Every finding on record at Springcreek Rehabilitation and Nursing Center

This citation pertains to intake 2803162 Based on observation, interview and record review the facility failed to prevent an avoidable fall as well as conduct a thorough root-cause analysis investigation into falls for five residents (R3, R17, R71, R98, and R106), of six residents reviewed for falls resulting in transfer to hospital and major injuries including fractures and subdural hematoma. Findings include: R3 Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unsteadiness on feet, lack of coordination, vascular dementia, and displaced subtrochanteric fracture of right femur. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/23/26, reflected R3 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 3/26/25 at 9:12 AM, R3 was observed in a common area seated in a wheelchair. A fall mat was observed in R3's room. Review of a Progress Note dated 6/4/25 stated R3 was discovered face down with left shoulder pinned under roommates' bed .Resident has bruise to his left eye and forehead. Resident being sent out to the ER (Emergency Department) . The Investigation Summary Note for the fall that occurred on 6/4/25 stated nurse description of the event is reported as resident (R3) called for help verbally and when staff entered resident was face down on the floor with his shoulder under roommates' bed. Resident was unable to give a description of what happened . new orders were to be sent out to ER for evaluation. Root cause to be determined to be resident was out earlier in the day for a cystoscopy and returned with a foley cath (catheter) .and was sent out to the ER earlier for gross bleeding around the catheter post cystoscopy and could have led to him being tired and weak. Review of a Progress Note stated that although R3 was sent to the hospital for the fall, R3 was admitted to the hospital for sepsis (a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction) secondary to a urinary tract infection, metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), rhabdomyolysis (muscle breakdown) and COVID. Review of an Incident Report dated 11/29/25 at 5:00 AM stated that R3 was found on the floor in front of his bed on his stomach. Patient (R3) had shoes on. The intervention was to, again, add nonskid strips on the floor next to the bed. The predisposing environmental factors did not indicate that the floor was wet/slippery at the time of the fall. Review of a Progress Note dated 1/20/26 revealed resident observed on floor next to roommates bed laying on his back with laceration to right of right eyebrow. resident assessed and no other immediate signs of injury or pain noted. Nasal cannula replaced and ambulance called for transport to ER for treatment of laceration . A progress note dated 1/20/26 indicated the hospital R3 was sent to reported R3 was admitted for a fracture to the right hip and a UTI (urinary tract infection). R3 readmitted to the facility on [DATE]. Review of the incident report dated 1/20/26 revealed R3 was observed on the floor in his room. His mental status was noted to be alert, disoriented and confused. It was noted on the incident report that he had a recent illness and weakness. On 3/26/26 at 10:26 am, Registered Nurse F stated that he was working on 1/20/26 when R3 sustained the fall. RN F reported that R3 had recently been ill and had been staying in bed mostly for days leading up to his fall. Review of a Progress Note dated 2/12/26 at 7:07 PM revealed resident (R3) experienced a witness [sic] fall at 1745 (5:45 pm) by the nurses station. Witness observed resident standing up from his chair and began walking while holding his pants. Witness attempted to assist resident by bringing a wheelchair and reaching for his hand, however, resident turned and did not make it into the wheelchair and subsequently fell . In an interview on 03/27/2026 at 9:40 AM, Director of Nursing (DON) B stated that the Interdisciplinary Team meets every morning to discuss falls, review care plan interventions, review the incident, and interview staff to review the situation surrounding the fall. Regarding the fall that occurred on 6/4/25, DON B stated R3 was experiencing weakness related to sedation from a procedure earlier in day. DON B reported the intervention implemented was the addition of nonskid strips to R3's floor, however DON B acknowledged increased supervision, or more frequent checks would have been a more appropriate intervention given R3's condition at that time. Review of R3's care plan revealed that nonskid strips were not added to the care plan as an intervention. During the same interview DON B stated that R3 sustained another fall on 11/29/25 where he was observed on the floor of his room. The intervention for this fall was to again, add non-skid strips to R3's floor, DON B was unable to confirm whether non skids strips were in place at the time of his 11/29/25 fall. DON B further stated that prior to the fall that occurred on 1/20/26, R3 had been ill, experienced increased weakness and remained in bed for several days not wanting to get up. Treatment was initiated and R3 was feeling better but then attempted to try and get up independently and fell. R3 was sent to the hospital and found to have sustained a hip fracture. Fall interventions included adding a fall mat and ensuring R3's bed was in its lowest position. These interventions are protective in nature and do not prevent falls, as they do not address the underlying causes of R3's reoccurring falls in his bedroom. Several requests for further fall investigations including root cause analysis investigations for the reoccurring falls went unfilled. After R3's fall with fracture on 1/20/26, it was determined that a significant change MDS was required due to the decline in Activities in Daily Living along with the fracture. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R4106 was a [AGE] year-old female admitted to the facility on [DATE], with recent re-admission 3/24/25 related to acute intercranial hemorrhage post fall, and other diagnosis that included dementia, frequent falls, and anxiety. The MDS reflected that R106 had a BIM (assessment tool) score of 3 which indicated her ability to make daily decisions was severely impaired. During an observation on 3/24/2026 at 10:47 AM, R106 was laying in bed with eyes closed and what appeared to be bloody contusion to right forehead area. During an observation on 3/24/2026 at 1:22 PM, R106 was independently ambulating in room and appeared very unsteady on feet. R106 exited room and entered the hall, observed by staff, wearing a hospital gown repeatedly touching right forehead area that appeared to be contusion with bloody matted hair. Staff did not attempt to assist resident. Review of R106 Provider Progress Note, dated 3/14/26, reflected, History Of Present Illness: Patient is an [AGE] year-old female with a history of dementia, frequent falls. Review of R106 Progress Note, dated 3/14/26 at 12:46 p.m., reflected, Pt[patient] is alert to self Pt is on room air Pt has a hx[history] of stroke, syncope, AFIB[atrial fibrillation], delirium Pt was admitted to hospital for cellulitis Pt has clear speech, wakes to voice Pt is a heavy 2 Pivot assist no walking. won't follow commands. Pt is passive during the day and sundown at night. Review of R106 Progress Note, dated 3/15/26 at 12:37 pm, reflected, pt home health aide providing care @ 1130. writer heard a loud bump. walked into to room to find pt tearful. writer asked if pt was in pain and if she hit her head, home health care said yes to hitting head, pt reported pain. home health aide said she was standing up doing care and pt fell back onto bed and hit her head on the wall. 4cmx4cm goose egg noted to back of head.orders to send pt to [named] ER[emergency room] for eval and treat due to head injury and pt on blood thinners. Review of R106 Nurse Progress Note, dated 3/15/26 at 3:08 p.m., reflected, pt returned from ER. Review of R106 Nurse Progress Note, dated 3/16/26 at 6:27 p.m., reflected, Resident has been up all night, trying to crawl out of bed, not sitting sill. Spouse was here till the middle of the night, but resident was still anxious and antsy. Staff have had to do 1:1 with resident due to resident not wanting to stay in her bed or her wheelchair. Review of R106 Nurse Progress Note, dated 3/19/26 at 2:02 a.m., reflected, Resident pacing up and down the hallways after her spouse left around 2230, resident is very unsteady on her feet and keeps grabbing at the side rails and treatment cart to keep herself upright. Staff have had to redirect resident multiple times as she keeps going into other residents' rooms. At one point, staff was doing 1:1 with resident and walking her up and down the hallway in a wheelchair. Resident seems anxious and doesn't respond well to redirection and will become aggressive or become more agitated. Staff will reapproach if that happens. Resident did eventually lay down and go to sleep with all safety measures in place. Review of R106 Event Progress Note, dated 3/19/26 at 12:48 p.m., reflected, Investigation Summary Note: Resident recently hospitalized for c/o worsening leg pain and treated for cellulitis to RLE[right lower extremity]. Resident has weakness, deconditioning secondary to advanced Dementia. Resident had a noted fall on 3/15/26. Nurse description of the event is reported as the nurse heard a loud bang from hallway, entered pts room. pts home health aide was in room giving care to pt, pt tearful. writer asked if pt fell, home health aide reported that pt was standing while receiving care and sat backwards on to bed and hit head on the wall. Resident could not give a description of the event r/t Dementia. Root cause has been determined to be that resident lost her balance when standing while receiving care from her home health aide and when she came to a rest on the bed, her head hit the wall, causing hematoma to the back of her head. Physician was notified and ordered to send to ER[emergency room] for eval. New intervention was husband was notified and explained that it was not necessary for residents' home health aide for provide care while resident is in this facility. Family in agreement with the current plan of care and care plan goal minimize risk for falls. (Interdisciplinary meeting noted completed 5 days after fall.) Review of R106 Nursing Progress Note, dated 2/24/26 at 12:28 a.m., reflected, Late Entry: Note Text: Resident observed in her room on the floor, floor was wet from possible spilled water, resident's brief was dry. bed was in the lowest position, call light was attached to edge of the bed and not used. Resident visibly bleeding from the right side and back of head. Review of R106 Nurse Progress Note, dated 3/24/26 at 7:15 a.m., reflected, Resident returned from ER, husband at bedside. resident is restless, up and down from bed and unable to express what she needs. writer asked her if she hurt and she brought her hand to her right side of her head and said no. Resident does have a red scab area noted to her right side of head from fall. Review of R106 Nurse Progress Note, dated 3/24/2026 at 7:16 a.m., reflected, Pt returned back to facility from CVH by ambulance. Moderate right frontal scalp hematoma. There is a left extra-axial slightly hyperdense fluid collection suggestive of subdural hemorrhage measuring 9-9mm with mild mass effect upon the left cerebral hemisphere. No shift of midline structures. There is small volume acute hemorrhage in the region of the left basal cisterns axial image. Review of R106 Event Progress Note, dated 3/25/2026 at 14:31 p.m., reflected, Investigation Summary Note: for [AGE] year resident with Dementia, hx[history] of falls, mitral valve replacement, A-fib, anxiety and insomnia. This Resident had a noted fall on 3/23/26. Nurse description of the event is reported as resident was observed in her room on the floor, floor was wet from possible spilled water, and the resident's brief was dry. bed was in a low position for safety while sleeping, call light was attached to edge of the bed and not used. Vitals obtained, resident visibly bleeding from the right side of her head and the back of her head, possible rib injury as well. Resident could not give a description of the event r/t her poor cognition. Root cause is resident has a misunderstanding of her limitations, is unsteady and restless. Resident was started on hydroxyzine 25mg at bedtime on 3/20 to help manage her anxiety symptoms of anxiety. Physician was notified and ordered to send to ER for eval was the immediate intervention. Resident returned, with orders to Monitor hematoma to right side of forehead for changes. IDT met and additional intervention was a floor mat was added next to the bed at night for safety. Husband was at the bedside when resident returned from the ER. During an observation on 3/25/2026 at 7:21AM, R106 was independently ambulating in the hall with unsteady gait and two nurses in area with no attempts to assist or redirect R106. Review of the Base Line Care Plan, dated 3/14/26, reflected R106 had a fall Care Plan that included, Resident has limited physical mobility r/t dementia.interventions; TRANSFER: 2-person pivot transfer. Review of the Care Plan, dated 3/18/26, reflected interventions that included, AMBULATION: The resident requires CGA [contact guard assist] x1 staff to walk without assistive devices.TRANSFER: CGA by 1 person for sit to stand transfers, dated 3/14/26. Review of the Hospital Physical Therapy assessment, dated 3/13/26, reflected R106 required maximum two person assist sit to stand, chair to bed transfer, and ambulation. Review of R106 Radiology Report, dated 3/24/26, reflected R106 had CT scan of brain that included, Acute small volume subarachnoid hemorrhage in the region of the left basal cisterns with isodense left subdural fluid collection or hemorrhage measuring 8 to 9 mm in thickness with minimal mass effect upon the left cerebral hemisphere. Small right frontal scalp hematoma. During an interview on 3/25/2026 at 4:35 PM, Licensed Practical Nurse Unit Manager (UM) H reported had been a Unit Manager for about seven years. UM H reported if resident had a fall would expect nurse to complete a head-to-toe assessment of resident, start neuro assessments as needed, obtain vitals, continue to assess, notify physician and follow orders. UM H reported depending on situation resident transferred off floor to bed with mechanical lift and assessments continued. UM H reported nurse would complete Incident Report and attempt to determine cause of fall and add new interventions to Care Plans. UM H reported Interdisciplinary (IDT) Team meeting next day to discuss all falls including how resident fell, injuries if any, what were they doing to attempt determine root cause of fall and document in the Progress Notes. UM H reported nurses can add interventions to Care Plans and often MDS nurse C added additional interventions if needed and reported MDS C often completes fall investigations and IDT fall follow up notes. UM H reported R106 was a high risk for falls on admission 3/14/26 with score of 60 and verified over 45 was high risk for falls. UM H verified R106 had a Base Line Care plan for falls dated 3/14/26 that included two-person assist with transfers and reported would expect Care Plans to be followed. UM H reported R106 had fall on 3/15/26(day after admission) during caregiver assisted care with one non-staff member and fell and obtained posterior head injury and was transferred to the hospital. UM H verified R106 was on blood thinners. UM H was verified IDT meeting Progress note was completed 3/19/26 and was unable to explain four-day delay and reported team always discusses falls the next day after a fall. During an interview on 3/25/2026 at 6:05 PM, Director of Nursing (DON) B reported MDS C completed fall investigations. DON B reported R106 first fall on 3/15/26 was with private caregiver present and family was educated after fall that staff was responsible for providing care. No evidence that facility had provided education to private caregiver prior to fall was located or provided prior to survey exit. DON B reported R106 second fall on 3/23/26 at 11:50 p.m., when resident independently transferred and lost balance and fell and sustained head injury including subdural hematoma that required emergent transfer to hospital. DON B verified had provided surveyor with Incident/Accident reports that did not include complete investigation including witness statements as requested and reported would follow up. DON B verified R106 Care Plans indicated one person assist with ambulation prior to 3/23/26 fall and remain current intervention and reported would expect staff to follow Care Plans. During an interview on 3/25/26 at 5:20 p.m., Registered Nurse (RN) J reported was currently R106 nurse along with RN F who was her Preceptor. RN J reported was unsure if R106 required assistance for ambulation and reported R106 frequently ambulated independently and with staff and reported routinely ambulated most of the day. During an interview on 3/25/26 at 6:45 p.m., MDS C reported completed fall investigations including IDT fall follow up Progress Notes. MDS C reported R106 falls included witness statements. MDS C reported R106 ambulates all day including with husband during the day and reported R106 had poor safety awareness and was very impulsive. During an interview on 3/26/2026 at 3:43 PM, MDS C verified R106 was assessed to need two person assist with transfers by nurse and was changed to one person contact guard on 3/18/26 reported that meant one-person hands-on assist. MDS C reported floor mat was added next to R106 bed after 3/23/26 fall. MDS C verified R106 fall on 3/23/26 fall happened in the doorway to hall. MDS C was queried if floor mat on floor by bed was an appropriate intervention for 3/23/26 fall and stated, maybe not the best for that situation but would need. MDS C reported R106 was very impulsive, up and down all day with poor safety awareness due to dementia. During a telephone interview on 3/26/2026 at 4:51 p.m., Licensed Practical Nurse(LPN) I reported was alerted by Certified Nurse Aid(CNA) staff that R106 had fallen on 3/23/26 shortly before midnight and as bleeding. LPN I reported had orientee working with her that evening and they returned to Hall C unit observed R106 on floor in doorway of room with feet towards door and head towards window of room, profusely bleedind from right temple area and back of head. LPN I reported other staff present and she went to Nurse station and called 911 and worked on paperwork to transfer to hospital and returned to R106 room. LPN I reported R106 was actively trying to get up off floor and CNA staff remained on floor with R106 until Emergency Medical Staff arrived. LPN I reported R106 had very poor safety awareness and often make LPN I very nervous when R106 walked independently. LPN I reported prior to R106 3/23/26 fall Care Planned interventions were low bed. LPN I reported a lot of the time staff were providing R106 1:1 assistance walking with R106 in the hall when they could but otherwise R106 ambulated independently whe staff were providing care to other residents. LPN I reported R106 was currently care planned to have contact guard with ambulation and the meant stand by assist with no need for hands on resident.(different that MDS C meaning of definition). LPN I reported R106 seemed to have nights and days mixed up and was often aware much of nights shift and reported R106 had slept most of the day on 3/23/26 prior to fall During a telephone interview on 3/26/2026 at 5:19 PM, Certified Nurse Aid(CNA) K reported witnessed R106 fall on 3/24/26 just before midnight. CNA K reported R106 exited room and attempted to close door behind her and fell into door and landed face first on floor. CNA K reported was close but unable to get to her in time prior t hitting the floor and R106 intently started bleeding from the front and back of head. CNA K reported resident kept trying to get up and then seemed to go in and out of conciseness while she was holding washcloth to head. CNA K reported LPN I and Nurse Orientee L were were first nurses who arrived after another CNA left unit to find notify them of fall. CNA K reported remained on floor with R106 until EMS arrived about 12:30 a.m. and reported seemed like a long time because fall occurred at 11:50 p.m. CNA K reported R106 also had knot on sternum and left rib appeared pushed out. CNA K reported R106 fall interventions prior to 3/23/26 fall were to attempt to keep R106 in chair but ambulated frequently on own and staff were required to supervise R106 during ambulation with no need to have hands on. CNA K reported no change interventions with exception of mat on floor was added. CNA K reported facility staff had not questioned her after this fall with exception of this surveyor about the fall and reported had completed a written witness statement at the time of the fall. (written statement not provided to surveyor after completed investigation had been requested.) CNA K verified typed witness statement appeared correct after reading aloud except had noted on written statement that nurses had woke R106 just prior to fall to administer Tylenol and reported R106 does not sleep well and R106 often gets out of bed after awaken for medications around midnight and paces halls. During a telephone call on 3/26/2026 at 5:39 PM, Nurse Orientee (NO) L reported was orienting with Preceptor with R106 fell on 3/23/26. NO L reported was on Hall D when CNA staff alerted nurses of R106 fall on Hall C memory unit. NO L reported they immediately went to R106 room and observed R106 on the floor with puddle of blood under her head bleeding from right front forehead and back head and reported R106 was on blood thinners. NO L reported another nurse also assisted after fall and she remained with LPN I who called 911 and worked on paperwork to transfer to hospital. NO L reported did not complete witness statement but CNA staff did and no facility staff had questioned NO L about R106 3/23/26 fall. NO L reported had overheard nursing staff tell EMS staff that R106 was on blood thinners. During a telephone call on 3/26/2026 at 5:47 PM, CNA M reported was working when R106 fell on 3/23/26 around midnight. CNA M reported nursing staff had woke R106 to administer medications and shortly after that R106 exited room and fell in doorway. CNA M reported R106 was always, floor pacing and was usually sleeping in bed. CNA M reported R106 front of right head and back of head was bleeding, quite a bit, and reported saturated 5 to 6 washcloths with blood holding pressure to R106 head. CNA M reported did complete written witness statement and was not questioned by facility staff about R106 fall. CNA M reported R106 had care planned interventions to keep clear path in room, bed low and toileted and after fall added mat on floor by bed. CNA M reported R106 self ambulates frequently but should have one person assist. Reported R106 walks independently in the hall when staff are providing care to other residents but otherwise try to keep eyes on R106. Resident #17 (R17) Review of the medical record reflected that R17 was admitted to the facility on [DATE]. Diagnoses of dementia, unsteady on her feet, weakness, muscle weakness, difficulty walking and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/25/2026 revealed R17 had a Brief Interview of Mental Status (BIMS) of 03 (moderately cognitively impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) R17 was partial to moderate assistance for toileting hygiene, showering, getting dressed, and putting on shoes. Section GG0120. Mobility Devices had walker checked off as yes in use, but wheelchair was checked off as no. During an observation and interview on 03/25/2026 at 2:00 PM, CNA EE was pushing a wheelchair down the hall without footrest on it from the dining room/activity room to R17's room as the nurse asked CNA EE to bring R17 back to take her medication. CNA EE stated they didn't have any footrest for R17, and she was trying to get her back to her room to take her medications. CNA EE continued to push R17 back to her room. During an interview and observation on 03/27/26 at 1020am, Regional Physical Therapist II stated nursing staff should be using a footrest if the resident is being pushed or needs assistance with getting from point A to point B. Regional Physical Therapist II stated CNAs do not need the therapy staff to get a footrest, they can come in and get it themselves. Regional Physical Therapist II pointed to 3 totes full of footrests and Regional Physical Therapist II stated he was not aware that they had a shortage or not enough footrest for residents. During an interview on 03/27/2026 at10:29 AM, DON B stated it would be the expectation that the CNA's use footrest when pushing a resident down the hall in a wheelchair. Resident #71 (R71) Review of the medical record reflected that R71 was admitted to the facility on [DATE]. Diagnoses of fractured right leg, repeated falls, heart failure, dementia, and lack of coordination. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2025 revealed R71 had a Brief Interview of Mental Status (BIMS) of 99 (rarely understood) out of 15. Under section G0100, Activities of Daily Living (ADL) R71 was maximum assistance to dependent of all care, toileting, showering, dressing lower body. During an observation and interview on 03/25/2026 at 9:00 AM, CNA NN pushing R71 in a wheelchair down the hall with R71's feet dragging on the floor. No footrest was attached to the wheelchair, CNA NN stated they don't have enough footrest for all of the residents that need it, so they have to share them, still not having one on the wheelchair. During an interview and observation on 03/27/26 at 1020am, Regional Physical Therapist II stated nursing staff should be using a footrest if the resident is being pushed or needs assistance with getting from point A to point B. Regional Physical Therapist II stated CNAs do not need the therapy staff to get a footrest, they can come in and get it themselves. Regional Physical Therapist II pointed to 3 totes full of footrests and Regional Physical Therapist II stated he was not aware that they had a shortage or not enough footrest for residents. During an interview on 03/27/2026 at10:29 AM, DON B stated it would be the expectation that the CNA's use footrest when pushing a resident down the hall in a wheelchair. Resident #98 (R98) Review of the medical record revealed R98 was admitted with 10/22/2025 with diagnoses that included laceration of right lower leg, cerebral infarction (stroke), acute cystitis (inflammation of the bladder), heart failure, cognitive communication deceit, depression, restlessness and agitation, hypertension, abnormal posture, adult failure to thrive, vascular dementia, atrial fibrillation, chronic pain, osteoarthritis (degenerative joint disease), atherosclerotic heart disease (plaque build-up in artery walls), and hypothyroidism (low thyroid hormone). Review of R98 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2025, revealed a Brief Interview of Mental Status (BIMS) of 05 (severe cognitive impairment) out of 15. Section GG-Functional Abilities of the MDS with the same ARD revealed R98 required set up or clean-up assistance for eating. R98 was discharged to the hospital 12/05/2025 related to an injury incurred during a fall and did not return to the facility. Review of R98's medical record revealed progress note, entered 12/03/2025 at 06:37 a.m. CNA (Certified Nursing Aide) report to RN (Registered Nurse) that resident was observed on the floor. RN went to room to assess resident. Resident was sitting on the floor, sitting up next to the bed, leaning against the bed. Resident was observed for new injuries, pain, ROM (Range of Motion) assessed. Neurochecks (Neurological checks) initiated. VS (Vistal Signs) obtained. Resident was placed back into bed; bed was lowered to lowest position. MD (Medical Doctor), Nurse Management on-call notified. Review of R98's plan of care revealed new intervention, date initiated 12/03/2025 but with a created date of 12/08/2025 (after the date of discharge), Bed in lowest position when not performing task. Review of R98's medical record revealed a progress note entered 12/08/2025 at 10:34 a.m. entitled Investigation Summary Note: . had a noted fall on 12/3/25. Nurse description of the event is reported as cna (certified nurse aide) reported to RN (Registered Nurse) that resident was observed on the floor in her room next to the bed with back against the bed, had her grip socks on, brief was dry, bed was in a low position but was not in the lowest position, call light was in reach but not in use. Resident could not give description of what happened or what she was trying to do. Root cause has been determined to be she possibly rolled out of bed. No injuries noted, neuros were initiated, and resident was placed back into bed with be in the lowest position, call light in reach and fluids offered. Resident continues Therapy Services, and her sitting balance has been improving. IDT (Interdisciplinary met and care plan had been reviewed and updated. Review of R98's medical record revealed progress note, entered 12/05/2025 at 23:21 (11:21 p.m.), Client observed on floor at 2045 (08:45 p.m.) with excessive bleeding from face, hematoma (bruising) to right side of forehead, dislocation of nose, swollen upper lip, and bilateral knee bruising with pain noted. Bleeding was controlled, vitals were BP(blood pressure)[TRUNC

Based on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 93 residents at the facility.Findings Included: On 03/27/2026 at 01:01 p.m. an interview was conducted with Nursing Home Administrator (NHA) A regarding concerns identified during the current Recertification Survey. NHA A explained that during the last year the QAPI committee had identified areas of concerns as return to hospital, weight loss, falls, and dietary menus. NHA A was asked how QAPI projects were identified. NHA A explained that items are identified through communication with staff, through the grievance project, and resident council. NHA A explained that any staff or resident may bring items to the QAPI committee. NHA A was asked how areas of concern were determined to need a QAPI project to resolve the identified concern. NHA A explained that the QAPI council would make that determination. NHA A was asked how items are tracked and trended on a regular basis to ensure quality of care of care to residents. NHA A could not provide answers to how systems or items are monitored on a regular basis or tracked and trend for compliance with quality of care. NHA A was provide with information with regarding to the odor on A hall. When asked if the issue had been monitored, tracked, and/or trended as a QAPI project she explained that the facility had been working and attempting to address the issue but could not provide any documentation. When asked again if it had been identified as QAPI project, NHA A explained that it had not been a project but she explained that it should have been. When asked if any issues had been identified during QAPI that had also been identified during the annual recertification survey, NHA A could only list falls and dietary menus. Review of facility policy entitled Quality Assessment & Assurance Program, adopted 07/11/208 and last revised 09/18/2019, revealed section entitled Data Collection which stated The QAA coordinator reviews information since the last QAA meeting with QA subcommittee(s) members, QAPI Action Plan Teams and QAA Committee members in order to formulate an agenda. The same policy listed Facility Trends: Admissions, Transfers, DischargesCustomer Service IssuesResident/Family Satisfaction SurveysResident RightsQuality of CarePressure ulcersPainRestraintsFalls,IncontinenceActivities of Daily Living(ADL) declineNosocomial infectionsWeight lossPsychoactive MedicationsMedication Management/Significant Medication ErrorsBowel/Bladder Function, CathetersUnexpected Hospital ReadmissionsSufficient StaffingStaff CompetencyThe same policy listed Additional DataIncident/Accident ReportsRisk Reports, Trigger Events, Occurrence Investigations Abuse Prevention/Allegation of AbuseConcern Forms/GrievancesDaily Meeting Care Line CallsNursing ServicesClinical GuidelinesQA/QIS Tools completed by Facility staffEmergency ManagementThe same policy listed ReportsSafety Committee MeetingEmployee Safety/Workplace SafetyOSHA LogResident Safety/Environmental SafetyEquipment SafeyLife Safety Code ComplianceFire SafetyEmergency PreparednessMedical Director's ReportRequested Consultant ReportsQuality of Life (QOL) OutcomesOpen Survey Timelines/F TagsCasper Reports5-Star RatingsSurvey Readiness VisitsThe same policy revealed section Leadership Oversight stated: Quality Assurance and Performance Improvement is facilitated through leadership oversight. This is achieved through structured and ad hoc committee meetings daily, monthly, and quarterly. The focus of a QAA meeting is to identify system to better meet the needs of residents, organize interdisciplinary teams, clarify the knowledge of the situation, understand the cause of variation within a system, select improvement strategies and monitor outcomes.

Based on interview and record review, the facility failed to adequately address and make good faith effort to resolve grievances for 7 of 7 Resident Council members. Finding incleude:Review of Resident Council meeting minutes dated 9/30/25 the council members complained in part, they were not receiving certain menu items and had concerns regarding the quality of the food. The response signed off by Nursing Home Administrator (NHA) A was to print menus ahead of time. There was no response provided the concern related to the quality of food being served. The Resident council meeting minutes 10/27/25 reflected the quality of food was bad and food was cold and some meals were being served late and menu items that were requested were not provided. The grievance/resolution form dated 10/28/25 that was signed off by NHA A revealed residents should talk with the Dietary manager if they have an issue and Dietary Manager will check with residents randomly to see if there are any issues. Review of Resident Council meeting minutes dated 12/30/25 revealed complaints that residents were not receiving items requested from menu. The response signed off by NHA A dated 1/05/26 was that the Dietary manger will audit requested items and Dietary manager will randomly check with residents and if residents have an issue, they should tell Dietary manager at that time, not wait for Resident council. Review of Resident Council meetings dated 1/30/26 revealed concerns that dietary staff were not following meal tickets and not receiving items requested from the menu. The response on the concern form signed off by NHA A on 2/05/26 was to let the Dietary manager know when this occurs, random questionnaires to be done and to remind staff about menus. Review of Resident Council meeting minutes dated 2/27/26 reflected concerns related to cold food, accuracy of the meal trays, not being given menus. The response signed off by NHA A dated 3/4/26 was random audits, test trays and reeducating staff on passing trays timely, educating dietary staff on reading meal tickets to ensure resident preferences are honored. During the Resident Council meeting held on 3/25/26 7 out 7 resident council participants reported month after month they complain food quality, temperatures, not being provided menus, not receiving items requested, receiving items they dislike etc . 7 of 7 participants stated it's the same complaints over and over falling on deaf ears and never getting resolutions. On 3/26/26 at 11:28 am during an interview with Dietary Manager Y she reported being aware of concerns brought forth by Resident council and was trying to address them. A request for the audits as described in the concern forms response was requested. Dietary manager Y provided audits with food temperatures, several pages of undated food temperatures, there were no audits that pertained to accuracy of meal trays/honoring food preferences and menu concerns. Dietary manager Y stated they use a buddy system to ensure menu were provided and received back to the kitchen along with tray accuracy to ensure resident preferences are met, however there was no documentation this was done. When quired why/how this was a constant concern brought up monthly by Resident Council, Dietary Manager Y stated food temperatures were within range when leaving the kitchen. During an interview with NHA A on 03/26/2026 at 12:28 PM, NHA A stated she does not attend Resident Council and could not speak on the matter but did confirm she was the person who signed off every month on the concern forms. When queried if she found it concerning the same topic is brought forth month after month and being signed off by NHA A, NHA A offered no response.

Based on interview and record review the facility failed to ensure that 7 of 7 of the Resident Council members were informed of their right on how to file a grievance with the facility.Findings include:On 3/25/26 at 10:00 during the Resident Council meeting, 7 of 7 of the participants reported they collectively had chronic complaints about food palatability, menu items, food preferences not being honored, and noise levels. Individual participants then voiced individual concerns (late medications, call lights response times etc ) when queried if they had voiced their concerns or filed a grievance/concern form. None of the seven participants knew that was an option or how/where the forms were located. One of the Resident Council participants stated they thought they had to attend resident council in order to get their grievance/concern documented. Review of Resident Council minutes from September 2025 through February 2026 did not reflect resident rights were reviewed in their meetings pertaining to the facility grievance policy. On 03/27/2026 at 9:51 AM, during an interview Activity Director BB she reported she conducted Resident Council meetings monthly and stated she thought she had mentioned it in previous meetings. Documentation over the last year that grievances, the facility policy and or resident rights related to filing grievances was reviewed since the last certification survey was requested. No documentation was provided by the exit of the survey on 3/27/26.

Based on interview and record review the facility failed to ensure 7 of 7 of the resident council members food preferences were met on a daily basis. Findings include:Review of the Resident Council meeting minutes dated 9/30/25, 10/27/25, 12/30/25, 1/30/26 and 2/27/26 reflected concerns that Resident Council members complained that food preferences were not being honored. During the Resident Council meeting held with the State Agency on 3/25/26 7 of 7 participants stated this had been a long standing issue that was not being addressed. Resident Council members reported being frustrated and angry that basic food and drink preferences were not honored. Example was given wanting orange juice every day at breakfast but receiving apple juice instead. On 3/26/26 at 11:28 am during an interview with Dietary Manager Y she reported there were no audits that pertained to accuracy of meal trays/honoring food preferences and menu concerns. Dietary manager Y stated they use a buddy system to ensure tray accuracy and resident preferences were met. When quired about the effectiveness of the buddy system for meal tray accuracy Dietary Manager Y did not respond. When asked the root cause of the ongoing issue Dietary Manager Y declined to answer.

Based on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#100) of two resident reviewed for advance directives.Findings include: Review of the clinical record revealed Resident 100 (R100) was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure and congestive heart failure. Review of the Minimum Data Set (MDS) with an assessment reference date of 3/25/26 revealed R100 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Review of the nursing progress notes dated 3/19/26 reflected R100 was alert and oriented x 4, was able to make needs known and had a diagnosis of respiratory failure with several comorbidities. The progress notes also reflected R100 made it known he did not want to be resuscitated in the event his heart stopped. Do Not Resuscitate (DNR). Further review of the clinical record reflected R100 and the facility Physician signed the Advanced Directive document on 3/19/2026 reflecting R100's wish to be a DNR. Review of Physician orders on March 25, 2026, reflected R100 was a full code. On 03/25/2026 at 7:46 AM, during an Interview with Licensed Practical Nurse (LPN) G stated in event of a code the first place to verify the code status would be the Medication Administration Record (MAR). R100's MAR was viewed with LPN G which reflected R100 was a full code.

Through interview and observations, the facility failed to maintain a homelike environment without the overpowering smell of urine for two residents (R7 and R11) of two residents reviewed for a homelike environment with the potential to affect all residents on that hall. Findings IncludeResident #11 (R11)Review of the medical record reflected that R11 was admitted to the facility on [DATE]. Diagnoses of paraplegia, acute kidney failure, encounter for fitting and adjustment of urinary device, abnormal gait and mobility.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2026 revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R11 was maximal assistance on toileting, showering, dressing lower body, sit to stand and transferring from one surface to another. Resident #7 (R7)Review of the medical record reflected that R7 was admitted to the facility on [DATE] and signed onto hospice 02/12/2026.Diagnoses of Huntington's disease, dementia, other disorders of the muscles, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness and repeated falls.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance revealed R7 was dependent on toileting, showering, lower body, sit to stand and transferring from one surface to another with a mechanical device. During the screening process on 03/24/2026 at 10:19 AM, R11 stated he had a few UTI's, with an overpowering smell of urine from this room. Writer observed R11 draining his foley catheter urine in a urinal, then sitting it on bedside table, R11 had a hand towel lying on his lap due to it spilling urine transferring it from the foley catheter to the urinal. R11 stated his hand towel got wet with urine and he let it dry over his lap. During this same screening process on 03/24/2026 at 10:19 AM, R11 had a room mate R7, who shared the room with the overpowering smell of urine.During an observation and interview on 03/23/2026 at 2:30 PM, R11 had the same soiled hand towel lying on his lap that he had used earlier today. An overpowering smell of urine can be detected by a few rooms down the hallway before reaching R11's room.During an interview on 03/25/2026 at 12:56 PM, LPN G and CNA CC stated housekeeping comes in and cleans R11's room, but R11 doesn't want the foley connected to the collection bag during the day, he prefers to drain it himself into the urinal. CNA CC stated when he disconnected the tubing from the bag, R11 spills urine on the floor, even when it was cleaned up, the smell of urine lingers. LPN G and CNA CC stated he had a towel he laid across his lap to catch the urine. CNA CC also stated when he drains the foley catheter, he kept the same hand towel and continued to use it. CNA CC also stated the urine was probable soaked in the flooring. Writer asked if roommate R7 was able to report the smell of urine to them, CNA CC stated no, he isn't not able to tell them. Writer asked CNA CC if R7 had visitors that had to spend time in that room. CNA CC stated the hospice staff come several times a week but was unsure about other visitors.During an interview on 03/25/2026 at 2:09 PM, housekeeper DD stated she cleaned his room every day, sometimes two times a day. Housekeeper DD stated she changed out her mop head every time she cleaned his floors because it is so bad. Housekeeper DD added she moves the bed and his dresser to clean under it, mentioned it soaked into the flooring. Housekeeper DD stated R11 had urine all over the bed table legs and base are always covered with urine and smells so strong. Housekeeper DD stated Maintenance Director P was aware of this, and they are going to do a deep cleaning in the next week or two. During an interview on 03/25/2026 at 2:19 PM, Maintenance Director P stated they have bought R11 a new mattress three or four times a year. Maintenance Director P stated they could strip the floor and rewax it but getting him out of his room is difficult. Maintenance Director P added R11's dresser probably needed to be swapped out too if it is absorbing the urine. Maintenance Director P stated he was going to talk to NHA A to swap out his dresser for a plastic/PVC (poly vinyl chloride) structure, so it won't absorb the urine. During an interview on 03/26/2026 at10:04 AM, DON B stated she didn't know if it was in an Interdisciplinary Team Meeting (IDT), and morning meetings, that they were using charcoal bags in R11's room due to the smell. DON B stated she was unsure what to do next. DON B stated the management team talked about it yesterday, replacing nightstand/dresser. DON B stated even after R11 shower, it still smells really strong, in his skin and in the room. Writer asked if roommate, R7 was able to complain about the smell, DON B stated no. Writer asked DON B if R7 had visitors that had to spend time in that room. DON B stated not sure. DON B stated they had heard issues with other residents that it was offensive to them and they were trying to find a solution. Writer asked DON B if they had talked to R11 about this concern. DON B stated R11 is non-complaint with receiving care, allowing staff to help with emptying his foley catheter. Regarding the resident's care plan, DON B stated all it said was to assist him, she was going to add something about him being non-compliant. DON B observed looking for nursing notes regarding non-compliance, nothing so far. Writer asked DON B what she would put in the care plan, and DON B asked writer what she should write on it. During an observation and interview on 03/26/2026 at 3:33 PM, CNA EE replaced the soiled towel on R11's lap that he had used to drain his foley catheter urine into a urinal that is currently on his over the bed table.During an observation and interview on 03/26/2026 at 3:38 PM, R7 was resting on his bed with his eyes closed. R7 had a BIMBS of 10 and was not able to speak for himself regarding the overpowering smell in his room. Using the reasonable person standard, R7 would be affected by this overpowering smell of urine in his homelike environment.

Based on observation, interview, and record review the facility failed to ensure that a significant change Minimum Data Set was completed timely in one (Resident 3) out of 19 reviewed for Significant Change Minimum Date Sets. Findings include. Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unsteadiness on feet, lack of coordination, vascular dementia, and displaced subtrochanteric fracture of right femur. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/23/26, reflected R3 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 3/26/25 at 9:12 AM, R3 was observed in a common area seated in a wheelchair. A fall mat was observed in R3's room. Review of a Progress Note dated 6/4/25 stated R3 was discovered face down with left shoulder pinned under roommates' bed .Resident has bruise to his left eye and forehead. Resident being sent out to the ER (Emergency Department) . The Investigation Summary Note for the fall that occurred on 6/4/25 stated nurse description of the event is reported as resident (R3) called for help verbally and when staff entered resident was face down on the floor with his shoulder under roommates' bed. Resident was unable to give a description of what happened . new orders were to be sent out to ER for evaluation. Root cause to be determined to be resident was out earlier in the day for a cystoscopy and returned with a foley cath (catheter) .and was sent out to the ER earlier for gross bleeding around the catheter post cystoscopy and could have led to him being tired and weak. Review of a Progress Note stated that although R3 was sent to the hospital for the fall, R3 was admitted to the hospital for sepsis (a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction) secondary to a urinary tract infection, metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), rhabdomyolysis (muscle breakdown) and COVID. Review of an Incident Report dated 11/29/25 at 5:00 AM stated that R3 was found on the floor in front of his bed on his stomach. Patient (R3) had shoes on. The intervention was to, again, add nonskid strips on the floor next to the bed. The predisposing environmental factors did not indicate that the floor was wet/slippery at the time of the fall. Review of a Progress Note dated 1/20/26 revealed resident observed on floor next to roommates bed laying on his back with laceration to right of right eyebrow. resident assessed and no other immediate signs of injury or pain noted. Nasal cannula replaced and ambulance called for transport to ER for treatment of laceration . A progress note dated 1/20/26 indicated the hospital R3 was sent to reported R3 was admitted for a fracture to the right hip and a UTI (urinary tract infection). R3 readmitted to the facility on [DATE]. Review of the incident report dated 1/20/26 revealed R3 was observed on the floor in his room. His mental status was noted to be alert, disoriented and confused. It was noted on the incident report that he had a recent illness and weakness. On 3/26/26 at 10:26 am, Registered Nurse F stated that he was working on 1/20/26 when R3 sustained the fall. RN F reported that R3 had recently been ill and had been staying in bed mostly for days leading up to his fall. Review of a Progress Note dated 2/12/26 at 7:07 PM revealed resident (R3) experienced a witness [sic] fall at 1745 (5:45 pm) by the nurses station. Witness observed resident standing up from his chair and began walking while holding his pants. Witness attempted to assist resident by bringing a wheelchair and reaching for his hand, however, resident turned and did not make it into the wheelchair and subsequently fell . In an interview on 03/27/2026 at 9:40 AM, Director of Nursing (DON) B stated that the Interdisciplinary Team meets every morning to discuss falls, review care plan interventions, review the incident, and interview staff to review the situation surrounding the fall. Regarding the fall that occurred on 6/4/25, DON B stated R3 was experiencing weakness related to sedation from a procedure earlier in day. DON B reported the intervention implemented was the addition of nonskid strips to R3's floor, however DON B acknowledged increased supervision, or more frequent checks would have been a more appropriate intervention given R3's condition at that time. Review of R3's care plan revealed that nonskid strips were not added to the care plan as an intervention. During the same interview DON B confirmed that R3 sustained another fall on 11/29/25 where he was observed on the floor of his room. The intervention for this fall was to again, add non-skid strips to R3's floor, DON B was unable to confirm whether non skids strips were in place at the time of his 11/29/25 fall. DON B further stated that prior to the fall that occurred on 1/20/26, R3 had been ill, experienced increased weakness and remained in bed for several days not wanting to get up. Treatment was initiated and R3 was feeling better but then attempted to try and get up independently and fell. R3 was sent to the hospital and found to have sustained a hip fracture. Fall interventions included adding a fall mat and ensuring R3's bed was in its lowest position. These interventions are protective in nature and do not prevent falls, as they do not address the underlying causes of R3's reoccurring falls in his bedroom. Several requests for further fall investigations including root cause analysis investigations for the reoccurring falls went unfilled. After R3's fall with fracture on 1/20/26, it was determined that a significant change MDS was required due to the decline in Activities in Daily Living along with the fracture. Review of R3's significant change MDS revealed a completed date of 2/23/26. In an interview on 03/27/2026 at 10:40 AM, MDS Licensed Practical Nurse (LPN) C stated that significant change MDS's are to be completed 14 days after the change occurs that requires a significant change MDS. MDS LPN C confirmed that R3 required a significant change MDSfor his hip fracture and decline in ADL function, however, confirmed it was completed past the 14 days.

Based on observations and interviews, the facility failed to revise care plans for three residents (R1, R4 and R7) to reflect a room change, use of hand rolls and receiving hospice services of 19 residents reviewed. Findings IncludeResident #1 (R1)Review of the medical record reflected that R1 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease with lower respiratory infection, weakness, presence of vascular implants and grafts, disorder of the brain, dementia, abnormalities of gait and mobility, colon cancer with a colostomy bag, anxiety and depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2025 revealed R1 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R1 needed substantial assistance with showering and personal care. R1 was maximal assistance on toileting, showering, dressing lower body, sit to stand and transferring from one surface to another.During an observation and interview on 03/24/2026 at 9:47 AM, R1 stated sometimes the staff shave the hair on my face and sometimes they do not. Observation of long hairs hanging off her chin at least 1 long. Writer asked if she preferred to have the chin hairs shaved. R1 stated yes, she does like her chin shaved.During an observation and interview on 03/25/2026 at 10:41 AM, R1 still had facial hair on her chin and stated tomorrow was her bath day.Record review of the care plan stated R1 needed physical assist by 1 staff with personal hygiene; I often need staff to shave whiskers on my chin and set-up assist for oral care. According to the task sheet, the facility staff had not given her a bath in the last 30 days.During an observation on 03/25/2026 at 1:05 PM, R1 still had chin hair longer than 1 .During an interview on 03/25/2026 at 1:10 PM, CNA Z stated R1 got showers on Monday and Thursdays. CNA Z stated when R1 refused her shower, they filled out a shower sheet, they ask her 3 times, then the nurse will ask after that. Writer asked about her facial hair and CNA Z stated that those last couple of months, she hadn't asked to have them shave her chin hair. Writer shared that R1 did mention she wanted the hair shaved on her chin. CNA Z stated that she would take care of that. Record review showed that R1 had not had a shower or bed bath in the last 30 days. Nor had her hair been washed. During an interview on 03/25/2026 at 4:06 PM, LPN/UM E was asked for shower sheets on R1. Requested Shower sheets from LNA A again at 4:42pm.During an interview on 03/26/2026 at 7:33 AM, LNA A still had not provided the requested shower sheets from yesterday. Requested again at 7:45 am and received them at 8:15am, 2 shower sheets for the last 30 days for R1. Dated 03/12/26 and 03/19/26. Both shower sheets provided documented resident was not shaved on either shower day. They did not provide any other documentation as to why they were not given a shower or refused one in the last 30 days.During an interview on 03/26/2026 at10:25 AM, DON B stated the CNA didn't know how to put in a prn shower, stated when they moved her from bed 1 to the bed 2, they didn't change her task itself on what days she was to receive her showers, CNA's would put NA because nobody changed the days under that task. DON B stated R1 moved from bed 1 to bed 2 back in June 2025. DON B stated the staff was going off of her old schedule. Writer asked DON B if staff had noticed R1 was not getting her showers? DON B stated apparently not.During an interview and observation on 03/26/2026 at 3:28 PM, R1 was sitting in her wheelchair in her room coloring, appeared to have had a shower today, facial hair was shaved, R1 stated she really didn't like the hair on her face, but it's shaved now. Resident #7 (R7) Review of the medical record reflected that R7 was admitted to the facility on [DATE] and signed onto hospice 02/12/2026.Diagnoses of Huntington's disease, dementia, other disorders of the muscles, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness and repeated falls.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance revealed R7 was dependent on toileting, showering, lower body, sit to stand and transferring from one surface to another with a mechanical device.Record review revealed R7 was admitted on hospice services 02/12/26. Binder contained no certification paperwork, no care plans, no medication list, nor a filled-out calendar with projected visits scheduled.During an interview on 03/24/2026 at 2:40 PM, LPN GG stated she didn't know where this required information would be. Writer asked other facility staff and was told there was a binder behind the nurses' station, labeled said hospice agency that would contain all required documentation. LPN GG went through the hospice binder to find a blank calendar, no nurse visit schedule, no CNA visit schedule, no Social Worker schedule, no Spiritual schedule, no volunteer schedule either, no certification copied to the binder, no medication list.During an interview on 03/25/2026 at 11:45 AM, Hospice Registered Nurse (RN) HH stated they usually put their schedule on the calendar, as she looked, writer stated there was nothing written on the calendar. Writer asked RN HH for the care plans, certification, medication list, filled out calendar of projected visits. RN HH went into her computer and told this writer the CNA is coming on Mondays and Wednesdays same for the nurse, no visits scheduled for social worker. Chaplin is 2 times a month. RN HH stated she would have the office send the information required.Record review revealed no documents scanned to the EMR from hospice as required by Medicare. During an interview and observation on 03/25/2026 at 1:13 PM, CNA Z stated hospice comes in and gave R7 a shower and bed bath every week. Writer asked CNA Z which days the facility CNA's give him baths or showers. CNA Z stated they don't, once the residents are on hospice, they do all of the personal care like showers and baths, unless the residents need one or the hospice CNA won't be coming in. CNA Z stated residents are marked for 2 showers or baths a week, pointing out the schedule on the wall of the linen closet. Stated again that when residents are on hospice, they do not give showers or baths, hospice does all of them and we do not do them unless they are soiled. During an interview and observation on 03/25/2026 at 3:49 PM, LPN/UM E and LPN/UM H stated hospice certification, care plan, medication list, calendar and visit notes should be in the hospice book/binder. LPN/UM H went out to the nurses' station to get the binder. Both LPN/UM E and LPN/UM H looking through R7s information, there was not a certification provided, no medication list, no care plans, the calendar with disciplines visits planned out, it was blank. Writer asked where the visit notes would be as they are not in PCC, the electronic medical record for R7. LPN/UM E stated there is a section where they tell what they did that visit. Writer asked if that was the visit note or a communication note. LPN/UM stated she wasn't sure. LPN/UM E stated shower days for R7 were Wednesdays and Saturdays by the facility CNAs. LPN/UM E stated hospice showers looked like Mondays and Wednesdays.Record review revealed R7 did not receive a shower or bath from the facility CNAs in the last 30 days, all showers were given by the hospice CNAs.During an interview on 03/25/2026 at 5:11 PM, CNA FF stated when the resident was on hospice, hospice CNAs do the showers, but if they do not come in for whatever reason, then the facility CNAs will provide that care.Writer requested R7s shower sheets on 03/25/26 at 4:42pm. The shower sheets were requested again on R7 as of 03/26/26 at 7:15am, requested shower sheets from LNA A on R7 again at 7:45am.Writer was given 3 sheets of hospice coordination notes showing the hospice CNA gave R7 showers or baths on 02/20/26, 03/04/26, 03/09/26, 03/11/26, 03/22/26 and 03/25/26. Facility CNAs did not provide any showers or baths or any documentation to support why they did not give any showers, baths during the last 30 days.During an interview on 03/26/2026 at10:29 AM, DON B stated they get the admission for hospice to business office. Hospice orders are put in by LPN/unit manager H. DON B stated depending on the resident, a CNA comes in spend time with him, personal care provided, get them ready for the day if it's a morning visit. Writer asked DON B how she knows who is coming in that day? DON B stated they had a book they sign in saying what they did for that visit. DON B stated she expected facility CNAs to provide care regardless of if hospice is on board. Writer asked DON B who sets up the Hospice Binder? DON B stated when they send them/facility the care plan, notes, contact information. DON B stated she knew R7s information. DON B stated hospice staff either bring it in or email it to her and the ward clerk, and it will get scanned for the electronic chart or the binder. Writer asked how often they email the facility the visit notes, care plans, completed calendar, certification and medication list. DON B stated definitely not daily or weekly, looks like monthly, some of the notes were emailed from 02/13/ to 03/04, but was not printed, it should go under the Miscellaneous tab.Record review did not reveal any Hospice documentation scanned into the electronic medical record, nor the paper chart Binder provided by hospice, that was sitting in someone's email account. Resident #22 (R22)Review of the medical record reflected that R22 was admitted to the facility on [DATE]. Diagnoses of hemiplegia and hemiparesis following a stroke, lack of coordination, disorder of the muscles, cervical disc disorder of cervical region, fistula of the stomach and duodenum, difficulty in walking and major depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2025 revealed R22 had a Brief Interview of Mental Status (BIMS) of 10 (moderately cognitively impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) R22 was dependent of all care, toileting, showering, dressing lower body, sit to stand and transferring from one surface to another.During an observation and interview on 03/24/2026 at 12:55 PM, R22 was lying back in her bed being fed breakfast by her husband. He brought in food from outside of the facility and she was enjoying it. Writer noted a buildup of plaque on her teeth. This was not a food build up from eating her breakfast. Writer also observed noticeable heavy facial hair on her chin and a mustache. R22 stated she had asked them to shave it off for her, until they told her they use the same razor on the residents. R22 told them she was not using the same razor as others. R22 had her husband bring in her electric razor from home, which sat on her over the bed table within site.During an observation on 03/25/2026 at 10:42 AM, R22 was resting with her eyes closed. Writer observed heavy facial hair present on her chin and a mustache. Electric shaver was still lying in the same place on her over the bed table. During an interview on 03/25/2026 at 1:19 PM, Certified Nursing Assistant (CNA) Z stated R22 had not had her facial hair shaved up until now. CNA Z added R22's husband brought in her electric shaver, must have been yesterday as she did not work yesterday and it wasn't there the day before. CNA Z added R22 is down for a bed bath today so she will shave her face. During an observation on 03/25/2026 at 3:19 PM, R22 was lying in her bed watching TV, her facial hair had been removed.During an interview on 03/25/2026 at 4:07 PM, Licensed Practical Nurse (LPN) AA stated when R22 came to the facility, she did not want her facial hair shaved. Writer asked LPN AA if it was on her care plan. LPN AA looking at R22's care plan and read aloud, staff were encouraged to shave her face as needed. Writer asked LPN AA if there was anything on the care plan stating not to shave R22's facial hair. LPN AA stated there was nothing about R22 not wanting to have facial hair shaved off as it is on the care plan. Record review revealed R22 was listed on the shower sheet for showers/bed baths on Wednesdays and Saturdays. It also revealed that R22 did not receive any bed baths or showers in the last 30 days according to the shower sheets provided to this writer. On 02/21/26- R22 refused care, on 03/12/26- R22 also refused care. No further documentation to support R22 was approached again and asked about taking a shower or in the CNA had reported this to the nurse.During an interview on 03/26/2026 at 10:16 AM, Director of Nursing (DON) B stated the expectation was to provide R22 showers or bed baths two times a week. DON B also stated when R22 refused, they encouraged her to allow care, R22 didn't always allow care, she refused to allow CNAs to shave her facial hair. Writer asked DON B if it was care planned. DON B stated she could not find anything at the moment, writer noted it was in the care plan to shave facial hair as needed. DON B then stated it read to encourage R22 to allow shaving.Under the two shower refusals sheets, R22 didn't refuse shaving, just showers or baths. DON B stated the refusal was on the shower sheets, she looked at yesterday, only two showers or bed baths offered, nothing documented in progress notes to reflect R22 refusing her shower/bed bath, it R22 was reapproached later or if it was reported to the nurse working on the floor that day. DON B stated there was a progress note on 02/16/26- R22 offered to be shaved and she said no from the wound care nurse. No follow up after this progress note was put in. During an observation and interview on 03/26/2026 at 2:30 PM, R22 stated they shaved her facial hair today and it's a lot better now. R22 also stated it will be a lot easier to keep it maintained now. R22 smiled sharing this with the writer and noted the plaque build up on her teeth was still visible.

Through observation, interview and record review the facility failed to ensure three residents (R1, R7 and R22) of four were bathed, had their hair washed, had their facial hair shaved to maintain the highest practicalable physical, emotional and psychological wellbeing.Findings IncludePertains to Intake #2728007Resident #1 (R1)Review of the medical record reflected that R1 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease with lower respiratory infection, weakness, presence of vascular implants and grafts, disorder of the brain, dementia, abnormalities of gait and mobility, colon cancer with a colostomy bag, anxiety and depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2025 revealed R1 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R1 needed substantial assistance with showering and personal care. R1 was maximal assistance on toileting, showering, dressing lower body, sit to stand and transferring from one surface to another.During an observation and interview on 03/24/2026 at 9:47 AM, R1 stated sometimes the staff shave the hair on my face and sometimes they do not. Observation of long hairs hanging off her chin at least 1 long. Writer asked if she preferred to have the chin hairs shaved. R1 stated yes, she does like her chin shaved.During an observation and interview on 03/25/2026 at 10:41 AM, R1 still had facial hair on her chin and stated tomorrow was her bath day.Record review of the care plan stated R1 needed physical assist by 1 staff with personal hygiene; I often need staff to shave whiskers on my chin and set-up assist for oral care. According to the task sheet, the facility staff had not given her a bath in the last 30 days.During an observation on 03/25/2026 at 1:05 PM, R1 still had chin hair longer than 1 .During an interview on 03/25/2026 at 1:10 PM, CNA Z stated R1 got showers on Monday and Thursdays. CNA Z stated when R1 refused her shower, they filled out a shower sheet, they ask her 3 times, then the nurse will ask after that. Writer asked about her facial hair and CNA Z stated that those last couple of months, she hadn't asked to have them shave her chin hair. Writer shared that R1 did in fact mention she wanted the hair shaved on her chin. CNA Z stated that she would take care of that today. Record review shows that R1 has not had a shower or bed bath in the last 30 days. Nor has her hair been washed. During an interview on 03/25/2026 at 4:06 PM, LPN/UM E was asked for shower sheets on R1. Requested Shower sheets from LNA A again at 4:42pm.During an interview on 03/26/2026 at 7:33 AM, LNA A still has not provided the requested shower sheets from yesterday. Requested again at 7:45 am and received them at 8:15am, 2 shower sheets for the last 30 days for R1. Dated 03/12/26 and 03/19/26. Both shower sheets provided documented resident was not shaved on either shower day. They did not provide any other documentation as to why they were not given a shower or refused one in the last 30 days.During an interview on 03/26/2026 at10:25 AM, DON B stated the CNA didn't know how to put in a prn shower, stated when they moved her from bed 1 to the bed 2, they didn't change her task itself on what days she was to receive her showers, CNA's would put NA because nobody changed the days under that task. DON B stated R1 moved from bed 1 to bed 2 back in June 2025. DON B stated the staff was going off of her old schedule. Writer asked DON B that nobody noticed this or noticed R1 was not getting her showers? DON B stated apparently not.During an interview and observation on 03/26/2026 at 3:28 PM, R1 was sitting in her wheelchair in her room coloring, appeared to have had a shower today, facial hair was shaved, R1 stated she really didn't like the hair on her face, but it's shaved now. Writer stated that task was in her care plan on the correct days and should have been done with her showers. Resident #7 (R7) Review of the medical record reflected that R7 was admitted to the facility on [DATE] and signed onto hospice 02/12/2026.Diagnoses of Huntington's disease, dementia, other disorders of the muscles, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness and repeated falls.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance revealed R7 was dependent on toileting, showering, lower body, sit to stand and transferring from one surface to another with a mechanical device.Record review revealed R7 was admitted on hospice services 02/12/26. Binder contains no certification paperwork, no care plans, no medication list, nor a filled-out calendar with projected visits scheduled.During an interview on 03/24/2026 at 2:40 PM, LPN GG stated she didn't know where this required information would be. Writer asked other facility staff and was told there was a binder behind the nurses' station, labeled said hospice agency that would contain all required documentation. LPN GG went through the hospice binder to find a blank calendar, no nurse visit schedule, no CNA visit schedule, no Social Worker schedule, no Spiritual schedule, no volunteer schedule either, no certification copied to the binder, no medication list.During an interview on 03/25/2026 at 11:45 AM, Hospice Registered Nurse (RN) HH stated they usually put their schedule on the calendar, as she looked, writer stated there was nothing written on the calendar. Writer asked RN HH for the care plans, certification, medication list, filled out calendar of projected visits. RN HH went into her computer and told this writer the CNA is coming on Mondays and Wednesdays same for the nurse, no visits scheduled for social worker. Chaplin is 2 times a month. RN HH stated she would have the office send the information required.Record review revealed a R7 revealed Hospice/Facility Coordinated task plan of care, SN to start 2 x a week, week of 02/12/26 and CAN 2 times a week, week on 02/16/26, Activities listed for CNA- bathing, oral care, hair care and toileting. SN to monitor pain and symptoms, vital signs, symptom management, bowel monitoring. No signature on the bottom of the page by hospice staff, facility or family member, labeled coordination note.Record review revealed no documents scanned to the EMR from hospice as required by Medicare. During an interview and observation on 03/25/2026 at 1:13 PM, CNA Z stated hospice comes in and gave R7 a shower and bed bath every week. Writer asked CNA Z which days the facility CNA's give him baths or showers. CNA Z stated they don't, once the residents are on hospice, they do all of the personal care like showers and baths, unless the residents need one or the hospice CNA won't be coming in. CNA Z stated residents are marked for 2 showers or baths a week, pointing out the schedule on the wall of the linen closet. Stated again that when residents are on hospice, they do not give showers or baths, hospice does all of them and we do not do them unless they are soiled. During an interview and observation on 03/25/2026 at 3:49 PM, LPN/UM E and LPN/UM H stated hospice certification, care plan, medication list, calendar and visit notes should be in the hospice book/binder. LPN/UM H went out to the nurses' station to get the binder. Both LPN/UM E and LPN/UM H looking through R7s information, there was not a certification provided, no medication list, no care plans, the calendar with disciplines visits planned out, it was blank. Writer asked where the visit notes would be as they are not in PCC, the electronic medical record for R7. LPN/UM E stated there is a section where they tell what they did that visit. Writer asked if that was the visit note or a communication note. LPN/UM stated she wasn't sure. LPN/UM E stated shower days for R7 were Wednesdays and Saturdays by the facility CNAs. LPN/UM E stated hospice showers looked like Mondays and Wednesdays.Record review revealed R7 did not receive a shower or bath from the facility CNAs in the last 30 days, all showers were given by the hospice CNAs.During an interview on 03/25/2026 at 5:11 PM, CNA FF stated when the resident was on hospice, hospice CNAs do the showers, but if they do not come in for whatever reason, then the facility CNAs will provide that care.Writer requested R7s shower sheets on 03/25/26 at 4:42pm.Have not received the shower sheets requested on R7 as of 03/26/26 at 7:15am, requested shower sheets from LNA A on R7 again at 7:45am.Writer was given 3 sheets of hospice coordination notes showing the hospice CNA gave R7 showers or baths on 02/20/26, 03/04/26, 03/09/26, 03/11/26, 03/22/26 and 03/25/26. Facility CNAs did not provide any showers or baths or any documentation to support why they did not give any showers, baths during the last 30 days.During an interview on 03/26/2026 at10:29 AM, DON B stated they get the admission for hospice to business office. Hospice orders are put in by LPN/unit manager H. DON B stated depending on the resident, a CNA comes in spend time with him, personal care provided, get them ready for the day if it's a morning visit. Writer asked DON B how she knows who is coming in that day? DON B stated they had a book they sign in saying what they did for that visit. DON B stated she expected facility CNAs to provide care regardless of if hospice is on board. DON B stated she will reeducate them. Writer asked DON B who sets up the Hospice Binder? DON B stated when they send them/facility the care plan, notes, contact information. DON B stated she knew R7s information. DON B stated hospice staff either bring it in or email it to her and the ward clerk, and it will get scanned for the electronic chart or the binder. Writer asked how often they email the facility the visit notes, care plans, completed calendar, certification and medication list. DON B stated definitely not daily or weekly, looks like monthly, some of the notes were emailed from 02/13/ to 03/04, but was not printed, it should go under the Miscellaneous tab.Record review did not reveal any Hospice documentation scanned into the electronic medical record, nor the paper chart Binder provided by hospice, that was sitting in someone's email account. Resident #22 (R22)Review of the medical record reflected that R22 was admitted to the facility on [DATE]. Diagnoses of hemiplegia and hemiparesis following a stroke, lack of coordination, disorder of the muscles, cervical disc disorder of cervical region, fistula of the stomach and duodenum, difficulty in walking and major depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2025 revealed R22 had a Brief Interview of Mental Status (BIMS) of 10 (moderately cognitively impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) R22 was dependent of all care, toileting, showering, dressing lower body, sit to stand and transferring from one surface to another.During an observation and interview on 03/24/2026 at 12:55 PM, R22 was lying back in her bed being fed breakfast by her husband. He brought in food from outside of the facility and she was enjoying it. Writer noted a buildup of plaque on her teeth, from not getting her teeth brushed. This was not a food build up from eating her breakfast. Writer also observed noticeable heavy facial hair on her chin and a mustache. R22 stated she had asked them to shave it off for her, until they told her they use the same razor on the residents. R22 told them she was not using the same razor as others. R22 had her husband bring in her electric razor from home, which sat on her over the bed table within site.During an observation on 03/25/2026 at 10:42 AM, R22 was resting with her eyes closed. Writer observed heavy facial hair present on her chin and a mustache. Electric shaver was still lying in the same place on her over the bed table. During an interview on 03/25/2026 at 1:19 PM, Certified Nursing Assistant (CNA) Z stated R22 had not had her facial hair shaved up until now. CNA Z added R22's husband brought in her electric shaver, must have been yesterday as she did not work yesterday and it wasn't there the day before. CNA Z added R22 is down for a bed bath today so she will shave her face. During an observation on 03/25/2026 at 3:19 PM, R22 was lying in her bed watching TV, her facial hair had been removed from shaving. During an interview on 03/25/2026 at 4:07 PM, Licensed Practical Nurse (LPN) AA stated when R22 came to the facility, she did not want her facial hair shaved. Writer asked LPN AA if it was on her care plan. LPN AA looking at R22's care plan and read aloud, staff were encouraged to shave her face as needed. Writer asked LPN AA if there was anything on the care plan stating not to shave R22's facial hair. LPN AA stated there was nothing about R22 not wanting to have facial hair shaved off as it is on the care plan. Record review revealed R22 was listed on the shower sheet for showers/bed baths on Wednesdays and Saturdays. It also revealed that R22 did not receive any bed baths or showers in the last 30 days according to the shower sheets provided to this writer. On 02/21/26- R22 refused care, on 03/12/26- R22 also refused care. No further documentation to support R22 was approached again and asked about taking a shower or in the CNA had reported this to the nurse.During an interview on 03/26/2026 at 10:16 AM, Director of Nursing (DON) B stated the expectation was to provide R22 showers or bed baths two times a week. DON B also stated when R22 refused, they encouraged her to allow care, R22 didn't always allow care, she refused to allow CNAs to shave her facial hair. Writer asked DON B if it was care planned. DON B stated she could not find anything at the moment, writer noted it was in the care plan to shave facial hair as needed. DON B then stated it read to encourage R22 to allow shaving. Under the two shower refusals sheets, R22 didn't refuse shaving, just showers or baths. DON B stated the refusal was on the shower sheets, she looked at yesterday, only two showers or bed baths offered, nothing documented in progress notes to reflect R22 refusing her shower/bed bath, it R22 was reapproached later or if it was reported to the nurse working on the floor that day. DON B stated there was a progress note on 02/16/26- R22 offered to be shaved and she said no from the wound care nurse. No follow up after this progress note was put in. During an observation and interview on 03/26/2026 at 2:30 PM, R22 stated they shaved her facial hair today and it's a lot better now. R22 also stated it will be a lot easier to keep it maintained now. R22 smiled sharing this with the writer and noted the plaque build up on her teeth was still visible.

Based on observations, interview and record review this facility failed to maintain range of motion in one resident (R#4) of two residents reviewed for range of motion resulting in failure to participate in her activities of daily living.Findings IncludeResident #4 (R4)Review of the medical record reflected that R4 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease, urinary tract infection, dysphagia (difficulty swallowing) chronic respiratory failure, pressure ulcer of sacral region- stage 3, paraplegia- incomplete, chronic pain, muscle wasting and atrophy.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R4 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R4 was dependent for showers, personal care, toileting, dressing lower body, sit to stand and transferring from one surface to another.During an interview on 03/24/2026 at 9:54 AM, R4 stated they don't do any Range of Motion (ROM) on her left side because her bed is up against the wall. R4 stated she was able to move her arms back and forth when she got to this facility, as her discharging hospital really worked with her in their inpatient therapy department. R4 also stated she could move her wrist, hand and fingers freely. R4 stated she still needed help with most things, but she had some mobility. R4 stated when the CNAs came in to change her brief, they would pull the head of the bed towards the middle of the room so each CNA could be on both sides of her. Writer asked R4 if they provided ROM when they got her dressed. R4 stated heck no! They haven't done it at all; R4 stated she doesn't get dressed so they don't do anything but change her brief. Writer asked R4 how often the staff come in to reposition her. R4 stated once a shift if that, added during the night, she may get her brief changed once, but they don't do anything but change her brief and left the room.Record review revealed R4 was care planned to be checked and changed every two hours and as needed. R4 was dependent of one staff to repositioning and turning in bed. R4 was dependent on two staff and use of a mechanical lift to transfer from one surface to another. R4 was care planned for staff to follow the plan of care to assist R4 in maintaining optimal level of strength, function and medical status. R4 was care planned for pain management, staff to evaluate the effectiveness of pain interventions, review for alleviating of symptoms, dosing schedule and resident's satisfaction with results, impact on functional ability and impact on cognition. R4 needed head of the bed elevated as needed for comfort and support respiratory function. Position R4 with proper body alignment for optimal breathing pattern. Elevate heels off the mattress/bed while at rest in bed as tolerated. Follow physician orders for treatment of skin impairments. Provide pain management with treatments as needed. Monitor/document location, size and treatment of skin injury, report abnormalities to the physician. Turn and reposition R4 every two hours and as needed as R4 tolerates, encourage R4 not to lay directly on her buttock for pressure relief.Record review also revealed R4 was rolled from left to right side, two to three times a day during the last 30 days according to the task sheet filled out by CNAs caring for her, not every two hours as care planned. R4 was not repositioned every two hours during the last 30 days according to the task sheet filled out by the CNAs caring for her. According to the Medication Administration Record (MAR) R4 received her Oxycodone HCI 5 mg capsule every 8 hours (0000, 0800,1600) and rated her pain #3 to #10 on a scale of 0-10, including the prn/as needed dose allowed once daily. R4 reported a pain level of #2 to #6 on a scale of 0-10 during wound care to her coccyx pressure ulcer, stage 3. Wound care orders to be done at 7:00AM, included cleanse the coccyx pressure ulcer with normal saline, pat dry, mix Triad paste and medi-honey together and apply to wound bed, leave open to air. R4 had Oxycodone HCI 5mg capsule scheduled at 0800, after the wound care for R4's pressure ulcers, not before the wound care for increased pain during treatment. During an interview on 03/26/2026 at 8:01 AM, Regional Physical Therapist II, stated he was filling in at this facility. Writer asked him about the condition of R4 when she got here. Regional Physical Therapist II, stated R4 was pretty much dependent on everything, bed mobility, mechanical lift, etc. Writer asked Regional Physical Therapist II about the Occupational Therapy (OT) evaluation on admission stated R4 was within functional limits. Regional Physical Therapist II, stated R4 had some elbow and wrist movement. Regional Physical Therapist II, then stated the OT evaluation cannot be right, because R4 isn't able to do anything. Regional Physical Therapist II stated he evaluated her repositioning in her bed, and she could not do it. Regional Physical Therapist II, questioned the OT evaluation. Writer asked about a restorative program, he didn't know if they had an actual program but stated the CNAs are to do some ROM with care. Regional Physical Therapist II, stated it would be best to speak to nursing about a restorative program, as Regional PT, he didn't know if they had a restorative program. During an interview on 03/26/2026 at 8:11 AM, Occupational Therapist (OT) JJ stated R4 had rolled wash cloths in the palms of her hand as tolerated to prevent further restriction of movement and prevent fingernails form going into her palms, adding she had educated the family/husband. During an interview on 03/26/2026 at 8:19 AM, unit manager/LPN E stated they did not have a restorative program, no, it is expected that the CNAs provide ROM with morning care and night care. Writer asked about R4 not getting dressed daily, she wears a hospital gown, so not getting ROM with getting dressed activities. Writer also noted R4 does not wear footwear. Unit manager/LPN E stated it is still the expectation.During an interview on 03/26/2026 at 10:39 AM, DON B stated it was incorporated into R4s ADLs, but there was very little she would let you do with her. DON B stated she was on routine pain medications and anxiety medications. DON B stated R4 came into the facility with prn/as needed anxiety medication of Xanax 0.5mg every 8 hours as needed, ended on 03/09/26, then on 03/10/26 new script for Xanax 0.5 mg bid. admitted with Oxycodone 5 mg every 6 hours as needed, changed on 03/10/26 to Oxycodone 5mg bid, then on 03/11/26 changed it to Oxycodone every 8 hours, added a prn dose. DON B stated R4 had a lot of chronic pain.Writer asked DON B about R4s ROM and wash clothes rolled up and placed in her hands to prevent further restriction of movement. DON B observed looking for it on R4's care plan. DON B stated she couldn't find it, was not added to the care plan. Writer asked what ROM was done if R4 wears a hospital gown and doesn't get dressed or wear footwear. DON B stated she didn't know. Writer asked if there was any documentation to support that R4 received ROM. DON B stated it was the expectation that staff provide ROM to residents, so no not specifically.Record review revealed R4 was admitted to facility and the OT evaluation and plan of care documented R4 had upper body range of movement within functional limits.During an interview on 03/26/2026 at 3:39 PM, CNA KK stated R4 would let them move her legs a little and maybe her arms due to her pain level, everything hurts R4. CNA KK stated R4 did not like having the head of the bed down at all because it was hard for her to breathe. During an observation and interview R4 did not have any movement or mobility in her arms, wrist, hands or fingers at the time of discharge from this facility on 03/25/2026 to another facility. R4 could be seen grimacing and calling out due to pain with movement of extremities, rolling to provide brief change and peri-care, completion of the wound care to her pressure ulcer, stage 3 on her coccyx. R4 stated many times that her pain was not maintained at a tolerable level. R4 was not wearing any washcloths rolled up in her palms. R4 also stated that she had lost the mobility she had on admission to this facility. R4 stated her pain was not managed, they knew the extent of her pain and did not offer pain medications prior to wound care, or the few times they did reposition her. R4 stated they did not use the rolled wash clothes in her palms to prevent further restriction of movement, because they didn't put it on the care plan after being ordered by occupational therapy. R4 was tearful and stated she was glad to be transferring to another facility because they did nothing for her here.

Based on observation, interview, and record review the facility failed to ensure respiratory care, including tracheal suctioning was provided consistent with professional standard of practice for one Residents (#6) of three Residents reviewed for respiratory care. Findings Included:Resident #6 (R6)Review of the medical record revealed R6 was admitted [DATE] with diagnoses that include dysphagia (difficulty swallowing), cerebral infarction (stroke), tracheostomy (a surgical opening in the trachea), gastrostomy (a feeding tube inserted through the abdomen directly into the stomach to provide nutrition), chronic respiratory failure, pressure injury to right heel, anxiety, insomnia, abnormal posture, lack of coordination, language deficits, paralysis right side of body, type 2 diabetes, hypertension, gastro-esophageal reflux, and protein-calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2023, revealed R6 had a Brief Interview of Mental Status (BIMS) that could not be assessed because the resident is rarely/never understood. During observation and attempted interview on 03/24/2026 at 01:24 p.m. R6 was observed lying down in bed. R6 did not respond to verbal stimuli. R6 was observed during this time to have a tracheostomy tube connected with tracheostomy ties. The tracheostomy ties appeared to be soiled with dried on mucus. A oxygen compressor was observed connected to an oxygen circuit of tubing with humidification that was connected to the oxygen collar and observed to be placed over R6's tracheostomy tube opening. The oxygen collar and oxygen circuit tubing was not observed to have been dated. Oxygen tubing was observed connected to a oxygen concentrator and the oxygen circuit. The oxygen tubing was not observed to be dated. Review of R6's treatment administration record (TAR) revealed an order Change all trach (tracheostomy) tubing, mask, and suction canister every night shift every Sun (Sunday) for reducing risk and change trach ties every night shift every Sun for management & infection risk reduction. Review of R6's March TAR revealed 03/22/2026 was blank for the treatments change all trach (tracheostomy) tubing, mask, and suction canister every night shift every Sun (Sunday) for reducing risk and change trach ties every night shift every Sun for management & infection risk reduction.On 03/25/2026 at 09:05 a.m. R6 was observed sitting up in a geriatric reclining wheelchair. At that time Licensed Practical Nurse (LPN) Q explained that she was going to suction R'6 and change the inner cannula of his tracheostomy. LPN Q was observed to place an isolation gown on. LPN Q was observed to open a suction kit which included sterile gloves and the suction catheter. LPN Q was then observed to place sterile gloves on both hands and proceed to connect the unsterile suction tubing (held with left hand) and connect it to the sterile suction catheter (held with the right hand). LPN Q was then observed to not have turned on the suction cannister. LPN Q explained that she needed to plug in the suction cannister. LPN Q was then observed to place her sterile gloved right hand (which was holding the sterile suction catheter) on the bed, with the suction catheter also touching the bed. Once the suction cannister was plugged in she was observed to suction R6's tracheostomy. LPN Q was observed to discard the suction catheter, remove her gloves, and then place non-sterile gloves on both of her hands. LPN Q was then observed to remove R6's inner tracheostomy cannula. LPN Q then was observed to perform outer tracheostomy care using sterile q tips and sterile saline. LPN Q was then observed to pick up a sterile inner tracheostomy cannula (without changing her gloves) from its container and place it in R6's outer tracheostomy cannula. LPN Q was then observed to change R6's tracheostomy ties without changing her gloves or washing her hands.On 03/25/2026 at 09:36 a.m. Director of Nursing (DON) B explained that suctioning of a tracheostomy was to be completed using sterile technique, which was facility policy and professional standards. DON B also explained that replacing the inner cannula of a tracheostomy was to be completed using sterile technique. Which was facility policy and professional standards. DON B explained that sterile technique was used to decrease the risk of infection to the Resident with a tracheostomy. DON B was asked to review R6's March Treatment Record (TAR). DON B confirmed that R6's March TAR did not demonstrate that R6's orders were completed on 03/22/26 as written to Change all trach (tracheostomy) tubing, mask, and suction canister every night shift every Sun (Sunday) for reducing risk and change trach ties every night shift every Sun for management & infection risk reduction. DON B explained that he was discharge to the emergency room on that date so that is why R6's treatments on 03/22/2026 was not completed. DON B confirmed that the last charting that all tracheostomy tubing, mask, and suction canister had been changed for R6 was 03/15/2026. On 03/25/2026 at 09:48 a.m. Director of Nursing (DON) B was observed going to R6's room. DON B explained that the oxygen tubing and the humidification tracheostomy circuit should be dated for the last time it was changed. DON B confirmed that no dates were present on the oxygen tubing and the tracheostomy humidification circuit. Review of facility policy entitled Tracheostomy, Suctioning of, adopted 07/11/2028 and last updated 04/01/2024, revealed the following procedure: . 4. Wash hands, set up equipment and put on personal protective equipment. 7. Open sterile packages and prepare irrigation and rinsing solutions, maintaining sterility.8. Put on sterile gloves in order to handle catheter. A sterile hand is maintained for the catheter, and a non-sterile hand is used to regulate the suction.

Based on observation and interview the facility failed to remove all expired medications from two of four medication administration carts used to administer medications to residents with the potential to affect half of the facility census of 93. Findings Include During observation and interview on 03/25/2026 at 8:16 AM, writer asked to look through medication cart labeled Hall A. Writer found Allergy Relief 24 hr. 180mg tab expired 01/26. Naproxen Sodium 220mg tab expiration date has been removed, all white with no date.During observation and interview on 03/25/2026 at 8:36 AM, writer asked to look through medication cart labeled Hall B. Writer found Cetirizine HCI 10 mg tab- Expiration date had been removed, wiped off, plain white area where expiration date was.During observation and interview on 03/25/2026 at 10:45 AM, writer asked to look through the medication room at the nurses' station. No outdated medications found, refrigerators and freezer temperatures were present and within normal range.During an interview on 03/26/2026 at10:29 AM, DON B stated it would be the expectation that all nurses look at the expiration dates on the bottles and dispose of them once they identify they are expired.

Based on observation, interview, and record review, the facility failed to ensure the published menu was served as planned to six residents and residents were consistently informed in advance of any menu changes affecting all residents consuming food from the kitchen resulting in resident dissatisfaction with their meal experience and feelings of frustration related to meals voiced in confidential resident group the the potential to effect all 93 residents. Findings include:During an observation and interview on 3/24/2026 at 9:19 AM, tour of kitchen with Kitchen Manager (KM) Y. Menus were reviewed and KM Y reported residents had option related to menus and reported if residents did not prefer main dish they had option for alternative option and also had options for always available items. During an observation, interview and record review on 3/25/2026 at 11:15am, this surveyor observed tray line services. KM Y and cook verified posted menu that included roast beef, potatoes, butter carrots, roll, and beverages. Observed several resident meal tickets with request for grilled cheese and veggie burgers honored. Observed entire try line that started with Hall C, followed by Hall D, Main Dinning Room, Hall B, and finished with Hall A. Observed six resident meal tickets that had requested main menu remaining during Hall A service that were served burgers after running out of posted main menu item roast beef. During an interview at 12:10 p.m., KM Y confirmed they had run out of roast beef for six residents who had ordered roast beef and alternative protein of burgers were placed in oven to serve to those residents. During an interview on 3/26/26 at 6:50pm, Nursing Home Administrator (NHA) A reported would expect meals to be served to residents as posted and according to resident preference including main menu items.

Based on observation, interview, and record review the facility failed to ensure palatable and appetizing food was served to two (Resident #2 and Resident #49) of 2 residents reviewed for receiving palatable and appetizing food, resulting in potential for decreased oral intake.Findings include:During an observation on 3/25/2026 7:21 AM, this surveyor observed a full uninsulated tray cart located on Hall C (secure memory unit) with no staff delivering trays at that time. Two nurses were observed at medication cart and several residents were observed wandering the hall and six residents were sitting at the dining room table at the end of the hall with no staff in the dark. Continued observation on 3/25/2026 at 8:08 AM, Certified Nurse Aid (CNA) LL entered R2 room with breakfast tray. (about 45 min after arrival of tray) Continued to observe and at 8:15 AM R49 was served first bite of breakfast with staff assist. (almost one hour after tray delivered). Observed 11 residents in secure memory dining room with two staff in dining room. Staff assist two other residents at Dining room table. Observed staff attempting to cut toast and unable to be cut after attempt and observed staff breaking up oatmeal that had [NAME] solid top layer and staff stirred for resident on her right side. During an interview on 3/25/2026 at 1050 am CNA LL and CNA MM reported resident on her right-side during morning meal did not eat well this morning and verified was unable to cut toast. During an interview on 3/26/2026 at 6:50 pm, Nursing Home Administrator (NHA) A reported would expect meal trays to delivered to residents immediately after arrival.

Based on observation, interview, and record review the facility Arbitration Agreement failed to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission, or as a requirement to continue to receive care at the facility and state that the binding arbitration agreement allows the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health departement employees and representatives of the Office of the State Long Term Care Ombudsman for one resident (#73) of three Resident reviewed for Arbitration Agreements. Findings Included:Resident #73 (R73) Review of the medical record revealed R73 was admitted to the facility 02/01/2023 with diagnoses that include atherosclerotic heart disease (plaque build-up in artery walls), polyneuropathy (wide spread peripheral nerve damage), insomnia, contracture (long lasting tightening of muscle) of left elbow, lack of coordination, muscle weakness, dementia, abnormal posture, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), hypertension, cognitive communication deficit, alcohol abuse, gastro-esophageal reflux, and chronic hepatitis (inflammation of the liver). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026, revealed R73 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During an interview on 03/26/2026 at 10:49 a.m. R73 was observed lying in bed. R73 explained the purpose of the facility arbitration agreement but was not willing to review the actual Resident Arbitration Agreement that was signed on 02/03/2023 or the Resident Arbitration Agreement that was signed on 03/25/2026. R73 could not explain why the Resident Arbitration Agreement was resigned by him on 03/25/2026.Review of the facility Resident Arbitration Agreement signed by R73 on 02/03/2023 did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission, or as a requirement to continue to receive care at the facility. The same Resident Arbitration Agreement signed by R73 on 02/03/2023 did not state that the binding arbitration agreement allows the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health departement employees and representatives of the Office of the State Long Term Care Ombudsman. During an interview on 03/26/2026 at 11:48 a.m. admission Director (AD) N explained that Residents are offered to enter into a Resident Arbitration Agreement upon admission. AD N confirmed that the Resident Arbitration Agreement, signed 02/03/2023 by R73, did not explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission, or as a requirement to continue to receive care at the facility. AD N confirmed that the Resident Arbitration Agreement, signed 02/03/2023 by R73 did not state that the binding arbitration agreement allows the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health departement employees and representatives of the Office of the State Long Term Care Ombudsman. AD N explained that the facility identified that R73's Resident Arbitration Agreement did not meet the requirements when the facility was asked to provide R73's Resident Arbitration Agreement during the survey process. AD N explained that R73 was asked to sign a new Resident Arbitration Agreement on 03/26/2026, after the above was identified.

Based on observation, interview, and record review the facility Arbitration Agreement failed to explicitly state that the agreement provided for the selection of a neutral arbitrator agreed upon by both parties for one resident (#73) of three Resident reviewed for Arbitration Agreements. Findings Included:Resident #73 (R73)Review of the medical record revealed R73 was admitted to the facility 02/01/2023 with diagnoses that include atherosclerotic heart disease (plaque build-up in artery walls), polyneuropathy (wide spread peripheral nerve damage), insomnia, contracture (long lasting tightening of muscle) of left elbow, lack of coordination, muscle weakness, dementia, abnormal posture, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), hypertension, cognitive communication deficit, alcohol abuse, gastro-esophageal reflux, and chronic hepatitis (inflammation of the liver). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026, revealed R73 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During an interview on 03/26/2026 at 10:49 a.m. R73 was observed lying in bed. R73 explained the purpose of the facility arbitration agreement but was not willing to review the actual Resident Arbitration Agreement that was signed on 02/03/2023 or the Resident Arbitration Agreement that was signed on 03/25/2026. R73 could not explain why the Resident Arbitration Agreement was resigned by him on 03/25/2026.Review of the facility Resident Arbitration Agreement signed by R73 on 02/03/2023, did not provide for the selection of a neutral arbitrator agreed upon by both parties.During an interview on 03/26/2026 at 11:48 a.m. admission Director (AD) N explained that Residents are offered to enter a Resident Arbitration Agreement upon admission. AD N confirmed that the Resident Arbitration Agreement, signed 02/03/2023 by R73 did not provide for the selection of a neutral arbitrator agreed upon by both parties. AD N explained that the facility identified that R73's Resident Arbitration Agreement had not meet the requirements when the facility was asked to provide R73's Resident Arbitration Agreement during the survey process. AD N explained that R73 was asked to sign a new Resident Arbitration Agreement on 03/26/2026, after the above was identified.

Based on observation, interview and record review the facility failed to provide coordination of care for hospice services for one resident (R7) of one reviewed for additional services above and beyond the facilities provides.Findings IncludeResident #7 (R7)Review of the medical record reflected that R7 was admitted to the facility on [DATE] and signed onto hospice 02/12/2026.Diagnoses of Huntington's disease, dementia, other disorders of the muscles, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness and repeated falls.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance revealed R7 was dependent on toileting, showering, lower body, sit to stand and transferring from one surface to another with a mechanical device.Record review revealed R7 was admitted on hospice services 02/12/26. Binder contains no certification paperwork, no care plans, no medication list, nor a filled-out calendar with projected visits scheduled.During an interview on 03/24/2026 at 2:40 PM, LPN GG stated she didn't know where this required information would be. Writer asked other facility staff and was told there was a binder behind the nurses' station, labeled said hospice agency that would contain all required documentation. LPN GG went through the hospice binder to find a blank calendar, no nurse visit schedule, no CNA visit schedule, no Social Worker schedule, no Spiritual schedule, no volunteer schedule either, no certification copied to the binder, no medication list.During an interview on 03/25/2026 at 11:45 AM, Hospice Registered Nurse (RN) HH stated they usually put their schedule on the calendar, as she looked, writer stated there was nothing written on the calendar. Writer asked RN HH for the care plans, certification, medication list, filled out calendar of projected visits. RN HH went into her computer and told this writer the CNA is coming on Mondays and Wednesdays same for the nurse, no visits scheduled for social worker. Chaplin is 2 times a month. RN HH stated she would have the office send the information required.Record review revealed no documents scanned to the EMR from hospice as required by Medicare. During an interview and observation on 03/25/2026 at 1:13 PM, CNA Z stated hospice comes in and gave R7 a shower and bed bath every week. Writer asked CNA Z which days the facility CNA's give him baths or showers. CNA Z stated they don't, once the residents are on hospice, they do all of the personal care like showers and baths, unless the residents need one or the hospice CNA won't be coming in. CNA Z stated residents are marked for 2 showers or baths a week, pointing out the schedule on the wall of the linen closet. Stated again that when residents are on hospice, they do not give showers or baths, hospice does all of them and we do not do them unless they are soiled. During an interview and observation on 03/25/2026 at 3:49 PM, LPN/UM E and LPN/UM H stated hospice certification, care plan, medication list, calendar and visit notes should be in the hospice book/binder. LPN/UM H went out to the nurses' station to get the binder. Both LPN/UM E and LPN/UM H looking through R7s information, there was not a certification provided, no medication list, no care plans, the calendar with disciplines visits planned out, it was blank. Writer asked where the visit notes would be as they are not in PCC, the electronic medical record for R7. LPN/UM E stated there is a section where they tell what they did that visit. Writer asked if that was the visit note or a communication note. LPN/UM stated she wasn't sure. LPN/UM E stated shower days for R7 were Wednesdays and Saturdays by the facility CNAs. LPN/UM E stated hospice showers looked like Mondays and Wednesdays.Record review revealed R7 did not receive a shower or bath from the facility CNAs in the last 30 days, all showers were given by the hospice CNAs.During an interview on 03/25/2026 at 5:11 PM, CNA FF stated when the resident was on hospice, hospice CNAs do the showers, but if they do not come in for whatever reason, then the facility CNAs will provide that care.Writer requested R7s shower sheets on 03/25/26 at 4:42pm. Having not received the shower sheets requested on R7 as of 03/26/26 at 7:15am, requested shower sheets from LNA A on R7 again at 7:45am.Writer was given 3 sheets of hospice coordination notes showing the hospice CNA gave R7 showers or baths on 02/20/26, 03/04/26, 03/09/26, 03/11/26, 03/22/26 and 03/25/26. Facility CNAs did not provide any showers or baths or any documentation to support why they did not give any showers, baths during the last 30 days.During an interview on 03/26/2026 at10:29 AM, DON B stated they get the admission for hospice to business office. Hospice orders are put in by LPN/unit manager H. DON B stated depending on the resident, a CNA comes in spend time with him, personal care provided, get them ready for the day if it's a morning visit. Writer asked DON B how she knows who is coming in that day? DON B stated they had a book they sign in saying what they did for that visit. DON B stated she expected facility CNAs to provide care regardless of if hospice is on board. DON B stated she will reeducate them. Writer asked DON B who sets up the Hospice Binder? DON B stated when they send them/facility the care plan, notes, contact information. DON B stated she knew R7s information. DON B stated hospice staff either bring it in or email it to her and the ward clerk, and it will get scanned for the electronic chart or the binder. Writer asked how often they email the facility the visit notes, care plans, completed calendar, certification and medication list. DON B stated definitely not daily or weekly, looks like monthly, some of the notes were emailed from 02/13/ to 03/04, but was not printed, it should go under the Miscellaneous tab.Record review did not reveal any Hospice documentation scanned into the electronic medical record, nor the paper chart Binder provided by hospice, that was sitting in someone's email account.

Based on observation, interview, and record review the facility failed to ensure that appropriate hand hygiene was conducted during dressing changes for two residents (#63, #88) and during medication administration observation with the potential to affect facility census of 93. Findings included:During an observation on 03/25/2026 at 8:04 AM, LPN OO was preparing medications for R57, writer did not see LPN OO perform hand hygiene prior to getting in the medication cart. LPN OO did not perform hand hygiene before going into the R57's room nor after administering R57's medication. No hand hygiene in R57's room or prior to returning back to the medication cart. During an interview with Infection Preventionist D stated she would expect the nurses to use hand hygiene between each resident. She did education on hygiene as well as an annual skills fair. During an interview on 03/26/2026 at10:29 AM, DON B stated it would be the expectation that all nurses use hand hygiene between residents and after administration of medications. During an observation on 3/25/2026 at 2:25 PM, Registered Nurse (RN) F reported was training RN J and planned to change R63 wound dressing. Observed RN J removed R63 soiled dressing from R63 right hip, wound was about baseball size diameter with rolled curled scared edges. RN J cleaned wound with normal saline, packed with fingers only with daken soaked gauze, covered with aquacell (not to wound bed), and ABD pad. RN J did not change gloves between soiled and clean dressing that required packing and did not follow treatment orders. During an interview on 3/25/2026 2:42 PM, RN F reported would expect gloves change between dirty and clean dressing and verified walked away from dressing change for additional supplies and did not correct RN J and should have. During an interview on 3/26/2026 at 1:28 pm, RN Infection Control D reported would expect nurse to follow provider order for treatments. During an interview on 3/26/2026 at 6:50 pm RN D reported would expect nurses to change gloves between dirty and clean dressing changes. Resident #88 (R88) Review of the medical record revealed R88 was admitted [DATE] with diagnoses that include Fournier gangrene (flesh-eating bacteria affecting genital, perineal, or perianal regions), retroperitoneal abscess (collection of pus behind the abdominal cavity), muscle wasting, anemia (low red blood cell count), type 2 diabetes, hypertension, hepatic encephalopathy (decline in brain functioning related to sever liver disease), abnormal posture, and alcoholic cirrhosis (liver scaring). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026, revealed R88 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. On 03/24/2026 at 10:18 a.m. during observation and interview R88 was observed sitting up a recliner. R88 explained that he was receiving dressing changes to his scrotum. R88 also explained that he had a JP (Jackson Pratt) drain near the surgical site by his scrotum. R88 explained that staff performed dressing changes twice daily. Review of R88 medical record revealed current treatment orders, Cleanse JP (Jackson Pratt) drain site with wound cleanser, pat dry, skin prep around site and cover with split gauze around site on time per day. R88's medical record also revealed a current treatment order cleanse residents scrotum surgical site with normal saline, pat dry, wick plain packing strip into wound be then cover area with calcium alginate dressing and then cover with ABD pad, secure with tape every day and night shift for surgical incision. On 03/25/2026 at 12:23 p.m. R88 was observed lying down in bed. R88 explained that he had removed his scrotal dressing so that Licensed Practical Nurse (LPN) O could perform the dressing to his surgical site and clean around his JP (Jackson Pratt) drain. LPN O was observed sanitizing hands, placed on gown, and then gloves. LPN O was then observed removing blood-soaked packing strips from R88's scrotum surgical site. Surgical site could not be viewed clearly as only present small hole with tunnelling. Observed LPN O cleanse the site with normal saline and packed with strips and removed. Skin prep was then applied, and site was packed with strips of calcium alginate and covered with dressing. R88 would not let nurse apply tap to dressing because he explained it irritated his skin. LPN O then went to closet and obtained a brief and assisted R88 applying brief. LPN O then removed her gloves and washed her hands. During an interview on 02/25/2026 at 12:40 p.m. Director of Nursing (DON)B was asked to explain the process of performing a dressing change. DON B explained that it was her expectation that the following procedure be followed: hands are to be sanitized, the nurse would apply gloves and gown, the old dressing would be removed and discarded, the nurse would remove her soiled gloves, the nurse would wash or sanitize her hands, new gloves would be applied, if the dressing change included cleansing the wound the nurse would remove her gloves and wash her hands before proceeding with the clean dressing being applied, the new dressing would be applied, the nurse would remove her gloves, wash or sanitized hands and assist the resident with any further necessary assistance. DON B explained that gloves are to be changed and hand sanitized between the removal of a soiled dressing and the application of the new dressing to decrease the possibility of contamination of the new dressing. Review of facility policy entitled Dressing, non-sterile, adopted 07/11/2018, revealed the following procedure .7. Wash hands, apply gloves, 8. Remove dressing and discard in plastic bag, 9. Remove gloves, wash hands, re-apply gloves, 10. Clean wound as ordered .11. Dispose of cleaning supplies in bag, 12. Remove gloves, wash hands, reapply gloves, . 14. Apply dressing as ordered, . 16. Remove gloves, 17. Assist resident to allowed position of comfort, ensure call light within reach, 18. Wash hands.

Based on observation, interview and record review, the facility failed to implement the Comprehensive Care Plan for one (R6) of three reviewed.Findings include:Review of the medical record reflected R6 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fracture of unspecified part of neck of left femur (6/8/25), seizures, difficulty walking, diabetes, dementia and impulse disorder. The modification of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/25, reflected R6 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had two or more falls since admission or the prior assessment. On 12/30/25 at 12:57 PM, R6 was observed up in their wheelchair, in a common area, with shoes on both feet. Anti-rollback brakes, rear anti-tip bars and a drop seat (seat tilted back) were observed on R6's wheelchair. R6's bed height was observed to be in a low position, with a standard mattress in place (sides of mattress were not elevated). The left side of the bed was against the wall. Non-skid strips were not observed on the floor at the bedside. R6's Care Plan reflected they were at risk for falls. Interventions included but were not limited to non-skid strips at the bedside (initiated 2/2/25) and an edge defined perimeter mattress (initiated 7/25/24).In an interview on 1/6/26 at 11:58 AM, Director of Nursing (DON) B reported Care Plans were reviewed by the MDS nurse quarterly. If a resident had a fall, the falls Care Plan was reviewed by the Interdisciplinary Team (IDT). DON B described an edge defined perimeter mattress as a mattress with slightly elevated sides. DON B reported R6 had a room change in October 2025, and their interventions were not moved to their new room. According to DON B, Unit Managers were to ensure all interventions were in place upon a room change.

This Citation Has Two Deficient Practice Statements A and B. DPS A. Based on observation, interview and record review the facility failed to investigate and identify root causes for falls and implement interventions as identified on incident and accident reports and physician orders, thus failing to prevent a series of falls for one resident (#52) of three residents reviewed for falls, resulting in a fall with a left hip fracture that required surgical repair. Findings include: Resident #52 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 52 (R52) was a [AGE] year old female admitted to the facility with a diagnoses of dementia, R52 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section G of MDS reflected R52 required extensive assistance from 2 staff for transfers, toileting, bed mobility and had lost the ability to walk. R52 was observed in the dining room/lounge area of the facility's secured dementia unit. R52 was observed in a regular wheelchair without anti tip Review of incident and accident reports pertaining to R52's falls for 2023 reflected R52 fell on [DATE] from her recliner because she was trying to get up. The incident report does not reflect if the fall was witnessed, it does not identify why R52 was trying to get up ; bathroom, get something eat, reposition etc . intervention was to but strips on the floor in front of recliner/bed. There was no indication of what time the fall occurred or when R52 was last visualized by staff. Of note, resident R52's room was observed not to have strips in front of the bed throughout the survey. Incident report dated 04/02/23 (time unknown) reflected R52 was observed sitting on the floor in front of her bed, there was no injury noted. Multiple blankets were on the bed and the intervention listed on the incident report was remove some of the blankets. It was unclear what time this occurred, the last time R52 was toileted, or the last time she was visualized by staff, there was no documentation that determined if R52 was tangled up in the blankets or intentionally tried to get out of bed. Incident report dated 04/06/23 (time unknown) reflected R52 was observed sitting on the floor in front of her recliner, no injury noted but R52 did complain of foot pain. There was no documentation that revealed time of day, last time she was visualized by staff, or where R52 was trying to get up and go to, i.e.: bathroom, get a snack, leave her room to socialize. The intervention listed on the incident report was to remove the recliner. Incident report dated 06/26/23 reflected R52 tripped over her shoe while leaving the dining room. Intervention was to ensure her shoes are on correctly. The report does not reflect if R52's shoes were untied, on the wrong foot, ill fitting or need to be replaced. R52 sustained swelling and bruising to the left side of her face as a result. Incident report dated 08/24/23 0006 reflected R52 was observed on the floor in front of her bed and complaining of left hip pain. R52 yelled out when left leg palpated and reported to License Practical Nurse (LPN) O that she had hit her head. R52 was transferred and admitted to the local hospital where she was admitted with a left hip fracture and underwent surgical repair. The intervention was to add a perimeter mattress. The incident report did not contain information such as the time of the fall, what R52 was attempting to do i.e. go to bathroom, get a snack reposition etc the new intervention listed on the incident report was to send to the hospital and add a perimeter mattress. Review of the October 2023 monthly Physician orders reflected an physician order that was written on 8/30/23 High back reclining [sic] w/c (wheel chair) with seat cushion and rear anti-tippers for Positioning and Locomotion. Of note, R52 was observed sitting throughout the survey in a regular (non high back, not reclining) wheelchair without rear anti-tippers. Review of the MDS dated [DATE] reflected a BIMS of 3 - section G prior to the 8/24/ 23 fall , R52 required supervision with the assist of one staff person for bed mobility, transfers, and ambulation, and toileting no mobility devices were needed. R52 was coded as being continent of bowel and bladder. Post 8/24/23 fall with left hip fracture was when R52 became dependent with the assist of two staff persons for transfers, toileting, bed mobility, was no longer able to walk and became occasionally incontinent of urine. Incident report dated 10/06/23 R52 was observed sitting in front of her wheelchair foot rests, R52 reported R52 slid out of the chair. There was no injury and the intervention was to add a non-slip pad to the chair. Review of R52's fall risk assessments dated 01/03/23, 04/06/23, 06/26/23, 08/24/23, 08/28/23 and 10/06/23 all identified R52 as High Risk for falls Review of R52's fall care plan reflected the Physician ordered high back reclining wheelchair with rear anti-tippers were never added or implemented despite the Physician order written on 08/30/23. On 10/11/23 at 10:00 AM, Certified Nursing Assistants (CNA)C and P were both CNAs reported working on the dementia unit for several years and both reported they were familiar with R52, CNA P reported prior to R52's fall with fracture hip in August, R52 was ambulatory, walked up and down the halls with no assisted devices, CNA C stated R52 wore pull ups and for the most part toileted herself. Neither CNA could recall use of a high back wheel chair with anti tippers and both reported strips on floor have been gone for awhile. Neither CNA recalled the use of floor mats being used, hipsters, or increased supervision as a post fall intervention for R52. On 10/11/23 at 10:53 am during an interview with LPN O who was on duty in August when R52 fell and fractured her hip, LPN O stated she could not exactly recall much without looking at her notes, when queried LPN O stated she thinks R52 fell at about midnight, she stated R52 was crying out in pain and looked scared. LPN O stated she didn't think the fall was witnessed but couldn't say for sure (incident report does reflect witnessed or not) LPN O stated she 'might have seen R52 right before the fall but was not sure, thinks R52 might have been asleep and fell out of bed, but didn't really know. LPN O did report R52 was known not to sleep well at night and would frequently get up, come out into the hall for a snack or out to socialize with her, LPN O also stated R52 was known to get up and use the bathroom independently . When queried last time the assigned CNA checked on R52 and asked about toileting or an evening snack, LPN O stated she did not know. On 10/11/23 at 11:01 AM, during an interview with Unit Manager/LPN D reported falls were discussed by the interdisciplinary team, Unit Manager?LPN D stated sometimes she attends the meetings and sometimes she doesn't, but the purpose is to implement interventions. When the incident and accident reports for R52 for the [AGE] year were reviewed , Unit Manager/LPN D acknowledged that a root cause analysis was not done or discussed in the meetings. When queried how the team determined what intervention to use without identifying a root cause, Unit manager LPN D stated she would have to talk with other members of the disciplinary team. When queried why R52 was observed throughout the survey in a regular wheel chair opposed to the high back reclining chair with anti-tippers ordered by the physician , Unit manager LPN D stated she wasn't sure. When queried why there weren't bed strips on the floor next to the bed as described to be implemented on the incident and accident report Unit manager LPN D stated when the recliner was removed maintenance also removed the strips by the bed last April. When queried if the non-skid strips were in place in August when R52 fell and fractured from her bed would it have prevented the fall. Unit Manager LPN D stated possibly, but nobody will know for certain. On 10/11/23 at 12:27 PM, during a follow up interview with Unit Manager LPN D she reported she thinks the root cause of R52's fall was dementia. When queried if it was discussed or determined or identified if R52's dementia led to an unmet needs such as socialization, hunger, repositioning, thirst, toileting? Unit manager/LPN D reiterated the root cause of R52's falls was dementia. When queried if interventions such as hipsters, matt on floor at the side of the bed or increased supervision was ever discussed or implemented at any of R52's post fall meeting or if the interdisciplinary team discussed patterns, such as time of day or location of falls, Unit Manager/LPN D stated No. According to the facility policy titled Fall Prevention dated 07/11/2018. POLICY: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated. PURPOSE: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls. 4. To evaluate outcomes. PROCEDURE: 1. A licensed nurse will complete a Fall Risk Assessment within 24 hours of admission to determine the resident's risk factors associated with the potential for falls. 2. A Fall Risk Assessment will be completed on a quarterly basis and as needed thereafter (i.e., a fall has occurred or a change in condition etc.). The Fall Risk Assessment will be maintained in the resident's permanent record. 3. The results of the Fall Risk Assessment will be scored to identify the resident's risk category. 4. The Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions. 5. The Director of Nursing/designee will be responsible for tracking resident falls. 6. The Director of Nursing/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place as well as current assessments and documentation reflecting notification of applicable disciplines, resident's physician and resident's family/responsible party. 7. The Director of Nursing/designee will conduct a weekly Fall Committee Meeting consisting of Interdisciplinary Team members. They will review the falls for the week to identify issues and/or trends. The minutes of all Fall Committee meetings will be documented on the FALL COMMITTEE MINUTES. The Fall Committee Meeting minutes will be maintained in the Fall Committee Manual. 8. The QA&A Team will meet monthly, and as needed, to review fall occurrences and give recommendations as deemed appropriate. 46955 DPS B: Based on observation, interview, and record review, the facility failed to implement ordered devices to prevent accidents/falls for 1 resident (Resident #31) of 2 reviewed for accidents, from a total sample of 19, resulting in the risk for falls and potential for injury. Findings include: Review of the medical record reflected that Resident #31 (R31) was readmitted to facility 4/18/2023 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, ataxia following cerebral infarction, repeated falls, difficulty in walking, unsteadiness on feet, lack of coordination, other abnormalities of gait and mobility, and weakness. Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 8/18/23 reflected that R31 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). Section G of the same MDS reflected that R31 required one-person extensive assist with bed mobility, transfers, and toilet use, and supervision for eating after set up. In an observation and interview on 10/9/23 at 1:11 PM, R31 was observed sitting in wheelchair, in room, with left arm positioned on wheelchair tray table and left leg on wheelchair foot pedal. R31 was observed with a soft palm protector positioned in left hand and a tennis shoe and sock on left foot. R31 stated that she had history of a stroke that affected her left side, could not walk but could stand on legs, and transferred from wheelchair with assist of one staff member. R31 further stated that her ability to stand and transfer had become more difficult as her left leg brace had been gone for quite some time. Per R31, brace had broken at least a month ago, was removed from room and believed taken to therapy, had never been returned, and had heard nothing about it since. R31 stated that she now just wore her tennis shoe on her left foot, that she had less control and felt more unsteady when she stood to transfer as the foot and ankle were not supported as they had been with the brace and feared that her foot may be injured, or ankle may give out and that she would fall. R31 stated that she transferred from wheelchair to toilet or bed multiple times daily. In an observation and interview on 10/10/23 at 12:01 PM, R31 was observed sitting in wheelchair, in dining room, awaiting lunch. R31's left lower extremity (LLE) was positioned on wheelchair foot pedal with gray knee-high sock and tennis shoe noted to left foot. No brace was observed at LLE with R31 stating that therapy had not brought it back yet. Review of R31's electronic medical record completed with the following findings noted: Order dated 4/18/23 stated, Lt (left) foot AFO (Ankle Foot Orthosis-brace, splint, or boot used to reduce, prevent or limit movement of the lower leg and foot by supporting weak muscles) to be worn when out of bed- assess skin prior to application and after removal every day and night shift. Review of the electronic Treatment Administration Record dated 10/1/2023 - 10/31/2023 reflected order for left foot AFO and was observed to be signed out by both day and night shift nurses from 10/1/23 through 10/10/23 day shift. Review of all progress notes from 9/11/23 to 10/10/23 included no documentation reflecting R31's broken AFO. Physical Therapy Evaluation and Plan of Treatment dated 8/19/23 indicated within Initial Assessment/Current Level of Function & Underlying Impairments section, Precautions: Fall Risk, Left Hemiplegia with Hand Splint and LE (lower extremity) AFO. Fall Risk assessment dated [DATE] indicated score of 50 (high risk for falling). Care Plan Focus with a 11/27/19 date of initiation and 11/28/19 date of revision stated, The resident is at risk for falls r/t (related to) CVA (cerebrovascular Accident-stroke) with left sided hemiparesis, history of multiple falls, diabetes, depression, left upper and lower extremity contractions with an associated intervention indicating, AFO to left foot to be worn when out of bed dated 11/28/19. Kardex (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) indicated, Left foot AFO to be worn out of bed-assess skin prior to application and removal and TRANSFERS: extensive assist x (times) 1-2, pivot on right. Use gait belt and Left foot AFO to be on . In an interview on 10/10/23 at 12:09 PM, Certified Nurse Aide (CNA) I confirmed familiarity with R31 and that she was her assigned CNA that date. Per CNA I, R31 required one-person extensive assist with most activities of daily living including bed mobility, dressing, transfers, and toilet use. Per CNA I, R31 had a soft palm protector that she wore in her left hand during the day and a wrist/hand splint that was placed on the same hand at night. CNA I further stated that R31 used to wear a brace to her left leg whenever she was out of bed, that the brace had broken approximately 1 month ago, had been taken to therapy and had never been returned. CNA I stated that she now just placed a tennis shoe on R31's left foot, continued to transfer her as a one assist as had never been told otherwise by therapy or nursing, and confirmed that R31 transferred from wheelchair to toilet or bed several times during her shift. In an interview on 10/10/23 at 12:41 PM, Licensed Practical Nurse (LPN) H confirmed familiarity with R31 as was the routine nurse on the unit where R31 resided. Per LPN H, R31 had left sided paralysis (loss of ability to move) due to history of a stroke, had both a soft palm protector and plastic wrist/hand splint that she wore to left hand depending on the time of day, but stated that she could not recall if R31 had a LLE splint or brace. Upon referencing R31's medical record, LPN H confirmed that R31 had an order for a LLE AFO, stated that R31 should have the brace on whenever she was out of bed, was uncertain as to whether she had the brace on that date, and should not have signed out that the brace was in place for that date as stated that she had not placed or verified that it was in place. LPN H also acknowledged that she had signed out R31's order for the AFO on the previous shifts that she had worked (10/2, 10/3, 10/4, 10/6, 10/7, 10/8) as was unaware that R31's AFO was broken until that date. In an interview on 10/10/23 at 12:50 PM, Occupational Therapist (OT) J stated she was familiar with R31, that she had recently participated in occupational therapy with goals to have included improving transfers, had been discharged from services on 9/14/23 with ongoing use of LLE AFO, and confirmed that R31's AFO was in good repair at the time of the occupational therapy discharge. OT J denied prior awareness that R31's AFO was broken, stated that there was a broken AFO in the therapy gym across the hallway that may be R31's but could not say with certainty as was not labeled with a name, that the orthotic representative had been at facility the prior Thursday and was asking questions about R31 so was under the impression that he may be ordering her a new AFO, and that she was currently trying to contact him for additional information as Nursing Home Administer (NHA) A had came to the therapy gym just prior to inquire about the status of R31's AFO. In an interview on 10/10/23 at 1:00 PM, Physical Therapist (PT) K confirmed familiarity with R31, stated that she had recently participated in physical therapy as bathroom transfers had become more difficult and unsafe for resident and staff with goal of improving dynamic and static standing balance with ongoing use of LLE AFO. Per PT K, R31 had left foot drop (difficulty lifting the front part of foot which may cause it to drag during transfer or walking) due to left sided paralysis making standing difficult with AFO needed for support. PT K stated that R31's AFO was utilized prior to and during the most recent therapy treatment and was in good repair at the time of R31's 9/15/23 therapy discharge. PT K further stated that transferring R31 without LLE AFO in place would be concerning, would not be a safe transfer, and was unsure as to why physical therapy was not notified that there was an issue with R31's brace so that therapy could have followed up with recommendations. On 10/10/23 at 2:15 PM, NHA A entered conference room, stated that she had been approached by OT J that date, that she had authorized the therapy department to order a new AFO for R31, and that therapy provided R31 with a temporary AFO to wear until new AFO was available. On 10/10/23 at 2:17 PM, entered R31's room in presence of NHA A with R31 observed to be sitting in wheelchair with blue AFO in place at LLE. R31 stated that someone had just placed the brace and had informed her that she could use it until the new one that was just ordered arrived. In a follow-up interview on 10/10/23 at 2:19 PM in presence of NHA A, CNA I confirmed that R31's LLE AFO had been broken for several weeks, that she had provided broken brace to and communicated directly with therapy department regarding brace but had not communicated to any individual in the nursing department that R31's brace was broken. Review of the facility policy titled Fall Prevention with an 7/11/18 adopted date stated, Policy: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents .Purpose: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. 3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls .

This citation pertains to intake MI 621. Based on observation, interview and record review, the facility failed to prevent and provide pressure ulcer care and services in one of two residents reviewed for pressure ulcers (Resident #103), resulting in delay in physician involvement in the care plan, potential for delayed wound healing, infection, and pain. Findings include: Resident #103 (R103) During an observation and interview on 11/08/21 at 10:00 AM, R103 was observed lying in bed with pillows on her right side. R103 reported to the surveyor she was in pain. R103's Minimum Data Set (MDS) 3.0 assessment dated [DATE] introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 4 (00-07 Severe Impairment). The same MDS assessment indicated she was admitted to the facility on [DATE], did not reject care during the 7-day look-back period, was always incontinent of bowel and bladder, was a risk for development of pressure ulcers, and did not currently have an unhealed pressure ulcer. The Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, manual, indicated pressure ulcers affect quality of life because they may limit activity, may be painful, may require time-consuming treatments and dressing changes. The same source indicated pressure ulcers at more advanced stages typically required more aggressive interventions, including more frequent repositioning, attention to nutritional status, and care that could be more time or staff intensive. R103's November 2021 Treatment Administration Record (TAR) and physician order with start date of 5/27/21 indicated a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The same TAR and Hospice plan of care dated 10/14/21 revealed R103 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R103's Care Plan date initiated 7/18/19, and revised on 5/27/21, indicated she had a potential impairment to skin integrity related to thin body frame, decreased mobility, needed staff for transfers, and occasional incontinence. The same care plan indicated she had a Stage III (full thickness tissue loss; subcutaneous fat could be visible, slough [non-viable yellow, tan, gray, green, or brown tissue; usually moist, could be soft, stringy and mucinous in texture] could be present) pressure ulcer on her coccyx (tailbone) that was resolved, and her goal was to maintain intact skin with no skin breaks through the next review date of 12/26/21. There was no care plan that indicated R103's skin was not currently intact. R103's care plan was not updated following her 10/10/21 MDS assessment to reflect increased incontinence of bowel and bladder, in which increased her risk of skin breakdown. In review of R103's progress notes dated 11/02/21 at 1:42 PM, a pressure ulcer was noted on her coccyx that measured 2.0 centimeters (cm) in length by 1.5 cm in width and was 0.8 cm in depth. The same note described the coccyx wound with slough (indicative of Stage III or IV pressure ulcer, yellow or white tissue adhered to ulcer bed in strings or thick clumps, or mucinous) in the middle of the wound and redness around the wound area. Notifications, as applicable was left blank; Treatment changes was left blank. On 11/08/21 at 12:00 PM R103's wound care treatment was observed with Licensed Practical Nurse (LPN) G. R103 complained of pain when rolled to her left side. R103 was observed with a pressure ulcer on her coccyx, the wound bed was covered with a white cream that appeared to be a [MEDICATION(S)] ointment cream (white cream that formed a barrier to protect skin from incontinence) in the wound bed and around the wound bed. LPN G cleansed R103's coccyx pressure ulcer with gauze that was moistened with normal saline, did not remove all the [MEDICATION(S)] residue, dried with a gauze pad, and covered with a 9 cm by 9 cm comfort foam boarder dressing. R103 stated it hurts, it hurts, my butt hurts. LPN G stated she had given R103 pain medication prior to the wound care treatment. R103's November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The same source indicated no additional PRN pain medication (Acetaminophen or [MEDICATION(S)]) was administered following R103's wound care treatment. In review of R103's November 2021's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON) B was interviewed on 11/09/21 at 9:00 AM and stated the nurses would apply the [MEDICATION(S)] type cream if ordered by the physician. In review of R103 electronic medical record (EMR), there was no physician's order for [MEDICATION(S)] cream. Registered Wound Nurse (WN) F was interviewed on 11/09/21 at 9:00 AM and stated R103 had a chronic ulcer that would come and go, did not know last time the coccyx pressure ulcer was open, and did not know if R103's physician was notified of R103's pressure ulcer noted on 11/02/21. On 11/09/21 at 9:25 AM, WN F stated she had talked to the nurse that wrote the nurses note that R103 had a pressure ulcer on her coccyx on 11/02/21 and that the nurse was not sure if she notified R103's physician. There was no indication in R103's EMR R103's physician was notified of her pressure ulcer that was observed on 11/02/21. During an interview on 11/09/21 at 10:00 AM, WN F confirmed R103's care plan was not updated after the pressure ulcer was noted on 11/02/21. In review of the Skin Monitoring and Management- Pressure Ulcer Policy dated 7/11/18, a resident with pressure ulcers would receive necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable pressure ulcers from developing. The same policy indicated the nursing staff would be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate.

This citation pertains to intake MI 382. Based on interview and record review, the facility failed to notify the physician of an acute change in condition in 1 resident (#4) of 2 residents reviewed for change in condition, resulting in Resident #4's physician not being notified in a timely manner, and Resident #4 being admitted to the hospital in Septic Shock (serious condition that occurs when a body-wide infection leads to dangerously low blood pressure). Findings Include: Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was an [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment revealed that Resident #4 had unclear speech, was usually understood, usually understands, was severely impaired cognitively and required staff assistance with activities of daily living (ADLs). Review of the hospital record revealed that Resident #4 was admitted to the hospital on [DATE], Due to the patient having 2/4 sirs (An [MEDICAL CONDITION] state affecting the whole body) positive urinalysis for a UTI, acute kidney injury and lactic acidosis (lactic acid build up in the bloodstream. Lactic acid is produced when oxygen levels, become low in cells within the areas of the body where metabolism takes place) the patient was admitted for [MEDICAL CONDITION] due to UTI (urinary tract infection) and acute metabolic [MEDICAL CONDITION] (brain malfunction) with [MEDICAL CONDITION] (high blood sodium levels) due to severe dehydration. Review of Dr. J's progress note dated 1/27/20 (Monday) revealed, Staff reports (Licensed Practical Nurse (LPN) I) resident with increased confusion, lethargy, restlessness, low BP (blood pressure), not eating or drinking well at all .Significant changes in mental conditions over the weekend .Over the weekend the nurse reported (Resident #4) is increasing lethargic, confused, restless, with increased agitation .It seems no one called the weekend on call doctor to report this information .Plan - nurse called for stat labs. Will start on IV (intravenous) fluids right now . During a telephone interview on 3/12/20 at 2:45 p.m., when asked about Resident #4's change in condition over the weekend (1/24/20-1/27/20) Dr J stated that he had seen Resident #4 before the weekend. Dr. J stated that on 1/27/20, the nurse had stated to him that over the weekend it was reported that Resident #4 was more lethargic, more confused and more restless. Dr J stated that he wanted stat labs and start IV because if the labs were worse, I would have sent him out of there (to the hospital). Dr. J continued, There was a change in his condition over the weekend and as far as I know nursing did not reach out to the on-call (physician) about the change. I went in on the 27th and I ordered the labs (LPN I) told me about the change over the weekend. Dr. J continued, I asked (LPN I) and she was told that he was more confused, lethargic and restless over the weekend and to me that was very concerning. I saw him first (on 1/27/20) and he looked more lethargic, I said that we need to get labs .I thought this was urosepsis and so when people are unstable for any reason, I do not want to wait. Dr. J stated that Resident #4 was sent to the hospital before the lab results were available. During this same interview, this surveyor reviewed the laboratory results with Dr. J, and discussed the change in the lab values from 1/24/20 to 1/27/20 which revealed Sodium increased from 158 to 166 (normal 136-145 mEq/L (milliequivalents per liter), white blood cell (WBC) count from 8.8 to 20.19 (normal 4.00-10.60 (10^3 units per microliter), BUN/Creat (lab results that indicate failing kidney function) increased from 69/2.16 to 76/3.04 (normal is 7-25/0.6-1.30mg/dL, milligram per deciliter). Dr. J stated that he was 100 percent sure and honest that there was a big change in condition over the weekend. When asked about the large increase in Sodium, BUN, Creatinine and WBCs, Dr. J stated if, I got the lab and his white count was 20,000 and his kidney functioning was worse and sodium was higher I would not keep him for a minute, I would not wait for anything. When asked if he should have been notified about this change in condition sooner, Dr. J stated, Yes, over the weekend something changed. Dr. J continued to talk about the current lab results and stated, So this meets the criteria of SIRS and I would have sent him right to the hospital .In this situation, this guy would go to ICU/CCU and loaded with ABX because he meets the criteria, and time is money (time is a valuable resource, therefore it is better to do things as quickly as possible). Dr. J continued, That jump from 8.8 to 20 (White Blood Cell Count), it doesn't happen out of nowhere, there was a big change of condition and it should have reported, it would have showed up Saturday or Sunday, should not have waited until Monday. During an interview on 3/12/20 at 11:57 a.m., when asked about Resident #4's change in condition over the weekend (1/24/20-1/27/20) LPN I was not able to recall that weekend.

This citation pertains to intake MI 638. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls in two of four residents reviewed with falls (Resident #71 and #72), resulting in a fracture, pain, hospitalization and surgical intervention. Findings include: Resident #71 (R71) R71's electronic medical record, included admission referral documents that were faxed on 8/27/19 at 1:05 PM. R71's admission referral revealed she was under hospice care and had the [DIAGNOSES REDACTED]. The same information indicated R71 ambulated short distances with shortness of breath, cognitive impairment and chronic condition limited mobility, and she had generalized weakness and gait instability. The same referral indicated R71 was able to ambulate with a walker, had no recent falls, and had a fear of falling. The same referral included contact information with telephone numbers, for R71's daughter and hospice. Nurses Notes dated 9/11/19 at 6:14 PM, indicated R71 arrived at the facility at 6:00 PM, without signs of discomfort or pain. A Baseline Care Plan dated 9/12/19, revealed R71 was alert and oriented to person, place and time with some confusion. The same care plan indicated R71 had frequency of urination due to a urinary tract infection, was incontinent of bowel and bladder, and wore briefs. The same care plan indicated R71 needed assistance with activities of daily living (ADL), required oxygen, and was admitted to the facility on [DATE] for a five-day respite stay. R71's same baseline care plan indicated she was at high risk for falls with a goal she would remain free from fall related injury through the review date. R71's baseline care plan did not indicate it was reviewed with the resident's representative or hospice, the same care plan indicated it was reviewed with the resident on 9/13/19 at 00:00 (12:00 AM). Resident Council Concern Response form dated 9/11/19 revealed concerns with call light response times, especially on the third shift (11:00 PM to 7:00 AM). The facility's response, written on the same form, signed on 9/16/19, revealed education was provided to clinical staff and would follow-up as needed. R71's Incident Report titled Self-Inflicted dated 9/11/19 at 3:00 AM, revealed R71 walked into the hallway with walker, threw her walker down, then fell to the floor in the hallway. The same report indicated R71 had a bruise and skin tear on her left elbow. The same report indicated the physician and daughter were not notified until the next day, over 24 hours on 9/12/19 at 8:21 AM. The Director of Nursing (DON) B was interviewed on 10/08/19 at 2:21 PM. DON B stated hospice was responsible in contacting R71's family with changes/falls No hospice notes were located in R71's electronic medical record (EMR) or in her paper chart. DON B called the hospice entity to request R71's hospice records during her stay at the facility during the survey. DON B stated in the same interview, after R71's fall on 9/11/19, the facility implemented 15-minute checks when she was in bed. Hospice nurse visit note dated 9/12/19 from 10:18 AM to 11:40 AM revealed staff reported R71 was .very restless last night and did not sleep well. The same note revealed R71 was very tired and fell asleep during visit. The same note indicated hospice had suggested use of a bed alarm and the facility response was it was against facility policy to use alarms. The same note indicated a business card was left with the facility with instructions to call hospice for any concerns and emphasized 24 hour on-call service. 10/09/19 at 11:50 AM, The Director of Nursing (DON) B, was interviewed and stated We are an alarm free building. DON B stated in the same interview they do not call hospice for every little thing, she didn't have access to R71's hospice notes. DON B stated in the same interview that facility staff do not call family/hospice in the middle of the night for falls, they wait until regular business hours. R71's Incident Report titled Observed on dated 9/12/19 at 7:05 PM, indicated writer was called to resident's room by the certified nurse assistant (CNA) and was observed sitting upright on the floor next to her bed. Nurses Noted dated 9/12/19 at 9:46 PM revealed R71 had reported when she was found on the floor, she had got up to answer the phone and slipped. The same note indicated R71 was anxious prior to and after the fall and it was unclear if she hit her head during the incident. physician progress notes [REDACTED]. Nurses notes dated 9/13/19 at 3:59 PM revealed R71 ambulated with wheeled walker to the bathroom without dizziness, unsteadiness, or complaints of pain. Hospice visit nurses note dated 9/14/19 from 8:56 AM to 10:13 AM revealed R71 ambulated with walker and one person assist. The same note indicated hospice had reminded facility staff to call 24/7 with concerns, changes in patient condition, falls, or symptoms not controlled with current medications/plan of care. The same note indicated facility staff were reminded to call R71's daughter for any falls as well. The same note revealed facility staff were instructed to call hospice even if R71 had increased anxiety to bring in familiar faces. The same note indicated facility staff verbalized understanding. Nurses Notes dated 9/14/19 at 11:13 PM revealed R71 received [MEDICATION NAME] (anti-anxiety) mediation for anxiety. There was no mention hospice was called. Nurses Notes dated 9/15/19 at 1:20 AM revealed R71 was getting in and out of bed without assistance, and in response, staff brought her to the nurses station in a wheelchair, and noted she was trying to stand up out of her wheelchair. The same note indicated they put R71 back to bed and she .would be trying to stand up out of bed. The same nurses note revealed R71 was currently out in the nurses station with staff at this time. There was no mention that hospice was called. Nurses Notes dated 9/15/19 at 3:50 AM, revealed R71 .continues to have increased anxiety, had seen small children in the bathroom and wanted her mother. The same note indicated R71 was at the nurses station eating applesauce. There was no mention in this note that hospice was notified. Incident Report titled Attended Fall dated 9/15/19 at 5:30 AM, revealed R71 slid out of her wheelchair onto her bottom after reaching for something on the floor that wasn't there. R71's skin tear on her left upper arm measured 6 centimeters (cm) by 1 cm and was cleansed with normal saline and treated with antibiotic cream. The same report indicated an initial x-ray stated Fx (fracture) to the Lt (left) hip, but the 2nd read stated it was an old fx with callus formation. The same report indicated hospice was notified at 9/15/19 at 8:30 AM and the physician was notified on 9/15/19 at 10:15 AM. On 10/08/19 at 3:45 PM Licensed Practical Nurse (LPN) C was interviewed and confirmed she was assigned to R71 at 9/15/19 at 5:30 AM when she slid out of her wheelchair. LPN C stated she and Certified Nurse Assistant (CNA) [NAME] assisted R71 from the floor back into her wheelchair. LPN C stated in the same interview R71 bared weight on both her legs when she stood her up. LPN C stated did not assess range of motion on R71 lower extremities prior to standing her up. LPN C stated R71 did not complain of pain. LPN C stated in the same interview, she was on another hall when R71 fell and stated on the night shift, one nurse was assigned to 2 units. LPN C stated in the same interview, the CNA assigned to R71 was on the unit, but was providing care in another resident's room. LPN C stated R71 was restless the night and morning of 9/15/19 and stated herself and CNA [NAME] kept R71 close by the entire shift because they were afraid, she would fall. On 10/08/19 4:02 PM, CNA [NAME] was interviewed and stated on the night/morning of 9/15/19, R71 did not sleep the entire night. CNA [NAME] stated in the same interview that she had R71 in her eyesight and tried to keep her safe. CNA [NAME] stated in the same interview R71 fell when she was caring for another resident, in that residents' room, and R71 was sitting in her wheelchair in the hallway, just was outside of door, and the door was open. CNA [NAME] stated in the same interview, she saw R71 slip out of the chair and R71 seemed to reach for something on the floor that wasn't there. CNA [NAME] stated she assisted the nurse in standing R71 up and sitting her back into the wheelchair. CNA [NAME] stated R71 went to bed after fall, she said was tired. In review of 24 Hour Resident Checks form dated 9/15/19, the was no documentation of 15-minute checks/or R71's behavior at the time of the 15-minute checks. Nurses Notes dated 9/15/19 at 7:32 AM indicated R71 complained of pain all over, her pain level was an 8, on a scale from 0 to 10, with 10 being the worst pain imaginable; and [MEDICATION NAME] 10-325 milligrams was administered for pain. Hospice visit nurses notes dated 9/15/19, from 8:42 AM to 11:10 AM, revealed R71 was .observed lying with her head at the foot of her bed, and she is soiled. This writer needed to request assistance to change, as entire bed was soaked, and patient was painful and would not sit up for writer. The same note revealed R71 was confused, agitated, and frustrated with her incontinence (bowel and bladder) care. The same note indicated during the bed change R71 could not sit up and cried out in pain with any pressure on her left hip, and when asked to place her left leg out straight, leg bowed out and was unable to straighten the leg completely. The same noted indicated an aide and R71 reported she fell during the night, however the facility nurse was not able to locate any documentation of a fall. The same document indicated there was no note in R71's hospice record of a call from the facility reporting a fall during the night. Certified Nurse Assistant (CNA) H was interviewed on 10/09/19 at 1:05 PM, and confirmed she was assigned to R71 on 9/15/19 beginning at 6:30 AM. The CNA that was assigned to R71 the prior shift told me she had fallen early that morning. CNA H stated she helped hospice staff with R71's incontinence care, and R 71 would not roll to one side she, said we were hurting her when cleaning her up. CNA H stated in the same interview, R71 had her ankles crossed and was fighting us when we cleaned her up. CNA H stated We kept trying to uncross her ankles. Nurses Notes dated 9/15/19 at 9:50 AM revealed the hospice nurse had requested facility nurse to administer [MEDICATION NAME] for R71 complaints of left hip pain. The same note indicate hospice had notified the family and they were on their way to the facility to she R71. Licensed Practical Nurse (LPN) I was interviewed on 10/09/19 at 11:34 AM and confirmed she was the nurse assigned to R71 on 9/15/19, on day shift. LPN I stated R71 had increased pain when she sat up and her was abducted slightly. LPN I stated she didn't perform range of motion (ROM), because she suspected something was not right with her leg. LPN I stated she did not notify R71's family because the hospice nurse had told her she already notified the family and her son was on his way in. R71's Medical Diagnostic Services Inc. indicated a 2 view anteroposterior x-ray of the pelvis/left were reported on 9/15/19 at 1:21 PM and revealed left femur subcapital (through the junction of the head and neck)/neck nonunited impacted (one of the fragments was driven into another fragment)/mildly angulated fracture. A second read of R71's Medical Diagnostic Services Inc. indicated a 2 view anteroposterior x-ray of the pelvis/left were reported on 9/15/19 at 1:21 PM and included the same information as the above, however, read PS: likely a subacute/nonunion subcapital [MEDICAL CONDITION] femoral neck seen. Not an acute appearing feature with minimal [MEDICAL CONDITION] of the fracture margins The Director of Nursing (DON) B was interviewed on 10/8/19 at 2:21 PM and stated she had requested a second read of R71's x-ray as a routine and because the findings indicated callus formation at the fracture site. Nurses Note dated 9/15/19 at 5:10 PM, revealed paramedics arrived to transfer R71 to the hospital. R71's Nurses Notes dated 9/16/19 at 11:40 AM, indicated nursing staff had contacted the hospital and was admitted with the [DIAGNOSES REDACTED]. The same note indicated there was no plan for resident to return to the facility. R71's Discharge Instructions for hospital stay from 9/15/19 to 9/21/19 revealed she underwent a left hip hemiarthroplasty on 9/17/19 and required physical therapy and occupational therapy following surgery. R71's same discharge instructions indicated she had [MEDICAL CONDITION] due to blood loss and was treated with antibiotics during her hospital stay. The same hospital instructions revealed R71 had an x-ray of the left femur that indicated an unchanged acute displaced and impacted transcervical [MEDICAL CONDITION] femoral neck with varus angulation (distal part of a bony section deviates in a medial location). The Director of Nursing (DON) B was interviewed on 10/8/19 at 2:21 PM. DON B stated hospice was responsible in contacting R71's family with changes/falls. We did not have any hospice notes in our system. DON B called the hospice entity to request R71's hospice records during her stay at the facility during the survey. DON B stated in the same interview, after R71's fall on 9/11/19, the facility implemented 15-minute checks when she was in bed. Resident #72 (R72) On 10/08/18 at 12:35 PM, R72 was observed sitting in a wheelchair, eyes closed, leaning to the right side, in the dining room on a secured dementia unit. R72's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], indicated he was originally admitted to the facility on [DATE] and his cognition was moderately impaired (decisions poor; cues/supervision required). R72's same MDS assessment dated [DATE], indicated R72's active [DIAGNOSES REDACTED]. An Incident Report titled Attended Fall dated 7/18/19 at 12:10 AM, indicated R72 attempted to sit down in a chair, but sat on the arm rest, and tipped over in the chair. The same report indicated the nurse was not able to determine if R72 had hit his head from her vantage point. The immediate intervention was for staff to encourage R72 to be in high traffic areas when up in wheelchair. The same report indicated R72 was confused, had a gait imbalance, weakness, was incontinent, and had recent change in medications. A Post Fall assessment dated [DATE], indicated R72 had poor safety judgement and new interventions included: Maintain with staff in common area to prevent future falls at that time. LPN I was interviewed on 10/09/19 at 11:34 AM regarding R72's fall intervention from 7/18/19 and confirmed the dining room and activity room were considered high traffic areas. R72's Interdisciplinary Rehabilitation Screening Form with screen dates of 4/18/19, 7/18/19, and 7/31/19; revealed he was screened on 7/18/19 and not been deemed appropriate for skilled therapy services. The same form under comments indicated R72 had falls due to a medication change, was unable to answer questions or directions. According to the Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), a previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. The same source revealed in planning for care to evaluate the physical environment as well as staffing needs for residents who are at risk for falls. The same source revealed a fall should stimulate evaluation of the resident's need for additional monitoring. An incident Report titled Observed on dated 7/19/19 at 1:26 AM, revealed R72 was observed next to his bed on a floor mat. Resident was seen by the physician for a medical work up. An incident Report titled Attended Fall dated 7/20/19 at 9:33 PM indicated R72 was observed sitting on the floor in the activity room with his back to his wheelchair. An anti-slip material was added to R72's wheelchair seat. An incident Report titled Reported Fall dated 7/21/19 at 10:30 PM revealed this writer was in another residents room giving care when staff called me to common room. Observed resident laying on his right side on floor by entertainment center. The same report indicated R72 had fell in the activity room. The same report indicated the plan was for staff to encourage R72 to go to bed by 9:00 PM. An incident Report titled Observed on dated 7/22/19 at 2:15 PM indicated R72 was observed sitting on his buttocks on the floor in the dining room. R72's Incident Report titled Reported Fall dated 7/25/19 at 8:20 PM indicated this writer was at Med (medication) cart when I heard a loud noise. While investigating noise observed resident sitting on his left side with his head on divider wall in front of his w/c (wheelchair). Resident unresponsive to stimuli and verbal commands. Resident color turned grey and was sweating profusely. The same report revealed the incident occurred in the activity room and R72 was transferred to the emergency department with a fracture. LPN D was interviewed 10/9/19 at 2:40 PM and stated the only way R72's fall could have been prevented if he was a one to one. LPN D stated in the same interview, she had personally stopped R72 from getting up a couple of times that shift. LPN D stated on the day or R72's fall, they were missing an activity aide, and activities were helpful for him. The (MONTH) 2019 Activity Calendar revealed the last group activity scheduled was at 6:45 PM. The (MONTH) 2019 Activity staff schedule indicated the activity staff worked on 7/25/19 until 8:00 PM, 20 minutes before R72's fall. R72's Radiology Results Report dated 7/28/19 revealed a [MEDICAL CONDITION] hip. R72 fell five times in (MONTH) 2019 in high traffic areas (activity and dining rooms). All R72's falls in high traffic areas were on the afternoon and night shifts (3:00 PM to 11:00 PM/and 11:00 PM to 7:00 AM). In review of the facility's Fall Prevention policy, dated 7/11/18, the Interdisciplinary Team would review falls to identify issues and/or trends. During an interview on 10/09/19 at 11:50 AM, DON B stated to have a one on one for R72 was not decided through interdisciplinary team (IDT) process.

Based on observation, interview and record review the facility failed to timely notify the physician of changes in blood pressure, confusion, vaginal drainage, refusals to ambulate, changes in urine and delayed urinalysis completion for Resident (R) #47, resulting in ambered/cloudy colored urine, hypotensive/hypertensive episodes, urinary tract infection with positive urine cultures and the potential [MEDICAL CONDITION]. Findings Include: This citation is related to intake MI 983 According to the Electronic Medical Record (EMR) reviewed on [DATE] at 09:55 am R47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R47's most recent Quarterly Minimum Data Set (MDS: resident assessment tool) dated [DATE] reflected: A BIMS (Brief Interview of Mental Status) score of 10 out of 15 (,[DATE]: moderately impaired cognition), required extensive assistance of 2 persons for bed mobility/transfers, required extensive assistance of 1 person for dressing/bathing and was always incontinent of her bladder. R47's Admission MDS dated [DATE] reflected she was occasionally incontinent of her bladder. Review of R47's care plans reflected the facility did not create a plan of care related to Infection until [DATE]. R47's Urinary Incontinence care plan created on [DATE] reflected as interventions: Obtain labs a ordered [DATE], Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine) [DATE]. Review of R47's Progress Notes (PN) dated [DATE] to [DATE] reflected the following: [DATE] 02:47 PM: Individual resident behavior log indicates that recent behaviors include: excessive use of her call light, anxiety, delusions and impulsiveness. [DATE] 02:08 AM: Weakness generalized [DATE] 12:47 AM: Has generalized weakness [DATE] 02:33 PM: Stated she did not feel well [DATE] 11:54 PM: Has weakness with mobility [DATE] 11:57 AM: IDT met r/t behaviors of crying and anxiety [DATE] 03:34 PM: Loose stools x 2 [DATE] 08:00 AM: Resident refused restorative ambulation [DATE] 05:59 PM: Resident refusing oob (out of bed) activities and ambulation per restorative program [DATE] 11:16 AM: Resident chooses to not get OOB today [DATE] 10:45 AM: Resident declines to participate in ambulation to the toilet [DATE] 04:03 PM: Resident refused to ambulate. [DATE] 12:15 AM: Green discharge noted. U/A (Urinalysis) obtained for C&S (Culture and Sensitivity). [DATE] 11:35 AM: Resident has refused every attempt to ambulate a few steps with the exception of one time. extensive assist x 2 to transfer onto the toilet, was incontinent of urine and had brownish colored (Continued .) [DATE] 03:58 PM: Resident A&O with some confusion, c/o (complaining of) SOB (Shortness Of Breath), lung sounds clear throughout, administered PRN O2 @ 2L via NC (nasal canula) resident able to maintain O2 sat of 98%, resident c/o back pain 6 on scale from ,[DATE], writer gave PRN (as needed) [MEDICATION NAME], results somewhat effective, resident anxious this shift, verbalizes increased confusion, UA results faxed to md, awaiting C&S results, writer encouraged fluids. [DATE] 10:30 AM: . PO (oral) intake is poor, ranging from ,[DATE]%. Resident does have a UTI at the time of this observation. [DATE] 01:37 PM: Dr. F notified of residents UA results of [DATE] and assessment. Urine culture is pending at this time. [DATE] 02:14 PM: Received orders from Dr. F for resident. Dr. F ordered CXR (Chest X-ray) 2 views d/t residents c/o SOB, and new need of O2. Orders written [MEDICATION NAME] mg one tablet by mouth twice daily x 10 days for Dx: UTI (Urinary Tract Infection). [DATE] 09:13 AM: Dr. F notified of residents urine culture results which shown 25,000 E coli. Dr. F wants to continue with current treatment as ordered. [DATE] 04:11 AM: ,[DATE] 90 17 97.5 Resident was being assisted to bed x 2 assist when the resident became non compliant with transfer. Refusing to let go of side rail, staff members, refused to pivot self to the bed. Resident was lowered to floor for safety and Hoyer lift used to transfer resident to bed. [DATE] 01:18 PM: Dr. F office aware of final results of urine culture of [DATE] that shows >100,000 mixed culture: (3) or more organisms isolated suggest repeat culture to rule out contamination. He wants resident to complete the order of the current antibiotic that she's already on then to repeat another UA C&S. [DATE] 01:39 AM: ,[DATE], 81, 16, 98.0. Still has confusion [DATE] 02:57 PM: resident A&O x ,[DATE] with some confusion, decrease in appetite noted, resident refused breakfast, ate 10% of lunch, states im just not hungry, resident continues on abt for uti, [DATE] 01:44 PM: ,[DATE] 89 16 96.4 a/o x 2 confusion with medications [DATE] 07:18 PM: sister and daughters in for visit 1400 celebrating Memorial day in activities. poor appetite and weakness family returned to room to report fatigue and saying good-after visit at 1625 sister remained and asked questions before leaving facility sister called writer to room [ROOM NUMBER] found resident fixed eyes head downward and lethargic oral and occular cyanosis in w/c sitting sternal rub for pain response negative notified second nurse of situation and clavicle rub met with eye popping response but respiration not present sent RN to call ems support staff immediate transfer to bed crash cart and board provided for start of cpr at 1635. full two minute of rapid compression per cpr training no pulse and quick 2 rescue breathes and resumed compressions. airway was cleared as rescue breath raised chest. compressions continued until ems arrived and assumed control of cpr at 1645. report given ems and then to er. sister present during code and daughter notified by her. ems left facility at 1707 (Continued .) A Nursing Documentation Record reflected an initialed entry on [DATE] at 02:30 AM , that R47 was incontinent of bowel/bladder and had amber colored urine. Based on the above PN R47 was experiencing periods of confusion, periods of refusing to get oob, ambulate/ambulate to toilet, and low oral intake. In addition R47 was observed to have green discharge on [DATE] at 12:15 AM and brown discharge at 11:35 AM, but Dr. F was not documented as being informed of the discharge along with the UA lab findings until [DATE] at 1:37 PM. In addition, R47 was documented to have Blood Pressures (B/P's) [DATE] to [DATE] that ranged from: ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE]. Pulses ranged from 72- 60 - 79- 66- 82. On [DATE] at 02:31 AM Pulse= 72 and at 03:22 PM the same day Pulse= 99. Temperatures ranged from 96.5 - 97.2 - 99 - 98.2. No BP's were observed to be documented in the PN from [DATE] to [DATE], specifically none were documented with R47's c/o of SOB on [DATE]. The next set of BP's were taken on [DATE] whereby R47's BP was ,[DATE] at 04:11 AM, which was a significant drop from the previous BP. The next BP's were as follows for (MONTH) (YEAR): ,[DATE] at 11:10 AM ,[DATE], ,[DATE] at 01:39 AM ,[DATE], ,[DATE] at 03:49 AM ,[DATE] and ,[DATE] at 01:44 PM ,[DATE]. There was no documentation to reflect Dr. F had been informed of R47's changes in blood pressures and/or periods of confusion. Pulses ranged from ,[DATE]. Temperatures ranged from 97.5 - 98.0 - 98.8 - 96.4. An anonymous Certified Nursing Assistant (CNA) was interviewed during the survey from [DATE] to [DATE] and asked to recall R47. The CNA revealed, R47 would be nice and at times mean and abusive. At times she would try to do things for herself then at times give up. Her appetite was good then it slowly started to decline, at around 70% then decreased. A lot of the times she would not drink, she would say leave it there, but she would not drink enough. She had a UTI, then we started pushing drinks. Even before that we would try but she would not drink. She would go in her brief, and she would ask for the bedpan, and she would not want to get up to go the bathroom. It got to a point when she did not want to get up from her bed. We would do peri-care, for her sometimes every 2 hours or 2.5 to 3 depending. She would ask to be changed at times. She would at times get confused once and in a while. She got confused about ,[DATE] weeks before she got sick. She would look for things that were right in front of her, and we would have to get them for her. When asked about R47's UTI the CNA revealed, It started with a nasty green discharge, we were trying to get a urine sample and we could not get her to go to the bathroom, to get a sample. The CNA denied R47 had green discharge before, but that it started off as creamy stuff, like a natural discharge by a women. The CNA stated, I noticed that maybe a week before the green colored discharge. The creamy was not smelly, but the green discharge was. I let the nurse know, but I don't remember what happened after that, I was off for a few days after that. The nurse would have to document the discharge. The CNA could not recall when her last peri-care education was given when asked. On [DATE] at 01:00 PM CNA E was interviewed and asked to recall R47. CNA E revealed that R47 would refuse to get oob a lot. They were trying to get her to start walking again. She was incontinent most of the time, and would push the call light (CL) when she wanted to be changed. She would want us to do a lot, that she could do herself. Near the end when she was here she refused to get up. On [DATE] at 01:08 PM CNA G was interviewed and asked to recall R47. CNA G revealed R47 did not want to get up. She was not continent and she would go then tell you that she went. When asked about discharge CNA G stated, I think she did have some green discharge once that had an odor to it and they treated her for that, can't recall when . Also, that R47 had loose stools. On [DATE] at 01:17 PM Licensed Practical Nurse (LPN D) was interviewed and asked to recall R47. LPN D revealed, I remember she did not talk much, liked to stay in bed a lot, occasionally got up and would go down for meals. When questioned about R47 having discharge LPN D replied, One of the girls said she had discharge. There was green/yellow discharge. I let the male nurse (Registered Nurse (RN I)) know. LPN D revealed she could not recall doing a UA for R47, but that CNA's did not do UA's. LPN X, who collected the urine sample for R47 on [DATE], was called up to 3 times during the survey from [DATE] to [DATE], voicemail of writer's and co-workers phone numbers were left for LPN X whom did not call back for an interview. On [DATE] at around 01:30 PM R47's closed records reflected the following Physician orders: On [DATE] an order was written reflecting: UA / C&S Vaginal Drainage, Frequency, Dysuria. (MONTH) St. cath for specimen if unable clean catch. Yet, there was no documentation in the EMR, progress notes, or closed record that the doctor had been notified, or that the UA had been completed. On [DATE] an order was written reflecting: CXR 2 view r/t SOB and decreased oxygen, [MEDICATION NAME] mg 1 tab by mouth twice daily x 10 days Dx: UTI. On [DATE] an order was written reflecting: Repeat UA/ C&S once finished with ABT. Also, a physician's orders [REDACTED]. On [DATE] at 02:08 PM R47 UA lab results dated received/reported on [DATE] reflected: cloudy amber urine, 2+ blood, 3+ protein, ,[DATE] white blood cells, many bacteria and few [MEDICATION NAME] cells. The lab result did not reflect how the sample was obtained, (clean catch or straight catheter). UA lab results dated [DATE] and reported on [DATE] reflected a urine culture with a source organism 1 as, 25,000 Eshcerichia Coli (E-Coli). UA lab results dated [DATE] and reported on [DATE] reflected a urine culture with a source organism as, >100, 000 mixed culture: (3) or more organisms isolated suggest repeat culture to rule out contamination. Dr F was interviewed on [DATE] at 07:01 AM related to R47. Dr F revealed that he was aware that R47 was a facility resident who was then transferred to the hospital. Dr. F was informed of R47's fluctuations in blood pressures, temperatures, behaviors, green/brown discharge and that there was an order for [REDACTED]. F revealed, No, I see those patients once a month. I have them get a set of Vital Signs (VS) before coming in and will ask if there has been a trend. Dr. F revealed he had been a family practice physician for [AGE] years, daily and/or once a week he had communications with different facilities about patients and made determination at times off of what facility staff told him. Related to the labs ordered [DATE] and performed on [DATE] Dr. F replied, If I order something, I want it done promptly. Also, that he depended on communication, and if not properly done it made it hard to react to. The most recent Physician's Progress Notes dated [DATE] and [DATE] by which appeared to be from Dr. F were negative for any documentation related to changes in b/p, behaviors, poor intake, discharge, refusals to ambulate/get out of bed, temperatures, or amber colored urine. On [DATE] at 09:21 AM the Director Of Nursing (DON) was interviewed. She revealed she had started the DON position around mid (MONTH) (YEAR). The DON was given the paper order dated [DATE], and asked to reveal the date on the order. DON B revealed the nurse signature on the order was RN I, and that it was dated [DATE]. The DON was then asked when would she expect the UA to be completed. The DON replied, I would anticipate they would get the UA by the first or at least by the 2nd. The DON was informed that the the UA lab was not done until [DATE]. When asked if that was acceptable the DON verbalized, that was not considered acceptable. The DON was then informed of R47's fluctuation in BP's, temperatures, weakness, behaviors, green drainage, brown drainage, SOB requiring oxygen, poor intake, E-coli UA C&S results and confusion. The DON revealed, that the differences in b/p's going on generally the range was around ,[DATE], and that physicians usually gave them parameters r/t to b/p but was not sure if R47 had any because she was not familiar with R47's chart. The DON then stated, ,[DATE] I would be calling the physician and doing something serious about it. You would notify him of the change. Depends on residents conditions. DON was asked after sharing the previous information, what did she think R47 was exhibiting. The DON replied, That she is going septic, the kicker is the low BP ,[DATE] with no temperature spike. I would have to look at the chart to to determine when sign and symptoms [MEDICAL CONDITION] were shown. The infection control (IC) RN K was interviewed on [DATE] at 10:20 AM. RN K was asked when was the most recent peri-care education training, whereby she replied [DATE]. The IC monthly tracking/trending records for (MONTH) to (MONTH) (YEAR) were reviewed r/t UTI's and reflected: March: ,[DATE] (acquired/facility), April: 2 (facility only with one number), May: 2, June: ,[DATE], July: 7, and for August: 1. RN K was asked what should nursing staff do, when a resident has green or brown drainage. RN K stated, Green or brown drainage, the nurse is supposed to call the doctor. If it happened in the middle of the night they should call in the middle for the night. RN K was asked to describe s/s [MEDICAL CONDITION]. RN K replied, UTI septic: lethargy, confusion, discharge, not voiding. RN I was interviewed on [DATE] at 10:46 AM, and was asked to recall R47. RN I revealed, She was her own person chose to do or not do physical therapy. Therapy she would not go at times or want to get out of bed. Before she past, the girls said she was getting more confused. I wanted to get a clean catch and dip it, just in case she could not do a clean catch, I wrote the order for a clean catch or straight cath UA. RN I was informed of the order dated [DATE]. RN I stated, To my recollection the order it was [DATE] or [DATE]. RN I was given 47's (MONTH) (YEAR) MAR (Medication Administration Record) to recollect the date. RN I revealed it was the last day he had worked and stated, Usually we would get a dip. I was going off her behavior because she was incontinent. When asked who obtained the urine. RN I revealed the CNA's would get the urine for a clean catch, dump urine from hat or bed pan, and pour into the cup. Also, that the resident is washed with soap and water in the peri-area first. After looking at the (MONTH) (YEAR) MARS, RN I revealed the date he wrote the UA order was [DATE]. I am going to say [DATE] when looking at the MAR's. I got the order but did not send it. When asked when did he think the UA order should have been completed RN I stated, Immediately or within 24 hours, and if you can't then straight cath or document if refused. RN I was asked if [DATE] was an appropriate time to send UA he replied, No, not really unless she refused. RN I was then asked how was R47's oral intake. RN I replied, Particularly on that day I made the UA order she had poor intake, she would drink some but not really well that day. RN I was informed of R47 having BP changes, weakness, refusals to get oob, behaviors, loose stool, green/brown drainage, SOB, need for oxygen, poor intake, UA with E-Coli, antibiotics and confusion. RN I was then asked what did he think was going on with the resident. RN I replied, [MEDICAL CONDITION]. When questioned what he would do if his resident had a BP of ,[DATE]. RN I revealed If he had a resident with a b/p ,[DATE], I would hold bp medication, re-check bp, call doctor and then of course push fluids. RN I revealed, Around the 17th she wasn't acting right so I got a UA. RN I revealed he did not write a note about ordering the UA or getting it, that it was standard nursing, and whenever you see behavior changes get a urine and dip it. I was going off her behavior. RN I stated he was not aware of the drainage, that he encouraged fluids, offered different fluids, encouraged peri-care with soap water, and offered to get her up off the toilet, and that it was better for her to have a sitting void than laying void. RN I revealed after he wrote the order before the end of his shift and was then off of work for a few days, and that he passed it on the nurse relieving him on [DATE]. When asked [MEDICAL CONDITION] and/or UTI education. RN I revealed, UTI education was done quarterly, and that nothing had changed recently related [MEDICAL CONDITION] education. The (MONTH) (YEAR) MAR indicated [REDACTED]. Also, that R47 was started [MEDICATION NAME](antibiotic) 500 mg 1 tab by mouth twice daily started on [DATE] at 18:00 PM and the last dose was given on [DATE] at 09:00 AM. The Centers for Disease Control and Prevention (CDC) online reference updated [DATE] [MEDICAL CONDITION] as:[MEDICAL CONDITION] is the body ' s extreme response to an infection. It is a life-threatening medical emergency.[MEDICAL CONDITION] happens when an infection you already have -in your skin, lungs, urinary tract, or somewhere else-triggers a chain reaction throughout your body. Without timely treatment,[MEDICAL CONDITION] can rapidly lead to tissue damage, organ failure, and death. Signs [MEDICAL CONDITION] that your doctor or nurse can measure include either of the following: High heart rate, fever, shivering, or feeling very cold, confusion, disorientation, SOB, extreme pain or discomfort, and clammy or sweaty skin. The (name of) Hospital where R47 was transferred to reflected she was admitted on [DATE] at 17:16 PM and discharged on [DATE] at 20:45 PM. The notice of death reflected [DATE] at 17:39 PM and that R47's body was released to the funeral home on [DATE] at 18:00 PM. The Emergency Department (ED) notes reflected: 70 y.o. F presents to ED via EMS with complaints of MI. Pt was found laying on the floor at her nursing home. EMS states the daughters were talking to the Pt about 2:30 and told the nursing home the Pt wasn't talking as much as normal. EMS states compressions began at 16:45. Pt has been given 3 epi's, was shocked 1 time at 200 volts. Hospital notes continued that R47 was a full code and the following was performed at the hospital: 17:20- Pt given one of epi. Faint pulse found in the coratid 17:30-Dopamene Drip started. CPR initiated. 1731- Compressions stopped. No pulse palpated. Compressions continued. One of epi given. 17:34- Compressions stopped. No pulse palpated. Compressions continued. One of EPI given. 1738- Cardioversion at 200 joules. One of epi given. 17:39- No pulse palpated. No rhythm on monitor. Time of death is 17:39. A document dated [DATE] by Dr./Pathologist Y reflected SUMMARY OF AUTOPSY EXAMINATION: Abdominal/pelvic abscess (localized peritonitis). Transmural active chronic [MEDICATION NAME] Mildly dilated ureters with bilateral hydro[DIAGNOSES REDACTED]. Hypertension (by history) [MEDICAL CONDITION] Obesity (BMI=48) Toxicology: Blood [MEDICATION NAME] Positive. [MEDICATION NAME] 5.66 mcg/ml. [MEDICATION NAME] not tested . COMMENT: (R47's name), a [AGE] year-old woman, was declared death at 5:39 p.m. on (MONTH) 28, (YEAR), in the emergency department at (name of) Hospital following transport from her residence at (facility name and address). Death was caused by chronic urinary tract infection associated with adjacent abscess and localized peritonitis, resulting in [MEDICAL CONDITION] blockage and hydro[DIAGNOSES REDACTED]. This is a natural cause of death. No injuries were present at postmortem examination.

Based on observation, interview and record review the facility staff failed to assess, monitor, notify physician of changes and perform laboratory test timely for Resident (R) #47 resulting in delayed treatment of [REDACTED]. Findings Include: This citation is related to intake MI 983 According to the Electronic Medical Record (EMR) reviewed on [DATE] at 09:55 am R47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R47's most recent Quarterly Minimum Data Set (MDS: resident assessment tool) dated [DATE] reflected: A BIMS (Brief Interview of Mental Status) score of 10 out of 15 (,[DATE]: moderately impaired cognition), required extensive assistance of 2 persons for bed mobility/transfers, required extensive assistance of 1 person for dressing/bathing and was always incontinent of her bladder. R47's Admission MDS dated [DATE] reflected she was occasionally incontinent of her bladder. Review of R47's care plans reflected the facility did not create a plan of care related to Infection until [DATE]. R47's Urinary Incontinence care plan created on [DATE] reflected as interventions: Obtain labs a ordered [DATE], Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine) [DATE]. Review of R47's Progress Notes (PN) dated [DATE] to [DATE] reflected the following: [DATE] 02:47 PM: Individual resident behavior log indicates that recent behaviors include: excessive use of her call light, anxiety, delusions and impulsiveness. [DATE] 02:08 AM: Weakness generalized [DATE] 12:47 AM: Has generalized weakness [DATE] 02:33 PM: Stated she did not feel well [DATE] 11:54 PM: Has weakness with mobility [DATE] 11:57 AM: IDT met r/t behaviors of crying and anxiety [DATE] 03:34 PM: Loose stools x 2 [DATE] 08:00 AM: Resident refused restorative ambulation [DATE] 05:59 PM: Resident refusing oob (out of bed) activities and ambulation per restorative program [DATE] 11:16 AM: Resident chooses to not get OOB today [DATE] 10:45 AM: Resident declines to participate in ambulation to the toilet [DATE] 04:03 PM: Resident refused to ambulate. [DATE] 12:15 AM: Green discharge noted. U/A (Urinalysis) obtained for C&S (Culture and Sensitivity). [DATE] 11:35 AM: Resident has refused every attempt to ambulate a few steps with the exception of one time. extensive assist x 2 to transfer onto the toilet, was incontinent of urine and had brownish colored (Continued .) [DATE] 03:58 PM: Resident A&O with some confusion, c/o (complaining of) SOB (Shortness Of Breath), lung sounds clear throughout, administered PRN O2 @ 2L via NC (nasal canula) resident able to maintain O2 sat of 98%, resident c/o back pain 6 on scale from ,[DATE], writer gave PRN (as needed) [MEDICATION NAME], results somewhat effective, resident anxious this shift, verbalizes increased confusion, UA results faxed to md, awaiting C&S results, writer encouraged fluids. [DATE] 10:30 AM: . PO (oral) intake is poor, ranging from ,[DATE]%. Resident does have a UTI at the time of this observation. [DATE] 01:37 PM: Dr. F notified of residents UA results of [DATE] and assessment. Urine culture is pending at this time. [DATE] 02:14 PM: Received orders from Dr. F for resident. Dr. F ordered CXR (Chest X-ray) 2 views d/t residents c/o SOB, and new need of O2. Orders written [MEDICATION NAME] mg one tablet by mouth twice daily x 10 days for Dx: UTI (Urinary Tract Infection). [DATE] 09:13 AM: Dr. F notified of residents urine culture results which shown 25,000 E coli. Dr. F wants to continue with current treatment as ordered. [DATE] 04:11 AM: ,[DATE] 90 17 97.5 Resident was being assisted to bed x 2 assist when the resident became non compliant with transfer. Refusing to let go of side rail, staff members, refused to pivot self to the bed. Resident was lowered to floor for safety and Hoyer lift used to transfer resident to bed. [DATE] 01:18 PM: Dr. F office aware of final results of urine culture of [DATE] that shows >100,000 mixed culture: (3) or more organisms isolated suggest repeat culture to rule out contamination. He wants resident to complete the order of the current antibiotic that she's already on then to repeat another UA C&S. [DATE] 01:39 AM: ,[DATE], 81, 16, 98.0. Still has confusion [DATE] 02:57 PM: resident A&O x ,[DATE] with some confusion, decrease in appetite noted, resident refused breakfast, ate 10% of lunch, states im just not hungry, resident continues on abt for uti, [DATE] 01:44 PM: ,[DATE] 89 16 96.4 a/o x 2 confusion with medications [DATE] 07:18 PM: sister and daughters in for visit 1400 celebrating Memorial day in activities. poor appetite and weakness family returned to room to report fatigue and saying good-after visit at 1625 sister remained and asked questions before leaving facility sister called writer to room [ROOM NUMBER] found resident fixed eyes head downward and lethargic oral and occular cyanosis in w/c sitting sternal rub for pain response negative notified second nurse of situation and clavicle rub met with eye popping response but respiration not present sent RN to call ems support staff immediate transfer to bed crash cart and board provided for start of cpr at 1635. full two minute of rapid compression per cpr training no pulse and quick 2 rescue breathes and resumed compressions. airway was cleared as rescue breath raised chest. compressions continued until ems arrived and assumed control of cpr at 1645. report given ems and then to er. sister present during code and daughter notified by her. ems left facility at 1707 (Continued .) A Nursing Documentation Record reflected an initialed entry on [DATE] at 02:30 AM , that R47 was incontinent of bowel/bladder and had amber colored urine. Based on the above PN R47 was experiencing periods of confusion, periods of refusing to get oob, ambulate/ambulate to toilet, and low oral intake. In addition R47 was observed to have green discharge on [DATE] at 12:15 AM and brown discharge at 11:35 AM, but Dr. F was not documented as being informed of the discharge along with the UA lab findings until [DATE] at 1:37 PM. In addition, R47 was documented to have Blood Pressures (B/P's) [DATE] to [DATE] that ranged from: ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE]. Pulses ranged from 72- 60 - 79- 66- 82. On [DATE] at 02:31 AM Pulse= 72 and at 03:22 PM the same day Pulse= 99. Temperatures ranged from 96.5 - 97.2 - 99 - 98.2. No BP's were observed to be documented in the PN from [DATE] to [DATE], specifically none were documented with R47's c/o of SOB on [DATE]. The next set of BP's were taken on [DATE] whereby R47's BP was ,[DATE] at 04:11 AM, which was a significant drop from the previous BP. The next BP's were as follows for (MONTH) (YEAR): ,[DATE] at 11:10 AM ,[DATE], ,[DATE] at 01:39 AM ,[DATE], ,[DATE] at 03:49 AM ,[DATE] and ,[DATE] at 01:44 PM ,[DATE]. There was no documentation to reflect Dr. F had been informed of R47's changes in blood pressures and/or periods of confusion. Pulses ranged from ,[DATE]. Temperatures ranged from 97.5 - 98.0 - 98.8 - 96.4. An anonymous Certified Nursing Assistant (CNA) was interviewed during the survey from [DATE] to [DATE] and asked to recall R47. The CNA revealed, R47 would be nice and at times mean and abusive. At times she would try to do things for herself then at times give up. Her appetite was good then it slowly started to decline, at around 70% then decreased. A lot of the times she would not drink, she would say leave it there, but she would not drink enough. She had a UTI, then we started pushing drinks. Even before that we would try but she would not drink. She would go in her brief, and she would ask for the bedpan, and she would not want to get up to go the bathroom. It got to a point when she did not want to get up from her bed. We would do peri-care, for her sometimes every 2 hours or 2.5 to 3 depending. She would ask to be changed at times. She would at times get confused once and in a while. She got confused about ,[DATE] weeks before she got sick. She would look for things that were right in front of her, and we would have to get them for her. When asked about R47's UTI the CNA revealed, It started with a nasty green discharge, we were trying to get a urine sample and we could not get her to go to the bathroom, to get a sample. The CNA denied R47 had green discharge before, but that it started off as creamy stuff, like a natural discharge by a women. The CNA stated, I noticed that maybe a week before the green colored discharge. The creamy was not smelly, but the green discharge was. I let the nurse know, but I don't remember what happened after that, I was off for a few days after that. The nurse would have to document the discharge. The CNA could not recall when her last peri-care education was given when asked. On [DATE] at 01:00 PM CNA E was interviewed and asked to recall R47. CNA E revealed that R47 would refuse to get oob a lot. They were trying to get her to start walking again. She was incontinent most of the time, and would push the call light (CL) when she wanted to be changed. She would want us to do a lot, that she could do herself. Near the end when she was here she refused to get up. On [DATE] at 01:08 PM CNA G was interviewed and asked to recall R47. CNA G revealed R47 did not want to get up. She was not continent and she would go then tell you that she went. When asked about discharge CNA G stated, I think she did have some green discharge once that had an odor to it and they treated her for that, can't recall when . Also, that R47 had loose stools. On [DATE] at 01:17 PM Licensed Practical Nurse (LPN D) was interviewed and asked to recall R47. LPN D revealed, I remember she did not talk much, liked to stay in bed a lot, occasionally got up and would go down for meals. When questioned about R47 having discharge LPN D replied, One of the girls said she had discharge. There was green/yellow discharge. I let the male nurse (Registered Nurse (RN I)) know. LPN D revealed she could not recall doing a UA for R47, but that CNA's did not do UA's. LPN X, who collected the urine sample for R47 on [DATE], was called up to 3 times during the survey from [DATE] to [DATE], voicemail of writer's and co-workers phone numbers were left for LPN X whom did not call back for an interview. On [DATE] at around 01:30 PM R47's closed records reflected the following Physician orders: On [DATE] an order was written reflecting: UA / C&S Vaginal Drainage, Frequency, Dysuria. (MONTH) St. cath for specimen if unable clean catch. Yet, there was no documentation in the EMR, progress notes, or closed record that the doctor had been notified, or that the UA had been completed. On [DATE] an order was written reflecting: CXR 2 view r/t SOB and decreased oxygen, [MEDICATION NAME] mg 1 tab by mouth twice daily x 10 days Dx: UTI. On [DATE] an order was written reflecting: Repeat UA/ C&S once finished with ABT. Also, a physician's orders [REDACTED]. On [DATE] at 02:08 PM R47 UA lab results dated received/reported on [DATE] reflected: cloudy amber urine, 2+ blood, 3+ protein, ,[DATE] white blood cells, many bacteria and few [MEDICATION NAME] cells. The lab result did not reflect how the sample was obtained, (clean catch or straight catheter). UA lab results dated [DATE] and reported on [DATE] reflected a urine culture with a source organism 1 as, 25,000 Eshcerichia Coli (E-Coli). UA lab results dated [DATE] and reported on [DATE] reflected a urine culture with a source organism as, >100, 000 mixed culture: (3) or more organisms isolated suggest repeat culture to rule out contamination. Dr F was interviewed on [DATE] at 07:01 AM related to R47. Dr F revealed that he was aware that R47 was a facility resident who was then transferred to the hospital. Dr. F was informed of R47's fluctuations in blood pressures, temperatures, behaviors, green/brown discharge and that there was an order for [REDACTED]. F revealed, No, I see those patients once a month. I have them get a set of Vital Signs (VS) before coming in and will ask if there has been a trend. Dr. F revealed he had been a family practice physician for [AGE] years, daily and/or once a week he had communications with different facilities about patients and made determination at times off of what facility staff told him. Related to the labs ordered [DATE] and performed on [DATE] Dr. F replied, If I order something, I want it done promptly. Also, that he depended on communication, and if not properly done it made it hard to react to. The most recent Physician's Progress Notes dated [DATE] and [DATE] by which appeared to be from Dr. F were negative for any documentation related to changes in b/p, behaviors, poor intake, discharge, refusals to ambulate/get out of bed, temperatures, or amber colored urine. On [DATE] at 09:21 AM the Director Of Nursing (DON) was interviewed. She revealed she had started the DON position around mid (MONTH) (YEAR). The DON was given the paper order dated [DATE], and asked to reveal the date on the order. DON B revealed the nurse signature on the order was RN I, and that it was dated [DATE]. The DON was then asked when would she expect the UA to be completed. The DON replied, I would anticipate they would get the UA by the first or at least by the 2nd. The DON was informed that the the UA lab was not done until [DATE]. When asked if that was acceptable the DON verbalized, that was not considered acceptable. The DON was then informed of R47's fluctuation in BP's, temperatures, weakness, behaviors, green drainage, brown drainage, SOB requiring oxygen, poor intake, E-coli UA C&S results and confusion. The DON revealed, that the differences in b/p's going on generally the range was around ,[DATE], and that physicians usually gave them parameters r/t to b/p but was not sure if R47 had any because she was not familiar with R47's chart. The DON then stated, ,[DATE] I would be calling the physician and doing something serious about it. You would notify him of the change. Depends on residents conditions. DON was asked after sharing the previous information, what did she think R47 was exhibiting. The DON replied, That she is going septic, the kicker is the low BP ,[DATE] with no temperature spike. I would have to look at the chart to to determine when sign and symptoms [MEDICAL CONDITION] were shown. The infection control (IC) RN K was interviewed on [DATE] at 10:20 AM. RN K was asked when was the most recent peri-care education training, whereby she replied [DATE]. The IC monthly tracking/trending records for (MONTH) to (MONTH) (YEAR) were reviewed r/t UTI's and reflected: March: ,[DATE] (acquired/facility), April: 2 (facility only with one number), May: 2, June: ,[DATE], July: 7, and for August: 1. RN K was asked what should nursing staff do, when a resident has green or brown drainage. RN K stated, Green or brown drainage, the nurse is supposed to call the doctor. If it happened in the middle of the night they should call in the middle for the night. RN K was asked to describe s/s [MEDICAL CONDITION]. RN K replied, UTI septic: lethargy, confusion, discharge, not voiding. RN I was interviewed on [DATE] at 10:46 AM, and was asked to recall R47. RN I revealed, She was her own person chose to do or not do physical therapy. Therapy she would not go at times or want to get out of bed. Before she past, the girls said she was getting more confused. I wanted to get a clean catch and dip it, just in case she could not do a clean catch, I wrote the order for a clean catch or straight cath UA. RN I was informed of the order dated [DATE]. RN I stated, To my recollection the order it was [DATE] or [DATE]. RN I was given 47's (MONTH) (YEAR) MAR (Medication Administration Record) to recollect the date. RN I revealed it was the last day he had worked and stated, Usually we would get a dip. I was going off her behavior because she was incontinent. When asked who obtained the urine. RN I revealed the CNA's would get the urine for a clean catch, dump urine from hat or bed pan, and pour into the cup. Also, that the resident is washed with soap and water in the peri-area first. After looking at the (MONTH) (YEAR) MARS, RN I revealed the date he wrote the UA order was [DATE]. I am going to say [DATE] when looking at the MAR's. I got the order but did not send it. When asked when did he think the UA order should have been completed RN I stated, Immediately or within 24 hours, and if you can't then straight cath or document if refused. RN I was asked if [DATE] was an appropriate time to send UA he replied, No, not really unless she refused. RN I was then asked how was R47's oral intake. RN I replied, Particularly on that day I made the UA order she had poor intake, she would drink some but not really well that day. RN I was informed of R47 having BP changes, weakness, refusals to get oob, behaviors, loose stool, green/brown drainage, SOB, need for oxygen, poor intake, UA with E-Coli, antibiotics and confusion. RN I was then asked what did he think was going on with the resident. RN I replied, [MEDICAL CONDITION]. When questioned what he would do if his resident had a BP of ,[DATE]. RN I revealed If he had a resident with a b/p ,[DATE], I would hold bp medication, re-check bp, call doctor and then of course push fluids. RN I revealed, Around the 17th she wasn't acting right so I got a UA. RN I revealed he did not write a note about ordering the UA or getting it, that it was standard nursing, and whenever you see behavior changes get a urine and dip it. I was going off her behavior. RN I stated he was not aware of the drainage, that he encouraged fluids, offered different fluids, encouraged peri-care with soap water, and offered to get her up off the toilet, and that it was better for her to have a sitting void than laying void. RN I revealed after he wrote the order before the end of his shift and was then off of work for a few days, and that he passed it on the nurse relieving him on [DATE]. When asked [MEDICAL CONDITION] and/or UTI education. RN I revealed, UTI education was done quarterly, and that nothing had changed recently related [MEDICAL CONDITION] education. The (MONTH) (YEAR) MAR indicated [REDACTED]. Also, that R47 was started [MEDICATION NAME](antibiotic) 500 mg 1 tab by mouth twice daily started on [DATE] at 18:00 PM and the last dose was given on [DATE] at 09:00 AM. The Centers for Disease Control and Prevention (CDC) online reference updated [DATE] [MEDICAL CONDITION] as:[MEDICAL CONDITION] is the body ' s extreme response to an infection. It is a life-threatening medical emergency.[MEDICAL CONDITION] happens when an infection you already have -in your skin, lungs, urinary tract, or somewhere else-triggers a chain reaction throughout your body. Without timely treatment,[MEDICAL CONDITION] can rapidly lead to tissue damage, organ failure, and death. Signs [MEDICAL CONDITION] that your doctor or nurse can measure include either of the following: High heart rate, fever, shivering, or feeling very cold, confusion, disorientation, SOB, extreme pain or discomfort, and clammy or sweaty skin. The (name of) Hospital where R47 was transferred to reflected she was admitted on [DATE] at 17:16 PM and discharged on [DATE] at 20:45 PM. The notice of death reflected [DATE] at 17:39 PM and that R47's body was released to the funeral home on [DATE] at 18:00 PM. The Emergency Department (ED) notes reflected: 70 y.o. F presents to ED via EMS with complaints of MI. Pt was found laying on the floor at her nursing home. EMS states the daughters were talking to the Pt about 2:30 and told the nursing home the Pt wasn't talking as much as normal. EMS states compressions began at 16:45. Pt has been given 3 epi's, was shocked 1 time at 200 volts. Hospital notes continued that R47 was a full code and the following was performed at the hospital: 17:20- Pt given one of epi. Faint pulse found in the coratid 17:30-Dopamene Drip started. CPR initiated. 1731- Compressions stopped. No pulse palpated. Compressions continued. One of epi given. 17:34- Compressions stopped. No pulse palpated. Compressions continued. One of EPI given. 1738- Cardioversion at 200 joules. One of epi given. 17:39- No pulse palpated. No rhythm on monitor. Time of death is 17:39. A document dated [DATE] by Dr./Pathologist Y reflected SUMMARY OF AUTOPSY EXAMINATION: Abdominal/pelvic abscess (localized peritonitis). Transmural active chronic [MEDICATION NAME] Mildly dilated ureters with bilateral hydro[DIAGNOSES REDACTED]. Hypertension (by history) [MEDICAL CONDITION] Obesity (BMI=48) Toxicology: Blood [MEDICATION NAME] Positive. [MEDICATION NAME] 5.66 mcg/ml. [MEDICATION NAME] not tested . COMMENT: (R47's name), a [AGE] year-old woman, was declared death at 5:39 p.m. on (MONTH) 28, (YEAR), in the emergency department at (name of) Hospital following transport from her residence at (name and address of facility). Death was caused by chronic urinary tract infection associated with adjacent abscess and localized peritonitis, resulting in [MEDICAL CONDITION] blockage and hydro[DIAGNOSES REDACTED]. This is a natural cause of death. No injuries were present at postmortem examination.

Based on observation, interview and record review the facility failed to timely notify the physician of changes in blood pressure, confusion, vaginal drainage, refusals to ambulate, changes in urine and delayed urinalysis completion for Resident (R) #47, resulting in ambered/cloudy colored urine, hypotensive/hypertensive episodes, urinary tract infection with positive urine cultures and the potential [MEDICAL CONDITION]. Findings Include: This citation is related to intake MI 983 According to the Electronic Medical Record (EMR) reviewed on [DATE] at 09:55 am R47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R47's most recent Quarterly Minimum Data Set (MDS: resident assessment tool) dated [DATE] reflected: A BIMS (Brief Interview of Mental Status) score of 10 out of 15 (,[DATE]: moderately impaired cognition), required extensive assistance of 2 persons for bed mobility/transfers, required extensive assistance of 1 person for dressing/bathing and was always incontinent of her bladder. R47's Admission MDS dated [DATE] reflected she was occasionally incontinent of her bladder. Review of R47's care plans reflected the facility did not create a plan of care related to Infection until [DATE]. R47's Urinary Incontinence care plan created on [DATE] reflected as interventions: Obtain labs a ordered [DATE], Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine) [DATE]. Review of R47's Progress Notes (PN) dated [DATE] to [DATE] reflected the following: [DATE] 02:47 PM: Individual resident behavior log indicates that recent behaviors include: excessive use of her call light, anxiety, delusions and impulsiveness. [DATE] 02:08 AM: Weakness generalized [DATE] 12:47 AM: Has generalized weakness [DATE] 02:33 PM: Stated she did not feel well [DATE] 11:54 PM: Has weakness with mobility [DATE] 11:57 AM: IDT met r/t behaviors of crying and anxiety [DATE] 03:34 PM: Loose stools x 2 [DATE] 08:00 AM: Resident refused restorative ambulation [DATE] 05:59 PM: Resident refusing oob (out of bed) activities and ambulation per restorative program [DATE] 11:16 AM: Resident chooses to not get OOB today [DATE] 10:45 AM: Resident declines to participate in ambulation to the toilet [DATE] 04:03 PM: Resident refused to ambulate. [DATE] 12:15 AM: Green discharge noted. U/A (Urinalysis) obtained for C&S (Culture and Sensitivity). [DATE] 11:35 AM: Resident has refused every attempt to ambulate a few steps with the exception of one time. extensive assist x 2 to transfer onto the toilet, was incontinent of urine and had brownish colored (Continued .) [DATE] 03:58 PM: Resident A&O with some confusion, c/o (complaining of) SOB (Shortness Of Breath), lung sounds clear throughout, administered PRN O2 @ 2L via NC (nasal canula) resident able to maintain O2 sat of 98%, resident c/o back pain 6 on scale from ,[DATE], writer gave PRN (as needed) [MEDICATION NAME], results somewhat effective, resident anxious this shift, verbalizes increased confusion, UA results faxed to md, awaiting C&S results, writer encouraged fluids. [DATE] 10:30 AM: . PO (oral) intake is poor, ranging from ,[DATE]%. Resident does have a UTI at the time of this observation. [DATE] 01:37 PM: Dr. F notified of residents UA results of [DATE] and assessment. Urine culture is pending at this time. [DATE] 02:14 PM: Received orders from Dr. F for resident. Dr. F ordered CXR (Chest X-ray) 2 views d/t residents c/o SOB, and new need of O2. Orders written [MEDICATION NAME] mg one tablet by mouth twice daily x 10 days for Dx: UTI (Urinary Tract Infection). [DATE] 09:13 AM: Dr. F notified of residents urine culture results which shown 25,000 E coli. Dr. F wants to continue with current treatment as ordered. [DATE] 04:11 AM: ,[DATE] 90 17 97.5 Resident was being assisted to bed x 2 assist when the resident became non compliant with transfer. Refusing to let go of side rail, staff members, refused to pivot self to the bed. Resident was lowered to floor for safety and Hoyer lift used to transfer resident to bed. [DATE] 01:18 PM: Dr. F office aware of final results of urine culture of [DATE] that shows >100,000 mixed culture: (3) or more organisms isolated suggest repeat culture to rule out contamination. He wants resident to complete the order of the current antibiotic that she's already on then to repeat another UA C&S. [DATE] 01:39 AM: ,[DATE], 81, 16, 98.0. Still has confusion [DATE] 02:57 PM: resident A&O x ,[DATE] with some confusion, decrease in appetite noted, resident refused breakfast, ate 10% of lunch, states im just not hungry, resident continues on abt for uti, [DATE] 01:44 PM: ,[DATE] 89 16 96.4 a/o x 2 confusion with medications [DATE] 07:18 PM: sister and daughters in for visit 1400 celebrating Memorial day in activities. poor appetite and weakness family returned to room to report fatigue and saying good-after visit at 1625 sister remained and asked questions before leaving facility sister called writer to room [ROOM NUMBER] found resident fixed eyes head downward and lethargic oral and occular cyanosis in w/c sitting sternal rub for pain response negative notified second nurse of situation and clavicle rub met with eye popping response but respiration not present sent RN to call ems support staff immediate transfer to bed crash cart and board provided for start of cpr at 1635. full two minute of rapid compression per cpr training no pulse and quick 2 rescue breathes and resumed compressions. airway was cleared as rescue breath raised chest. compressions continued until ems arrived and assumed control of cpr at 1645. report given ems and then to er. sister present during code and daughter notified by her. ems left facility at 1707 (Continued .) A Nursing Documentation Record reflected an initialed entry on [DATE] at 02:30 AM , that R47 was incontinent of bowel/bladder and had amber colored urine. Based on the above PN R47 was experiencing periods of confusion, periods of refusing to get oob, ambulate/ambulate to toilet, and low oral intake. In addition R47 was observed to have green discharge on [DATE] at 12:15 AM and brown discharge at 11:35 AM, but Dr. F was not documented as being informed of the discharge along with the UA lab findings until [DATE] at 1:37 PM. In addition, R47 was documented to have Blood Pressures (B/P's) [DATE] to [DATE] that ranged from: ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE] - ,[DATE]. Pulses ranged from 72- 60 - 79- 66- 82. On [DATE] at 02:31 AM Pulse= 72 and at 03:22 PM the same day Pulse= 99. Temperatures ranged from 96.5 - 97.2 - 99 - 98.2. No BP's were observed to be documented in the PN from [DATE] to [DATE], specifically none were documented with R47's c/o of SOB on [DATE]. The next set of BP's were taken on [DATE] whereby R47's BP was ,[DATE] at 04:11 AM, which was a significant drop from the previous BP. The next BP's were as follows for (MONTH) (YEAR): ,[DATE] at 11:10 AM ,[DATE], ,[DATE] at 01:39 AM ,[DATE], ,[DATE] at 03:49 AM ,[DATE] and ,[DATE] at 01:44 PM ,[DATE]. There was no documentation to reflect Dr. F had been informed of R47's changes in blood pressures and/or periods of confusion. Pulses ranged from ,[DATE]. Temperatures ranged from 97.5 - 98.0 - 98.8 - 96.4. An anonymous Certified Nursing Assistant (CNA) was interviewed during the survey from [DATE] to [DATE] and asked to recall R47. The CNA revealed, R47 would be nice and at times mean and abusive. At times she would try to do things for herself then at times give up. Her appetite was good then it slowly started to decline, at around 70% then decreased. A lot of the times she would not drink, she would say leave it there, but she would not drink enough. She had a UTI, then we started pushing drinks. Even before that we would try but she would not drink. She would go in her brief, and she would ask for the bedpan, and she would not want to get up to go the bathroom. It got to a point when she did not want to get up from her bed. We would do peri-care, for her sometimes every 2 hours or 2.5 to 3 depending. She would ask to be changed at times. She would at times get confused once and in a while. She got confused about ,[DATE] weeks before she got sick. She would look for things that were right in front of her, and we would have to get them for her. When asked about R47's UTI the CNA revealed, It started with a nasty green discharge, we were trying to get a urine sample and we could not get her to go to the bathroom, to get a sample. The CNA denied R47 had green discharge before, but that it started off as creamy stuff, like a natural discharge by a women. The CNA stated, I noticed that maybe a week before the green colored discharge. The creamy was not smelly, but the green discharge was. I let the nurse know, but I don't remember what happened after that, I was off for a few days after that. The nurse would have to document the discharge. The CNA could not recall when her last peri-care education was given when asked. On [DATE] at 01:00 PM CNA E was interviewed and asked to recall R47. CNA E revealed that R47 would refuse to get oob a lot. They were trying to get her to start walking again. She was incontinent most of the time, and would push the call light (CL) when she wanted to be changed. She would want us to do a lot, that she could do herself. Near the end when she was here she refused to get up. On [DATE] at 01:08 PM CNA G was interviewed and asked to recall R47. CNA G revealed R47 did not want to get up. She was not continent and she would go then tell you that she went. When asked about discharge CNA G stated, I think she did have some green discharge once that had an odor to it and they treated her for that, can't recall when . Also, that R47 had loose stools. On [DATE] at 01:17 PM Licensed Practical Nurse (LPN D) was interviewed and asked to recall R47. LPN D revealed, I remember she did not talk much, liked to stay in bed a lot, occasionally got up and would go down for meals. When questioned about R47 having discharge LPN D replied, One of the girls said she had discharge. There was green/yellow discharge. I let the male nurse (Registered Nurse (RN I)) know. LPN D revealed she could not recall doing a UA for R47, but that CNA's did not do UA's. LPN X, who collected the urine sample for R47 on [DATE], was called up to 3 times during the survey from [DATE] to [DATE], voicemail of writer's and co-workers phone numbers were left for LPN X whom did not call back for an interview. On [DATE] at around 01:30 PM R47's closed records reflected the following Physician orders: On [DATE] an order was written reflecting: UA / C&S Vaginal Drainage, Frequency, Dysuria. (MONTH) St. cath for specimen if unable clean catch. Yet, there was no documentation in the EMR, progress notes, or closed record that the doctor had been notified, or that the UA had been completed. On [DATE] an order was written reflecting: CXR 2 view r/t SOB and decreased oxygen, [MEDICATION NAME] mg 1 tab by mouth twice daily x 10 days Dx: UTI. On [DATE] an order was written reflecting: Repeat UA/ C&S once finished with ABT. Also, a physician's orders [REDACTED]. On [DATE] at 02:08 PM R47 UA lab results dated received/reported on [DATE] reflected: cloudy amber urine, 2+ blood, 3+ protein, ,[DATE] white blood cells, many bacteria and few [MEDICATION NAME] cells. The lab result did not reflect how the sample was obtained, (clean catch or straight catheter). UA lab results dated [DATE] and reported on [DATE] reflected a urine culture with a source organism 1 as, 25,000 Eshcerichia Coli (E-Coli). UA lab results dated [DATE] and reported on [DATE] reflected a urine culture with a source organism as, >100, 000 mixed culture: (3) or more organisms isolated suggest repeat culture to rule out contamination. Dr F was interviewed on [DATE] at 07:01 AM related to R47. Dr F revealed that he was aware that R47 was a facility resident who was then transferred to the hospital. Dr. F was informed of R47's fluctuations in blood pressures, temperatures, behaviors, green/brown discharge and that there was an order for [REDACTED]. F revealed, No, I see those patients once a month. I have them get a set of Vital Signs (VS) before coming in and will ask if there has been a trend. Dr. F revealed he had been a family practice physician for [AGE] years, daily and/or once a week he had communications with different facilities about patients and made determination at times off of what facility staff told him. Related to the labs ordered [DATE] and performed on [DATE] Dr. F replied, If I order something, I want it done promptly. Also, that he depended on communication, and if not properly done it made it hard to react to. The most recent Physician's Progress Notes dated [DATE] and [DATE] by which appeared to be from Dr. F were negative for any documentation related to changes in b/p, behaviors, poor intake, discharge, refusals to ambulate/get out of bed, temperatures, or amber colored urine. On [DATE] at 09:21 AM the Director Of Nursing (DON) was interviewed. She revealed she had started the DON position around mid (MONTH) (YEAR). The DON was given the paper order dated [DATE], and asked to reveal the date on the order. DON B revealed the nurse signature on the order was RN I, and that it was dated [DATE]. The DON was then asked when would she expect the UA to be completed. The DON replied, I would anticipate they would get the UA by the first or at least by the 2nd. The DON was informed that the the UA lab was not done until [DATE]. When asked if that was acceptable the DON verbalized, that was not considered acceptable. The DON was then informed of R47's fluctuation in BP's, temperatures, weakness, behaviors, green drainage, brown drainage, SOB requiring oxygen, poor intake, E-coli UA C&S results and confusion. The DON revealed, that the differences in b/p's going on generally the range was around ,[DATE], and that physicians usually gave them parameters r/t to b/p but was not sure if R47 had any because she was not familiar with R47's chart. The DON then stated, ,[DATE] I would be calling the physician and doing something serious about it. You would notify him of the change. Depends on residents conditions. DON was asked after sharing the previous information, what did she think R47 was exhibiting. The DON replied, That she is going septic, the kicker is the low BP ,[DATE] with no temperature spike. I would have to look at the chart to to determine when sign and symptoms [MEDICAL CONDITION] were shown. The infection control (IC) RN K was interviewed on [DATE] at 10:20 AM. RN K was asked when was the most recent peri-care education training, whereby she replied [DATE]. The IC monthly tracking/trending records for (MONTH) to (MONTH) (YEAR) were reviewed r/t UTI's and reflected: March: ,[DATE] (acquired/facility), April: 2 (facility only with one number), May: 2, June: ,[DATE], July: 7, and for August: 1. RN K was asked what should nursing staff do, when a resident has green or brown drainage. RN K stated, Green or brown drainage, the nurse is supposed to call the doctor. If it happened in the middle of the night they should call in the middle for the night. RN K was asked to describe s/s [MEDICAL CONDITION]. RN K replied, UTI septic: lethargy, confusion, discharge, not voiding. RN I was interviewed on [DATE] at 10:46 AM, and was asked to recall R47. RN I revealed, She was her own person chose to do or not do physical therapy. Therapy she would not go at times or want to get out of bed. Before she past, the girls said she was getting more confused. I wanted to get a clean catch and dip it, just in case she could not do a clean catch, I wrote the order for a clean catch or straight cath UA. RN I was informed of the order dated [DATE]. RN I stated, To my recollection the order it was [DATE] or [DATE]. RN I was given 47's (MONTH) (YEAR) MAR (Medication Administration Record) to recollect the date. RN I revealed it was the last day he had worked and stated, Usually we would get a dip. I was going off her behavior because she was incontinent. When asked who obtained the urine. RN I revealed the CNA's would get the urine for a clean catch, dump urine from hat or bed pan, and pour into the cup. Also, that the resident is washed with soap and water in the peri-area first. After looking at the (MONTH) (YEAR) MARS, RN I revealed the date he wrote the UA order was [DATE]. I am going to say [DATE] when looking at the MAR's. I got the order but did not send it. When asked when did he think the UA order should have been completed RN I stated, Immediately or within 24 hours, and if you can't then straight cath or document if refused. RN I was asked if [DATE] was an appropriate time to send UA he replied, No, not really unless she refused. RN I was then asked how was R47's oral intake. RN I replied, Particularly on that day I made the UA order she had poor intake, she would drink some but not really well that day. RN I was informed of R47 having BP changes, weakness, refusals to get oob, behaviors, loose stool, green/brown drainage, SOB, need for oxygen, poor intake, UA with E-Coli, antibiotics and confusion. RN I was then asked what did he think was going on with the resident. RN I replied, [MEDICAL CONDITION]. When questioned what he would do if his resident had a BP of ,[DATE]. RN I revealed If he had a resident with a b/p ,[DATE], I would hold bp medication, re-check bp, call doctor and then of course push fluids. RN I revealed, Around the 17th she wasn't acting right so I got a UA. RN I revealed he did not write a note about ordering the UA or getting it, that it was standard nursing, and whenever you see behavior changes get a urine and dip it. I was going off her behavior. RN I stated he was not aware of the drainage, that he encouraged fluids, offered different fluids, encouraged peri-care with soap water, and offered to get her up off the toilet, and that it was better for her to have a sitting void than laying void. RN I revealed after he wrote the order before the end of his shift and was then off of work for a few days, and that he passed it on the nurse relieving him on [DATE]. When asked [MEDICAL CONDITION] and/or UTI education. RN I revealed, UTI education was done quarterly, and that nothing had changed recently related [MEDICAL CONDITION] education. The (MONTH) (YEAR) MAR indicated [REDACTED]. Also, that R47 was started [MEDICATION NAME](antibiotic) 500 mg 1 tab by mouth twice daily started on [DATE] at 18:00 PM and the last dose was given on [DATE] at 09:00 AM. The Centers for Disease Control and Prevention (CDC) online reference updated [DATE] [MEDICAL CONDITION] as:[MEDICAL CONDITION] is the body ' s extreme response to an infection. It is a life-threatening medical emergency.[MEDICAL CONDITION] happens when an infection you already have -in your skin, lungs, urinary tract, or somewhere else-triggers a chain reaction throughout your body. Without timely treatment,[MEDICAL CONDITION] can rapidly lead to tissue damage, organ failure, and death. Signs [MEDICAL CONDITION] that your doctor or nurse can measure include either of the following: High heart rate, fever, shivering, or feeling very cold, confusion, disorientation, SOB, extreme pain or discomfort, and clammy or sweaty skin. The (name of) Hospital where R47 was transferred to reflected she was admitted on [DATE] at 17:16 PM and discharged on [DATE] at 20:45 PM. The notice of death reflected [DATE] at 17:39 PM and that R47's body was released to the funeral home on [DATE] at 18:00 PM. The Emergency Department (ED) notes reflected: 70 y.o. F presents to ED via EMS with complaints of MI. Pt was found laying on the floor at her nursing home. EMS states the daughters were talking to the Pt about 2:30 and told the nursing home the Pt wasn't talking as much as normal. EMS states compressions began at 16:45. Pt has been given 3 epi's, was shocked 1 time at 200 volts. Hospital notes continued that R47 was a full code and the following was performed at the hospital: 17:20- Pt given one of epi. Faint pulse found in the coratid 17:30-Dopamene Drip started. CPR initiated. 1731- Compressions stopped. No pulse palpated. Compressions continued. One of epi given. 17:34- Compressions stopped. No pulse palpated. Compressions continued. One of EPI given. 1738- Cardioversion at 200 joules. One of epi given. 17:39- No pulse palpated. No rhythm on monitor. Time of death is 17:39. A document dated [DATE] by Dr./Pathologist Y reflected SUMMARY OF AUTOPSY EXAMINATION: Abdominal/pelvic abscess (localized peritonitis). Transmural active chronic [MEDICATION NAME] Mildly dilated ureters with bilateral hydro[DIAGNOSES REDACTED]. Hypertension (by history) [MEDICAL CONDITION] Obesity (BMI=48) Toxicology: Blood [MEDICATION NAME] Positive. [MEDICATION NAME] 5.66 mcg/ml. [MEDICATION NAME] not tested . COMMENT: (R47's name), a [AGE] year-old woman, was declared death at 5:39 p.m. on (MONTH) 28, (YEAR), in the emergency department at (name of) Hospital following transport from her residence at (facility name and address). Death was caused by chronic urinary tract infection associated with adjacent abscess and localized peritonitis, resulting in [MEDICAL CONDITION] blockage and hydro[DIAGNOSES REDACTED]. This is a natural cause of death. No injuries were present at postmortem examination.

Based on observation, interview, and record review, the facility failed to prevent a fall, in one of three residents reviewed for falls (Resident #43), resulting in a major injury and change of condition. Findings include: 8/14/18 at 12:00 PM Resident # 43 (R43) was observed sitting in a broda chair (speciality wheelchair) with her feet resting on a platform foot rest eating lunch. R43's Resident Face Sheet (no date), revealed she was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. R43's Minimum Data Set (MDS) 3.0 assessment dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, was a score of 01 (00-07 indicated severe impairment). The same MDS assessment indicated R43 was independent in walking in room and walking in the corridor on the unit. Resident Progress Notes revealed on 6/4/18 at 4:25 PM, the Interdisciplinary Team met to discuss R43's restorative nursing program and she could benefit in an ambulation program, ambulating 50 to 100 feet daily with stand by assist and no assist devices. Resident Progress Notes revealed on 6/13/18 at 12:01 PM, the Interdisciplinary Team met to discuss R43's restorative ambulation program, and her walking program was discontinued, she was able to ambulate without assist devices and had not had any falls. Accident/Incident Report dated 6/18/18 at 6:10 AM, revealed R43 was observed sitting on the floor in the hallway and a bruise was noted on her right forearm, the fall was not witnessed. Witness Statement dated 6/18/18 indicated the nurse assistants were in another resident's room and responded to a loud noise outside of the room. Post-Fall assessment dated [DATE] revealed R43 was .in progressive decline w/ (with) mobility, dementia, very frail . In review of R43's medical record, there was no evidence she was re-evaluated for a restorative ambulation program or for physical therapy. Accident/Incident Report dated 6/23/18 at 5:30 AM, revealed staff responded to a noise in the hallway and observed R43 laying in a face down position with hands and arms at her side. The same report revealed a wound noted on the right side of R43's temple, she did not initially respond to stimuli, and tremors were noted in her arms. The same report indicated the nurse called 911 and R43 was transported to the hospital. The same report indicated to encourage R43 to use a wheelchair, as gait was unsteady. Physician's Progress Notes dated 6/27/18 (no time), revealed R43 fell from a standing position on 6/23/18, and Computed Tomography (CT) of the brain revealed she had sustained bilateral acute subdural hemorrhage (collection of blood outside the brain usually caused by a severe head injury). The same note indicated R43's family was consulted and wished for comfort care, therefore, there was no neurosurgery evaluation. The same note indicated R43 sustained a laceration to her right temple from her fall on 6/23/18 that was repaired with sutures. The same physician progress notes [REDACTED]. The same note revealed R43's exam, 4 days after her fall, presented ecchymosis (bruising) along the right side of her face and neck, and large hematoma (collection of blood outside the blood vessels) on the right temple with intact sutures below. The same note indicated R43 was awaiting a hospice consult. 8/16/18 at 8:15 AM, the Director of Nursing (DON) was interviewed and stated R 43 was not referred to therapy following her fall on 6/18/18 because they did not have a therapy department in the facility and was not considered for outpatient therapy at the hospital.

This citation pertain to intake number MI 292 Based on observation, interview, and record review the facility failed to prevent 1 out of 4 residents (#53), out of a total sample of 4, was free from involuntary seclusion resulting in psychosocial harm and resulting in Resident #53 being fearful and potential having [MEDICATION NAME] psychosocial effects. Resident #53: Per the facility face sheet Resident #53 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed Resident #53 had a Brief Interview of Mental Status (BIMS) score of 8 out of 15, which indicated an impairment in his cognitive ability. Record review of a care plan titled, Falls, dated 2/23/2018 revealed, Resident #53 was at risk for falls, and revealed an intervention for staff to attempt to keep Resident #53 in visual field when up in broda chair (deep seat chair that cannot be pushed by resident via wheels) to prevent falls. Another intervention on Resident #53's fall care plan revealed, when Resident #53 had increased behaviors or increased restlessness when in bed and not able to relax, staff were to bring him to the nurses station for closer monitoring and give reassurance. Another care plan reviewed, dated 02/22/2018, revealed Resident #53 had mood concerns, and would displaying signs and symptoms of mood distress such as anxiety, restlessness, hallucinations, rejection of care and agitation. A care plan for an impairment of cognitive functioning dated 2/22/2018 revealed, Resident #53 had a cognitive loss and dementia with poor short term memory loss, periods of delusions and hallucinations during which he often yells out or yells for help. The care plan revealed an intervention to re-direct Resident #53 as needed with meaningful conversation to divert behavior, and avoid arguing with resident. Another care plan, dated 2/22/2018, revealed Resident #53 had Behavioral Symptoms, and would have physical behavioral symptoms toward others (e.g., hitting, kicking, pushing, scratching during care). The care plan revealed interventions to avoid power struggles with Resident #53, convey an attitude of acceptance toward him, encourage supervised activities of interest, if Resident #53 had delusions or hallucinations not to try to reason with or confront Resident #53, but offer reassurance. The care plan also revealed staff were to maintain a calm, slow, understandable approach with the Resident #53. In an interview on 3/30/18 at 10:51 AM, Certified Nurse Aid (CNA) D stated on 3/21/2018 around 9:00 PM, CNA E asked her where Resident #53 was, and said she told her she did not know. CNA D said usually resident #53 would be at the nurses station, because that would calm him down. CNA D said she and CNA E went and asked Licensed Practical Nurse (LPN) H where Resident #53 was, and said LPN H said he was in room [ROOM NUMBER] down D-hall. CNA D said LPN H told her Resident #53 was screaming, and that is why she put him back there. CNA D said she went to room [ROOM NUMBER], and knocked on the closed room door, and said she scared him. CNA #D stated when she went into room [ROOM NUMBER] Resident #53 was shaking, and terrified. CNA D said Resident #53 did not know why he was back there, was confused about his whereabouts asking how she got the key, and he thought he was locked in. CNA D said Resident #53 was sitting in his broda chair, with the TV on, and no call light in reach. CNA D said the room door was shut, and she had to unlatch it to open it. CNA D also stated that the D-hall double doors were shut also. CNA D said Resident #53 had told her that he was sorry, he wont do it again, asked her to get him out of there, and told her he would not scream again. CNA D said Resident #53 thought he was in jail and wanted out. CNA D said when she first walked in Resident #53 was shaking, his mouth was quivering, he just wanted water, and asked if she could get him some water. CNA D said she thought Resident #53 was in room D-4 about 30, and said she asked LPN H why Resident #53 back there in room D-4, and LPN H said she could not stand it anymore ( referring to Resident #53 yelling). Observation of D-hall; and room D-4 on 3/30/2018, with CNA D immediately following the interview revealed, room D-4 was 4 rooms down the D-hall on the right side. CNA D stated she found Resident 353 inside the room in his broda chair, in front of the TV that was on. Observation of room D-4 revealed the room could not be seen from outside of the D-hall while at the nurses' station. It was also observed that with the 2 doors closed at the beginning of D-hall it was not possible to hear or see anyone in room D-4 with the doors closed. The D-hall was observed to be an empty hall where no residents resided. In a telephone interview on 3/30/2018 at 4:47 PM, LPN H said Resident #53 was yelling out while in his room, so she put him in his wheelchair and took him to the nursing station. LPN H said Resident #53 kept yelling out, and it was disturbing other resident's so she put him in a broda chair, and put him into room [ROOM NUMBER] on the D-hall. LPN H said Resident #53 was very confused, and she felt bad for him. LPN H said she put Resident 353 on the D hall so no one could not hear him yelling out in the main area; so other residents could sleep and be comfortable, LPN H said she did not consider her actions to be involuntary seclusion, and stated Resident #53 was in room D-4 about an hour or so. LPN H said Resident #53 was not able to wheel his broda chair, walk, or get himself out of room D-4. LPN H also stated Resident #53 did not ever use a call light. In an in interview on 3/30/2018 at 2:50 PM, Director of Nursing (DON) B stated LPN H was fired due to the incident with Resident #53 and did not work again after the incident. DON B and stated LPN H's actions were not acceptable. In an interview on 3/30/2018 at 5:02 PM, Resident #53's wife C stated Resident #53 had gone home on Saturday 3/24/18, and all he kept talking about was being locked in that room (D-4). Wife C said Resident #53 kept asking her why the nurse put him in jail, and stated he truly thought he was in jail. Wife C said all Resident #53 did was cry all night for the first three nights he was home, and said she did not get any sleep for the first 3 nights, because Resident #53 was scared, and kept asking why they put him in jail.

Based on observation, interview and record review the facility failed to A) follow doctor's orders for Resident #1, B) provide coordination of dementia care for Resident #7, and C) failed to provide coordination of hospice care for Residents #4, #8 and #12 from a total of 15 sampled residents, resulting in potential for a decline in health status, and the absence of specialty health care services being provided. Findings include: Resident #4 Resident (R) #4 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. While reviewing R4's chart on 6/14/17 at around 10:15 AM, it reflected R4 was receiving Hospice care. Name of Hospice Agency started hospice services for R4 on 3/14/17 related to his [DIAGNOSES REDACTED]. An initial Registered Nurse (RN) visited was noted for R4 on 3/14/17. Additional hospice documentation was looked for in R4's chart but could not be located. Later on the same day at 10:44 AM, the Medical Records Associate (Staff V) was asked where additional hospice records were located for R4. Staff V revealed, Hospice has a tab in the charts where they keep their documentation. The initial hospice documentation dated 3/14/17, reflected nursing frequency of visits were to be 3 - to - 5 times a week (the exact days the visits were to take place was not listed). Later on 6/14/17 at 5:13 PM Unit Manager (UM) Licensed Practical Nurse (LPN GG) revealed that the hospice service for R4, did their visits differently. UM GG was informed that all hospice notes in the chart for R4 were dated 3/14/17. UM GG stated, Let me see, I will call medical records. I think hospice documents are in Matrix (computer system). UM GG was asked to provide all hospice Nursing and Nursing Assistant (NA) notes/charting for R4 in Matrix. UM GG returned at 5:48 PM and stated, Hospice is willing to bring in notes that are not in matrix. UM GG was Informed that hospice records should be available in the medical record (R4's chart or in Matrix) currently. UM GG was queried how would nursing staff know what type of nursing care was provided when visit notes were not available in the chart or Electronic Medical Record (EMR). Also, how would nursing staff know what services hospice RN's and NA's provided if it was not documented. UM GG stated, she did not know how to answer that question. UM GG was asked if hospice staff gave report after visits and stated, Sometimes. UM GG was asked when the hospice services for R4 visited. She replied, I don't. Within about twenty minutes UM GG provided writer documentation by R4's hospice service that was available in the EMR Matrix. Progress notes reflected hospice visited R4 on the following days: March: 14, 15 and 21 (3 times). April: 4, 10, 13, 18 and 25 (5 times). May: 2, 9, 22, 30 (4 times). June: 5 and 13 (2 times). UM GG was unable to provide any documentation from the EMR Matrix, to reflect that NA care had ever been provided since 3/14/17 to 6/14/17. The Director of Nursing (DON B) approached writer and stated that the hospice service for R4 were going to fax over notes, in addition to the one listed above today. The facility had not requested, nor had they processed any other hospice related notes for R4 other than the ones listed above. Resident #12 R12 was most recently admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. While reviewing R12 chart, documentation reflected R12 was seen by the same hospice service as R4. On 6/15/17 At 2:35 PM DON B and UM BB were interviewed, and asked to provide all Nursing and NA documentation from the hospice service. UM GG was asked when did the hospice service come to the facility. UM GG stated, I don't know their schedule. I have no idea when they come. When reviewing the EMR for RN hospice notes, UM GG stated she only had 2, and would have to look for notes completed by NA. Within the hour UM GG returned and stated, She (R12) started hospice around 6/4/27. That's all the documentation I have. DON B also revealed hospice services for R12 started on 6/4/27. The progress notes reflected a RN from the hospice service visited R12 on 6/6/17 and 6/13/17 only. There were no documents available to reflect a NA ever visited R12. Resident #8 Based on the Minimum Data Set (MDS) assessment, dated 5/1/17, Resident #8 was a [AGE] year old cognitively intact male whose [DIAGNOSES REDACTED]. The above MDS reflected Resident #8 was dependent on staff for all care except eating. The physician orders [REDACTED]. On 6/14/17 at 4:20 PM Resident #8 was observed in his bed lying on his back with his knees bent and the head of the bed elevated 45 degrees. Resident #8 stated he was comfortable and a little sleepy from the pain medication he had received prior to his wound dressing changes. Review of the clinical records for Resident #8 in both the electronic medical record (EMR) and physical (paper) records reflected no documentation from the hospice provider since the 5/26/17 admission. On 6/15/17 at 11:35 AM Licensed Practical Nurse (LPN) H stated the hospice provider's Certified Nurse Aide (CNA) reported to her yesterday prior to giving care to Resident #8 but did not report to her after the care was completed. LPN H stated other hospice providers had the facility nurse sign for hospice CNA visits but not the provider for Resident #8. LPN H stated the nurse for the hospice provider had been in to see Resident #8 earlier in the week and gave a verbal report to LPN H. LPN H stated the notes from the hospice provider should be under the Hospice tab in the physical chart. No Hospice tab was found in the physical chart. On the same date at 11:42 AM Social Worker (SW) Z stated there was a social worker for the hospice provider but did not know if that social worker had seen Resident #8 since his admission to hospice services. SW Z was not able to locate any progress notes by the hospice social worker. On 5/31/17 an End of Life care plan for Resident #8 was added by LPN PP related to Resident has end-stage disease, 6 or fewer months to live r/t (related to) post [MEDICAL CONDITION](stroke) with the goal that Resident #8 would actively participate in decision making related to end-stage disease as able and he would be comfortable. The approach was to allow the Resident and family to express feelings, concerns and fears. There was no mention of the hospice services and there was no care plan found from the hospice provider. Resident #7 According to Resident #7's MDS/Minimum Data Set, dated dated [DATE] and Face Sheet, dated 6/15/17, she was admitted to the facility on [DATE], had severe cognitive impairment, and [DIAGNOSES REDACTED]. Resident #7 had been on Hospice since her admission. According to Resident #7's June, 2017 Medication Administration Record, [REDACTED] [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 7.5 - 325 one tablet every 6 hours around the clock. [MEDICATION NAME] (antidepressant) 30 mg one tablet by mouth at bedtime. Trazadone (antidepressant) 50 mg one tablet by mouth every 12 hours. [MEDICATION NAME] (antipsychotic) 25 mg by mouth at bedtime. [MEDICATION NAME] (antianxiety) 0.5 mg one tablet by mouth twice daily. [MEDICATION NAME] Sprinkles (anticonvulsant) 250 mg by mouth at bedtime (for Mood disorder). According to Resident #7's June 2017 Medication Administration Record, [REDACTED].; however, it was only signed as being done on one 3-11 shift on one day during June 2017 (6/09/17), but whether she was experiencing side effects was not documented. On 5/13/17 at 12:50 PM, Resident #7 was observed sitting quietly at a table in the dining area of the Dementia Unit, slowly feeding herself. In an interview, on 6/14/17 at 10:19 AM, Nurse Aide L reported she worked full time in the Dementia Unit for the past 1 1/2 years. Nurse Aide L was queried as to what, if any, behaviors Resident #7 exhibited, and she replied, (Resident #7) is always very tearful .and is always cold .she has no hallucinations, but sometimes thinks men are her husband; especially (Resident #20), but she doesn't bother him. She sleeps a lot, between breakfast and lunch, after lunch, sleeps mostly through the night, but wakes up crying . Review of Resident #7's Medication Administration Records and Treatment Administration Records for May and June 2017 revealed no pain assessments that indicated the presence, level, or location of pain. Review of facility Nursing Progress Notes between 3/09/17 - 6/13/17 revealed only 5 notes documenting Resident #7's pain levels. There was no documentation regarding pain or the absence of pain during March or April 2017: 5/07/17 at 4:25 PM - .PRN medication controlling pain at this time. 5/14/17 at 3:26 PM - .UTI (urinary tract infection) .C/O (complaint of) lower back pain, resident is on schedule [MEDICATION NAME] (narcotic pain medication) in which is given as ordered . 5/18/17 at 11:38 AM - .C/O pain (place and intensity not documented) and resident has schedule pain medication ordered . 5/20/17 at 5:18 AM - . Res does not display signs of pain/discomfort . 5/21/17 at 11:54 AM - .C/O back pain at this time, resident has routine [MEDICATION NAME] in which was given with relief . Review of Resident #7's Hospice Staff Collaboration Log since 5/16/17 revealed only the following mention of pain: 5/23/17 (not timed) - Denies pain 5/24/17 (not timed) - Denies pain 6/05/17 (not timed) - denies pain 6/07/17 (not timed) - no s/s (signs or symptoms) of pain 6/07/17 (not timed) - Denies pain 6/08/17 (not timed) - no pain Review of Resident #7's Care Plans revealed the only mention of crying was in her [MEDICAL CONDITION] Drug Use Care Plan, start date 3/29/17 (and not edited until 5/19/17/no new interventions or revisions): Resident is at risk for adverse consequence R/T (related to) receiving antipsychotic, antidepressant and antianxiety medications as ordered for Alzheimer's Dementia with behaviors, affective mood disorder and cries frequently (which appears to be her baseline), Depression anxiety .Attempt gradual dose reduction (if not contraindicated) .Monitor resident's behavior and response to medication .Pharmacy consultant review .Review for continued need at least quarterly .Try non-pharmacological interventions before initiation drug therapy . Review of Resident #7's Pain Care Plan, start date 3/29/17 (not edited and no interventions revised), Resident has Arthritis, [MEDICAL CONDITION] with history of femur fracture & Generalized pain and discomfort .Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects .Allow sufficient uninterrupted rest periods .Assess effects of pain on the resident (disturbances in sleep .) .Evaluate effectiveness of pain management interventions . The Pain Care Plan did not instruct staff how often to assess for pain, or how often to assess for effectiveness of pain relief measures, or to reassess for the continued use of scheduled narcotics for largely resolved pain. Resident #7's Care Plans did not address her discomfort from always being cold, how many hours of uninterrupted sleep she should receive per night, nor an individualized plan to assess, monitor, and intervene for ongoing crying/weeping and psychological distress. In an interview, on 6/14/17 at 11:36 AM, SW/Social Worker Z reported there had been no documented behaviors for Resident #7 for the past 3 months, and the last documented behaviors were regarding increased agitation on 1/13/17. SW Z said, I touch base with the nurses (in the Dementia Unit) every day, look at the 24 hour Report, go to Clinical Meetings, Behavior Management meetings every week. SW Z said Hospice makes decisions about her meds. SW Z stated she did not think she was responsible for following up on Pharmacy recommendations for gradual dose reductions of [MEDICAL CONDITION] medications .Pharmacy recommendations don't come to me. SW Z said she was not aware of Resident #7 crying when woken up at night, nor that she was awakened for dressing changes, medication administrations, and every 2 hours for brief checks. In an interview, on 6/14/17 at 12:49 PM, Unit Manager C reported the Nurse Aides do not document behaviors in the electronic medical record or no where. The facility did not have Behavior Logs for Nurse Aides' documentation. Review of Resident #7's Quarterly Care Conference notes, dated 5/16/17 and documented by SW Z, revealed, .No current mood or behavior concerns ., and no mention of pain or medications. Review of facility Nursing Progress Notes between 3/09/17 - 6/13/17 revealed only 2 notes regarding Resident #7 crying: (5/07/17) Due to diagnosis (not named), resident frequently is tearful thinking that she 'had young children at home that she has to get to', and (5/22/17 at 5:18 AM) .frequently cries when being given the medication . In an interview, on 6/14/17 at 3:05 PM, Hospice RN/Registered Nurse I reported she was unaware of a Pharmacy Recommendation to try a gradual dose reduction for [MEDICATION NAME] and Trazadone (antidepressants) recommended via a Medication Regimen Review, dated 2/20/172/20/17; it was indicated on the Review form there still had been no response to the recommendation as of 5/30/17. (There were no recommendations to reduce narcotic pain medication, or any of the other [MEDICAL CONDITION] medications Resident #7 was being administered.) Hospice RNI said, Usually, Social Work communicates with me if there is a recommendation for a gradual dose reduction . When queried as to what, if any, behaviors Hospice had seen exhibited by Resident #7, RN I said, We generally see sobbing .seems emotionally distressed . Hospice RN I was queried as to why Resident #7 sustained recurring pressure ulcers on her left outer foot, and Hospice RN I stated she had not spoken to the Nurse Aides about the pressure ulcers, and said, I'm not sure why its happening. In an interview, on 6/14/17 at 3:47 PM, Unit Manager C reported it was her responsibility to assure Pharmacy recommendations had been communicated to the appropriate staff, and she had failed to do so for the gradual dose reduction recommendation of Resident #7 [MEDICATION NAME] and Trazadone. In an interview, on 6/14/17 at 4:45 PM, RN E reported Resident #7 cries during dressing changes, but when she asks, Resident #7 says she has no pain. RN . said, She doesn't say why she's crying. She weeps often when we wake her up for Activities, and bed check her every two hours during the night .I would have no problem with letting her sleep, but I'm not sure if its care planned to let her sleep. In an interview regarding Resident #7, on 6/15/17 at 8:50 AM, RN F reported she was the regular midnight nurse on the Dementia Unit, RN F said, I wake (Resident #7) up for pain meds, though she's not necessarily in pain. It's scheduled at 11:00 PM and 5:00 AM. She cries when I wake her up to do her dressing at 6:00 AM. I passed it on in report, but I haven't told the Unit Manager (C) about it. There's never a problem with her sleeping, just waking her up. Yes, we wake her up for meals .I don't think it's justified to wake Dementia residents up for most of their meds. When asked what kind of pain Resident #7 is given pain medication for, RN F said, I don't know what kind of pain she has; she sleeps a lot. In a telephone interview, on 6/15/17 at 9:25 AM, Resident #7's Son KK reported, (Resident #7) sleeps a lot. She's not having any pain. Son KK reported Resident #7 began crying and was started on a lot of medications when she was first admitted to a different facility 2 1/2 years ago. Son KK said She still cries once in awhile. Son KK said he assumed Resident #7 slept during the night, did not know she was awakened twice for medications, once for a dressing change, and every 2 hours to see if she was wet; he said, I don't know about her crying when woken up . During an observation of a dressing change performed by Wound Nurse D on 6/15/17 at 10:05 AM, Resident #7 stated she was cold; she was wearing a thin cotton, long sleeved shirt that was loose fitting, and exposed her neck and half of her shoulders. When LPN .palpated the top of the left foot, Resident #7 jerked, winced and began to cry; LPN .reported 1+ [MEDICAL CONDITION]. Wound Nurse D said, I will see when she was last on an antibiotic and call the doctor. Resident #7 was asked why she was crying, or if she was in pain, and she responded between sobs, I don't know. Resident #7 continued to cry, her eyes were red, and fluid began to drip from her nose. There was no observed redness or swelling on Resident #7's right foot, and Wound Nurse D confirmed this. Wound Nurse D said, I should have changed the treatment last week when I saw the maceration (soft, wet tissue). I only see the wounds once a week. In an interview, on 6/15/17 at 10:54 AM, Son KK reiterated Resident #7 has been crying for 2 1/2 years, but I thought it was better, because I don't see it as much. I don't know why you would wake her up at night unless you absolutely must. Resident #1 Resident #1's Physician's Progress Note dated 5/6/17, indicated he was seen after re-admission to the facility from the hospital for aspiration pneumonia, fever, and weakness. The same note, under treatment, indicated for physical therapy, occupational therapy, and speech therapy to evaluate and provide treatment. Physician admission orders [REDACTED]. Unit Manager GG was interviewed on 6/14/17 at 2:45 PM and was not able to produce Resident #1's chest x-ray completed on 6/5/17. Therapy Director V was interviewed on 6/15/17 at 9:10 AM and stated speech therapy did not evaluate or screen Resident #1.

Based on observation, interview, and record review, the facility failed to ensure safety and supervision for 2 out of 3 residents (Resident #60 & 66), out of a total sample of 13, resulting in a fall that resulted in a hip fracture, and the potential for a fall due to lack of supervision. Findings included: Resident #60: Per the facility face sheet Resident #60 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed Resident #60 had a Brief Assessment of Mental Status (BIMS) score of 3, which indicated impaired cognitive status. The MDS revealed Resident #60 did not ambulate but used a walker to get around the facility. Record review of an incident report dated 6/22/2017 revealed Resident #60 was found sitting on the floor in front of his wheelchair while in the dining room at 9:45 AM. The report revealed Resident #60's fall alarm sounded, which alerted staff to the dining room where they observed him to be on the floor. The report also revealed under, Immediate action to be taken to prevent further incidents, was assessed for injury, return to wheelchair, and toilet/cleansed. Under Section B, The P[NAME] (plan of care) updated with immediate interventions was not checked to have been completed. Review of another incident report dated 7/27/2017 revealed Resident #60 got up out of his bed and attempted to transfer to his wheelchair, but the wheelchair was not locked and it rolled away causing Resident #60 to land on the floor. Under, Immediate action to be taken to prevent further incidents, was a notation to stress to Resident #60 the importance of locking wheelchair and waiting for assistance, and under, Under Section B, The P[NAME] (plan of care) updated with immediate interventions was not checked to have been completed. An incident report dated 8/15/2017, and timed at 7:10 AM, revealed Resident #60 was observed by another resident walking out of the dining room door and falling sideways to the floor. The report revealed Resident #60 was sitting at a table in the dining room, and upon assessment sustained 3 skin tears to his right hand, wrist, and forearm, and 1 to his head. The report revealed Resident #60's fall alarm did not sound when he got up out of his wheelchair. The immediate action taken was treatment to his skin tears, and change of his fall alarm to a tab alarm (connects to his person) from a pressure alarm (sits on a pad that alarms when pressure is removed). The report revealed no changes were made to Resident #60's plan of care. Record review of nurses' notes dated 8/17/2017 at 8:33 PM revealed, Resident #60 complained of pain to his right hip during repositioning and care. The note revealed Resident #60 was observed to have discoloration and swelling to his right hip, and an x-ray was ordered. The nurses' notes revealed a notation on 8/15/2017 that at 7:10 AM Resident #60 was seen by another resident walking out of the dining room, and was found lying on his right side in the doorway of the dining room with an abrasion to his forehead and skin tears to his right hand and wrist. No other nursing progress note was documented again until 8/17/2017 at 1:49 PM, which indicated Resident #60 had a fever. Record review of a care plan titled, Falls dated 6/7/2017 revealed Resident #60 was at risk for falls related to Alzheimer's disease, dementia, poor safety awareness, weakness, history of recurrent falls, needed staff assistance to ambulate, and unsteady gait (walking). The care plan revealed Resident #60 had an intervention, dated 6/7/2017, for a bed and chair alarm for poor safety awareness. No interventions were added to Resident #60's fall care plan until 8/18/2017, which revealed added interventions for non-weight bearing status, bed rest, assist with bed mobility, and low bed; due to a right hip fracture. Record review of a hospital physician's note dated 8/18/2017 revealed, Resident #60 had a fracture of his right hip and surgery would not be performed due to Resident #60's age and the risks involved. Review of physician orders [REDACTED]. In an interview on 8/29/2017 at 2:07 PM, Certified Nurse Aid (CNA) O said she was Resident #60's CNA on 8/15/2017 when he fell . CNA O said Resident #60 had been up and down the night before, and was in the dining room at 6:30 AM on 8/15/2017. CNA O said Resident #60 had a pressure alarm on, and stated the CNA's were supposed to document placement and functioning of a fall alarm every shift. CNA O said there used to be a binder at the nurses' station where the CNA's were to document placement and functioning of fall alarms, but stated the binder went away when the facility discontinued the use of fall alarms. CNA O said Resident #60 would stand up and attempt to self-transfer. CNA O also stated she did not confirm Resident #60's fall alarm was in place and functioning on 8/15/2017 before he fell . In an interview on 8/29/2017 at 2:37 PM, Registered Nurse (RN) H said he was Resident #60's nurses on 8/15/2017 at the time of his fall. RN H said he was counting narcotics with another nurse at 6:30 AM, when he heard a resident yell out in regards to Resident #60 falling. RN H said he could not see Resident #60 until he walked over to the dining room door. RN H stated Resident #60 was sitting at a table in the dining room, and no other staff members were in the area. RN H also stated Resident 60's fall alarm had not sounded, and he had walked approximately 75 feet from the table before he fell . RN H said Resident #60 had 3 skin tears to his right extremity and one to his head, but stated he was all over the facility in his wheelchair after his fall. RN H said no staff member had seen Resident #60 get up from his wheelchair and walk to the dining room door. RN H said the nurses did not update care plans, but the Unit Managers were to do the updates on the care plans. Observation, with RN H of the dining room table, where Resident #60 was sitting on 8/15/2017 at 6:30 AM, revealed an approximate measurement of 65 feet from the table Resident #60 was sitting at to the door where he fell . RN H stated Resident #60 was not stable to walk, and was not sure how he got so far before he fell . In an interview on 8/29/2017 at 3:30 PM, Licensed Practical Nurse (LPN) D said the floor nurses did not update resident care plans, but stated the MDS nurse did that. At 4:16 PM, on 8/29/2017, LPN D provided all of Resident #60's care plans, including interventions that had been resolved. LPN D said no changes were made, or interventions added after each of Resident #60's falls, and stated it did not get done. In an interview on 8/29/2017 at 3:00 PM LPN [NAME] said the CNAs were to check placement and functioning of fall alarms, and then report to the nurse, who then documents to alarm check on the resident's Treatment Administration Record (TAR). On 8/29/2017 at 4:16 PM, Resident #60's TAR for the month of (MONTH) (YEAR) was received from Director of Nursing (DON) B, and upon review of the TAR no documentation of Resident #60's fall alarms was found. Observation on 8/28/2017 at 1:30 PM and again at 5:05 PM revealed Resident #60 in his bed asleep. In an interview on 8/28/2017 at 1:30 PM LPN Y said Resident #60 had not gotten out of bed since 8/17/2017 per physician's orders [REDACTED].#60 had to use a urinal and bedpan now when he needed to use the bathroom, and also had to eat all his meals in bed. Resident #66: Per the facility face sheet Resident #66 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] revealed Resident #66 had a BIMS score of 6, indicating an impairment in her cognitive functioning. The MDS revealed Resident #66 did not walk, and required extensive assistance for transfers and toileting. Record review of a care plan for falls dated 1/19/2016 revealed Resident #66 was at risk for falls related to poor safety awareness, mental retardation, debility, history of falls and a left hip fracture, and needs of staff assistance for transfers. The care plan revealed Resident #66 required a mechanical lift for transferring, give Resident #66 verbal reminders to not transfer by herself, and when up in wheelchair keep Resident #66 in common areas, and keep in eye sight due to poor safety awareness. Another care plan for Communication dated 1/19/2016 revealed Resident #66 had difficulty understanding other related to mental retardation. A care plan for Bowel, Bladder, and ADL (Activities of Daily Living) dated 1/19/2017 revealed Resident #66 required extensive assistance with toileting. During an observation on 8/30/2017 at 8:20 AM of the A/B hall shower room, during an inspection of the environment, revealed a large room with 3 shower stalls and 1 toilet stall. A curtain was pulled over the toilet stall doorway. While inspecting at the A hall end of the shower room a loud moan was heard. Upon calling out if someone was in the shower room Resident #66 yelled out, Yes my leg hurts. Resident #66 was observed sitting behind the curtain on the toilet, with the mechanical lift in front of her, and the sling portion of the lift wrapped around her back, and attached to the lift. No staff member was in the shower room. Resident #66 stated her name, but said she did not know her last name, or what her room number was. A call light cord was observed to hang over the rail of the toilet. Resident #66 was asked if she knew how to use the call light and she said no, and began to yell loudly crying out in pain. Upon stepping out into the hallway CNA P was asked to come into the Shower room. From 8:20 AM to 8:40 AM no staff entered the shower room, until CNA P was asked to step in, by this surveyor. CNA P began to attend to Resident #66, and put on the call light for more assistance. CNA Q entered the shower room responding to the call light CNA P turned on, within 1 minute. In an interview on 8/30/2017, at 8:40 AM, CNA P stated that she would not leave Resident #66 in the shower room on the toilet alone, or the mechanical lift sling around Resident #66 and connected. CNA P said Resident #66 had a history of [REDACTED]. In an interview on 8/30/2017 at the time she entered the shower room, CNA Q stated she was caring for Resident #66 that day, but said CNA Z had assisted Resident #66 to the toilet in the shower room. CNA Q said Resident #66 was oriented and could use the call light when she had finished using the bathroom. CNA Q also stated Resident #66 could be left alone in the shower with the mechanical lift attached to her while she sat on the toilet. CNA Q said the mechanical lift sling was left on Resident #66 while she sat on the toilet for safety reasons, because Resident #66 would tip to the side while sitting. In an interview on 8/30/2017 at 10:30 AM, DON B said Resident #66 was oriented, but stated that a staff member was expected to be in the shower room with her while she was on the toilet, with or without the mechanical lift sling attached to her or not. In an interview on 8/30/2017 at 9:05 AM, LPN C said if a resident was a fall risk it was not acceptable to leave the resident alone while on the toilet in the shower room. LPN C said Resident #66, due to a BIMS score of 6, and a fall risk was not to be left alone while on the toilet in the shower room, and the mechanical lift sling was to be removed. In an interview on 8/30/2017 at 9:30 AM, CNA Z stated she had assisted Resident #66 to the toilet in the shower room at approximately 8:12 AM. CNA Z said Resident #66 would throw herself to the floor due to her behaviors, and said Resident #66 was able to be left alone in the shower room while on the toilet, and would use the call light when she was done. CNA Z said she was not sure if the mechanical lift sling should be left strapped onto Resident #66 or not. Record review of the manufactures' instructions for the mechanical lift used on Resident #66 revealed on page #3, under Intended Use revealed the mechanical lift, shall always be handled by a trained caregiver, and continuously attending to the resident .

Based on observation, interview, and record review, the facility failed to ensure safety and supervision for 2 out of 3 residents (Resident #60 & 66), out of a total sample of 13, resulting in a fall that resulted in a hip fracture, and the potential for a fall due to lack of supervision. Findings included: Resident #60: Per the facility face sheet Resident #60 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed Resident #60 had a Brief Assessment of Mental Status (BIMS) score of 3, which indicated impaired cognitive status. The MDS revealed Resident #60 did not ambulate but used a walker to get around the facility. Record review of an incident report dated 6/22/2017 revealed Resident #60 was found sitting on the floor in front of his wheelchair while in the dining room at 9:45 AM. The report revealed Resident #60's fall alarm sounded, which alerted staff to the dining room where they observed him to be on the floor. The report also revealed under, Immediate action to be taken to prevent further incidents, was assessed for injury, return to wheelchair, and toilet/cleansed. Under Section B, The P(NAME) (plan of care) updated with immediate interventions was not checked to have been completed. Review of another incident report dated 7/27/2017 revealed Resident #60 got up out of his bed and attempted to transfer to his wheelchair, but the wheelchair was not locked and it rolled away causing Resident #60 to land on the floor. Under, Immediate action to be taken to prevent further incidents, was a notation to stress to Resident #60 the importance of locking wheelchair and waiting for assistance, and under, Under Section B, The P(NAME) (plan of care) updated with immediate interventions was not checked to have been completed. An incident report dated 8/15/2017, and timed at 7:10 AM, revealed Resident #60 was observed by another resident walking out of the dining room door and falling sideways to the floor. The report revealed Resident #60 was sitting at a table in the dining room, and upon assessment sustained 3 skin tears to his right hand, wrist, and forearm, and 1 to his head. The report revealed Resident #60's fall alarm did not sound when he got up out of his wheelchair. The immediate action taken was treatment to his skin tears, and change of his fall alarm to a tab alarm (connects to his person) from a pressure alarm (sits on a pad that alarms when pressure is removed). The report revealed no changes were made to Resident #60's plan of care. Record review of nurses' notes dated 8/17/2017 at 8:33 PM revealed, Resident #60 complained of pain to his right hip during repositioning and care. The note revealed Resident #60 was observed to have discoloration and swelling to his right hip, and an x-ray was ordered. The nurses' notes revealed a notation on 8/15/2017 that at 7:10 AM Resident #60 was seen by another resident walking out of the dining room, and was found lying on his right side in the doorway of the dining room with an abrasion to his forehead and skin tears to his right hand and wrist. No other nursing progress note was documented again until 8/17/2017 at 1:49 PM, which indicated Resident #60 had a fever. Record review of a care plan titled, Falls dated 6/7/2017 revealed Resident #60 was at risk for falls related to Alzheimer's disease, dementia, poor safety awareness, weakness, history of recurrent falls, needed staff assistance to ambulate, and unsteady gait (walking). The care plan revealed Resident #60 had an intervention, dated 6/7/2017, for a bed and chair alarm for poor safety awareness. No interventions were added to Resident #60's fall care plan until 8/18/2017, which revealed added interventions for non-weight bearing status, bed rest, assist with bed mobility, and low bed; due to a right hip fracture. Record review of a hospital physician's note dated 8/18/2017 revealed, Resident #60 had a fracture of his right hip and surgery would not be performed due to Resident #60's age and the risks involved. Review of physician orders [REDACTED]. In an interview on 8/29/2017 at 2:07 PM, Certified Nurse Aid (CNA) O said she was Resident #60's CNA on 8/15/2017 when he fell . CNA O said Resident #60 had been up and down the night before, and was in the dining room at 6:30 AM on 8/15/2017. CNA O said Resident #60 had a pressure alarm on, and stated the CNA's were supposed to document placement and functioning of a fall alarm every shift. CNA O said there used to be a binder at the nurses' station where the CNA's were to document placement and functioning of fall alarms, but stated the binder went away when the facility discontinued the use of fall alarms. CNA O said Resident #60 would stand up and attempt to self-transfer. CNA O also stated she did not confirm Resident #60's fall alarm was in place and functioning on 8/15/2017 before he fell . In an interview on 8/29/2017 at 2:37 PM, Registered Nurse (RN) H said he was Resident #60's nurses on 8/15/2017 at the time of his fall. RN H said he was counting narcotics with another nurse at 6:30 AM, when he heard a resident yell out in regards to Resident #60 falling. RN H said he could not see Resident #60 until he walked over to the dining room door. RN H stated Resident #60 was sitting at a table in the dining room, and no other staff members were in the area. RN H also stated Resident 60's fall alarm had not sounded, and he had walked approximately 75 feet from the table before he fell . RN H said Resident #60 had 3 skin tears to his right extremity and one to his head, but stated he was all over the facility in his wheelchair after his fall. RN H said no staff member had seen Resident #60 get up from his wheelchair and walk to the dining room door. RN H said the nurses did not update care plans, but the Unit Managers were to do the updates on the care plans. Observation, with RN H of the dining room table, where Resident #60 was sitting on 8/15/2017 at 6:30 AM, revealed an approximate measurement of 65 feet from the table Resident #60 was sitting at to the door where he fell . RN H stated Resident #60 was not stable to walk, and was not sure how he got so far before he fell . In an interview on 8/29/2017 at 3:30 PM, Licensed Practical Nurse (LPN) D said the floor nurses did not update resident care plans, but stated the MDS nurse did that. At 4:16 PM, on 8/29/2017, LPN D provided all of Resident #60's care plans, including interventions that had been resolved. LPN D said no changes were made, or interventions added after each of Resident #60's falls, and stated it did not get done. In an interview on 8/29/2017 at 3:00 PM LPN E said the CNAs were to check placement and functioning of fall alarms, and then report to the nurse, who then documents to alarm check on the resident's Treatment Administration Record (TAR). On 8/29/2017 at 4:16 PM, Resident #60's TAR for the month of August 2017 was received from Director of Nursing (DON) B, and upon review of the TAR no documentation of Resident #60's fall alarms was found. Observation on 8/28/2017 at 1:30 PM and again at 5:05 PM revealed Resident #60 in his bed asleep. In an interview on 8/28/2017 at 1:30 PM LPN Y said Resident #60 had not gotten out of bed since 8/17/2017 per physician's orders [REDACTED].#60 had to use a urinal and bedpan now when he needed to use the bathroom, and also had to eat all his meals in bed. Resident #66: Per the facility face sheet Resident #66 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] revealed Resident #66 had a BIMS score of 6, indicating an impairment in her cognitive functioning. The MDS revealed Resident #66 did not walk, and required extensive assistance for transfers and toileting. Record review of a care plan for falls dated 1/19/2016 revealed Resident #66 was at risk for falls related to poor safety awareness, mental retardation, debility, history of falls and a left hip fracture, and needs of staff assistance for transfers. The care plan revealed Resident #66 required a mechanical lift for transferring, give Resident #66 verbal reminders to not transfer by herself, and when up in wheelchair keep Resident #66 in common areas, and keep in eye sight due to poor safety awareness. Another care plan for Communication dated 1/19/2016 revealed Resident #66 had difficulty understanding other related to mental retardation. A care plan for Bowel, Bladder, and ADL (Activities of Daily Living) dated 1/19/2017 revealed Resident #66 required extensive assistance with toileting. During an observation on 8/30/2017 at 8:20 AM of the A/B hall shower room, during an inspection of the environment, revealed a large room with 3 shower stalls and 1 toilet stall. A curtain was pulled over the toilet stall doorway. While inspecting at the A hall end of the shower room a loud moan was heard. Upon calling out if someone was in the shower room Resident #66 yelled out, Yes my leg hurts. Resident #66 was observed sitting behind the curtain on the toilet, with the mechanical lift in front of her, and the sling portion of the lift wrapped around her back, and attached to the lift. No staff member was in the shower room. Resident #66 stated her name, but said she did not know her last name, or what her room number was. A call light cord was observed to hang over the rail of the toilet. Resident #66 was asked if she knew how to use the call light and she said no, and began to yell loudly crying out in pain. Upon stepping out into the hallway CNA P was asked to come into the Shower room. From 8:20 AM to 8:40 AM no staff entered the shower room, until CNA P was asked to step in, by this surveyor. CNA P began to attend to Resident #66, and put on the call light for more assistance. CNA Q entered the shower room responding to the call light CNA P turned on, within 1 minute. In an interview on 8/30/2017, at 8:40 AM, CNA P stated that she would not leave Resident #66 in the shower room on the toilet alone, or the mechanical lift sling around Resident #66 and connected. CNA P said Resident #66 had a history of [REDACTED]. In an interview on 8/30/2017 at the time she entered the shower room, CNA Q stated she was caring for Resident #66 that day, but said CNA Z had assisted Resident #66 to the toilet in the shower room. CNA Q said Resident #66 was oriented and could use the call light when she had finished using the bathroom. CNA Q also stated Resident #66 could be left alone in the shower with the mechanical lift attached to her while she sat on the toilet. CNA Q said the mechanical lift sling was left on Resident #66 while she sat on the toilet for safety reasons, because Resident #66 would tip to the side while sitting. In an interview on 8/30/2017 at 10:30 AM, DON B said Resident #66 was oriented, but stated that a staff member was expected to be in the shower room with her while she was on the toilet, with or without the mechanical lift sling attached to her or not. In an interview on 8/30/2017 at 9:05 AM, LPN C said if a resident was a fall risk it was not acceptable to leave the resident alone while on the toilet in the shower room. LPN C said Resident #66, due to a BIMS score of 6, and a fall risk was not to be left alone while on the toilet in the shower room, and the mechanical lift sling was to be removed. In an interview on 8/30/2017 at 9:30 AM, CNA Z stated she had assisted Resident #66 to the toilet in the shower room at approximately 8:12 AM. CNA Z said Resident #66 would throw herself to the floor due to her behaviors, and said Resident #66 was able to be left alone in the shower room while on the toilet, and would use the call light when she was done. CNA Z said she was not sure if the mechanical lift sling should be left strapped onto Resident #66 or not. Record review of the manufactures' instructions for the mechanical lift used on Resident #66 revealed on page #3, under Intended Use revealed the mechanical lift, shall always be handled by a trained caregiver, and continuously attending to the resident .

The following citation relates to intake MI 848. Based on interview and record review the facility failed to provide care according to acceptable standards of trauma treatment immediately after falls, determine root cause, develop interventions, update care plans, monitor injuries after a fall, complete accurate occurrence reports for falls and develop a policy that meets acceptable standards for fall management for 3 sampled residents (#50, 55 & 56) out of 3 assessed for falls from a total sample of 6 resulting in multiple falls with bruising on the forehead and around the eyes, an elbow fracture, and potential neck/head injuries related to being moved for #50 and #55; and multiple falls with dislocation of the surgical hip and failure to monitor the resulting large hematoma for #56. Findings include: Resident #50 According to, Diseases: Causes and [DIAGNOSES REDACTED]. The real danger lies in possible spinal cord damage .The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage. Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture. According to a facility policy/procedure titled, Fall Management, under procedure: 3) If a fall occurs, the staff will assess for injury and investigate the fall to identify causative factors. The care plan will be revised with post fall intervention(s) when indicated (sic). If the resident has a fall, long-term interventions must be evaluated and revised to prevent further falls and injury, , as well as an immediate plan to protect the resident from falls. According to, Diseases: Causes and [DIAGNOSES REDACTED]. The real danger lies in possible spinal cord damage .The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage. Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture. According to the facility's electronic medical record, Resident #50 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 12/9/16, Resident #50 had unclear speech, was usually understood and usually understood others, had some short-term memory issues, decreased hearing and vision, made her own decisions, required the assist of 2 staff persons for bed mobility, transfers with a total mechanical lift, dressing and toileting; had a urinary catheter; was always incontinent of bowels; and required the assist of 1 staff person for pushing her wheelchair, hygiene and bathing. Resident #50 was documented to refuse cares, medications and lab draws. Resident #50 was deemed incompetent on 6/4/16, and her daughter had the final say for medical/financial decisions According to the facility's Accident/Incident Report, on 11/8/16 at 10:00 a.m., Resident #50 was seated in her wheelchair while 3 staff prepared to transfer her to her bed with the lift. Resident #50 said that her bottom hurt, leaned forward, fell from the wheelchair and bumped her forehead on the bookcase that was directly in front of her. Resident #50 had 2 cushions in her wheelchair to pad the open surgical wound on her bottom. The immediate intervention was for 1 staff person to stand directly in front of Resident #50 to prevent her falling forwards, until the lift was properly positioned. Therapy lowered the seat of Resident #50's wheelchair, and a gel cushion was placed on the seat. No pillows were to be used in the wheelchair. Due to continued pain of the right elbow, additional X-rays were taken 11/23/16, and a fractured elbow was diagnosed . The fall with fracture was not reported to the state agency. The fall care plan for Resident #50, dated 4/26/16 and updated 12/20/16, mentioned a risk for falling, but failed to mention the fractured elbow that occurred after the 11/8/16 fall. Previous interventions, dated 4/26/16, were: 2 staff assist with lift for transfers; wheelchair for locomotion - staff to propel; give resident verbal reminders not to ambulate/transfer without assistance; proper footwear for transfers; provide an environment free of clutter with adequate lighting; keep call light in reach at all times and keep personal items and frequently used items within reach. There was no mention in Resident #50's plan of care for activities of daily living that she had her right arm in a sling due to a fracture of the elbow. The care plan for skin impairment still an intervention, dated 12/29/16, stated that Resident #50's T-gel cushion with the black cover goes on top of the blue gel cushion. According to the facility's Accident/Incident Report, on 11/8/16 at 10:00 a.m., Resident #50 had an unwitnessed fall to the floor. Resident #50 had requested to get out of bed and into her wheelchair and put on her call light. Certified Nurse Assistant (CNA) C answered the light and informed Resident #50 that she would get another CNA to assist with the transfer. While CNA C was out of the room another resident reported a fall to her, and the code was called overhead for a fall in Resident #50's room. CNA C returned to the room and observed Resident #50 on there left side on the floor by her bed, and noted that the radio was playing loudly. CNA C had to turn the radio down so she could hear Resident #50. Licensed Practical Nurse (LPN) F walked into the room, assessed Resident #50, and determined that she required the emergency room . LPN F told CNA C that she preferred Resident #50 not be moved off the floor. CNA E entered the room and noticed that the overbed table was pushed away from the bed, Like it had been moved in the fall and there was water on the floor. Resident #50 was screaming, I want to get up, I want to get up this floor hurts and I want to get up. CNA E noted that Resident #50 was naked and covered her. CNA E went to get CNA D to assist with the lift, and the CNAs returned Resident #50 to bed. CNA D reported that the resident wanted off the floor, and that the reason she fell was because she was trying to get up and get out of bed. Resident #50 also complained of the inability to move her legs. According to a statement written by CNA D, when she entered the room with the lift, she observed Resident #50 on the floor with a pillow under her head. CNA C was with her, and ((CNA C) specifically) moved the wheelchair out of the way to get the lift in. Resident #50 was saying, Get me off the floor, and said that she was trying to get up because she wanted out of bed. When LPN F came in and said, What are you guys doing I said not to move her off the floor. According to a statement written by CNA C, when she answered the call light, Resident #50 was lying in bed and wanted to get up. CNA C went to get the lift and some help. After another resident mentioned a fall, CNA C returned to the room and observed Resident #50 lying on her left side without her gown, as follows,With her head pressed up against the stationary chair (sic) back was against W/C (wheelchair) laying on L (left) side. I moved stationary chair so head wasn't resting against it .When I left to get a pillow for under her head, (CNAs D and D) had used the lift to assist Resident #50 to her bed. Resident #50 was transferred to the emergency room and diagnosed with [REDACTED]. She passed in the hospital after surgical intervention. The fall was not reported to the state agency until after a consultation with the survey manager. used the lift to put her back in bed. Resident #50 did say 'ouch' a few times while the sling was positioned, but there was no yelling. A review of the facility's resident progress notes, when questioned by staff, Resident #50 refused to say what she had done to get on the floor, but did say that, she didn't put herself on the floor. At this point, Resident #50 was documented as becoming defensive about the questions, and talked about her sore bottom, and refused to move her legs. A small hematoma (collection of blood above the skin) was documented on her left shin area. On 3/29/17 at 2:30 p.m., CNA E was interviewed about Resident #50's fall on 11/8/16, as follows: When asked what happened, CNA E said that she responded to the overhead page for a fall, entered the room and observed Resident #50 on her left side, facing her bed. She was lying, naked, in a puddle of water. and the night stand was pushed off to the side. CNA C was in the room and said that we had to move the wheelchair out of the way, so CNA E did so. I covered Resident #50 with a sheet, left and asked CNA D to help us put her back in bed. Resident #50 had been having a bad day. When asked to elaborate, CNA E said throwing things, screams, and now she was screaming in pain. CNA E said that the nurse had assessed her, so CNAs C , D and I used the lift to place her in her bed. When asked, CNA E said that no one told her the nurse wanted her left on the floor. On 3/29/17 at 3:10 p.m., LPN F was interviewed about Resident #50's fall on 11/8/16, as follows: Resident #50 had seemed more anxious, required more verbal cues, was unable to sit still in recent weeks and had always refused to get off her bottom to promote healing of the wounds on her bottom. When I first entered the room, Resident #50 was sitting on her bottom on the floor, her legs were flexed to one side with one hand propped behind to hold her up. When LPN F asked if she had pain, Resident #50 yelled, Yes, and she refused to move her legs when asked. She kept saying, My legs, my legs, over and over. LPN F said that she made eye contact with CNA C and told CNA C that Resident #50 was to be kept comfortable, but not moved, and suggested CNA C place a pillow under Resident #50's head, stay and talk with her and that she's probably going out (to the hospital). LPN F left the room to arrange transport and when she returned to the room, Resident #50 was on the lift above the bed, ready to be lowered to the mattress. LPN F said that she looked at CNA C and said, I didn't want her to get up. CNA C replied that Resident #50 wanted up so we got her up. When asked if she had assessed Resident #50's neck, LPN F said that she had not. LPN F did notice the water puddle, and Resident #50 had a sheet over her. LPN F said that CNA C asked to move her out of the water, but was told not to move her. On 3/29/17 at 4:10 p.m., CNA D was interviewed about Resident #50's fall on 11/8/16, as follows: When CNA D entered the room, Resident #50 was lying on the floor with her head towards the air conditioner and the sink, between the chair and the bed. Resident #50 had a gown on. CNA E had asked her to help get Resident #50 off the ground. The lift was used to put her back in bed. LP Fé returned to her room just as we were lowering her onto her bed. No one told CNA D that Resident #50 was not to be moved. I assumed the nurse was done with her, and it was OK, said CNA D, Now I will check with the nurse myself. CNA D said that Resident #50 said, Ouch, when we moved her, but she was not yelling. CNA Fé added that (Resident #50 name), would try to do for herself if she waited too long. She could be impatient, CNA D said. On 3/30/17 at 12:15 p.m., CNA AC was interviewed about Resident #50's fall on 11/8/16, as follows: CNA AC returned to Resident #50's room after another resident said someone fell , and observed Resident #50 lying on the floor with her head against a regular chair. CNA C did not notice water/fluid on the floor. Resident #50 said that she fell out of bed, when asked, and did not answer when asked if she had pain. CNA C moved the regular chair because it was crowding Resident #50's head; her head was at an angle against the chair. CNA C did not ask a nurse about moving the chair, I did that on my own, CNA C said. CNA C left Resident #50 alone while she went to get a nurse. CNA C said that she wasn't in the room when the nurse checked range of motion on Resident #50's extremities, but agreed that LPN F, Made eye contact and told me {Resident #50) was not to get up. LPN F suggested a pillow for Resident #50's head to make her comfortable, so CNA C left the room to get one. Upon return, CNA C Resident #50 was in the lift and about to be lowered to her bed. CNA C does not recall advising CNAs D and E that Resident #50 was not to be moved, off the floor. Resident #55 According to the facility's electronic medical records, Resident #55 was an [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. of weight loss, decreased appetite, poor nutrition, and inactivity), dysphagia (difficulty swallowing) and dissociative disorder (loss of memory due to trauma). According to the Minimum Data Set (resident assessment), dated 2/1/17, Resident #55 had severe memory problems, was usually understood, sometimes understood others, exhibited disorganized thinking, had hallucinations, required the assist of 1 staff person for bed mobility, transfers, walking with a 4-wheeled walker, dressing, hygiene, bathing and toileting, was occasionally incontinent of bowel and always incontinent of bladder, could feed herself after set-up and propel her own wheelchair. According to the accident/incident report, on 12/17/16 at 12:30 a.m., Resident #55 was observed lying on her right side on the floor mat by her bed, and said that she was trying to get to the bathroom. The call light had been within reach on the bed but not activated, and the pressure sensor alarm on her bed was not sounding. A bruise was observed on the right side of Resident #55's head, and the nurse assessed Resident #55 for other injury. Resident #55 had received encouragement to use her walker and wheelchair as she was observed up without either assistive device several times during the evening. Slipper socks were placed, as she was barefoot, and she was wheeled to the nurse's station for observation until the ambulance came to transport her to the emergency room . According to the facility's witness statement, CNA G was walking down the hall and heard a light cry. Resident #55 was observed, On the floor leaning over into her bedside table. CNA G had seen Resident #55 ten minutes before, during bed checks, but did not state where Resident #55 was. On 3/10/17 at 1:15 p.m., CNA G was interviewed about Resident #55's fall on 12/17/16 as follows: CNA G said that there was no alarm, and Resident #55's bed was by the wall. CNA G said that she observed that Resident #55's head was resting on the bar on the bottom of the overbed table, and she moved Resident #55 because it looked uncomfortable. Resident #56 According to the facility's electronic medical record, Resident #56 was an [AGE] year old admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 10/8/16, Resident #56 had minimal memory problems, usually understood others, showed minor symptoms of depression, required almost no assist with bed mobility, stand by assist with ambulation in her room, fed herself after set up; required the assist of 1 staff person for ambulation outside her room and off the unit, dressing, hygiene, bathing and toileting; was continent of bowel and frequently incontinent of bladder, had no pain and no pressure ulcers. According to the fall care plan, Resident #56 had the following interventions in place as of 12/1/2015, give resident verbal reminders not to ambulate/transfer without assistance, low bed, floor mat, encourage resident to stand slowly, provide proper footwear, keep environment free of clutter, adequate lighting, call light in reach at all times, keep personal items and frequently used items in reach. As of 9/22/16, add (sticky fabric) to wheelchair to prevent slipping. A review of facility Accident/Incident Reports, the following falls occurred for Resident #56: -11/2/16 at 11:45 a.m., Resident #56 was pulling up her pants after using the toilet, fell backwards and hit her head on the wall. A CNA was in the room, heard a noise, but was unable to get to Resident #56 in time. The intervention on the report stated that Resident #56 was educated to sit when putting on clothes until she needs to pull pats up and wait for staff to help. This intervention did not appear on her plan of care. -11/9/16 at 3:00 a.m., a CNA answered her call light and observed Resident #56 sitting on her bottom on the floor mat between the wheelchair and bed. The call light was on. Resident #56 said, I lost balance and the chair moved. She was last observed at 1:30 a.m., but not where/doing what. However, the witness statement by CNA I read that she had last seen Resident #56 at 3:30 a.m., and she was up in her wheelchair. The immediate interventions were to encourage use of the call light with all transfers (which was not a new intervention), keep bed in lowest position and educated on locking wheelchair brakes before transferring. The second and third interventions did not appear on her plan of care. -11/17/16 at 6:20 a.m., after crying/yelling for help Resident #56 was observed lying on her back on the floor in the middle of her room. She stated, I lost my balance while I was trying to look at my calendar. Resident #56 was last provided care at 4:30 a.m., did not use her call light and was brought to the nurse's station for monitoring. A therapy evaluation was requested, and the daughter wanted the walker back. The therapy request was never made, and no new interventions were planned. -1/17/17 at 8:20 a.m., Resident #56 was last toileted at 7:45 a.m., was observed on the floor between the bed and night stand. Did not use call light. Although there was no statements attached to the accident/incident report, the report reflected that the resident was walking from the toilet, back to her bed without calling for assistance. No injury, was checked, but under range of motion, the words, very painful to touch was hand-written under leg (hip & knee without specifying left, right or both. Resident #56 was transported to the emergency room with nothing found. Although monitoring Resident #56 while she was using the toilet was mentioned, but was not added to the plan of care. Dated 1/17/17. a new intervention was a bed alarm. Old interventions added again, but dated 1/17/17, were to remind to use call light and call for help with moving low bed and floor matt On 1/20/17, Resident #56 had developed a large hematoma on the right hip. On 2/1/17, Resident #56 was transferred to a hospital in Indiana and the right hip was found to be dislocated. -3/25/17 at 8:15 p.m., CNA H was doing her rounds and observed Resident #56 on her left side on the mat by her bed, and had last seen her 10 minutes prior seated at the edge of her bed. CNA H left the resident alone to get assistance. Resident #56 stated that she rolled out of bed, then, turned her fall alarm off. She complained of pain in both legs with movement. The report reflected that she was last toileted at 6:30 p.m. No interventons were planned as yet. A review of resident progress notes reflected the following monitoring documentation for Resident #56's hematoma: -1/20/17 at 3:24, Resident was sent to (hospital) ER (emergency room ) for txt (treatment) for large hematoma on right hip. Resident was attempting to get up o ut of bed for lunch and was unable to put any pressure on that leg, very painful .sent to ER at 1215, There was no description of the exact location, measurements were not made, nor the edges outlined to monitor progress or a potential increase in size. -1/22/17 at 2:03 a.m., no mention of hematoma. -1/22/17 at 6:57 a.m., right hip bruising noted. -1/23/17 1:51 a.m., right hip continues to be bruised continues to guard right hip area. -1/24/17 at 2:48 p.m., .very large dark purple (sic) bruise at right lateral side of thigh .the area of right thigh is warm to touch and is swollen at this time. -1/25/17 at 3:56 p.m., Dark bruising continues on right hip. Right hip is warm to the touch. -1/28/17 at 7:53 p.m., .hematoma to Right hip area .no edema noted except for right hip area .Will con't (continue?) to monitor. -1.29.17 at 11:30 a.m., Resident cont' (continue) with large purple bruise to right hip . There was no documentation to reflect that the bruise was monitored/assessed each shift. On 3/29/17, during the morning, the Director of Nurse's (DON) B was asked to check if there were any more to the facility's fall program/policy/procedure. Nothing was provided by end of survey on 3/30/17. On 3/30/17 at approximately 5:00 p.m., Director of Nurse's B reviewed falls for Residents #50, 55 and 56 with the surveyor. No further interventions/documents were available.

This citation pertains to intake #MI 762 Based on observation, interview and record review, the facility failed to consistently assess and implement interventions to prevent pressure sores for one (#301) of two residents reviewed for pressure sores out of a total of three sampled residents, resulting in the development of a new pressure sore. Findings include: On 10/15/13 at 11:55 a.m., resident #301 was observed in bed. The resident's eyes were closed and the resident did not respond to questions. Nurse "C" was present in the resident's room and explained the resident was non verbal and unable to make her needs known. Nurse "C" then proceeded to perform a head to toe skin observation. Resident #301 only responded with moaning and groaning when turned and repositioned. Nurse "C" was observed as he opened the resident's brief. The resident was observed with a [MEDICAL CONDITION] and a Peg (percutaneous gastrostomy tube). The resident's brief was soiled with a large amount of bloody drainage that appeared to be coming from a wound on resident #301's coccyx, which was not covered, but open to air. Nurse "C" explained the resident had not been in the facility that long, but he could not recall if the resident's bottom was improved or worsened. Nurse "C" explained the resident was to receive Zinc ointment for treatment to her bottom and he expected the wound Doctor to be in today. When asked if the resident was incontinent of urine, Nurse "C" confirmed the resident was. When asked if the resident's wounds should have been covered and protected from urine, Nurse "C" offered no explanation. On 10/15/13 at 12:45 p.m., a review of the clinical record revealed the following: According to the admission face-sheet, resident #301 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission minimum data set ((MDS) dated [DATE] and the 30 day MDS dated [DATE], documented resident #301 was severely cognitively impaired for decision making skills and required total assistance for bed mobility, transfers and all activities of daily living. The MDS assessments documented that the resident did not have pressure sores but was at risk for pressure sores. A review of resident #301's admission nursing skin assessment dated [DATE] documented resident #301 had an old scar on the abdomen, a peg tube, an ostomy, vaginal redness, a bandage to the left upper arm, with the right upper extremity swollen and no skin ulcers noted. A Review of physicians' orders revealed an order written [REDACTED].#301's coccyx each shift. A review of resident #301's skin care plan dated 9/7/13 documented: Resident (#301) is at risk for impaired skin integrity related to debility, Braden scale score of "7", incontinent of bladder, at risk for skin tears. Goal: Resident will have reduced risk for development of pressure ulcers. Will remain free from open areas. Resident's skin will be healthy, clean and well hydrated... Will demonstrate healing without signs/symptoms infection. Approaches included: Weekly skin assessment and monitor skin daily and report any changes. Observe for any evidence of infection, drainage, swelling, localized heat, increased pain or impaired skin integrity and notify physician. Monitor wounds weekly and as needed as ordered. Update physician with concerns. There were no revisions or updates to resident #301's skin care plan after 9/7/13 for dietary interventions nor interventions for optimal turning and repositioning the resident to prevent shearing documented on the care plan. A review of resident #301's weekly skin check record forms documented: 10/4/13, "no new concerns." There were no further weekly skin check records after 10/4/13. A review of resident #301's weekly skin assessments per treatment administration record (TAR) for October 2013 documented that on 10/4/13, a skin assessment was performed, but there was no corresponding description of the resident's skin condition or other results of the assessment. There were no further skin assessments documented in the clinical record after 10/4/13. There was a box on the TAR dated for 10/11/13 that was left blank. There were no additional notes documented in the clinical record that indicated why the resident #301's weekly skin assessment were not performed on or after 10/11/13 as indicated. A review of resident #301's bi-weekly shower sheets documented: 10/4/13 red area treatment in progress. 10/7/13 treatment in place. 10/10/13 treatment in place. On 10/15/13 at 3:20 p.m., during an interview with the Director of Nursing (DON) regarding the aforementioned observation of resident #301's coccyx wound stated, "I wasn't aware of the resident's wound. I have a treatment nurse. You can talk to her." On 10/15/13 at 4:00 p.m., during an interview and record review with Treatment Nurse "E" when asked who was responsible for completing weekly skin assessments for the resident's in the facility stated, "I do wound measurements for the residents. Whatever staff is assigned to the resident does weekly skin assessments." Treatment Nurse "E" stated, "I don't know why it (weekly wound assessment) was not done on 10/11/13 as indicated." Treatment Nurse "E" then explained on 9/30/13 "shearing" was identified as causing the residents "abrasion" (wound). The wound measured 1.8 centimeters (cm) x 2.9 cm. On 10/8/13 the wound measured 1.5 cm x 2.0 cm. When asked if she was aware of the large amount of bloody drainage that was observed during the skin observation early this a.m., and the wound being uncovered and subjected to urine contamination she offered no explanation. On 10/16/13 at 8:55 a.m., during an interview and observation of resident #301's coccyx wound with the following facility staff members: Treatment Nurse "E", Certified Nurse Assistant "J", and Physician Assistant (PA) "K". PA "K" opened the resident's brief. The wound on resident #301's coccyx was bloody and open to air. None of the facility staff could explain why the wound was uncovered. The wound was observed with full thickness skin loss with approximately 80 percent yellowish fatty tissue (stage III). PA "K" commented, "It looks worse than last week." PA "K" then measured the resident wounds as 5.0 cm x 5.0 cm coccyx that extended to the resident's left sacrum. Additionally, there was a non-blanchable center core wound (unstageable) that was dark purple/black in color that measured 1.2 cm x 2.3 cm. PA "K" then stated, "We have to make a change to the treatment orders." PA "K", further stated, "We think it may have been caused by shearing. We've started her on additional supplements in addition to the tube feeding. When asked if shearing would be considered as pressure applied to the skin. PA "K" explained, "we (facility staff) should always make sure" that at least two people assist with turning, repositioning the resident to avoid undue pressure to the skin. On 10/16/13 at 1:30 p.m., review of resident #301's medication orders revealed there were no supplement orders documented in the clinical record to aid and assist in promoting wound healing. On 10/16/13 at 1:40 p.m., a review of the facility's "Pressure/Non-Pressure Ulcer" policy dated 8/2013, documented: Purpose: Upon identification of a pressure/non-pressure ulcer, a baseline assessment will be completed and documented on the weekly pressure or non-pressure ulcer record. Outcome of wound care interventions will be assessed weekly. Staff education and recommendations will be made by the wound team during the wound rounds and documented weekly on the weekly wound round record. Procedure: Weekly pressure ulcer record: Complete one record for each ulcer. The Director of Nursing will be responsible to ensure ulcer record is completed weekly. Pressure/Non pressure log: The Director of Nursing will be responsible to ensure logs are completed weekly. Weekly wound round record: Weekly wound round team consist of nurse completing pressure ulcer record, nurse and aide responsible for care of resident, nursing administration, dietary and therapist, if indicated. Weekly wound rounds should occur within 24 hours of weekly assessment.( )

This Citation pertains to MI 039 Based on observation, interview and record review, the facility failed to ensure the highest practical physical well-being by not providing emergency Cardiopulmonary Resuscitation (CPR) per facility policy and the residents Advanced Directive in 1 of 4 sampled residents (Resident #103), from a total of 8 sampled residents, resulting in an Immediate Jeopardy (IJ) when, on [DATE], Resident #103 was found by Certified Nursing Assistant (CNA) #5 "sometime before 5:00 AM", unresponsive, without pulse or respirations, who then notified Licensed Practical Nurse (LPN) #3 who did not promptly initiate CPR or immediately notify Emergency Medical Services (EMS) which resulted in a delay in emergency treatment for [REDACTED]. This deficient practice placed 52 residents, identified as a full code status, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and [DIAGNOSES REDACTED]. upper respiratory infection. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had severely impaired cognitive daily decision making skills. Review of the Facility Advanced Directive Form dated [DATE] revealed Resident #103's wife signed a request which indicated that in the event the heart or breathing stops cardiopulmonary resuscitation (CPR) would be attempted, with emergency transportation to the hospital where full life support measures may be undertaken. Review of the Facility Nurses Notes dated [DATE] and timed ,[DATE], "CENA's (certified nursing assistants) called this nurse to go to room C-11, upon entering room of served pt. (patient) purple, unresponsive, no pulse or VS (vital signs) audible. Pt. was put back into bed this nurse and another nurse attempted CPR, with no results. Call made to 911, LCA (named Ambulance) arrived and took over resuscitation he was declared dead at 5:33 AM, call family to inform of death also called physician to obtain order to release body to funeral home. Waiting for funeral home to pick up body". During an interview on [DATE] at 1:40 PM, Director of Nursing (DON) #12 stated that LPN #3 called her the morning of [DATE] at 5:07 AM. DON #12 stated "yes they called and she (Licensed Practical Nurse/LPN #3) told me he was a code. I told them to hang up, do CPR, and call 911". DON #12 showed this surveyor her cell phone call history and it was observed to have had a call received date [DATE] at 5:07 AM. During a telephone interview on [DATE] at 9:40 AM, Firefighter Specialist #8 stated that according to Fire Department run logs, the 911 call was dispatched at 5:10 AM (approximately 10 minutes after Resident #103 was found unresponsive), arrived on scene at 5:17 AM (approximately 17 minutes from the time Resident #103 was found unresponsive) and the scene was cleared at 5:51 AM. During a telephone interview with Ambulance Advanced Care Paramedic # 10 on [DATE] at 9 AM he reported that upon arrival on the scene (the facility) that the Fire Department had arrived first and no CPR was being done. Paramedic #10 stated, "Staff showed us to the room and then left the room because I had to go find someone. I asked what the down time was (time of discovery without CPR) had been and staff told me it had been more than 20 minutes, that no CPR was going on or had been done. That was pretty much a no brainer for us we have specific protocols to follow the patient was mottled, cyanotic (blue) no oxygen was on the patient and no equipment was in the room, when I placed the leads for the monitor on his chest there were no signs that CPR had been done, the chest was firm, no fractured ribs and no discoloration. I called the hospital to speak with the physician and he called the time of death at 5:33 AM." Review of the Ambulance Pre-hospital Care Report Summary dated [DATE] revealed the call to the facility was dispatched at 5:12 AM, arrival on scene was 5:20 AM, contact with patient was at 5:22 AM and Resident #103 was pronounced dead at 5:33 AM. Narrative Text of report: "Presented with [MEDICAL CONDITION]. No CPR started patient was mottled. In full [MEDICAL CONDITION], upon arrival no one was doing CPR on the patient, staff states he has been down more than 20 minutes. Placed patient on monitor and was in asystole (flat lined). Cardiovascular system: skin color: cyanotic, temperature cool, capillary refill absent, pupils unreactive dilated, unresponsive". During an interview on [DATE] at 9:30 AM, CNA #5 reported Resident #103 began calling out at approximately 4 AM, "his usual time", and at approximately 4:,[DATE]:20 AM he was dressed and assisted to the chair. LPN #3 came and began an NMT (nebulized mist treatment for [REDACTED]. CNA #5 stated, "As I was walking out of the room he was gasping for breath; it was around 5 AM. I called for help and CNA #7 ran to get LPN #3. I tried to get vitals after CNA #7 and I got him to bed but I didn't get a blood pressure or pulse. LPN #3 asked me to go and direct the ambulance back to the locked unit where we were. LPN #3 dismissed both CNA #7 and myself to go back to work. I saw the nurses go into the room and shut the door. I did the vital signs they never asked me what they were. No one ever said get more help or to get oxygen. I'm not sure what they did in the room until EMS got here, it was a good 10 minutes they were in the room, both CNA #7 and I thought it strange they shut the door. When I did post- mortem care, I saw no evidence of CPR having been done. No bruises or redness, I didn't think they touched him." During a telephone interview on [DATE] at 3:10 PM, CNA #7 reported that around 4 AM on [DATE] Resident #103 awoke and said that he didn't want to get up yet and about 20 minutes later called again. CNA #7 reported she heard him talking to CNA #5. She heard CNA #5 leave the room to retrieve items and was out of the room "maybe 2 minutes" when CNA #5 returned to the room she yelled out for CNA #7 to come. CNA #7 reported she left CNA #5 with the resident and ran out to get LPN #3. CNA #7 reported while waiting for LPN #3 they attempted to take vital signs and feel for a pulse without getting anything. CNA #7 reported both LPN #2 and LPN #3 listened for a pulse and then both nurses left the room and reported she was uncertain where they went. CNA #7 reported LPN # 3 and LPN #2 went in the room and both CNA # 5 and #7 were directed away by LPN #3 and the door to Resident #103's door was shut. No emergency equipment, oxygen concentrator or Code Blue was called. CNA #7 reported she attempted to crack the door ,[DATE] times to check if LPN #2 and LPN #3 required assistance and LPN #3 came to the door each time and stated " No everything is OK we don't need anything I told them if they needed anything to let me know, I had residents getting up and getting restless. I did direct EMS to the room when they got to the unit". CNA #7 also stated that she was never instructed to obtain any emergency equipment or record any information for the nurses or page overhead for help. During an interview on [DATE] at 1:50 PM, LPN #3 reported that a CNA called for her at approximately 5 AM on [DATE] and stated "something's wrong". LPN #3 reported upon entering Resident #103's room he was sitting in a chair, "I could tell by looking at him he was gone". When questioned how this was determined, LPN #3 replied "I just knew" and stated she did not go to Resident #103 and assess for pulse or take a blood pressure at that time. LPN #3 stated that the blood pressure equipment was on Resident #103's arm, but she did not do any vital signs. LPN #3 reported, "I wasn't sure what to do next; if he was a code or no code. I had the CNA go get the other nurse (LPN #2) and I went to go get the chart. I had to leave the locked unit and go to the main nurses station to find the chart and call the DON (DON #12). At first, I assumed he was a no code and was surprised to find he was a code. I had left the room to go get LPN #2 so she could verify death. I never had anyone code on me before that was a full code. I called the DON and realized he (Resident #103) was a code when I saw it on his chart after I talked to the DON (at 5:07 AM). Then I called 911 after talking with the DON." LPN #3 stated, "I didn't know we had to do CPR on someone who expired. I didn't intentionally kill him, there was no way to save him." LPN #3 stated that she nor LPN #2 at any time, instructed any other staff member to get the emergency equipment. LPN #3 stated, "I probably should have grabbed the crash cart but didn't." LPN #3 reported she did not document any information related to the event or use the overhead page to call for assistance after finding Resident #103 unresponsive. During an interview on [DATE] at 1 PM, LPN #2 reported that at approximately 5 AM on [DATE], LPN #3 motioned for her to come to the C-hall and gave her a stethoscope. LPN #2 said she attempted to listen for a heart rate, which was not present. LPN #2 stated, "I thought that I was there to pronounce a death". LPN #2 reported she thought LPN #3 left to find the chart, call the DON and EMS, and that when LPN #3 returned she told her that Resident #103 was a full code. LPN #2 reported that she and LPN #3 were alone in the room with Resident #103 "attempting CPR" but did not remember if any special resuscitation equipment was used and did not call "Code Blue" per facility policy. LPN #2 reported she recognized that CPR had to be done after the chart arrived. LPN #2 stated, "I did compressions (unable to recall how many) and LPN #3 did compressions a little of the time". LPN #2 when asked how many compressions was given, LPN #2 said "probably 30". LPN #2 was unable to describe hand placement, who counted during compressions, who delivered breaths, or how breaths were given (using what piece of equipment). LPN #2 also reported she did not instruct or use any emergency equipment (such as oxygen, ambu bag, oxygen mask, backboard),nor document any of the events that occurred on [DATE] related to Resident #103. LPN #2 stated, "I probably should have but no I didn't." When asked if she paged overhead for assistance per Facility policy a "Code Blue", LPN #2 stated "no we can't use the overhead at night, we would get into trouble". Review of the facility Policy and Procedure Section: Nursing Standards of Practice Subject: Emergency - Code Blue medical undated revealed: 1) follow practice guidelines for CPR, 2) PAGE Code blue (room or location), 4) Call 911 for emergency transfer to acute care center, 7) continue CPR until advanced medical personnel arrive or until spontaneous respirations, pulse and blood pressure return. The Facility "Crash Cart" was observed on [DATE] at 1 PM with the contents checked by DON #12. Contents included: back board, Ambu bag, CPR mask, suction equipment, oxygen and oxygen supplies (regulator, wrench, non-rebreather mask, cannulas, tubing and airways), Gloves, PPE (personal protective equipment gowns and masks), blood pressure cuff and stethoscope, clip board with paper and pen to document events and times, and blood spill kit. Review of the Facility "Emergency Crash Cart Checklist" dated [DATE] for the 10:30 PM to 7 AM shift LPN #3 signed that the contents of the crash cart which included the inventory above was present. On [DATE] at 3:30 PM, Administrator #11 was notified of the Immediate Jeopardy that was identified on [DATE] and began on [DATE] due to the facility's failure to ensure the highest practical physical well-being by not providing emergency Cardiopulmonary Resuscitation (CPR) per facility policy and the residents Advanced Directive when Resident #103 was found "sometime before 5:00 AM", unresponsive, without pulse or respirations and CPR was not promptly initiated or EMS immediately notified which resulted in a delay in emergency treatment for [REDACTED]. On [DATE], Surveyor # confirmed that the facility completed the following to remove the Immediate Jeopardy: 1. Beginnin [DATE], education was provided to 23 of 26 licensed nurses regarding "Full Codes" and resident who are found unresponsive. The three remaining nurses would be in-serviced prior to working the floor. 2. Audit was completed on [DATE] by the social worker verifying all resident's Code status. 52 of the 105 residents were verified to be full codes. 53 of the 105 were verified to be DNR (Do not resuscitate) status. 3. On [DATE], the 52 residents identified as full code had heart stickers placed on their name tags outside their room verifying "Full Code" status as a result of the [DATE] audit. 4. Beginning [DATE]m, education included Mock Code Drills with Crash cart, Policy and Procedures, DNR, Code Blue (medical emergency) provided to 15 of 20 staff LPN's, 6 of 6 staff RN's. Mock Code Drills will be conducted each shift at random times and will be ongoing. 5. New 24 hour report sheet with resident name, room number and code status was implemented on [DATE]. 6. LPN # 2 and LPN #3 involved in the event on [DATE] were permanently removed from the schedule as of [DATE]. 7. Both crash carts were audited by DON #12 on [DATE] to assure equipment availability and function. 8. Crash carts were outfitted with a lock mechanism on [DATE] with a plastic numbered tag to verify the crash cart is complete. 13 of 20 LPN's and 3 of 6 RN's were in-serviced on [DATE]. Nurses would be in-serviced prior to their next scheduled shift. 9. Policy and Procedures for Death of a Resident, Emergency Code Blue, Emergency 911 and Do Not Resuscitate were reviewed on [DATE] and deemed appropriate. 10. Policy and Procedure for Crash Cart checks was reviewed on [DATE] and nursing staff on the 11 PM-7 AM shift will be responsible to check the crash cart was added. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of no actual harm with the potential form more than minimal harm that is not immediate jeopardy due to all staff had not yet been in-serviced and sustained compliance had not been verified by the State Agency. ( )

This citation pertains to MI 039 Based on observation, interview and record review the Facility failed to provide care and services to meet the professional standards of practice and facility policy and procedure (ensure emergency equipment and procedures were followed per policy and standards of practice) in 1 of 4 sampled residents (Resident #103), resulting in Resident #103 being found unresponsive with no pulse or respirations and facility staff did not bring emergency equipment for resuscitation when responding or immediately initiate Emergency Medical Response (EMS). Findings include: According to the Fundamentals of Nursing (Potter and Perry, 6 th ed., 2005), "[MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has had a [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respirations and manual external cardiac massage". Per the American Red Cross First Aid and Safety Handbook (2011) "A person in [MEDICAL CONDITION] is unconscious, not breathing, and has no heartbeat." The Handbook revealed that "a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is: 1). Early access to the emergency medical services (EMS) system, 2). Early CPR, 3). Early defibrillation, and 4). Early advanced medical care. The Handbook also revealed that "without early CPR and defibrillation, the chance for survival is greatly reduced." According to the Handbook, "once you begin CPR, do not stop except in one of these situations, another trained responder or EMS personnel take over." Review of the facility Policy and Procedure Section: Nursing Standards of Practice Subject: Emergency - Code Blue medical (undated) revealed: 1) follow practice guidelines for CPR 2) PAGE Code blue (room or location) 4) Call 911 for emergency transfer to acute care center 7) continue CPR until advanced medical personnel arrive or until spontaneous respirations, pulse and blood pressure return. Review of the Face Sheet and [DIAGNOSES REDACTED]. upper respiratory infection. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #103 had severely impaired cognitive daily decision making skills. Review of the Facility Advanced Directive Form dated [DATE] revealed Resident #103's wife signed a request which indicated that in the event the heart or breathing stops cardiopulmonary resuscitation (CPR) would be attempted, with emergency transportation to the hospital where full life support measures may be undertaken. Review of the Facility Nurses Notes dated [DATE] and timed ,[DATE], "CENA's (certified nursing assistants) called this nurse to go to room C-11, upon entering room of served pt. (patient) purple, unresponsive, no pulse or VS (vital signs) audible. Pt. was put back into bed this nurse and another nurse attempted CPR, with no results. Call made to 911, LCA (named Ambulance) arrived and took over resuscitation he was declared dead at 5:33 AM, call family to inform of death also called physician to obtain order to release body to funeral home. Waiting for funeral home to pick up body". During an interview on [DATE] at 9:30 AM, CNA #5 reported Resident #103 began calling out at approximately 4 AM, "his usual time", and at approximately 4:,[DATE]:20 AM he was dressed and assisted to the chair. LPN #3 came and began an NMT (nebulized mist treatment for [REDACTED]. CNA #5 stated, "As I was walking out of the room he was gasping for breath; it was around 5 AM. I called for help and CNA #7 ran to get LPN #3. I tried to get vitals after CNA #7 and I got him to bed but I didn't get a blood pressure or pulse. LPN #3 asked me to direct the ambulance. I saw the nurses go into the room and shut the door. I did the vital signs they never asked me what they were. No one ever said get more help or to get oxygen. I'm not sure what they did in the room until EMS got here, it was a good 10 minutes they were in the room, both CNA #7 and I thought it strange they shut the door. When I did post- mortem care, I saw no evidence of CPR having been done. No bruises or redness, I didn't think they touched him " . In an interview on [DATE] at 1:50 PM, LPN #3 reported that a CNA called for her at approximately 5 AM on [DATE] and said "something's wrong". LPN #3 reported she entered the room and found Resident #103 sitting in a chair with no blood pressure, no pulse, no vital signs. LPN #3 said, "I wasn't sure what to do next or if he was a code or no code. I had the CNA go get the other nurse (#2) and I went to go get the chart. At first I assumed he was a no code and was surprised he was a code. I had left the room to go get LPN #2 to verify death. I never had anyone code on me before that was a full code. I called the Director of Nurses (DON) and realized he was a code when I saw it on his chart. After I talked to the DON, I called 911. LPN #3 stated, "I didn't know we had to do CPR on someone who expired, I didn't intentionally kill him, there was no way to save him". LPN #3 also stated that she nor LPN #2 at any time instructed any other staff member to get emergency equipment, document any information related to the event, or use the overhead page to call for help. In an interview on [DATE] at 1 PM, Licensed Practical Nurse (LPN) #2 reported at approximately 5 AM on [DATE], LPN #3 motioned for her to come to the C-hall, gave her a stethoscope, and she attempted to listen for a heart rate on Resident #103, which was not present. LPN #2 stated, "I thought that I was there to pronounce a death". LPN #2 reported she thought LPN #3 left to call the Director of Nurses and EMS and that when LPN #3 returned after finding the chart it was discovered Resident #103 was a full code. LPN #2 reported that she and LPN #3 were alone in the room with Resident #103 "attempting CPR" but did not remember if any special resuscitation equipment being in the room and did not call a "Code Blue" per facility policy. LPN #2 reported she recognized that CPR had to be done after the chart arrived. LPN #2 stated, "I did compressions, LPN #3 did compressions a little of the time". LPN #2 stated she did not instruct or use any emergency equipment nor document any of the events that occurred on [DATE] related to Resident #103. LPN #2 stated, "I probably should have, but no I didn't." When asked if she paged overhead a "Code Blue" for assistance per Facility policy, LPN #2 stated "no we can't use the overhead at night, we would get into trouble". In a telephone interview on [DATE] at 3:10 PM, Certified Nurse Aide (CNA) #7 reported that around 4 AM on [DATE], Resident #103 awoke and said that he didn't want to get up yet and then about 20 minutes later called again. CNA #7 reported she heard him talking to CNA #5 who had stepped out of the room to retrieve items and was out of the room "maybe 2 minutes" when she returned to the room she yelled out for CNA #7 to come. CNA #7 reported she left CNA #5 with Resident #103 and ran out to get LPN #3. CNA #7 reported while waiting for LPN #3 they attempted to take vital signs and felt for a pulse without getting anything. CNA #7 reported both LPN #2 and LPN #3 listened for a pulse and then both nurses left the room and reported she was uncertain where they went. CNA #7 reported that when both nurses returned to the room, both CNA #5 and CNA #7 were directed away, and the door to Resident #103's door was shut. No emergency equipment, oxygen concentrator, or Code Blue was called. CNA #7 reported she attempted to crack the door ,[DATE] times to check if LPN #2 and LPN #3 required assistance, and LPN #3 came to the door each time and stated 'everything is OK, we don't need anything'. I told them if they needed anything to let me know. I had residents getting up and getting restless. I did direct EMS to the room." CNA #7 also stated that she was never instructed to obtain any emergency equipment or record any information for the nurses or page overhead for help. The Facility "Crash Cart" (emergency cart) was observed on [DATE] at 1:00 PM with the contents checked by DON #1. Contents included: items needed to initiate CPR backboard, Ambu bag, CPR mask, suction equipment, oxygen and oxygen supplies (regulator, wrench, non-rebreather mask, cannulas, tubing and airways), gloves, PPE (personal protective equipment gowns and masks), blood pressure cuff, stethoscope, clip board with paper and pen to document events and times, and a blood spill kit. Review of the Facility "Emergency Crash Cart Checklist" dated [DATE] for the 10:30 PM to 7 AM shift revealed that LPN #3 signed that the contents of the crash cart, which included the inventory above, was present. ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO MANAGE BOWEL IRREGULARITIES OF 21 SAMPLED RESIDENTS FOR 5 (#2,7,11,14,18) WHO WERE REVIEWED FOR BOWEL PROTOCOL, RESULTING IN DISCOMFORT, AND A FECAL IMPACTION FOR RESIDENT #2 RESULTING IN PAIN FROM THE FECAL IMPACTION ITSELF AND THEN THE PROCEDURE TO REMOVE IT. FINDINGS INCLUDE: ACCORDING TO THE FEBRUARY 2011 PHYSICIAN ORDER [REDACTED]. THE FACILITY'S BOWEL REPORT FOR NOVEMBER 2010 REFLECTED THAT RESIDENT #2 WENT 5 DAYS WITHOUT HAVING A BOWEL MOVEMENT (11/4-11/8/10 AND AGAIN 11/9-11/14)) THE physician's orders [REDACTED]. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE NURSES NOTES DATED 11/22/10 "...LG (LARGE) IMPACTION DIGITALLY REMOVED." THE BOWEL RECORD FOR RESIDENT #2 REFLECTED NO BM FROM 11/25,11/26,11/27,11/28. ACCORDING TO THE Medication Administration Record, [REDACTED]. DURING AN INTERVIEW THE DIRECTOR OF NURSING STAFF "B" STATED, SHE WAS NOT SURE WHY THE NURSES WHO CARED FOR THE RESIDENT DIDN'T ADMINISTER THE MEDICATIONS AS ORDERED, AND AGREED "...THIS IS A PROBLEM." APPLYING THE REASONABLE PERSON CONCEPT WOULD RESULT IN THE RESIDENT EXPERIENCING PAIN RELATED TO THE FECAL IMPACTION REMOVAL. ( ) RESIDENT #14 WAS AN [AGE] year OLD MODERATELY IMPAIRED FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE FACILITY BOWEL PROTOCOL (UNDATED) STATED, "ANYONE ON THE 6 SHIFT NO OR SMALL BM REPORT WILL RECEIVE MOM (MILK OF MAGNESIUM) AT THE 1800 MED PASS." RECORD REVIEW OF RESIDENT # 14'S "BOWEL AND BLADDER DETAIL REPORT" AND THE "AS NEEDED" Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 09/23/10 TO 09/29/10 (7 DAYS)- NO DOCUMENTED BM OR PRN MILK OF MAGNESIUM ADMINISTERED AND NO [MEDICATION NAME] SUPPOSITORY ADMINISTERED. 10/01/10 TO 10/06/10 (6 DAYS) WITH NO DOCUMENTED BM AND PRN MILK OF MAGNESIUM ADMINISTERED ON 10/15/10. 10/08/10 TO 10/19/10 (12 DAYS) WITH NO DOCUMENTED BM AND PRN MILK OF MAGNESIUM ADMINISTERED ON 10/14/10, 10/18/10 AND [MEDICATION NAME] SUPPOSITORY ADMINISTERED ON 10/13/10 WITH NO RESULTS. 11/10/10 TO 11/14/10 (5 DAYS) WITH NO DOCUMENTED BM AND NO PRN MILK OF MAGNESIUM AND NO [MEDICATION NAME] SUPPOSITORY ADMINISTERED. 12/06/10 TO 12/13/10 (8 DAYS) WITH NO DOCUMENTED BM AND PRN MILK OF MAGNESIUM ADMINISTERED ON 12/07/10 AND [MEDICATION NAME] SUPPOSITORY ADMINISTERED ON 12/09/10 WITH NO RESULTS. 01/26/11 TO 01/30/11 (5 DAYS) WITH NO DOCUMENTED BM AND NO PRN MILK OF MAGNESIUM ADMINISTERED AND NO [MEDICATION NAME] SUPPOSITORY ADMINISTERED. 02/11/11 TO 02/16/11 (6 DAYS) WITH NO DOCUMENTED BM AND NO PRN MILK OF MAGNESIUM ADMINISTERED. RESIDENT #16 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE] WITH ADMITTING [DIAGNOSES REDACTED]. RECORD REVIEW OF RESIDENT # 16'S "BOWEL AND BLADDER DETAIL REPORT" AND THE "AS NEEDED" Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ( ) ACCORDING TO THE FEBRUARY 2011 "physician's orders [REDACTED]. THE FACILITIES BOWEL REPORT FOR DECEMBER 2010 REFLECTED THAT RESIDENT #18 WENT 4 DAYS WITHOUT HAVING A BOWEL MOVEMENT (12/27/10 - 12/31/10). THE FACILITIES BOWEL REPORT FOR JANUARY 2011 REFLECTED THAT RESIDENT #18 WENT 4 DAYS AND 4 DAYS RESPECTIVELY WITHOUT HAVING A BOWEL MOVEMENT (12/31/10 - 1/3/11 AND 1/21/11 - 1/25/11). THE FEBRUARY 2011 "physician's orders [REDACTED]. THE (DECEMBER 2010 AND JANUARY 2011) "PRN MEDICATION ADMINISTRATION RECORD" REFLECTED NO MILK OF MAGNESIA OR [MEDICATION NAME] SUPPOSITORIES WERE ADMINISTERED FOR RESIDENT #18. THE "TENDERCARE OF ADRIAN BM PROTOCOL" STATES: "(1) 2ND SHIFT PULLS THE 6 AND 9 NO OR SMALL BM REPORT AT THE BEGINNING OF THE SHIFT (AFTER 3 PM), (2) ANYONE ON THE 6 SHIFT NO OR SMALL BM REPORT WILL RECEIVE MOM AT THE 1800 MED PASS, (3) ANYONE ON THE 9 OR MORE OR SMALL BM REPORT WILL RECEIVE A [MEDICATION NAME] AT THE 2100 MED PASS, (4) PASS THESE REPORTS ON TO THE NEXT SHIFT, (5) 3RD SHIFT WILL GIVE AN ENEMA TO ANYONE WHO IS ON THE 9 SHIFT REPORT BY 0300 IF THEY DO NOT HAVE A BM, (6) IF THE RESIDENT HAS NOT HAD A BM BY 0600, CHECK BOWEL SOUNDS, CHECK RECTALLY, AND CALL MD, (7) THE NEXT MORNING, 1ST SHIFT WILL GIVE MOM TO ANYONE WHO WAS ON THE 6 SHIFT REPORT AND DID NOT HAVE A BM, (8) TO BE CONSISTENT, 2ND SHIFT IS THE ONLY SHIFT TO PULL THIS REPORT, SO WE ARE ALL WORKING WITH THE SAME INFORMATION, AND (9) MOM, DULCS, AND ENEMAS SHOULD BE SIGNED OUT ON THE MAR." THE FAILURE TO FOLLOW THE BOWEL PROTOCOL MAY HAVE CONTRIBUTED TO RESIDENT #2 EXPERIENCING FECAL IMPACTION. ( )