 at 9:49 a.m., Wound Nurse A reported the floor nurses are responsible for completing wound care when the wound nurse is not present. In an interview on 11/30/23 at 12:04 p.m., the Director of Nursing (DON) reported the floor nurse is responsible for wound treatments when the wound nurse is not present. The DON then reported wound care should be documented after completion.

Based on interview and record review the facility failed to ensure the physician received the pharmacist Medication Regimen Review (MRR) recommendations timely for one resident (R73) of five residents reviewed for medication regimen review, resulting in the physician being unaware of medications that may cause resident discomfort. Findings include: On 11/28/23 at 11:24 a.m. R73 was observed resting in bed, awake, and alert. During the resident interview, R73 complained of having chronic pain and wanting an increase in pain medication. R73 said bowel movements are regular and had no complaints of constipation, Sometimes I go too much. On 11/29/23 at 11:40 a.m. review of the electronic clinical record documented R73 was admitted into the facility on [DATE] with diagnoses that included low back pain, low back pain, radiculopathy, lumbosacral region, discitis, and thoracic region. According to the quarterly Minimum Data Set assessment dated [DATE], R73 required setup of one person assistance with activities of daily living. Review of monthly pharmacy recommendations documented the following: 7/22/23- Medication Regimen Review - Pharmacy Consultation Report (R73) receives routine docusate (stool softener, brand name Colace)) 100mg q day in addition to Lactulose (constipation) 20gm q 8hours and MiraLAX (stool softener) 17gm q day. There is insufficient quality evidence supporting the effectiveness of docusate . Recommendation: Please consider discontinuing docusate. There was no physician signature indicating review of the MMR. However, the Director of Nurses (DON) signed the recommendation on 11/29/23. Handwritten on the bottom of the report documented, Colace d/c on 9/4/2023. 8/28/23- Medication Regimen Review - Pharmacy Consultation Report (R73) prescriber accepted a pharmacy recommendation to discontinue Colace, but the order has not yet been processed. Recommendation: Please discontinue Colace. There was no physician signature indicating physician review or Director of Nurses signature on the document. Handwritten on the bottom of the report documented, Colace d/c 9/4/2023. Review of the physician's orders confirmed the medication Colace 100 mg (Docusate Sodium) was discontinued on 9/4/23. On 11/30/23 at 2:32 p.m. the Director of Nurses (DON) was interviewed about the delay in the facility responding to the pharmacy recommendations for the month of July 2023 and August 2023. The DON stated, 'The pharmacist emails the reports within twenty-four to forty-eight hours after they are completed. Generally, the DON and the Unit Manager handle the pharmacy recommendations. They are put in the physician's book and a decision is made by the physician whether to follow the recommendation or not to. The order is then changed based on the recommendation. Some how this was missed. Review of the facility's policy titled Timeliness of Medication Regimen Review (MRR) Reports dated 9/7/2023 documented: The pharmacist will review and report any medication irregularities at least once a month . The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt . If the attending Physician does not respond to the resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports . If by the 21st day, the attending physician has not yet responded to the resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports .

This citation pertains to intakes MI00132631, MI00132812, MI00132884, and MI00133311. Based on observation, interview, and record review, the facility failed to consistently implement interventions to prevent the development of pressure injuries for one resident (#26) of three residents reviewed for pressure ulcers, resulting in the potential for the development of a pressure injury. Findings include: During an observation on 1/4/2023 at 10:41 AM, Resident #26 (R26) was observed awake, lying in her bed, with bed covers over her body. R26's feet appeared to be lying directly on the mattress beneath the bed covers. At 10:47 AM when R26's bed covers were pulled back in preparation to perform a wound dressing change, her feet were observed to be resting directly on the mattress. During an observation and interview on 1/5/2023 at 10:43 AM, R26 was awake and lying in her bed. When asked if she wore soft boots on her feet while in bed, R26 said she has not had the boots on in at least two weeks. R26's feet were observed to be resting directly on the mattress. During an observation and interview on 1/5/2023 at 10:47 AM, Certified Nurse Aide (CNA) J said she provides care to R26 but was unaware that she was supposed to wear soft boots. At 10:49 AM, CNA J went into R26's room and located two soft boots in the resident's property. During an interview on 1/5/2023 at 10:54 AM, CNA K stated, (R26) is supposed to wear (soft boots) while in bed, but in the morning when I come to work (R26) does not have them on. I get her up, but I don't put the boots on. I don't think she should have them on in the chair. I wasn't told she should wear them in the chair. CNA K said it has been at least three weeks since she put the boots on R26. During an interview on 1/5/2023 at 11:09 AM, Director of Nursing (DON) stated, (R26) has the heel boots and they can (also) use a pillow (to elevate her feet in order to float her heels). The boots are heel protectors, and she should have them on whenever she's in bed to prevent breakdown. A review of R25's Face Sheet documented an admission to the facility on [DATE] with diagnoses that include burn of unspecified body region and major depressive disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A physician order dated 9/9/2016 stipulated to float heels off mattress q (every) shift. A review of R25's care plans documented in part the following: -Focus: (R26) has an actual impaired skin integrity related to pressure injury. Site: left bunion: Stage 3. Revised 4/21/2021. Interventions included: Bilateral soft heel boots; elevate bilateral lower extremity, and float heels. -Focus: (R26) is at risk for skin breakdown/pressure ulcers related to history of pressure ulcer, decreased mobility, incontinence, and history of burns, scratches, and diabetes diagnoses, Stage 3 pressure ulcer left bunion. Revised 4/21/2021. Interventions included: Float heels if possible heel protectors while in bed. A review of the facility document titled, Skin Management, dated 12/15/2022, revealed in part the following: - Guest/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. - Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented in the care plan. On 1/5/2023 at 2:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to intake MI00132766. Based on interview and record review, the facility failed to follow therapy recommendations and a physician's order to provide restorative services to maintain/increase range of motion for one resident (#25) of four residents reviewed for therapy services, resulting in resident frustration and the potential for a decline in range of motion and mobility. Findings include: It was reported to the State Agency that the resident was frustrated regarding his mobility status. A review of the Face Sheet for Resident #25 (R25) documented an admitted [DATE] with diagnoses that included mood disorder and peripheral vascular disease. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, dependence upon a wheelchair for mobility, and direct care staff and R25 believed he was capable of increased independence in at least some activities of daily living. During an interview and record review of therapy notes on 1/5/2023 at 12:37 PM, Registered Physical Therapist (RPT) C said R25 was totally in the bed upon his arrival to the facility but upon his discharge he was able to transfer from a bed to a chair and was able to stand but not walk. A review of R25's discharge summary from physical therapy dated 11/22/2022 documented in part the following: -R25's prognosis to maintain his current level of functioning was excellent with participation in RNP (restorative nursing program). -The recommendation for RNP was to facilitate patient maintaining current level of performance and in order to prevent decline . Further review of R25's clinical record revealed the following: 1. Facility document titled, Therapy to Restorative Program Plan, dated 11/25/2022, indicated: - Restorative Plan: 3 times a week for 4 weeks. - Goal: Maintain/increase bilateral upper and lower extremity range of motion. - Interventions: Bilateral U/E (upper extremity) AROM (active range of motion) 10 sets times 4 reps (repetitions), all joints-in all planes. Bilateral L/E (lower extremity) AROM 10 sets times 4 reps, all joints-in all planes. 2. A physician order signed on 11/28/2022 stipulated, Restorative exercise program 3 days a week for 8 weeks to maintain BUE (bilateral upper extremity) and BLE (bilateral lower extremity) ROM (range of motion) and strength. BUE and BLE AROM 4 sets of 10 reps in all planes as tolerates. 3. Nursing Kardex (used to communicate resident care instructions) for mobility directed the following for ambulation: Resident is unable to ambulate and requires a wheelchair for locomotion. Resident needs to be pushed to desired locations. BUE and BLE AROM 4 sets of 10 reps in all planes as tolerates. 4. Care Plan Focus: (R25) is at risk for decline in function and requires Restorative Nursing related to impairment in range of motion, muscle weakness. Dated 11/25/2022. Related interventions included: BUE and BLE AROM 4 sets of 10 reps in all planes as tolerates; Observe and document progress of the restorative program per the facility policy. Dated 11/25/2022. 5. Review of the Plan of Care Response History related to the task of Nursing Rehab: BUE and BLE AROM 4 sets of 10 reps in all planes as tolerates for a 30-day look-back period documented R25 received restorative services only on 12/10/2022, 12/14/2022, 12/15/2022, and 12/17/2022 (four sessions of a total of 28 per physician's order.) There were no resident refusals documented. During an interview on 1/5/2023 at 1:37 PM, the Director of Nursing (DON) stated restorative services were not provided three times a week as recommended by therapy. The DON stated the lack of restorative services could result in decline in mobility. When asked, the DON did not provide a reason why restorative services were not provided as recommended and ordered. A review of the facility document titled, Restorative Nursing, dated 4/26/2022, revealed in part the following: The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. The interdisciplinary team (IDT) works with the resident and family to identify measurable restorative goals and practical interventions that can be implemented and achieved with nursing support. A licensed nurse will help manage the restorative nursing process with assistance of nursing assistants trained in restorative care .Nursing Restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria. On 1/5/2023 at 2:45 PM during the exit conference, the Nursing Home Administrator and DON did not provide additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to consistently administer prescribed skin treatments or implement interventions to promote healing for three (R9, R65, and R80) of five residents reviewed for pressure ulcers resulting in the development of new pressure ulcers, the worsening of existing pressure ulcers, and the potential for delayed healing of pressure ulcers. Findings include: The National Pressure Injury Advisory Panel (NPIAP) Pressure Injury 2019 Guidelines for Pressure Injuries identified the following: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Wound bed is viable, pink, or red, moist, and may also present as an abrasion, intact or ruptured serum-filled blister, or shallow crater Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dark, dead skin) may be visible Stage 4 Pressure Injury: Full-thickness skin and adipose tissue loss with exposure of muscle, ligament, and/or bone. They often cause extreme pain, infection, invasive surgery, or even death. Resident #65 (R65) On 10/19/22 at approximately 10:00 AM the Wound Care Nurse Practitioner (NP) G completed wound care for R65's pressure ulcer on her coccyx. During an interview, NP G said the resident's pressure ulcer had worsened in the last few weeks and she would be prescribing oral antibiotics along with a topical anti-fungal medication to the pressure ulcer wound bed due to signs of infection. Review of the 10/19/22 wound care assessment for R65 revealed the following: pressure ulcer coccyx stage 3 = 2.94 cm (centimeter) x 1.54 cm x 1.7 cm with an area of 4.528 sq (square) cm .There is moderate amount of serosanguineous drainage (discharge that contains clear yellow fluid and blood) which has a mild odor. Review of the previous wound care assessment dated [DATE] (5 days earlier) revealed the pressure ulcer on the coccyx measured; 2.4 cm x 0.4.cm x 0.4 cm with an area of 0.96 sq cm with no drainage. On 10/4/22 (15 days earlier) the wound care assessment indicated the pressure ulcer on the coccyx measured; 1.3 cm x 0.4 x 0.2 cm with as area of 0.524 sq cm with no drainage. According to R65's Electronic Medical Record (EMR), the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/28/22 a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/18/22 the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . From 4/29/22 through 10/14/22 R65 had the following prescribed pressure ulcer treatment: [MEDICATION(S)] CA (calcium) Alginate 2, apply to coccyx daily and as needed. Review of R65's Treatment Administration Records (TAR) from 6/1/2022 through 10/14/2022 documented treatment administration times were left blank (without nurse initials), and no corresponding progress notes to indicate the pressure ulcer treatments had been administered. The June 2022 TAR had 11 of 30 (36%) prescribed treatments left blank on the TAR; 6/1, 6/4, 6/7, 6/8, 6/10, 6/13, 6/15, 6/22, 6/23, 6/25, and 6/27. The July 2022 TAR had 8 of 31 (25%) prescribed treatments left blank on the TAR; 7/1, 7/5, 7/6, 7/12, 7/13, 7/19, 7/26, and 7/27. The August 2022 TAR had 7 of 31 (22%) prescribed treatments left blank on the TAR; 8/3, 8/10, 8/17, 8/18, 8/19, 8/22, and 8/25. The September 2022 TAR had 13 of 30 (43%) prescribed treatments left blank on the TAR; 9/1, 9/6, 9/7, 9/8, 9/14, 9/15, 9/16, 9/21, 9/23, 9/24, 9/28, 9/29, and 9/30. The October TAR from 10/1 - 10/14/2022 had 4 of 14 (28%) prescribed treatments left blank on the TAR; 10/4, 10/5, 10/7, and 10/8. On 10/20/22 at 1:23 PM during an interview with the Director of Nursing (DON) she confirmed the standard of practice is for the nurse to document her initials on the TAR when a treatment is administered. R65's EMR was reviewed, and the DON acknowledged the lack of documentation to support that many of the prescribed pressure ulcer treatments had been administered. According to the Minimum Data Set (MDS) dated [DATE], R65 had severely impaired cognition, a stage 3 pressure ulcer, and required total assistance from one to two staff for all Activities of Daily Living (ADLs). A care plan for skin integrity revised on 5/17/22 included the following intervention: follow facility policy/protocol for treatments of impaired skin integrity. On 10/19/22 the following orders were prescribed by NP G: Antibiotic; [MEDICATION(S)] 100 mg tablet by mouth every 12 hours for 10 days . Treatment; apply [MEDICATION(S)] + [MEDICATION(S)] every day and as needed around the wound. Apply crushed [MEDICATION(S)] 500 mg + hydrogel every day and as needed for 7 days to the wound base. Resident #80 (R80) A review of the most current MDS, dated for 7/29/2022, revealed R80 was readmitted on [DATE] with the medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS revealed Resident #80 had a BIMs score of 0 (which indicated impaired cognition), long term and short-term memory problems, and daily decision-making skills that were severely impaired. It was also noted that R80 was totally dependent on staff for bed mobility and toileting use. The pressure ulcer determination risk noted that R80 had no pressure ulcer injury. There were no turning/ repositioning programs in place at the time of the assessment. EMR record review revealed that R80 was hospitalized on [DATE] and was readmitted to the facility on [DATE]. A nursing note dated for 7/21/22 states, patient arrived at the facility via stretcher, with two paramedics at bedside. Alert to name, VS 99.1, 67, 118/70, sp02 98 on room air. admitted with leaking peg tube. Small open are on coccyx, red area on right and left hip. all medication confirmed by facility physician. On 10/19/22 at 3:36pm Certified Nurse Aide (CNA) I was observed to reposition R80 while in bed. A black calloused growth was observed on the right hip. On 10/19/22 at 3:40pm Licensed Practical Nurse (LPN) H was queried and stated she knew that the wound was there and that there was no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/22 at 3:55pm the Director of Nursing (DON) and the Regional Clinical Nurse observed resident 80's wound. The right hip had an overgrowth of black scaly skin, and the coccyx and buttock appeared as if it is split in the middle. The DON stated that the Wound Nurse Practitioner (NP) G said there was nothing wrong with the area. Also, the DON stated herself and the nurses oversee the wound care. The DON stated the Wound NP G and herself looked at the wound when it was first noticed. The DON stated there was no documentation to support evaluation of the wound and that orders were not put in place per Wound NP G. Resident #9 (R9) During observations on 10/20/2022 at the times specified, Resident #9 (R9) was lying on her back in the bed: 8:45 AM, 11:01 AM, 12:19 PM, 1:42 PM, and 4:15 PM. A review of the Face Sheet for R9 documented an initial admitted [DATE] and readmitted [DATE]. R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] documented modified independence related to cognitive skills for daily decision making and total dependence upon staff for bed mobility and transfers. Further review of R9's clinical record documented in part the following: 1. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Wound care specialist, Nurse Practitioner (NP) G, note of 9/28/2022: Turn/reposition every two hours. Avoid direct pressure to wound site. 3. Physician note of 10/9/2022: Skin surveillance: High risk for nonhealing of established and existing skin breach, and high risk for development of new pressure injuries. Risk factors include immobility, nutritional status, and multiple medical comorbidities described here in. Strategies to reduce vulnerability include enhanced mobility, offloading, nutritional support and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Wound care specialist, NP G note of 10/14/2022: Turn/reposition every two hours. Avoid direct pressure to wound site. During an interview on 10/20/2022 at 12:37 PM, NP G said R9 had a chronic wound on her coccyx. R9's dressing change should occur daily and as needed. There should be documentation of the dressing being changed or if R9 is refusing. During an interview and record review on 10/21/2022 at 9:49 AM, the DON confirmed R9 had a pressure ulcer on her coccyx. A review of the October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, If it's not documented it's not done. The DON stated It is extremely important to turn and reposition residents with pressure ulcers. (Resident's) refusal to turn and reposition should be documented when it occurs. During the review of R9's clinical record, the DON was unable to produce documentation of any refusal by R9 during October 2022. On 10/21/2022 at 3:30 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to ensure a resident's pain medication was consistently available and provided, for 1 of 1 resident (R54) reviewed for pain, resulting in voiced feelings of anxiety, frustration, and unmet pain needs. Findings include: On 8/3/21 at 10:AM R54 was observed lying in bed. When asked how she was doing, R54 stated, I am in pain, they always wait until my [MEDICATION(S)] completely runs out before ordering some more, it can take 2-3 days before the new order comes in. My [CONDITION(S)] has gotten worse; it is now stage 4 and has spread to my bones. I have pain, right under my breasts now and I am to get [MEDICATION(S)] patches, I have only received 2 patches since it was ordered for me. When ask about the [MEDICATION(S)] patches, R 54 stated, I am told they do not have them, they have to look and see if anybody else has them. R54 pulled up her gown to show the surveyor where the patch should be placed under the left breast, there was no patch located at the spot R54 pointed to. R54 stated, the [MEDICATION(S)] patch really helps a lot, and began crying. Review of the face sheet indicated, R54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed R54 had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated R54 was cognitively (thought processes) intact. The MDS indicated R54 had frequent pain and rated her pain 8 on a scale of 1-10. The MDS indicated R54 was a 2- person extensive physical assistance with bed mobility, transfers, and hygiene. A review of MD pain MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed R 54 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 7/4/21. [MEDICATION(S)] Patch 5% ([MEDICATION(S)]) apply to abdomen topically in the morning for pain and remove per schedule. The order was dated 7/3/21. In an interview on 8/4/21 at 1:34PM, Director of Nursing BB stated, The [MEDICATION(S)] Patch never came to the facility. The [MEDICATION(S)] Patch was discontinued and replaced with Bengay Ultra Strength Patch. The resident did receive her [MEDICATION(S)] as ordered. Director of Nursing BB reviewed the MAR (medication administration record) for R54 with the surveyor. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no [MEDICATION(S)] administered on July 22, 24, 28, 29, and 30th. Director of Nursing BB pulled the narcotic sheets from the Narcotic Book for R54. The narcotic sheets indicated [MEDICATION(S)] was signed out for R54 on: July 22, July 24, July 28, and July 30th. Director of Nursing BB stated, I don't know what happened on July 29th. I don't know why the July 22, July 24, July 28, and July 30 doses are not signed out on the MAR. A medication record review was conducted via the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] pain levels on a 1-10 scale included: 7/19-5, 7/20-4, 7/21-4, 7/23-8, 7/25-7, 7/26-5, 7/27-5. There were no doses of [MEDICATION(S)] 5% via patch administered in the month of July 2021. Bengay Ultra Strength Patch was ordered on 7/14/21. R54 received the first patch on 7/14/21. The Bengay Ultra Strength Patch was scheduled for a 0600 application and removal at 1800. On 8/4/21 at 3:00PM R54 was observed sitting up in bed. The surveyor made an inquiry regarding R54 current pain status. R54 stated, I am feeling better, I have a patch under my breast. R54 raised her gown, and there was a patch dated 8/4/21 on the upper abdomen under the right breast. On 8/5/21 at 08:55 AM, R 54 was observed sitting up in bed, R54 stated, I have a patch under my breast. R 54 lifted her gown to show the surveyor a patch under the right breast. The patch was dated, 8/5/21 8AM. R54 stated, this is not a [MEDICATION(S)] Patch, it is a Bengay Patch. The surveyor stated, does this patch help with your pain as much as the [MEDICATION(S)] Patch did, R54 replied, no. R54 stated, now my vertebra hurts. That is where the cancer metastasized. It spread there and in my hips. I would like to get the patch on my vertebra so when the therapist comes to get me, I can get up better. R54, stated, they decided to give me my [MEDICATION(S)] regularly now. On 8/5/21 Director of Nursing BB provided the surveyor with a document entitled, Pain Management with a revision date of 7/2021. Under the section entitled Procedure, interventions specified: 1. Upon admission/re-admission, quarterly, and with a significant change in condition and PRN guest/residents will be evaluated for pain by the licensed nurse. 2. Additionally, guests/residents will be monitored for the presence of pain and evaluated where there is a change in condition and whenever new pain, or an exacerbation of pain is suspected. 3. Observe guest/residents for indicators of pain. 15. The licensed nurse, when administering PRN pain medications will record the drug administration on the medication administration record.

Based on observation, interview and record review, the facility failed to care plan and implement appropriate and timely safety interventions, provide adequate supervision, behavior management and psychoactive drug monitoring, administer medications as prescribed and facilitate timely diagnostic testing as ordered for one (#4) of 28 sampled residents reviewed for quality of care, resulting in multiple falls, bruises, hematomas, lacerations, uncontrolled adverse behaviors, continued, abnormal blood test results and multiple emergency hospital and mental health crisis center transports for care and treatment. Findings include: On 8/28/19 at 1 PM, resident #4 was observed lying crosswise on the bed on the second floor memory care secured (locked) unit with his legs hanging over the side. The right side of the bed was positioned next to the wall. He was alert, very confused, restless, had pulled open his incontinence brief and was using his feet attempting to knock over the nightstand, which caused a plastic bottle to fall on the floor. He had a wanderguard on the right ankle, a huge yellowish/greenish bruise on the left lateral upper thigh near the hip, a black scab over the left eyebrow and had a strong odor of urine. The resident was flailing his arms and legs and was unable to sit himself upright, with his head pressed firmly against the wall. Staff members were observed passing the room back and forth attending to other duties over a 10 minute period without looking in that direction. Nurse aide B finally saw resident #4 while escorting another resident in the hallway and went into the room to assist. The resident mumbled in a low tone as the aide was helping him to sit up, but was able to say no, use profanity and resist care when told he needed to be changed. On 8/28/19 at 1:30 PM, the resident's clinical record and Incident/Accident (I/A) reports were reviewed. The minimum data set ((MDS) dated [DATE] noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. He had severe cognitive impairment, was incontinent of bowel/bladder, required only supervision to limited assistance for all activities of daily living including ambulation, transfers and bed mobility, exhibited adverse and wandering behaviors that were not disruptive or posed a risk to self or others and had no falls since the previous MDS. The MDS dated [DATE] noted one fall without injury and no behaviors except wandering, otherwise the same as on 2/14/19. Other [DIAGNOSES REDACTED]. Per a progress note dated 1/18/19 by the facility's contracted Psychiatrist: The resident was seen for a medication (med) review and Staff wanted him seen because he hit another resident. The Psychiatrist recommended to continue the following prescribed medications: [REDACTED] Valproate Sodium 750 milligrams (mg) 3 times a day for [MEDICAL CONDITION] and to stabilizer mood, [MEDICATION NAME] 0.5 mg every 8 hours for anxiety and agitation, [MEDICATION NAME] 50 mg 3 times a day for depression and anxiety, [MEDICATION NAME] (anti-psychotic) 4 mg twice a day for paranoia, [MEDICAL CONDITION] and mood stabilizer. The Psychiatrist conducted an AIMS (Abnormal Involuntary Movement Scale) test to determine the presence of side effects from use of the psychoactive medications, including abnormal trunk and extremity movements that could increase risks for falls. The resident's other prescribed meds included: Alendronate Sodium once a week and Oyster Shell twice a day for [MEDICAL CONDITION], and [MEDICATION NAME] 60 milliliters (ml) 3 times a day. Per the website, Drugs.com (referenced on 8/29/29 at 8 AM), [MEDICATION NAME] is used to reduce elevated blood ammonia levels caused by liver conditions (such as [MEDICAL CONDITION]), which can lead to confusion, problems with memory or thinking, behavior changes, tremors, feeling irritable, sleep problems, loss of coordination, and loss of consciousness, which could all contribute to falls. The next documented mental health progress note was dated 3/7/19: The resident was seen for an annual evaluation. The resident was deemed stable, continue the same psychoactive meds and a reduction in the meds was not recommended at that time for risk of decompensation with increased paranoia, [MEDICAL CONDITION], poor impulse control and behavioral problems. There were no further documented visits by mental health professionals from 3/7/19 to present and no other AIMS test since 1/8/19. Throughout the clinical record from (MONTH) 2019 thru present and in the I/A reports, the resident exhibited adverse behaviors leading to falls, injuries, hospital emergency room treatment and mental health crisis hospitalization s (to be detailed later in cite). On 8/28/19 at 2 PM, the resident's clinical record was reviewed with Social Worker A. When asked if the resident had been seen by mental health staff and had AIMS testing to review [MEDICAL CONDITION] meds for appropriateness, effectiveness and adverse reactions, staff A said the resident should have been seen by mental health at least quarterly and was supposed to have AIMS testing every six months. When asked, she said the resident was not scheduled to be seen by mental health staff and was not on a schedule for quarterly or periodic visits. She said, I'm usually good about that. I missed him. I can call and ask them when he is going to be seen. There was no mention in social service progress notes dated 1/14/19 to 8/12/19 regarding adverse behaviors, falls, injuries or hospital and crisis center transports for treatment. Staff A had noted on 1/15/19: It is recommended that (resident) continue with specialized mental health services for on-going med reviews and consultation to monitor mood and behaviors. Per the resident's medication records, side effects for anti-anxiety meds included: confusion, dizziness, drowsiness and sedation, for anti-depressants: [MEDICAL CONDITION] and for anti-psychotics: confusion, involuntary movements, restlessness, sedation, sleep disturbance and orthostatic [MEDICAL CONDITION] (a sudden drop in blood pressure when sitting up or standing). On 8/29/19 at 1 PM, resident #4's record and Incident/Accident (I/A) reports were reviewed with the Director of Nursing (DON) and revealed the following from 3/2019 to present: 3/11/19-eloped from the building and was brought back in by staff. 3/31/19-on the floor in room, no noted injury or documented corrective measures taken to reduce repetition of the incident. 4/2/19-ammonia level high at 84 (normal range 16-53), no change in [MEDICATION NAME] dosage. 4/23/19-ammonia level high at 81. 6/16/19-fell in hallway, had unsteady gait, sustained laceration between eyebrows, corrective measures included-check ammonia level. 6/17/19-ammonia level high at 72. 6/20/19-[MEDICATION NAME] level (blood test to check for therapeutic levels of Valproate Sodium) was low at 31 (normal range 50-100), no change in med dosage. 6/22/19-lost balance and fell in hallway, hit head on nurses station, right eyebrow laceration-no documented corrective measure. 6/23/19-fell while walking/running down hall with unsteady gait, hit head on a door, sustained bruise to right lateral forehead, bruising left side of neck, corrective action included-order to check ammonia level, no I/A report, no documented corrective measures. 6/24/19-blood sample drawn to check ammonia level was hemolyzed (cells damaged, commonly caused by incorrect collection of the specimen or improper handling) and could not be used for testing, which caused a delay in getting the results. 6/25/19-blood drawn to check ammonia level, but was again hemolyzed causing further delay in the results; fell while running down hall, no noted injury, no I/A report and no documented corrective measures. 6/26/19-lost balance and fell in hall, gash by right eyebrow, no I/A report, no corrective measures; blood drawn a third time for ammonia level. The level was very high at 105; a routine, scheduled dose of [MEDICATION NAME] given; transported to hospital for evaluation. 6/28/19-returned from hospital with 6 stitches to right eyebrow. (Per the resident's orders and med records, he remained on the same previously mentioned medications at the same dosages until return from the hospital on [DATE] when the dosage of [MEDICATION NAME] was reduced from 4 mg twice a day to 1 mg.) 6/28 thru 6/30/19-Valproate Sodium, [MEDICATION NAME] and [MEDICATION NAME] was not given on those days per medication records, no documented reason why. 6/29/19-[MEDICATION NAME] reduced to 15 ml once a day from 60 ml 3 times a day, physician noted: Note (ammonia) level, not convinced of cause and effect monitoring for now. Adjusting ([MEDICATION NAME]) pending outcomes, clinical trends. 6/30/19-stumbling gait, listless. 7/1/19-ammonia level high at 85. 7/3/19-yelling and cursing staff, hitting walls, running down hall, exit seeking, Valproate Sodium doses reduced from 750 mg 3 times a day to 750 mg twice a day after placing call to mental health Nurse Practitioner. There was no follow-up visit/exam by mental health staff. 7/5/19-ammonia level high at 104, no change in [MEDICATION NAME] order. 7/8/19-transported to mental health crisis center for attacking nurse on unit, swung on nurse and hit her in jaw then attempted to charge with a knife from breakfast tray police were called 3 police officers transferring resident to crisis center. 7/9/19-returned from crisis center with an order for [REDACTED]. 7/14/19-fall in hallway, leaning toward left side with unsteady gait, no noted injury or corrective action. 7/15/19-fall in hallway, unsteady gait, no noted injury or corrective action. 7/16/19-Ammonia level 84, no change in [MEDICATION NAME] dosage. 7/17/19-gait increasingly unsteady and actually becomes dead weight; transported to hospital. 7/20/19-returned from hospital with both eyes bruised and swollen and bruises to left knee. 7/22/19-4 stitches to right eyebrow, left eye hematoma, no control of extremities, cannot feed himself, placed in a recliner chair for his safety, attempts made to get up unsuccessful, resident being followed by psych, but no documented indication of this. 7/25/19-uncontrolled tremors-hitting, kicking, spitting, stumbling trying to walk; transferred back to crisis center; returned to the facility on [DATE]. 8/1/19-[MEDICATION NAME] changed from 2 mg every 8 hours PRN to 1 mg scheduled every night, [MEDICATION NAME] changed from 3 times a day to every 6 hours (4 total doses a day). 8/2/19-ammonia level 70. 8/3/19-combative with staff, refusing care. 8/5/19-fell walking/running down hallway with unsteady gait, no noted injury, corrective measure included-monitor, guide him when walking, encourage to slow down. 8/13/19-fell running down hallway, no noted injury, corrective measure including-walk with resident, distract with activities. 8/17/19-fell in room, no noted injury, I/A report or corrective actions, skull x-ray ordered. 8/19/19 at 6:43 PM-Writer called x-ray company to check why skull x-ray was not done x-ray completed that night at 11:30 PM (negative for fracture). 8/22/19-fell in hallway, no noted injury, I/A report or corrective measure. 8/23/19-fell in front of doorway, left forehead swelling, no I/A report or corrective measure. 8/24/19-red bruise left eyebrow, red left knee, purple/red bruise left hip area. 8/24/19 Physician's note- Fall risk remains very high cognitive limitations and impulsivity offering instructions for mobility with supervision and assist. Patient not consistently comprehending Will discuss merry walker trial with administration (a weighted-bottom device used to facilitate walking without tipping over/falling). 8/27/19 at 12:31 PM per a SBAR (acute change in condition) report-The change in condition reported on this change in condition evaluation are/were: Functional decline (worsening function and/or mobility recommendations are: resident assessed per the (therapy staff) for wheelchair use. Wheelchair given due to difficulty in mobility Continuous monitoring. 8/27/19-fell in dining room-The (nurse aide) watching resident in the dining room stepped out to the hall Gait very unstable, couple of tremors. Resident is no more able to walk alone Dr recommended recliner wheelchair or wheelchair seatbelt for protection, no noted injury, I/A report or corrective measure, such as proper supervision for the resident. 8/28/19 at 3:42 PM-sitting on floor at bedside, no noted injury, I/A report or corrective measure. 8/28/19 at 4:47 PM-AIMS test conducted by the Assistant DON (after asking staff A why it was not done since 1/18/19). 8/29/19 at 9:42 AM note by staff A: Writer spoke with (mental health agency) regarding resident being seen by a psychologist stated that Dr was assigned to the resident on 8/26/19 and was recently assigned to the facility stated that Dr will see the resident within '14' days. There was no mention of a Psychiatrist seeing the resident who could review/prescribe/adjust medications and no mention of a more urgent visit requested. Per chart reviews, resident #14 was seen by a mental health prescriber on 4/5/19, resident #149 was seen on 6/12 and 7/10/19, resident #1 was seen on 7/18/19 and resident #3 was seen three days ago, indicating there were opportunities for resident #4 to have been seen by others since 3/2019. When asked the DON said she could not explain why blood samples hemolyzed twice causing a three day delay in obtaining an ammonia level. She did not know why the skull x-ray was not done initially and why it was not ordered to be done Stat (immediately) causing a two day delay. She said it should have been ordered Stat to rule out a head injury. She did not know why interventions for this resident, with brittle bones, such as consistent 1 to 1 monitoring or at least proper supervision, placement in a reclining wheelchair, a seatbelt or a helmut to prevent head injury, were not implemented. When asked about the merry walker, the DON said, He (physician) discussed it with me 'yesterday.' There was no order, just a conversation. It didn't go anywhere. It never came to conclusion. The DON was asked why staff A or other staff did not facilitate regular, consistent mental health visits since 3/2019, [MEDICAL CONDITION] med reviews, timely AIMS testing, adequate and timely treatment of [REDACTED]. Care plans for resident #4 were reviewed and revealed: Impaired Cognition, Elopment Risk/Wanderer, Fluctuation in Mood, Antipsychotic Medication and Dementia care plans were revised 5/28 and 8/1/19 by staff A. Interventions included: Refer to psych as needed, Behavioral health/psych consults as needed and follow recommendations as indicated, Administer all medications as prescribed and Monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communications, violence/aggression towards staff/others, etc.) and document per facility protocol. Mental health services care plan-created 2/12/18, revised 8/1/19-mental health follow up and med reviews with adjustment as needed. Risk for Liver Complications Related to [MEDICAL CONDITION] Adverse Reactions Related to Multiple [MEDICAL CONDITION] Medications care plans-revised 3/4/19, 6/29/19, 8/1/19-Give medications as ordered, Administer [MEDICAL CONDITION] meds as ordered, Obtain lab/diagnostic work as ordered by MD, AIMS every 6 months and Dose reduction will be attempted as appropriate. [MEDICAL CONDITION] care plan- revised 6/29 and 8/1/19- Monitor for complications related to [MEDICAL CONDITION]: Compression (due to trauma or bone weakening) fractures. Risk for Falls care plan- revised 6/17 and 8/22/19: Assist resident to ambulating when unsteady gait observed, Observe resident for side effects that increases the risks for falls and Obtain series of labs per MD. On 8/30/19 at 8 AM, per review of facility policies on Fall Management dated 8/2016, Behavior Management dated 11/2017 and Psychoactive Medication Management dated 11/2017: Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls The licensed nurse will complete: Incident/Accident Report. Review and/or revise care plan and resident Kardex (care guide used by nurse aides). The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors. Residents with behavioral symptoms or those receiving psychoactive medications are evaluated, monitored and managed by an interdisciplinary behavior team (IDT) The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize the use of [MEDICAL CONDITION] medications in managing behaviors when non-pharmacological interventions have failed. Residents receiving psychoactive medications to treat behavioral symptoms are evaluated, monitored, and managed by the IDT The facility will provide appropriate treatment and services for residents who display or are diagnosed with [REDACTED]. and adverse consequences of the medication The AIMS will be completed at a minimum of every six months.