Every finding on record at The Laurels of Carson City

This citation pertains to Incident 3042858Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of an allegation of abuse in accordance with section 1150B of the Act for one (R18) of four residents reviewed for abuse. Findings Include:R26Review of the Minimum Data Set (MDS) dated [DATE] revealed R26 was admitted to the facility 5/22/2026 with diagnosis that included Alzheimer's disease and Dementia. The MDS Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which indicated the Resident was severely cognitively impaired. The MDS reflected R26 was independently ambulatory.R18Review of the MDS date reflected R18 admitted to the facility 5/5/2024 with diagnoses that included Dementia. Review of the MDS BIMS reflected a score of 4 out of 15 which indicated R18 was severely cognitively impaired. The MDS reflected R18 was non-ambulatory and wheelchair dependent.A review was conducted of the initial report (MI-FRI-ID 00064918) submitted by the facility to the State Agency (SA) on 6/5/2026 at 9:00 AM. The initial report reflected on 6/4/2026 at 5:30 PM an allegation of abuse was identified when R26 was observed to inappropriately touch R18 prompting staff intervention. The documentation of this report reflected the incident was discovered in an Electronic Medical Record (EMR) entry on 6/5/2026. The entry reflected this was identified as an allegation of abuse and the facility Abuse protocol was implemented and an investigation began.On 6/23/2026 an interview was conducted with the Nursing Home Administrator (NHA) in the NHA office. The NHA reported on 6/5/2026 she had conducted the daily review of the EMR Clinical Alert Report. The NHA reported an entry documented by a Certified Nurse Aide (CNA) on 6/4/2026 revealed the inappropriate touching of R18 by R26 that had not been reported to the Abuse Coordinator according to facility policy as potential abuse. The NHA reported immediate actions were initiated to ensure resident safety and an investigation was initiated. The NHA acknowledged that timely reporting to the SA was not in accordance with facility policy or regulatory requirement. The NHA indicated that a plan was formulated and implemented to ensure future compliance with abuse prevention and reporting.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:- Initiation of an investigation on 6/5/2026 to identify details of the incident and to identify any potential deficient practice in relation to the incident.- Facility policy and procedure for Abuse were reviewed and deemed appropriate.- All facility staff education on abuse reporting and prevention began on 6/8/2026 and completed on 6/15/2026. Any staff who were not educated by this date are to receive this education prior to the start of their next shift.- One-on-one education was provided to the staff member directly involved in the delay of reporting the incident.- Audits were developed for employee education validation and to ensure there were no unreported concerns of abuse from residents.- A schedule of audits was formulated and implemented to ensure staff understanding of abuse prevention and reporting. Continued review by the QA Committee of the audit results was conducted.The facility was able to demonstrate monitoring of corrective action and maintained compliance.

Based on interview and record review, the facility failed to ensure the physician reviewed monthly drug regimen review recommendations for 1 resident (R20) of 5 residents reviewed for unnecessary medications. Findings include:Review of an admission Record revealed R20 admitted to the facility on [DATE] with pertinent diagnoses which included heart failure, hypertensive heart disease, and dementia. Review of R20's drug regimen review Note to Attending Physician/Prescriber dated 5/6/2026 revealed .This resident has received cranberry for prevention of UTI (urinary tract infection). Please re-evaluate the continued use of cranberry supplement. Further review of a drug regiment review Note to Attending Physician/Prescriber dated 6/4/2026, revealed .This resident has advanced dementia with a BIMS (brief interview for mental status) of 3 (indicating severe cognitive impairment), and receives Aricept and Aspirin which may be of limited benefit in advanced dementia. There was no indication that the physician had reviewed these recommendations. In an interview on 6/24/2026 at 10:30 AM, the Director of Nursing (DON) reported R20's drug regimen review Note to Attending Physician/Prescriber dated 5/6/2026 and 6/4/2026 had not been reviewed by the physician. Review of facility policy/procedure Timeliness of Medication Regimen Review (MRR) Reports, last revised 9/7/23, revealed .The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations withing 14 days of receipt.

Based on interview and record review, the facility failed to prevent the development of a pressure ulcer for one resident (R7) of two residents reviewed for treatment of pressure ulcers.Findings include:Review of an admission Record revealed R7 admitted to the facility on [DATE] with pertinent diagnoses which included atrial fibrillation (a heart arrhythmia characterized by an irregular and often rapid heartbeat), depression, anxiety, and type 2 diabetes mellitus.Review of a current skin risk Care Plan for R7, initiated upon admission on [DATE], revealed R7 was at risk for impaired skin integrity/pressure injury related to urinary incontinence and type 2 diabetes mellitus, with an intervention initiated to cue to reposition self as needed and provide assistance to reposition as needed.Review of R7's Skin Issues note, dated 6/13/2026, revealed R7 had no new skin issues. Further review of the Electronic Medical Record (EMR) revealed R7 had no identified active skin issues on 6/13/2026.Review of R7's Nurses Notes, dated 6/13/2026 at 7:06 PM, revealed .patient refused to get up this (morning) for breakfast, stated she was in pain. pain meds given and ate breakfast in bed. patient was told she would need to get up for lunch and sit up for a short time, laying in bed is not good and could cause more pain, or pneumonia. No further documentation could be found in the EMR on 6/13/2026 or 6/14/2026 regarding R7's symptoms, activity, or ability to reposition self in bed.Review of R7's Nurses Notes, dated 6/15/2026 at 6:26 AM, revealed .Resident has new open area at the top of her coccyx. Area cleaned well and thin layer of zinc applied, covered with Optifoam. Wound team notified of new area.Review of R7's Skin Issues note, dated 6/15/2026 at 10:06 AM, revealed .New skin issue. Location: Coccyx. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 3 Pressure ulcer/injury- full thickness skin loss. Wound acquired in-house. It is unknown how long the wound has been present. Length (cm): 0.86 Width (cm): 0.6 Depth (cm): 0.3.Review of R7's impaired skin integrity Care Plan, initiated 6/15/2026, revealed generic interventions placed regarding conducting skin assessments and wound measurements, enhanced barrier precautions, observing for pain and signs of infection, and treating wound as ordered, but no resident specific or personalized interventions were formulated.In an interview on 6/23/2026 at 2:35 PM, Registered Nurse Unit Manager (RN UM) A reported she was not aware whether R7's new facility acquired pressure ulcer had been reviewed by the treatment team to discuss whether the wound was avoidable or to conduct a root cause analysis. RN UM A reported this was usually done at the weekly at risk team meetings, but she could not locate documentation in R7's EMR that this new wound was reviewed during the at risk meeting that took place on 6/17/2026. RN UM A reported she did not know how much assistance R7 currently needed to reposition in bed.In an interview on 6/24/2026 at 9:00 AM, the Director of Nursing (DON) reported facility acquired pressure ulcers are typically discussed during the weekly at risk meetings, but the pressure ulcer identified on R7's coccyx was missed and not discussed at the at risk meeting that took place on 6/17/2026. The DON replied that the treatment team had not yet discussed R7's new wound, and the Clinically Unavoidable Pressure Injury form had not been completed. R7's Care Plan was reviewed, and the lack of resident specific interventions was discussed. The DON reported she had started the Clinically Unavoidable Pressure Injury form and the care plan would be reviewed and updated. Review of facility policy/procedure Skin Management, revised 1/28/2026, revealed .It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. A 'Resident at Risk' meeting will be conducted at least monthly by the Interdisciplinary Team (IDT). During the meeting, the IDT will evaluate resident skin changes, review treatment modalities, interventions and will make recommendations as needed. Care plan and resident kardex will be updated accordingly.

Based on observation, interview, and record review, the facility failed to obtain a physician order for a continuous positive airway pressure (CPAP) machine and schedule cleaning for a CPAP machine for one resident (R88) of three residents reviewed for respiratory care. Findings include:Review of an admission Record revealed R88 admitted to the facility on [DATE] with pertinent diagnoses which included hypertension, sleep apnea, and chronic obstructive pulmonary disease. In an observation and interview on 6/22/2026 at 11:34 AM, R88 was lying in bed in her room. R88 had a CPAP machine that sat on her bedside stand and the mask sat on top of the machine uncovered. R88 reported that she used the CPAP machine the last three nights. R88 reported that the CPAP mask or humidifier container had not been cleaned or covered since her admission. Review of an Order Summary dated 6/22/26 at 12:43 PM, revealed no physician order for R88's CPAP machine or for the cleanliness of the CPAP machine. In an observation and interview on 6/23/2026 at 8:03 AM, R88 reported that she used the CPAP machine and wore the CPAP mask the previous night. R88 reported that facility staff did not clean the humidifier or cover the mask, but she still needed to wear it. The CPAP mask sat on top of the bedside stand, uncovered. In an interview and record review on 06/23/2026 at 11:49 AM, Unit Manager (UM) A reported that she had difficulty obtaining orders and CPAP machine settings from the corporate Respiratory Therapist. UM A reported that the physician orders for the CPAP machine and cleanliness of the CPAP were missed when R88 admitted to the facility on [DATE]. In an interview on 06/23/2026 at 12:46 PM, the Director of Nursing (DON) reported that R88's CPAP machine and cleanliness of the CPAP should have had physician orders upon admission on [DATE]. Review of facility policy/procedure Cleaning of Non-Invasive Respiratory Equipment reviewed 12/01/2022 revealed .Wash humidifier container with soap and water daily, rinse and let air dry. Refill container as needed for continued use. Wash tubing and mask weekly with soap and water, rinse and let air dry.

This citation pertains to Complaint 2975929Based on interview and record review, the facility failed to ensure appropriate caregiver/support availability for an incapacitated resident who did not have a guardian/Power of Attorney and implement a safe discharge plan for one resident (Resident #1) out of 4 residents reviewed for discharge planning. Findings include:Resident #1 (R1)Review of the admission Record reflected R1 was admitted to the facility on [DATE] and again on 1/16/26 with diagnoses that included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, a wedge compression fracture of the T11-T-12 vertebra, and hypertensive heart disease without heart failure. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R1 had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognitive function. R1 did not have any mood disturbances or indicators of psychosis. A discharge, return not anticipated MDS assessment dated [DATE] reflected R1 scored a 12/15 on the BIMS, indicating moderate cognitive impairment. (This score suggests the individual may have some memory and thinking challenges but is not considered severely impaired.) Review of a Specific Durable Power of Attorney for Personal and Medical Care and Patient Advocate Designation, notarized on 12/3/2024 reflected that as of 12/3/2024, R1 had designated Family Member (FM) E to be their Power of Attorney (POA)/Patient Advocate; FM H was designated the successor POA in the event FM E was no longer willing or able to act as R1's POA. Attached to the Specific Durable Power of Attorney for Personal and Medical Care and Patient Advocate Designation was a letter, sent to FM E by the attorney representing the estate of R1, and indicated R1 no longer wished to have FM E act as their POA, thereby putting the successor POA (FM H) into effect as of 6/2/2025. A second attachment to the POA designation form reflected that two physicians had determined that R1 was unable to participate in treatment decisions on 5/7/2025 (seven months prior to R1 admitting to the facility).Review of an Activities Note dated 1/20/2026 reflected R1 reported that he lived at home with his wife. Review of a Nurses Note dated 1/20/2026 indicated R1's POA (FM H) reported concerns with R1's mental capacity. The nurse documented Pt (patient, R1) showing signs of confusion and cognitive decline.Review of a Statement of Capacity for R1 reflected This is to certify the above guest/resident (R1) has been examined by me and I have reviewed the medical record. I find this guest/resident: X to be incapable and unable to make his/her informed medical decisions. Note: Two practitioner examinations are needed to activate a Power of Attorney. The form was signed by the Medical Doctor (MD) B on 1/22/2026 and Medical Doctor (MD) C on 1/23/2026. The Statement of Capacity was received/reviewed by the facility Social Services Director (SSD) A as evidenced by SSD A's signature dated 1/26/2026.Review of an untitled memo, discovered in R1's Electronic Medical Record (EMR), dated 1/29/2026 reflected I (name of FM H) am resigning as Medical Power of Attorney for my brother (name of R1) as of 1/29/2026.Review of a Notice of Medicare Non-Coverage reflected Medicare Coverage of Your Current Skilled Nursing Facility Services Will End on 02/02/2026 . Sign below to show you received and understood this notice. I have been notified that coverage of my services will end on the date on this notice, and that I can appeal this decision by contacting my QIO (Quality Improvement Organization) and was signed by R1 on 1/29/2026, even though R1 was deemed NOT capable of making his own medical and/or treatment decisions as of 1/23/2026. The form was witnessed by Business Office Manager (BOM) I on 1/29/2026. Review of a Care Plan initiated on 1/18/2026, reflected R1 had a functional ability deficit and requires assistance with self-care/mobility r/t (related to) acute fracture of T11 (thoracic vertebra), worsening fracture of T12, anemia in CKD (chronic kidney disease), ulcerative colitis, metabolic acidosis, hyponatremia (low sodium in the blood), HTN (high blood pressure), falls, CKD stage 3, hyperlipidemia, COPD (Chronic Obstructive Pulmonary Disease), OSA (Obstructive Sleep Apnea), BPH (Benign Prostatic Hyperplasia), neuropathy, asthma, DM2 (Type 2 Diabetes). The goal of the care plan was that R1 would improve or maintain current level of function. Interventions included Home Safety Visit prior to discharge.During an interview on 4/16/2026 at 1:45 PM, Physical Therapy Assistant (PTA) D reported that a home safety visit was not completed with R1 prior to his discharge from the facility. Review of a Social Services Note dated 1/30/2026 reflected, Resident with planned discharge of 1/30/26. Resident (R1) requesting to discharge home with concerns noted from brother (FM H, former POA) regarding his safety being at home alone. Resident to have (name of home healthcare provider) PT (physical therapy), OT (occupational therapy), nursing, HHA (Home Health Aide) services upon discharge with a PCP (Primary Care Provider) app (appointment) on 2/5/26 at 10 AM with (name of provider) and office nurse. No new equipment needed to be ordered. This writer did provide resident (R1) and his brother (FM H, former POA) with a list of private duty nursing companies that may service the (name of community where R1 lived) area. Resident's brother stated that multiple nurses and a social worker from COA (Commission on Ageing) will meet with him next week. Resident's brother to transport via private vehicle around 10AM. During an interview on 4/14/2026 at 1:10 PM with the Nursing Home Administrator (NHA) and Social Services Director (SSD) A, SSD A reported that they were aware R1 had been deemed incompetent to make their own medical decisions and that FM H had provided written notice that they were unwilling to be the POA for R1. SSD A said that in situations where a resident lacked the mental capacity to make their own medical decisions and a POA was not identified, the facility would seek emergency guardianship via a partnership with a senior care network. SSD A reported the facility did not seek a public guardian for R1 due to believing FM H was still supporting R1, despite having provided written notice revoking their willingness to act as R1's POA/Patient Advocate. SSD A said that a sister facility reached out to them asking for information about R1 when he admitted there, but said they never specified that R1 did not have a guardian or POA because the sister facility never asked. The NHA and SSD A reported they could not confirm they knew R1 was safe to discharge to his home alone without confirmation appropriate support services and a patient representative were set up. During an interview on 4/14/2026 at 2:04 PM, FM F reported that three days after discharging from the facility they discovered FM H had dropped R1 off at home and left the state. FM F said R1 was divorced, lived alone, very unkempt, could not manage his ileostomy (a surgical opening that redirects the small intestine through the abdominal wall to bypass a damaged large intestine, allowing waste to exit into an external pouch) and said there was feces all over R1's bedding and bedroom. FM F reported R1 did not have any food in the house, very little water, and had not been taking his medications because they were discovered in a black plastic bag, not set up in a pill box. FM F reported they never saw any evidence Home Health services had been set up for R1 and that R1's condition continued to decline resulting in an admission to a different, sister facility from the one R1 had discharged from on 1/30/26. According to FM F, when the sister facility contacted R1's previous facility, they were not told R1 needed a public guardian or POA. During an interview on 4/14/2026 at 3:15 PM, a representative from the home health agency listed in R1's discharge summary reported that R1 was never seen or evaluated by anyone with their agency and was never enrolled for services.

Based on observation, interview, and record review the facility failed to 1) use Personal Protective Equipment (PPE) according to Transmission Based Precaution (TBP) orders for 1 resident (R61) of two residents reviewed for TBP, 2) implement the facility water management policy/procedure, and 3) dispose of soiled linens in a sanitary manner for 1 resident (R25) of 18 residents reviewed. Findings include: PPE- R61 Review of an Admission Record revealed R61 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and muscle weakness. Review of R61's Physician's Orders, initiated 4/23/2025, revealed an order for contact precautions related to suspected Methicillin-resistant Staphylococcus aureus (MRSA) in his heel wound. In an observation on 4/23/2025 in the hallway outside R61's room, contact precaution signage was on the outside of his door directing staff to don gloves and a gown prior to entering his room. In an observation on 4/24/2025 at 7:57 AM in the hallway outside R61's room, Certified Nursing Assistant (CNA) D entered R61's room with his breakfast tray without donning gloves or a gown. Contact precautions signage directing staff to don gloves and a gown prior to entering the room was visible on R61's door. In an interview on 4/24/2025 at 8:04 AM, Infection Preventionist (IP) B reported R61 recently changed from Enhanced Barrier Precautions to Contact Precautions due to pending MRSA concerns. IP B reported gloves and gown were required to be donned prior to room entry. Water Management Program Review of a blank Water Management Team Meeting Minutes form provided by the facility, undated, revealed attendance verification, space to document control limits for chlorine levels, pH range, and water temperatures throughout the building, and direction that testing outside of the documented acceptable limits required intervention to be documented on the form in the comment section. The control limit for an acceptable chlorine level was documented as 0.2 to 4.0 ppm. Review of facility chlorine level testing revealed the following tests outside of documented acceptable parameters- -0.07 on 5/16/2024 -0.10 on 5/22/2024 -0.16 on 6/5/2024 -0.13 on 6/19/2024 -0.18 on 6/28/2024 -0.12 on 7/2/2024 -0.15 on 7/11/2024 -0.17 on 7/18/2024 -0.12 on 7/30/2024 -0.02 on 8/8/2024 -0.19 on 8/16/2024 -0.18 on 8/22/2024 -0.16 on 9/13/2024 -0.18 on 9/20/2024 -0.14 on 10/30/2024 -0.19 on 11/7/2024 -0.10 on 11/26/2024 -0.17 on 12/12/2024 -0.15 on 2/14/2025 -0.15 on 4/3/2025 -0.19 on 4/23/2025 In an interview on 4/25/2025 at 10:00 AM, Regional Consultant E reported she could find no documentation that the facility had been using the Water Management Team Meeting Minutes form or that the facility had intervened when chlorine levels were documented to be outside of the acceptable parameters. Regional Consultant E reported the form should be used at least quarterly and each time testing is found to be outside of acceptable parameters. Regional Consultant E reported the facility should have documented interventions taken for each chlorine level below 0.2 ppm on the Water Management Team Meeting Minutes form. Review of facility policy/procedure Water Management Program, revised 2/1/2024, revealed .Water management programs identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems . Control measures may include visible inspections, use of disinfectant, and temperature . Monitoring such controls include testing protocols for control measures, acceptable ranges, and documenting the results of testing . Interventions will be implemented when control limits are not met . 37577 Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old female, last admitted to the facility on [DATE] with pertinent diagnoses of dementia and right sided weakness and paralysis following a stroke. During an observation on 04/25/25 at 9:29 AM certified nurse aide (CNA) A provided peri-care to R25. CNA A used three wash clothes to wipe the resident's skin clean of urine and fecal matter. Once finished cleaning R25, CNA A placed all three contaminated wash clothes on top of R25's over bed table. CNA A did not clean and sanitize R25's over bed table prior to leaving R25's room.

Based on observation, interview, and record review, the facility failed to ensure dignified care for four residents (R50, R11, R4, R75) of six reviewed for dignity. Findings include: Review of the Admission Record reflected R50 was admitted to the facility 1/24/25 with diagnoses that included: Debilitating Cardiorespiratory Conditions, Muscle Weakness, History of Stroke and Aphasia (difficulty in speaking). Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the Resident was moderately cognitively impaired. Section GG (Functional Abilities and Goals) reflected R50 was dependent on staff for bed mobility and all transfers. On 4/24/25 at 9:34 AM an interview was conducted with R50 in his room. R50 reported delayed call light response when he needed to get cleaned up after episodes of incontinence, R50 stated delayed care makes me feel like crap. During a second interview conducted 4/24/25 at 1:28 PM R50 reported during the night staff will respond to his call light but will turn if off, indicate they will return shortly but often fail to return leaving him wet and uncomfortable for extended periods of time. R11 Review of the MDS dated [DATE] reflected R11 admitted to the facility 4/10/25 with pertinent diagnoses that included Fractures and Other Multiple Trauma and Unsteadiness on Feet. The MDS reflected a BIMS score of 13 which indicated the Resident was cognitively intact. The Functional Abilities section of the MDS (GG) reflected R11 required moderate assistance with chair and toilet transfer but maximal assist with toilet hygiene. On 4/23/25 at 1:05 PM an interview was conducted with R11 in her room. R11 reported she used to be an Elder Companion and indicated she knows what it takes to provide care to older adults. R11 reported some staff do well but others need to go back and have some more classes on how to care for people. R11 reported some staff are rough with transfers, pulling up in bed, will move legs and then just drop your feet'. R11 reported night staff are often crabby and ornery' and will argue with you about little things. R11 reported I'm one of those people that has to go to the bathroom every half hour. R11 reported she has peed my pants'' because of delayed call light response. R11 reported the delays occur more often during the evenings and nights. R11 reported episodes of delayed response and then after being placed on the toilet another delay in getting off of the toilet. R11 reported my butt gets real sore from long waits to be assisted back to bed. 45410 R4 Review of an Admission Record revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, unsteadiness of feet, and history of falling. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R4, with a reference date of 3/23/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10, out of a total possible score of 15, which indicated R4 was moderately cognitively impaired. Further review of same MDS assessment revealed R4 was dependent on staff assistance with toileting and transferring. In an interview on 4/23/2025 at 2:25 PM in R4's room, R4 reported staff answered her call light promptly when her family was there, but she frequently waited for 30 minutes or longer after pressing her call light for toileting assistance when her family was not visiting. R4 reported she was often continent but about once a week she would have an accident in her brief because of the extended wait for her call light to be answered. R4 reported staff often turned her call light off and left the room without helping her. R4 reported the facility put a sign on her wall to prevent staff from doing this. R4 reported urinating in her brief while waiting extended periods of time for her call light to be answered made her feel unwanted. In an interview on 4/24/2025 at 4:16 PM, R4 reported a certified nursing assistant (CNA) turned her call light off earlier that morning and left her room without assisting her. R4 reported staff returned approximately 15 minutes later to assist her to the toilet. In an interview on 4/25/2025 at 11:45 AM, CNA C reported staff are not to turn resident's call lights off until they met the need of the resident. CNA C reported she saw some staff turning call lights off and leaving the room without meeting the resident's need, but this should not be done. R75 Review of an Admission Record revealed R75 admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, unsteadiness on his feet, and falls. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R75, with a reference date of 4/1/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 11, out of a total possible score of 15, which indicated R75 was moderately cognitively impaired. Further review of same MDS assessment revealed R75 required assistance with toileting and transferring. In an observation and interview on 4/24/2025 at 8:17 AM in R75's room, R75's call light was activated, and he was leaning forward in his bedside chair. R75 stated, I have to go number two. In an observation on 4/24/2025 at 8:25 AM in the hall outside R75's room, a Registered Nurse walked to the end of the hallway outside R75's door, looked in the direction of R75's door with activated call light, and walked back down the hall away from R75's door without answering the call light. At 8:31 AM a CNA entered R75's room and answered his call light. In an interview on 4/24/2025 at 11:35 AM, R75 reported he remembered he had turned his call light on at 08:00 AM that morning. R75 reported he was barely able to hold his stool prior to his call light being answered approximately 30 minutes after he turned it on. R75 reported he frequently waited 30 to 60 minutes for his call light to be answered. R75 reported waiting extended periods of time for his call light to be answered frequently caused him to lose control of his bowel and bladder. R75 reported losing control in his brief made him feel embarrassed and stated, a young girl has to come and clean me up. Review of facility policy/procedure Resident Dignity & Personal Privacy, revised 3/28/2024, revealed .The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy . Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth . Review of facility policy/procedure Call Lights, revised 3/12/2025, revealed .Call lights will be placed within the resident's reach and answered in a timely manner . turn off the call light if you are able to meet the resident request . When finished, turn the call light off .

Based on interview and record review, the facility failed to hold blood pressure medication according to the physician's order for 1 resident (R69) of 18 residents reviewed. Findings include: Review of an Admission Record revealed R69 admitted to the facility on [DATE] with pertinent diagnoses which included sepsis, congestive heart failure, and endocarditis (an infection of the heart's inner lining usually involving the heart valves). Review of R69's Physician's Orders active 4/30/2025 revealed an order to give hydralazine (a medication used to treat high blood pressure) HCI 25 milligrams by mouth twice a day, hold for systolic blood pressure (the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats and pumps blood) less than 140. Review of R69's April 2025 Medication Administration Record (MAR) revealed hydralazine given with the systolic blood pressure (SBP) less than 140 at the following times by different nurses: -on 4/3/2025 at 12:00 PM with SBP of 138 -on 4/6/2025 at 12:00 AM with SBP of 122 -on 4/6/2025 at 06:00 AM with SBP of 129 -on 4/8/2025 at 12:00 AM with SBP of 132 -on 4/8/2025 at 06:00 AM with SBP of 134 -on 4/9/2025 at 12:00 AM with SBP of 132 -on 4/13/2025 at 6:00 PM with SBP of 106 -on 4/18/2025 at 12:00 AM with SBP of 115 -on 4/18/2025 at 06:00 AM with SBP of 123 -on 4/20/2025 at 06:00 AM with SBP of 116 -on 4/21/2025 at 6:00 PM with SBP of 122 In an interview on 4/24/2025 at 11:00 AM, the Director of Nursing (DON) confirmed hydralazine was documented as given to R69 in April of 2025 with a SBP of less than 140 several times and the medication should have been held per the physician's order. The DON reported she would review the Electronic Medical Record (EMR) to determine if there was any further documentation showing the medication had been held appropriately on the dates in question. In an interview on 4/24/2025 at 1:47 PM, the DON reported she reviewed R69's EMR and could find no documentation that hydralazine was held in accordance with the physician's order on the dates in question. Review of the facility policy/procedure Medication Administration, revised 10/17/2023, revealed .Medications are administered in accordance with written orders of the attending physician .

Based on observation, interview, and record review the facility failed to utilize an intervention to enhance the comfort and functionality for one of three residents (Resident #25) reviewed for range of motion. Findings: Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old female, last admitted to the facility on [DATE] with pertinent diagnoses of dementia and right sided weakness and paralysis following a stroke. During an observation on 04/23/25 at 11:07 AM, R25 laid in bed resting with her eyes closed. R25's right hand was contracted into a bent fist position and R25 did not have a splint on her right hand. A splint sat on the bedside table in R25's room. During an observation on 04/24/25 at 9:15 AM, R25 laid in bed and did not have a splint on her right hand. The splint sat on the bedside table in the resident's room. During an interview at the same time, R25 stated no staff had not asked her today if they could put the splint on her. During an observation on 04/24/25 at 11:54 AM, staff assisted R25, who sat in a wheelchair, to the dining room. R25 did not have a splint on the right hand. During an observation on 04/24/25 at 1:54 PM, R25 sat in her wheelchair in the dining room and played bingo. R25 did not have a splint on her right hand. During an observation on 04/24/25 at 3:56 PM, R25 laid in bed resting with her eyes open. There was not a splint on her right hand and the splint sat on the bedside table. R25 stated no staff had not asked her today if they could put the splint on her. R25 stated yes that sometimes staff do ask her if she wanted to have the splint on. During an observation on 04/25/25 at 8:24 AM, R25 laid in her bed resting with her eyes closed. The splint was not on her right hand and it sat on the bedside table. During an observation on 04/25/25 at 9:30 AM, staff entered R25's room and provided peri-care. Staff did not ask R25 if the hand splint could be placed. Review of a Care Plan for R25 revealed the intervention: wear right hand resting splint from morning (am) to bedtime (hs).

Based on observation and record review, the facility failed to follow a safety intervention for one of three resident's (Resident #25) reviewed for falls and accidents. Findings: Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old female, last admitted to the facility on [DATE] with pertinent diagnoses of dementia, morbid obesity, and right sided weakness and paralysis following a stroke. During an observation on 04/25/25 at 9:30 AM, certified nurse aide (CNA) A provided peri-care to R25. During the care, CNA A instructed R25 to roll onto her right side and then over onto her left side. Only one staff person was present to assist with bed mobility. Review of a Care Plan for R25 revealed the following safety intervention: resident is dependent on two staff assist with bed mobility. (Initiated 01/19/24)

This Citation pertains to Intake Number MI00145232. Based on interview and record review the facility failed to ensure adequate assessment and monitoring of a resident having chest pain and using nitroglycerin for one resident (Resident #101) of 3 residents reviewed for change of condition, resulting in incomplete information being communicated to the medical practitioner, the potential for unnoticed cardiovascular compromise, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #101: Review of an Admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure and hypertensive heart (complications of high blood pressure that affect the heart). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/15/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Review of risk for pain Care Plan interventions for Resident #101, initiated 6/11/2024, directed staff to anticipate resident's need for pain relief as needed, respond immediately to any complaint of pain, and notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. In an interview on 7/1/2024 at 11:06 AM, Family Member L reported she received a phone call from Resident #101 on 6/14/2024 at 9:30 PM and Resident #101 was distraught because he was having chest pains. Family Member L reported a nurse came into the room and demanded Resident #101 to give the bottle of nitroglycerin to her. Family Member L reported they told the nurse Resident #101 needed to keep the nitroglycerin and that he was having chest pain. Family Member L reported the nurse was focused on removing the bottle of nitroglycerin from Resident #101's room and never took his vital signs or assessed him for his symptoms of chest pain. Family Member L reported she stayed on the phone with Resident #101 from 9:30 PM until she arrived at the facility at approximately 00:13 AM. Family Member L reported the nurse did not return to Resident #101's room from 9:30 PM until she returned to administer medication at approximately 11:00 PM. Family Member Y reported Resident #101 took 3 nitroglycerin tablets in this timeframe and continued to notify staff by pressing his call light with each dose of nitroglycerin. Family Member Y reported the nurse kept sending the Certified Nursing Assistant (CNA) into the room when Resident #101 pressed his call light. Family Member Y reported the nurse never attempted to assess Resident #101 or take his vital signs from 9:30 PM until family removed him from the facility at approximately 00:30 AM. Family member Y reported Resident #101 appeared pale and upset when family arrived at the facility. Review of Resident #101's Nurses Notes, dated 6/15/2024 at 8:41 AM, documented by Licensed Practical Nurse (LPN) B, revealed .2000 hrs. while administering meds, this nurse noted that the resident had Nitroglycerin in a bottle, sitting on his overbed table. I stated that I needed to have them to place locked up in the nurses cart. Resident refused. He stated that because he is on Hospice he can do what he wants. His son was on the cell phone. Phoned on call ADON who listened as I explained that this is serious and that he can't just take them whenever. I was informed by management that I cannot force the resident to give up the little bottle. Phoned on call physician. Was told that I need hospice to talk with him. Phoned (Hospice company) to inform of situation. Hospice nurse said she would educate family and (patient). Next the (certified nursing assistant) working reported that the resident had taken a fourth pill. I approached resident and explained that 1) the medicine should only be administered while having chest pain per protocol 2) it shall remain on nurses cart. Family arrived and gathered belongings and resident and left without taking any medications with them and refused to sign discharge paperwork . Review of Resident #101's Physician's Orders on 7/1/2024 at 10:30 AM revealed Resident #101 had an order for Nitroglycerin Sublingual Tablets 0.4 mg during his stay, with a start date of 6/10/2024, and instructions to give 1 tablet sublingually every 5 minutes as needed for Angina (chest pain) with a maximum of 3 doses. Further review of Resident #101's Electronic Medical Record (EMR) revealed no further documentation by LPN B of vital signs the evening of 6/14/2024 and no attempted assessment of Resident #101's chest pain or re-evaluation after taking doses of nitroglycerin. In an interview on 7/1/2024 at 12:54 PM, CNA I reported he was caring for Resident #101 the evening of 6/14/2024. CNA I reported at some point that evening Resident #101 pressed his call light and complained of chest pain while his family was on speaker phone. CNA I reported he notified LPN B that Resident #101 was having chest pain. CNA I reported Resident #101 had been taking nitroglycerin from a bottle he had in his room and LPN B had attempted to remove the bottle of nitroglycerin from the room, upsetting Resident #101 and the family who were on the speaker phone. CNA I reported family arrived and removed Resident #101 from the facility that evening. In an interview on 7/1/2024 at 2:48 PM, LPN B reported during medication pass the evening of 6/14/2024 Resident #101 reported to her that he was having chest pains and was going to take a nitroglycerin tablet. LPN B reported she observed a nitroglycerin bottle in his possession and explained that this needed to be stored in the medication cart. LPN B reported she had not witnessed Resident #101 take nitroglycerin tablets, but he reported taking multiple doses that evening to relieve his chest pain. LPN B reported resident did not seem like he wanted her near him and so she did not assess him or get his vital signs. In an interview on 7/2/2024 at 9:46 AM, Assistant Director of Nursing (ADON) C reported she received a call from LPN B the evening of 6/14/2024 regarding Resident #101's chest pain and the bottle of nitroglycerin in his room. ADON C reported she instructed LPN B to check vital signs every hour as they were not exactly sure when Resident #101 was taking nitroglycerin. ADON C reviewed Resident #101's EMR and could not find any vitals signs, assessments, or assessment refusals documented by LPN B the evening of 6/14/2024. In in interview on 7/2/2024 at 1:35 PM, Registered Nurse (RN) A reported she was working on the other side of the building the evening of 6/14/2024 when LPN B notified her that she found a bottle of nitroglycerin in Resident #101's room. RN A reported she was not aware Resident #101 was complaining of chest pain or that he was taking doses of nitroglycerin. RN A reported resident complaints of chest pain require prompt evaluation by nursing staff including vital signs regardless of whether the resident has a history of chest pain. RN A reported she would evaluate a resident after each dose of nitroglycerin, including vital signs. In in interview on 7/2/2024 at 2:47 PM, Nurse Practitioner K reported she received a call from nursing staff the evening of 6/14/2024 regarding a bottle of nitroglycerin found in Resident #101's room. Nurse Practitioner K reported she was not notified Resident #101 had chest pain or was taking doses of nitroglycerin. In an interview on 7/2/2024 at 11:50 AM, the DON reported residents complaining of chest pain should be promptly evaluated by nursing staff, including vital signs. The DON reported nursing staff should pause medication lines if necessary to ensure prompt evaluation of complaints such as chest pain. The DON reported nursing staff are expected to check vital signs 5 minutes after doses of nitroglycerin are administered. The DON reported nursing staff should document any refused assessments in the EMR. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The presence of chest pain requires an immediate thorough assessment, including location, duration, radiation, and frequency. In addition, it is important to note any other symptoms associated with chest pain, such as nausea, diaphoresis, extreme fatigue, or weakness. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 922). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to accurately assess, provide treatments as ordered, and ensure physician oversite for wounds for 2 residents (Resident #276 and #64) out of 18 residents reviewed for alterations in skin integrity/pressure injuries, resulting in an immediate jeopardy when on 12/21/23, an alteration in skin integrity was identified on R276's left heel. R276 was not provided care in accordance with professional standards of practice and facility policy to treat and prevent the deterioration pressure injuries, did not have an accurate assessment of the pressure injury, and was not provided the necessary treatment for a deteriorating pressure injury resulting in the development of osteomyelitis. Additionally, upon return from a hospitalization , R276 was not provided the ordered treatments to prevent the worsening of his pressure injury and/or infection. R64 experienced the worsening/deterioration of the wound on his right heel and developed an additional wound to his left heel with a delay in treatment. This deficient practice placed all residents at risk for pressure injuries at high likelihood for the development of new pressure injuries. All residents with existing wounds are at risk for new and unreported wounds, the delay in wound treatment, the potential for delayed wound healing, infection, and the high likelihood for overall deterioration in health status. The Immediate Jeopardy identified on 4/24/24 and began on 12/21/23 when facility licensed nurses failed to accurately assess, provide treatments as ordered, and ensure physician oversite for R276 and R64's newly identified pressure injury. Nursing Home Administrator and Director of Nursing were notified of the Immediate Jeopardy on 4/24/24 at 4:30 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/29/24, but noncompliance remains at scope of isolated and severity of actual harm due to sustained compliance that has not been verified by the State Agency. Resident #276 (R276) Review of an Admission Record revealed R276 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Type II Diabetes with neuropathy (nerve pain), history of chronic osteomyelitis of left heel, venous insufficiency, and peripheral vascular disease (poor blood flow). Review of R276's Skin & Wound-Total Body Skin assessment dated [DATE] revealed no skin impairment/wounds. Review of R276's Nurses Note dated 12/22/23 at 12:02 AM revealed, Resident asked this nurse to assess left lateral heel where he has a healed scab from a previous wound. He said he was having some pain to that area and on inspection scab is closed but has green drainage. Notified NP (nurse practitioner) on call. Review of R276's Electronic Health Record revealed no order for wound treatment at the time the wound was identified, and the provider was notified. No documentation that R276 was added to residents to be reviewed by the wound team. Review of R276's Radiology Report dated 12/22/23 revealed an xray was completed and showed no signs of osteomyelitis (bone infection). Review of R276's Skin & Wound-Total Body Skin assessment dated [DATE] revealed no documentation skin impairment/wounds. Review of R276's Provider Note dated 12/26/23 revealed, Nurse reports purulent drainage with foul odor to left heel wound. States when she assessed wound this evening, dressing was from 12/21 . (Soiled dressing was left on heel for approximately 5 days.). No wound treatment order was initiated at that time. Review of R276's Provider Note dated 12/27/23 revealed, Left heel with open area and mild serous drainage on old dressing. No surrounding erythema and no odor to wound. (See photo for measurements). Wound cleansed and calcium alginate covered with optifoam applied . Pressure ulcer of left heel, unspecified stage . An order for wound care was implemented following this assessment. (Approximately 6 days from the discovery of the wound). Review of R276's Skin and Wound Evaluation dated 12/27/23 revealed the wound was staged as a Stage 1: Non-blanchable erythema of intact skin, did not identify the date the wound was identified and did not include the providers observation of drainage. Review of R276's Treatment Administration Record revealed, Cleanse L heel w/ NS (cleanse left heel with normal saline). Apply Calcium Alginate to open area cover w/ Opti foam. Encourage blue boots while in bed. With a Start date of 12/28/23. No treatments were documented as completed prior to this order indicating a delay in treatment. Review of R276's Nurses Note dated 12/31/23 revealed, Drsg (dressing) changed to rt (sic) heel. Wound entirely covered with thick white slough. Foul odor persists after cleaning. Scant amt of thick yellow drainage on old dressing. Denies pain, no redness. (Note: R276 had a right leg amputation). Indicating R276's wound had deteriorated and exhibited signs/symptoms of infection. Review of the National Pressure Ulcer Advisory Panel (NPUAP) revealed If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Review of R276's Electronic Health Record revealed no documentation that the provider was notified of the change of the condition of the wound, not followed by the wound team and/or Interdisciplinary Team, and no treatment changes were initiated. Review of R276's Provider Note dated 1/4/24 revealed, LT heel with open wound, cared daily with wound nurse and nursing staff .cleanse wound and apply calcium alginate covered with optifoam daily . No wound assessment, measurements, or treatment changes documented. Review of R276's Skin and Wound Evaluations revealed no other assessments until 1/11/24 which was incomplete. R276 was assessed by provider on 1/5/24 related to a COVID diagnosis, on 1/8/24 related to a fall, and on 1/12/24, 1/17/24, and 1/22/24 for routine follow-up. Wound assessment and treatments were not discussed. Review of R276's Skin and Wound Evaluations dated 1/17/ 24 revealed an incomplete assessment. Review of R276's Order Summary dated 1/17/24 revealed an order for podiatry consult. (Approximately 4 weeks after the identification of his wound.) Review of R276's Wound Consultant Note dated 1/24/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.59 x 0.8 centimeter with a depth of 0.2 centimeter. This wound is partial thickness .Tx: (treatment) This area is to be cleaned daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with an ABD pad and wrapped in kerlix. Secure with tape initial and date. Daily . A wound with partial thickness tissue loss is considered a Stage 2 pressure injury. (This was R276's first wound consultation, approximately 5 weeks after the identification of his wound.) The NPUAP defines a Stage 1 pressure injury as intact skin with a localized area of non blanchable erythema/redness. Stage 2 pressure injures are defined as Partial-thickness loss of skin with exposed dermis. Review of R276's Treatment Administration Record revealed the recommended wound treatment was not ordered/implemented. Review of R276's Skin and Wound Evaluation dated 1/24/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth of 0.2 centimeters. Review of R276's Podiatry Report of Consultation dated 1/30/24 revealed the measurements of R276's left heel pressure injury to be 4 cm (width) x 2cm (length) x 0.8cm (depth). Indicating the worsening of the pressure injury. Review of R276's Wound Consultant Note dated 1/31/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.46 x 0.79 centimeter with a depth of 0.2 centimeter. This wound is partial thickness .Tx: This area is to be cleaned daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Secure with tape initial and date. Daily . Indicating a discrepancy of the measurements of the wound and inaccurate staging of the wound. Review of R276's Skin and Wound Evaluation dated 1/31/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth. R276's wound treatment order was updated to reflect the providers recommendation. Review of R276's January Treatment Administration Record revealed R276's wound care was not completed on 1/4/24 or 1/17/24 with no documentation as to why it was not completed. Review of R276's Podiatry Report of Consultation dated 2/6/24 revealed Posterior ulceration with mild maceration .2.5 cm x 1cm, 0.3cm .no probing to bone .sharp excisional debridement performed today (removal of dead/infected tissue) .f/u in 2 weeks . (Sharp excisional debridement is a surgical procedures using scalpels/scissors to remove infected and dead tissue from a wound bed.) Review of R276's Wound Consultant Note dated 2/7/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.77 x 0.92 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a light amount of serous drainage from this area . Review of R276's Skin and Wound Evaluation dated 2/7/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth or the wound drainage. Review of R276's Wound Consultant Note dated 2/14/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 4.52 x 1.23 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a light amount of serous drainage from this area . There was no treatment change implemented. Review of R276's Skin and Wound Evaluations revealed no completed wound assessment for 2/14/24. The evaluation was In Progress. Review of R276's Wound Consultant Note dated 2/21/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 2.13 x 1.47 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a moderate amount of serous drainage from this area .Tx: This area is to be cleaned daily with wound cleanser and santyl ointment (wound treatment) and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Secure with tape initial and date. Daily. Doxycycline ordered daily for 14 days . Indicating the worsening of the wound including infection which required the use of antibiotics. Review of R276's Skin and Wound Evaluations revealed no completed wound assessment for 2/21/24. The evaluation was In Progress. Review of R276's Wound Consultant Note dated 2/28/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.68 x 1.29 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a light amount of perulent (purulent-pus) drainage from this area. Wound bed consists of 100% eschar tissue. Edges are attached and there is no slough, tunneling, undermining, or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection . There was no treatment change ordered. Review of R276's Skin and Wound Evaluation dated 2/28/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth. During an interview on 04/29/2024 at 12:50 PM, Regional Nurse Consultant (RNC) A reported that a change in treatment should be implemented if a wound deteriorated or showed no signs of improvement in a 2-week timespan. Review of R276's Podiatry Report of Consultation dated 3/1/24 revealed, 2cm fibrotic wound posterior lateral (left) calcaneus (heel). + malodor (foul odor), + edema (swelling), + erythema (redness), probing to bone. Diagnosis: Cellulitis with probable osteomyelitis left heel region .Recommendations: Patient sent to ER (emergency room ) for admission/IV antibiotics, debridement and possible amputation (left) lower extremity. Confirming a significant change in R276's pressure injury from 2/28/24. R276 was hospitalized from 3/1/24-3/10/24 for osteomyelitis (severe bone infection): *3/1/24 Hospitalist Service H&P (history and physical) He was seen at the podiatrist office this morning and was instructed to go to the emergency department for IV antibiotics His foot ulcer has been worsening over the past week .at the outlying ED, he was found to have ongoing left foot ulcer, with elevated white blood count of 17 K .LACTIC ACIDOSIS, elevated C-RP (indicates systemic infection/sepsis). *3/2/24 Wound Consult Hospital Wound Services: Asked to see patient for diabetic foot ulcer. Dressing removed with large amount of brown, foul smelling drainage. Cleansed left heel with saline moistened gauze and odor remained. Left heel injury measures 3.5 x 1.75, 1cm with undermining (erosion under the skin surface-resulting in large wound with smaller opening) from 1 to 6 o'clock (along heel bone) of 4 cm. Tissues are brown. Surrounding ulcer is soft yellow/cream tissue .Patient has been following with (name omitted) DPM (podiatrist) for heel ulcer. Yesterday patient went to [NAME] Hospital ER for ulcer to left foot and was then transferred to [NAME] main for podiatry consult and surgery. *3/3/24 Podiatric Surgery Consult Note .Cellulitis LT (left) lower extremity, necrosis (death) of bone, Acute on chronic osteomyelitis LT calcaneus .presents to ED (emergency department) with worsening of left foot ulcer. The pt (patient) had hx (history) of heel ulcer and osteomyelitis. He reports that wound was healed and reopened 3 months ago . *3/5/24-surgical wound debridement (removal of infected/dead tissue from wound) and wound vac (vacuum assisted closure of wound) 3/6/24 Review of R276's Order Summary revealed, wound vac to lt heel at 125mmHg change 3 times per week every day shift every Mon, Wed, Fri for wound care -Start Date- 03/13/2024. Review of R276's Wound Consultant Note dated 3/13/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 2.25 x 1.42 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of serosanguinous drainage from this area . Treatment for the wound vac was continued. Review of R276's Skin and Wound Evaluation dated 3/13/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment measured the length of the wound as 0cm, the width as 0cm, and depth not applicable. Review of R276's Wound Consultant Note dated 3/20/24 revealed, .1. (19) Left heel pressure stage IV - This wound measures 2.43 x 1.18 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of sanguinous drainage from this area . Treatment for the wound vac was continued. Review of R276's Skin and Wound Evaluation dated 3/20/24 revealed no date the wound began and no wound depth measurement. Review of R276's Wound Consultant Notes and Skin and Wound Evaluations revealed no evaluation was completed on 3/27/24. Review of R276's Skin and Wound Evaluation dated 4/3/24 revealed no date the wound began and no wound depth measurement. R276 was hospitalized for a DVT (blood clot) from 4/4/24-4/9/24. Review of R276's Wound Consultant Note dated 4/10/24 revealed, .1. (20) Rear Left Malleolus Lateral pressure stage IV - Picture was taken but did not upload into (Electronic Health Record), nursing staff informed. Wound has improved, measurements and treatment remain the same. Wound measurements from 4/3/24 are 2.85 x 1.69 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of sanguinous drainage from this area . Indicating the wound was not assessed by the wound consultant and/or rounding wound nurse and no treatment changes were made. Review of R276's Skin and Wound Evaluations revealed no completed evaluation for 4/10/24 with the documentation In Progress. Review of R276's Skin and Wound Evaluation dated 4/19/24 revealed the onset date of the pressure injury was documented as unknown and no measurable depth was documented. (Date the area was first identified was 12/21/23). Review of R276's Podiatry Report of Consultation dated 4/19/24 revealed, .continue wound vac until next visit on May 7th . Review of R276's Wound Consultant Note dated 4/19/24 revealed, .1. (20) Rear Left Malleolus Lateral pressure stage IV - This area measures 2.54 x 1.19 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of sanguinous drainage from this area. Wound bed consists of 100% granulation tissue. Edges are attached and there is no slough, tunneling, undermining, or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection. Improving. Tx: This area is to be cleaned daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Initial and date. Daily. Change to wound vac once supplies become available. Review of R276's Treatment Administration Record revealed the wound vac was not changed on 4/19/24 or 4/22/24. Review of R276's Nurses Note dated 4/22/24 at 4:35 AM revealed, .Wound vac in place . Indicating an inaccurate resident assessment. Review of R276's Medication Administration Note dated 4/22/24 at 3:32 PM revealed, (Wound Vac) supplies unavailable. Supplier number called and to be delivered Wednesday. (Podiatrist) office called to notify but unable to reach at this time. Bordered foam dressing applied while awaiting delivery. Confirming the lack of follow up for an ordered treatment and recommended treatment not completed/ordered. During an observation on 04/22/24 at 10:37 AM, R276 was in his room. He did not have a wound vac applied to his left foot. A wound vac was on his nightstand. During an observation on 04/23/24 at 08:04 AM, R276 did not have a wound vac applied to his left heel. Review of R276's Order Summary and Treatment Administration Record on 4/23/24 revealed no order for wound treatment in place of the wound vac as recommended by Wound Consultant (WC) B on 4/19/24. During an interview on 4/23/24 at 3:35 PM, Licensed Practical Nurse (LPN) C confirmed that R276 did not have a wound vac in place and was without wound treatment orders. LPN C reported there was no excuse for not having wound vac supplies and for treatments not being entered. LPN C stated a delay in care can cause sepsis and the deterioration/worsening of R276's wound. Review of R276's Order dated 4/23/24 at 4:10 PM revealed, Lt heel; clean daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Initial and date. Daily. Change to wound vac once supplies become available. every day shift for wound care -Start Date-04/24/2024 0700. During an interview on 04/24/24 at 09:26 AM, LPN C reported there was a dedicated wound nurse that was responsible for all pressure injuries and wounds in the facility. LPN C reported the wound nurse rounded with the provider, completed weekly wound measurements and pictures, and ensured the orders were entered into the electronic health record. LPN C reported the residents weekly wound assessments included measurements including depth, the description of the wounds, and treatment changes. During an interview on 4/24/24 at 11:26 AM, WC B reported that LPN D was the rounding wound nurse at the facility and would assist with wound measurements and complete the weekly wound assessment form. WC B reported the facility utilized a camera that would measure length and width, but the depth was done manually and was to be documented in the wound assessment. WC B reported he was not notified that the treatment he ordered on 4/19/24 for R276 had not been implemented and reported his expectation was that treatment orders were transcribed into the electronic health record. WC B reported he ordered a bridge (interim) treatment for R276 until the wound vac supplies came in but expected the wound vac supplies would have arrived prior to his return to the facility. During an interview on 4/24/24 at 12:13 PM, LPN D (rounding wound nurse) reported she had not been notified that R276 did not have wound vac supplies. LPN D reported there were appropriate supplies for R276's wound vac and obtained them at that time. Per the facility policy Skin Management last revised 7/14/21, A Guest/Resident at Risk meeting will be conducted at least monthly by the Interdisciplinary Team (IDT). During the meeting, the IDT will evaluate guest/resident skin changes, review treatment modalities, interventions and will make recommendations as needed .Guests/residents reviewed for skin alterations are as follows: *Newly developed vascular, diabetic/neuropathic and pressure injuries *Any pressure or non-pressure area that has shown no signs of healing within a two week time frame . During an interview on 04/25/24 at 12:51 PM, Nursing Home Administrator (NHA) reported that R276's left heel pressure injury had not been identified/reviewed during the Resident at Risk meetings until 4/15/24 when he was reviewed for readmission to the facility following a DVT. During an interview on 04/29/2024 at 12:50 PM, Regional Nurse Consultant (RNC) A reported that the information documented in the Skin & Wound Evaluation pulls over to the dashboard in the electronic health record system and alerts management if a wound is deteriorating/worsening. RNC A confirmed that an accurate depth measurement would be essential in identifying if a wound had deteriorated/worsened. Resident #3 (R3) Review of an Admission Record revealed R3 was an [AGE] year-old male, admitted to the facility on [DATE]. Review of R3's Wound Consultant Note dated 3/27/24 revealed, .Sacrum pressure stage III .This wound is full thickness .Tx: This area is to be cleaned daily with wound cleanser. Apply zinc cream to surrounding areas. Apply skin prep to surrounding tissue. Wound should be covered with a bordered gauze. Initial and date. Daily . Review of R3's Order Summary revealed the wound consultant's recommendations were not entered into the electronic health record until 4/26/24. Review of R3's Total Body Skin assessment dated [DATE] revealed, New stage 2 pressure injury noted to right inner buttock. Area cleansed and measured. Measurements 0.8 cm x 0.5 cm x 0.1 cm .treatment ordered . Review of R3's Order Summary on 4/29/24 revealed no order for wound treatment for the newly identified pressure injury. Resident #9 (R9) Review of an Admission Record revealed R9 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R9's Wound Consultant Notes beginning on 1/31/24 revealed an area of abrasion on her scalp with the following order, This area is to be cleaned daily with wound cleanser and skin prep applied to the area. Wound should be open to air. Daily. Review of R9's Order Summary revealed that from 11/27/23-4/26/24 her treatment was ordered as Skin prep to scalp BID every day and night shift for scabbed areas. Review of R9's Order Summary dated 4/26/24 revealed an order change to, Front scalp abrasions: cleanse site with wound cleanser, pat dry. Apply skin prep, leave open to air. every day shift for scabbed areas Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R11's Wound Consultant Note dated 4/19/24 revealed, .Right Dorsum-1st Digit Diabetic-This area measures 1.22 x 0.79 centimeter with a depth of 0.1 centimeter. This wound is full thickness. There is a moderate amount of serous drainage from this area . Review of R11's Skin & Wound Evaluation dated 4/24/24 revealed no documentation of the measurable depth or drainage. Review of R11's Order Summary revealed Cleanse R great toe and second digit with NS, apply Santyl to wound bed, cover w/ Calcium alginate and dry dressing every day shift for Diabetic ulcer. Start Date 2/8/24. Review of R11's April Treatment Administration Record revealed the treatment was not completed on 4/2/24, 4/9/24, 4/10/24, and 4/15/24. Resident #19 (R19) Review of an Admission Record revealed R19 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R19's Skin & Wound Evaluation dated 4/24/24 revealed an area of Moisture Associated Skin Damage (MASD) on left gluteus measuring 0.8cm x 0.8cm x 0.2cm. (MASD is widespread erythema, maceration, and irregular or diffuse edges.) During an observation and interview on 4/29/24 at 1:15 PM, R19's Skin & Wound Evaluation dated 4/24/24 was reviewed with the Director of Nursing. Review of the picture of the wound revealed a circular open area on the ischial tuberosity (point of pressure on buttocks) with defined edges and a reddened wound bed. DON confirmed that the area of breakdown/injury was a Stage II pressure injury and not MASD. Review of R19's Electronic Health Record revealed no documentation that the family or provider was notified of the Stage II pressure injury. There were no treatments ordered for the newly identified pressure injury. Resident #228 (R228) Review of an Admission Record revealed R228 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R228's Total Body Skin assessment dated [DATE] revealed, 2 non-documented wounds noted upon total body assessment. 1 wound is localized to the left posterior heel. Area is scabbed over and pea sized. Resident explains she has history of a previous wound here. The second wound is localized to her bottom, which appears to be shearing/ skin tear caused by moisture associated damage .New orders input for daily skin prep to the left posterior heel and zinc oxide ointment for her bottom every shift. Review of R228's Order Summary dated 4/29/24 revealed, Zinc Oxide Ointment to buttocks every day and night shift for MASD and Skin prep to posterior left heel every day and night shift for prevention of skin breakdown on old healing wound. Indicating a delay in treatment. 29073 Resident #64 (R64) Review of an Admission Record reflected R64 admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, severe, without behavioiral disturbance, psychotic disturbance, mood disturbance and anxiety. R64 was given a secondary, during stay diagnosis on 8/8/2023 of pressure ulcer of right heel, stage 3. R64 was also diagnosed with Methicillin susceptible staphylococcus aureus (MSSA). Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R64 admitted to the facility with one stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister), and 2 unstageable pressure ulcers with suspected deep tissue injury in evolution. The most recent MDS assessment dated [DATE] reflected R64 had a stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). The assessment indicated the stage 3 was present on admission. R64 was no longer coded as having any unstageable-deep tissue, suspected deep tissue injuries. Review of a Care Plan last revised 1/03/2024 reflected R64 has actual impairment to skin integrity r/t (related to) heel stage 3 pressure injury. The Goal of the care plan was that R64 would not develop an infection to the wound and was not centered on healing or preventing the worsening of the wound. Interventions included, Conduct weekly head to toe skin assessments and report new/abnormal findings to physicians as needed; enhanced barrier precautions: don gown and gloves during high-contact resident care; Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to physician. During an observation on 4/23/2024 at 1:39 p.m., Licensed Practical Nurse (LPN) Q removed the dressing covering the pressure ulcer on R64's right heel. The dressing was dated 4/20 and indicated the dressing was last changed three days prior to the observation. The dressing was saturated with brown, serous drainage. The skin around the pressure ulcer on R64's right heel was macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture). LPN Q said that the dressing was to be changed daily. R64 also had a round, nickel sized dark reddened area on the lateral aspect of his left heel. LPN Q said she was not aware of the area. Additionally, there was a thick scab on R64's right great toe. LPN Q said she wasn't comfortable reapplying a fresh dressing until R64's right heel had a chance to air dry and said she would return in an hour to reassess the area. Review of the April 2024 Treatment Administration Record (TAR) reflected an order Cleanse right heel with NS (normal saline), apply skin prep to surrounding skin, and cover with calcium alginate and bordered gauze every day shift-Start Date-02/08/2024. The record reflected the dressing had not been changed on 4/21/24 or 4/22/2024. A dressing change was not documented as done on 4/1/2024. Review of the March 2024 TAR reflected the order Cleanse right heel with NS (normal saline), apply skin prep to surrounding skin, and cover with calcium alginate and bordered gauze every day shift-Start Date-02/08/2024. The ordered treatment was not completed on 3/8/24 or 3/13/24. During a follow-up observation on 4/23/24 at 3:37 p.m., LPN Q was assisted by LPN C in getting measurements and completing the dressing change. LPN Q obtained a camera phone and took pictures of the areas which she explained would measure the wound at the same time. No manual measurements or measurement of the depth of the wound were taken at this time. The Skin & Wound Evaluation V7.0 dated 4/19/2024 (4 days prior to the wound observations made on 4/23/24 indicated R64's right heel wound measured 3.8 cm long x 2.3 cm wide. No depth was recorded despite there being measurable depth apparent in the photograph that accompanied the evaluation. Review of the Skin & Wound Evaluation V7.0 dated 4/23/2024 reflected R64's right heel measured 12.6 centimeters (cm) long x 7.0 cm wide. No depth was recorded on the evaluation, despite there being measurable depth to R64's stage 3 pressure ulcer to the left heel and represented a significant deterioration/worsening in the condition of R64's wound. Review of a Skin & Wound Evaluation V7.0 dated 4/23/24 reflected R64's left heel had a 1.3 cm long by 1.0 cm wide wound. No additional details were recorded on the skin and wound evaluation. Review of the Skin & Wound EvaluationV7.0 dated 4/24/24 reflected R64 had a stage 3 pressure ulcer on the right heel that was present on admission. This evaluation indicated the wound measured 4.3 cm long by 2.4 cm wide. No depth was recorded. The wound measurements taken on this day reflected a deterioration of the wound compared to the measurements taken on 4/19/24 (noted above) and differed significantly from the measurements recorded the day before (4/23/24). Further review of the Electronic Health Rec [TRUNCATED]

This citation is related to intake #MI00140932 Based on interview and record review, the facility failed to 1.) promptly identify an outbreak of acute respiratory illness and implement facility infection prevention and control policies and procedures, 2.) implement transmission-based precautions for residents with signs and symptoms of acute respiratory illness to prevent the spread of infection, 3.) ensure prompt testing for residents with signs and symptoms of acute respiratory illness, 4.) investigate the outbreak and document the surveillance of respiratory infections, and 5.) follow transmission based precautions for suspected Clostridum difficle (C-diff). This deficient practice resulted in the widespread transmission and infection of residents and staff with COVID-19, Influenza, and Respiratory Syncytial Virus. Findings: Review of the facility policy Infection Prevention Program Overview last revised 9/9/22 revealed, INFECTION PREVENTION PROGRAM-MISSION OF PROGRAM- The facility establishes a program under which it: Investigates, identifies, prevents, reports and controls infections and communicable disease for all guests/residents, staff, contractors, consultants, volunteers, visitors and others who provided care and services to the guests/residents on behalf of the facility, and students in the facility's nurse aide training program or from affiliated academic institutions .*Decides what procedures such as isolation, should be applied to an individual guest/resident *Maintains a record of incidents and corrective actions related to infections .Preventing Spread of Infection *When the infection control program determines that a guest/resident needs isolation to prevent the spread of infection, the facility must isolate the guest/resident . The major activities of the program are: A. Surveillance of infections with implementation of control measures and prevention of infections * There is on-going monitoring to identify possible communicable diseases or infections among guests/residents and personnel and subsequent documentation of infections that occur. *Preventing the spread of infections is accomplished by use of standard precautions and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness. *Staff and guest/resident education will focus on risk of infection and practices to decrease the risk. B. Outbreak Investigation *Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks . REPORTING MECHANISMS FOR INFECTION PREVENTION A. Guest/resident infection cases are monitored by the IP (Infection Preventionist). The IP completes the Infection Surveillance Tracking Tool in InfectionWatch and: 1. Reports to the Infection Prevention Committee 2. Provides feedback to staff as needed. 3. Reports notifiable disease to the local health department as directed. B. Employee infections are reported by the employee to his/her supervisor then to the IP. The IP enters the employee infection data into InfectionWatch and reports to the: 1. Infection Prevention Committee monthly 2. The QAPI Committee on a quarterly or more often as needed. C. Compliance with Infection Prevention practice is monitored and documented by the IP through surveillance and observation . Review of the State Operations Manual revealed, Recognizing, Containing and Reporting Communicable Disease Outbreaks The facility must know how to recognize and contain infectious disease outbreaks. An outbreak is the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.31 If a condition is rare or has serious health implications, an outbreak may involve only one case. While a single case of a rare infectious condition or one that has serious health implications may or may not constitute an outbreak, facilities should not wait for the definition of an outbreak to act. For example, one case of laboratory confirmed influenza in a resident should alert the facility to begin an outbreak investigation. If an outbreak is identified, the facility must: *Take the appropriate steps to diagnose and manage cases, implement appropriate precautions, and prevent further transmission of the disease as well as documentation of follow-up activity in response; and *Comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. Timeline of Covid-19 Outbreak *On 12/9/23 a CNA (Certified Nursing Assistant) tested positive. There was no documentation that an outbreak investigation/contact tracing was initiated to contain and prevent the spread of COVID-19 in the facility. Comments Worked shifts 48 hours prior on 100 hall. 100 hall residents tested days 1, 3, and 5. There was no documentation that staff members were included in the covid testing or any other residents that may have been exposed (dining room, activities, therapy, etc). *On 12/11/23 R58 tested positive *On 12/15/23 an LPN (Licensed Practical Nurse) tested positive with symptom onset 12/12/23. *On 12/18/23 a CNA tested positive with symptom onset 12/16/23 *On 12/18/23 a dietary worker tested positive with symptom onset 12/17/23 *On 12/23/23 R38 tested positive *On 12/24/23 a CNA tested positive with symptom onset 12/23/23 *On 12/27/23 R58 tested positive *On 12/27/23 an activities staff member tested positive with symptom onset 12/27/23 *On 12/28/23 an RN (Registered Nurse) tested positive with symptom onset 12/28/23 *On 12/30/23 a facility staff member tested positive with symptom onset 12/29/23. No close contact with residents (receptionist). Indicating other staff members that may have come in contact with the staff member were not monitored for potential exposure. *On 12/30/23 a CNA tested positive with symptom onset 12/29/23 *On 1/1/24 a CNA tested positive with symptom onset 1/1/24. There was no documentation that staff members were included in the contact tracing or any other residents that may have been exposed (dining room, activities, therapy, etc). *On 1/1/24 R3 tested positive *On 1/1/24 R276 tested positive *On 1/3/24 R8 tested positive *On 1/4/24 R289 tested positive *On 1/6/24 R25 tested positive *On 1/7/24 a CNA tested positive with symptom onset 1/6/24. Comments: Sent home 1/7 on 300 hall. Worked shifts 48 (hours) prev (previously. 300 Hall residents tested day 1, 3, 5. There was no documentation that staff members were included in the covid testing or any other residents that may have been exposed (dining room, activities, therapy, etc). *On 1/7/24 R65 tested positive *On 1/7/24 R50 tested positive *On 1/8/24 a CNA tested positive with symptom onset 1/7/24. Comments: Sent home at beginning of shift on 100H. Residents on 100 hall tested days 1,3,5. There was no documentation that staff members were included in the covid testing or any other residents that may have been exposed (dining room, activities, therapy, etc). Confirming the spread of infection to other halls. *On 1/8/24 R6 tested positive *On 1/10/24 R290 tested positive *On 1/19/24 R286 tested positive *On 1/30/24 R55 tested positive *On 2/17/24 an environmental worker tested positive for COVID with onset of symptoms 2/16/24. Comments: Laundry aid who worked the day of testing positive 2/17. Wears N95 regularly . There was no documentation that an outbreak investigation and/or contact tracing was initiated, routine testing was initiated, or that the health department was notified of a positive Covid result. *On 3/1/24 a CNA tested positive with symptom onset 3/1/24. No additional information regarding the date last worked or the unit worked provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. *On 3/8/24 an RN tested positive with symptom onset 3/7/24. No additional information regarding the date last worked or the residents in contact were provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. *On 3/13/24 R291 tested positive. There was no documentation that contact tracing was initiated to identify staff and residents exposed. *On 3/20/24 a dietary staff member tested positive on 3/20/24 with symptom onset 3/19/24. No additional information regarding the date last worked or the residents in contact were provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. *On 3/31/24 a CNA tested positive with symptom onset 3/30/24. No additional information regarding the date last worked or the unit worked provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. During an interview on 5/1/24 at 2:32 PM, Regional Nurse Consultant (RNC) A confirmed there was no outbreak investigation related to the Covid outbreak that began on 12/9/23. Timeline of Influenza Outbreak Review of the Centers for Disease Control and Prevention Key Facts About Influenza dated 3/22/24 revealed, Period of Contagiousness-You may be able to spread flu to someone else before you know you are sick, as well as when you are sick with symptoms. *People with flu are most contagious during the first 3 days of their illness. *Some otherwise healthy adults may be able to infect others beginning one day before symptoms develop and up to five to seven days after becoming sick. *Some people, including young children and people with weakened immune systems, may be contagious for longer periods of time. Onset of Symptoms-The time from when a person is exposed and infected with influenza virus to when symptoms begin is about two days, but can range from about one to four days. Https://www.cdc.gov/flu/about/keyfacts.htm#print *On 12/9/23 a CNA (Certified Nursing Assistant) tested negative for COVID but exhibited headache, fever, and chills beginning on 12/8/23. The CNA was not tested for influenza or RSV and was estimated to return to work on 12/14/23. *On 12/13/23 a staff member tested positive with symptom onset 12/11/23. There was no documentation that an outbreak investigation and/or contact tracing was initiated. The unit the LPN worked, and the last date worked, was not identified to monitor the residents for signs and symptoms of influenza. There was no documentation that residents exposed were offered antiviral medications. *On 12/15/23 a staff member tested positive with symptom onset 12/13/23. There was no documentation that contact tracing was initiated to identify residents exposed and to monitor the residents for signs and symptoms of influenza. *On 12/20/23 R8 began exhibiting symptoms of a respiratory illness. R8 was noted to have a new unproductive cough. LS were CTA (lung sounds were clear to auscultation). A covid test was done and was negative. An order was placed in the elctronic health record, for a covid test to be done again in 48 hours. On 12/23/23 the facility Obtained specimen for Influenza A and B and RSV testing to be completed. On 12/24/23 R8 was found to be positive for Influenza A. There was no documentation that R8 was placed in droplet isolation while symptomatic for a respiratory illness and while the test results were pending (placing staff and residents at risk for exposure) until 12/23/23 Guest to be in droplet isolation precautions until results of RSV and Influenza results received. On 12/24/23 the provider ordered Tamiflu 30mg capsule two times a day. Review of the FDA (food and drug administration) package insert for Tamiflu revealed TAMIFLU is for treating adults and children age 1 and older with the flu whose flu symptoms started within the last day or two. R8's respiratory symptoms began approximately 4 days prior to the initiation of Tamiflu. There was no documentation that contact tracing was initiated to identify other staff and residents that were exposed. *On 12/24/23 R283 tested positive. There was no documentation that Tamiflu was offered and/or ordered. *On 12/26/23 an environment worker tested positive with symptom onset 12/26/23. There was no documentation that contact tracing was initiated to identify residents exposed and to monitor the residents for signs and symptoms of influenza. *On 12/27/23 R284 tested positive. There was no documentation that Tamiflu was offered and/or ordered. There was no documentation that contact tracing was initiated to identify residents exposed and to monitor the residents for signs and symptoms of influenza. *On 2/17/24 an environmental worker tested positive for Influenza A with onset of symptoms 2/13/24. Comments: Did not work 48 hours prior to scheduled shift . *On 3/18/24 a CNA tested positive with symptom onset 3/18/24. No additional information regarding the date last worked or the unit worked provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. *On 3/20/24 a CNA tested positive with symptom onset 3/19/24. No additional information regarding the date last worked or the unit worked provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. *On 3/25/24 a CNA tested positive with symptom onset 3/25/24. No additional information regarding the date last worked or the unit worked provided. There was no documentation that contact tracing was initiated to identify staff and residents exposed. During an interview on 5/1/24 at 2:32 PM, RNC A confirmed there was no outbreak investigation completed for the influenza outbreak. No further documentation was received prior to survey exit. Timeline of RSV Outbreak *On 1/26/24 a CNA tested positive with symptom onset 1/22/24. Comments: Worked 1/22 on 300 Hall. Sent for PCR 1/23 after negative POC (point of care). PCR (polymerase chain reaction) came back + RSV 1/26. An outbreak investigation/contact tracing was not initiated. *On 1/30/24 R55 tested positive *On 2/5/24 R34 tested positive *On 2/7/24 R65 tested positive *On 2/9/24 R287 tested positive *On 2/9/24 R20 tested positive *On 2/12/24 R52 tested positive *On 2/13/24 R23 tested positive *On 2/16/24 R36 tested positive *On 2/17/24 R276 tested positive *On 2/20/24 R57 tested positive *On 2/20/24 R125 tested positive *On 2/21/24 R58 tested positive *On 3/4/24 R278 tested positive *On 3/4/24 R8 tested positive *On 3/4/24 R45 tested positive *On 3/6/24 R4 tested positive *On 3/22/24 R279 tested positive *On 3/27/24 R22 tested positive *On 3/29/24 R11 tested positive *On 3/31/24 R55 tested positive During an interview on 04/30/2024 at 10:58 AM, RN/ICP E reported the policy for transmission-based precautions for RSV for contact isolation only. RN/ICP E reported that initially she was placing residents positive for RSV in contact and droplet isolation, however, Corporate Infection Control Preventionist (CICP) T reported only contact precautions were required for RSV. During an interview on 04/30/24 at 01:20 PM, ICP E reported that she did not have an outbreak investigation for the RSV outbreak, because she wasn't trained how to do one. She reported that she knows now and moving forward outbreak investigations will be completed. During an interview on 4/30/24 at 02:50 ICP E reported that staff and residents were first tested for COVID and if that was negative, testing for RSV and Influenza was completed. Beginning in March 2024, a Resp-4-flex swab was obtained (COVID, RSV, Influenza A&B testing). ICP E reported if the COVID and Influenza testing was negative, contact precautions and standard precautions remained and droplet precautions were no longer implemented. During an interview on 5/1/24 at 10:28 AM, RNC A reported that the RSV vaccination was not offered to residents residing in the facility and was not required by CMS (center for medicare and medicaid services). Ongoing Respiratory Tracking On 4/30/24 there remained no system in place for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services despite the notification to the Regional Nurse Consultant (RNC) and Nursing Home Administrator of the serious concerns with the infection control program on 4/29/24. On 4/30/24 there were 2 residents (R67 and R278) that were started on cough medication for symptoms of a respiratory illness. There were no transmission-based precautions in place and no surveillance for an unknown respiratory illness (following an outbreak of Covid, RSV and Influenza from 12/9/23-3/31/24.). Review of R67's Order Summary dated 3/19/24 revealed, GuaiFENesin Liquid 100 MG/5ML Give 10 ml by mouth every 4 hours as needed for Cough. Review of R67's Medication Administration Record revealed R67 received a dose of the Guaifenesin (cough medicine) on 4/24/24, 4/28/24, and 4/30/24. Review of R67's Electronic Health Record revealed R67 had a diagnosis of pneumonia and received antibiotics for the diagnosis from 3/27/24-4/1/24. There was no documentation that R67 was being monitored for an increase in respiratory symptoms which required the use of guaifenesin. Review of R278's Order Summary dated 4/30/24 revealed, GuaiFENesin ER Tablet (Extended Release) 12 Hour 600 MG (milligram) Give 1 tablet by mouth every 12 hours for cough productive for 5 Days. Review of R278's Medication Administration Record revealed R278 received a dose of guaifenesin in the morning of 4/30/24 and the evening of 4/30/24. Review of R278's Electronic Health Record revealed R278 had a diagnosis of pneumonia and received antibiotics for the diagnosis from 4/11/24-4/21/24. There was no documentation that R278 was being monitored for an increase in respiratory symptoms which required the use of guaifenesin. During an interview on 5/1/24 at 2:32 PM, RNC A confirmed that R67 and R278 were not being monitored or tested for a possible respiratory virus (RSV, COVID, Influenza) and were not in transmission-based precautions. 29073 ENHANCED BARRIER PRECAUTIONS Resident #35 (R35) Review of an Admission Record revealed R35 admitted to the facility with diagnoses that included discitis of the lumbosacral region, cellulitis of the back, streptococcus as the cause of diseases classified elsewhere, and a pressure ulcer of sacral region. Review of a Care Plan revealed R35 was at risk for complications of IV (intravenous) therapy and had a PICC (Peripherally inserted Central Catheter) line to his right arm. Interventions included Enhanced Barrier Precautions: don gown and gloves during high-contact resident care. Review of the April 2024 treatment Administration Record (TAR) reflected R35 was in Enhanced precautions for medical indwelling device and chronic wounds-Start Date-4/10/2024. During an observation on 4/23/2024 at 10:38 AM, Signage on the door of R35's room indicated he required enhanced barrier precautions. The sign indicated providers and staff were to wear gloves and a gown for high contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy and wound care: any skin opening requiring a dressing change. A tower of Personal Protective Equipment (PPE) was available near the door. During the observation on 4/23/24 at 10:38 AM, Licensed Practical Nurse (LPN) S entered R35's room with IV (intravenous) supplies and medication. LPN C disconnected the current IV set from the pump, cleaned the PICC line with an alcohol swab and flushed the PICC line with normal saline. LPN C then [NAME] the new bag of IV antibiotics, attached new tubing to the bag, primed the tubing, attached the tubing to the PICC on R35's right upper arm, set the pump and left the room. LPN S donned gloves for the administration of the IV medication but did not don a gown. Resident #64 (R64) Review of an Admission Record reflected R64 admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, severe, pressure ulcer of right heel, stage 3, Methicillin Susceptible Staphylococcus Aureus (MSSA) and obstructive and reflux uropathy. Review of the April 2024 Medication Administration Record (MAR) reflected Enhanced Precautions every shift for medical indwelling device and chronic wound-Start Date-4/10/2024. During an observation on 4/23/2024 at 1:39 PM, signage outside R64's room indicated he was in Enhanced Barrier Precautions. PPE was in a tower outside the door. LPN Q entered R64's room and physically assisted R64 transfer from his wheelchair into bed and assisted R64 getting his legs onto the bed once seated on the edge of the bed. LPN Q disconnected his urinary catheter collection bag from the wheelchair and maneuvered the tubing and catheter while securing the device to the bed. LPN Q removed R64's shoes, socks, and with gloved hands, removed a dressing saturated with serosanguanious drainage from R64's right heel. LPN Q did not don a gown for the extensive contact with R64. During an observation on 4/23/24 at 3:37 PM., LPN Q was assisted by LPN C in completing a dressing change and catheter care. LPN C held up R64's left lower leg and support the foot while LPN Q cleaned and dressed the stage three pressure ulcer. LPN C also held up R64's right lower leg while LPN Q treated an area and photographed a wound on R64's right heel. LPN Q obtained three 10 milliliter pre-filled normal saline syringes, uncovered R64's lower body, leaned away from R64's catheter to avoid any splashes, separated/disconnected the drainage tubing from the catheter insertion near the urethra at the tip of the penis. LPN Q pinched the open end of the drainage tubing with her left hand, uncapped the prefilled syringe and flushed R64's urethra with all three syringes, one after the next. LPN Q then reattached the drainage tubing to the catheter emerging from R64's urethra. LPN Q and LPN C said they did not know why R64 was having his urethra flushed in this manner twice a day and did not know why the flush was being done with normal saline. LPN Q and LPN C did not don gowns or face shields to protect against contact or droplets during the procedures. 37577 Resident #228 (R228) Review of an Admission Record revealed R228 was a [AGE] year old female, last admitted to the facility on [DATE] with pertinent diagnoses of pneumonia, chronic kidney disease stage 3, and a recent fall with fracture. R228 is her own responsible party. During an observation/ interview at the nurses station on 04/24/24 at 11:50 AM, Nurse Practitioner (NP) H told RN I that an order to check R228 for c-diff (clostridium dificile-a contagious stomach disorder) was being placed into the computer. NP H had been made aware that R228 had loose watery stools. Review of physician orders for R228 revealed an order on 04/24/25 for: stool for c-diff (clostridium dificile-contagious stomach disorder) today due to loose stools. During an interview on 04/24/24 at 12:45 PM, the Director of Environmental Services indicated that if there is an outbreak, a change or addition to who is in enhanced barrier precautions, or if a patient is placed in isolation, the ICP/ADON notifies her and then the information is passed to the housekeeping staff right away. During an observation on 04/24/25 at 2:40 PM, R228 did not have any signage or PPE tower alerting staff and visitors that R228 was in isolation. During an interview on 04/2524 at 7:45 AM, the Director of Environmental Services had not been made aware of any changes to the rooms that are designated enhanced barrier precautions or isolation contact precautions. During an interview on 04/25/24 at 7:50 AM, CNA F (a) assisted R228 to use the bathroom without the use of contact precaution PPE, (b) reported being aware that stool samples were ordered for R228 to rule out c-diff, and (c) stated that until the results come back staff are to follow universal precautions. During an observation on 04/25/24 at 7:55 AM, R228's room did not have signage for staff to use contact precautions when entering the room, nor was there a PPE (personal protective equipment) tower outside R228's room. During an interview on 04/25/24 at 8:10 AM, RN G stated, if a patient had an order to check for c-diff, the patient is placed in isolation until the results are back. During an interview on 04/25/24 at 9:10 AM, the DON indicated that she had not been made aware that R228 was being tested for c-diff and that anyone being tested for c-diff is placed in contact precautions right away until the results are back.

Based on interview and record review, the facility failed to provide the pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for 1 (Resident #287) out of 5 reviewed for immunizations, resulting in residents not receiving the pneumococcal immunization. Findings: Resident #287 (R287) Review of an Admission Record revealed R287 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R287's Pneumococcal Immunization Consent revealed R287 consented/requested the pneumonia vaccine on 1/23/24. Review of R287's Nurses Notes dated 2/7/2024 revealed, (name omitted), an ER (emergency room ) nurse from (hospital), called and stated that the guest was being admitted r/t (related to) RSV (Respiratory Syncytial Virus), right lobe pneumonia, CXR (chest x-ray) showing failure . Review of R287's Nursing Summary dated 2/9/24 revealed, Guest out to the hospital for 2 overnights due to community acquired pneumonia and diagnosed with RSV . During an interview on 5/1/2024 at 3:10 PM, Infection Control Preventionist (RN/ICP) E reported that R287 did not receive the pneumonia vaccine. RN/ICP E reported that R287 admitted on the 1/23/24 and was discharged before RN/ICP E realized that R287 did not receive the pneumonia vaccine. I guess that I just missed that one. Review of the facility policy Immunizations: Pneumococcal Vaccination (PPV) of Guest/Residents last revised 3/27/23 revealed, I. GUIDELINE: The Advisory Committee on Immunization Practices (ACIP) recommends vaccinating persons at high risk for serious complications from pneumococcal pneumonia, including those [AGE] years and older and all guests/residents of nursing homes. Recognizing the major impact and mortality of pneumococcal disease on guests/guest/residents of nursing homes and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization and death, this facility has adopted the following policy statements: 1. All guests/residents of our facility should receive the pneumococcal vaccine if they are [AGE] years of age or older or younger than [AGE] years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease and its complications .

This citation relates to intake #MI00-140932 Based on observation, interview, and record review the facility failed to 1.) administer controlled medications following a physician order and professional standards of practice, 2.) ensure medications were administered following nursing professional standards of practice, and 3.) ensure medications were administered follow the physician ordered parameters for 6 residents (R13, R25, R58, R11, R275, R225), resulting in the lack of assessment, monitoring, and documentation, medication errors, and the withholding of medications without a physician order. Findings: Resident #13 (R13) Review of an Admission Record revealed R13 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R13's Order Summary revealed, Gabapentin Capsule 300 MG Give 1 capsule by mouth at bedtime for Pain Start Date 11/27/21. Review of R13's Controlled Substances Proof of Use form revealed R13 did not receive a scheduled dose of gabapentin on 3/30/24. (The medication was not signed out of the narcotic book). Review of R13's March Medication Administration Record revealed it was documented that R13 received her scheduled dose of gabapentin on 3/30/23. Resident #25 (R54) Review of an Admission Record revealed R25 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R25's Order Summary revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 0.5 tablet by mouth two times a day for Pain Start Date 11/27/23. To be administered twice a day at 8:00 AM and 8:00 PM. Review of R25's Controlled Substances Proof of Use form revealed R25 did not receive tramadol on 4/13/24 at 8:00 PM, 4/14/24 at 8:00 AM, or 4/20/24 at 8:00 PM. Review of R25's April Medication Administration Record revealed documentation that R25 received all scheduled doses of tramadol. Resident #58 (R58) Review of an Admission Record revealed R58 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R58's Order Summary revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth two times a day for pain AND Give 1 tablet by mouth every 12 hours as needed for pain Start Date 4/2/24. To be administered twice a day at 8:00 AM and 8:00 PM. Review of R58's Controlled Substances Proof of Use form revealed R58 did not receive her 8:00 AM dose of tramadol on 4/19/24. Review of R58's April Medication Administration Record revealed documentation that R58 received all scheduled doses of tramadol. During an interview on 04/23/24 at 12:44 PM, Director of nursing confirmed the medication errors for R13, R25, and R58 and reported immediate education on narcotic administration would begin. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R11's Order Summary revealed, Metoprolol Tartrate Oral Tablet 100 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Hypertension hold for hr (heartrate) below 60 or sbp (systolic blood pressure) below 100. -Start Date- 01/08/2024. To be administered at 8:00 AM and 5:00 PM. Review of R11's April Medication Administration Record revealed: *On 4/8/24 at 5:00 PM R11's heartrate was 56 and the metoprolol was administered. *On 4/10/24 at 5:00 PM R11's heartrate was 58 and the metoprolol was administered. *On 4/12/24 at 8:00 AM R11's heartrate was 58 and the metoprolol was administered. *On 4/19/24 at 8:00 AM R11's heartrate was 58 and the metoprolol was administered. Resident #275 (R275) Review of an Admission Record revealed R275 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes. Review of R275's Order Summary revealed, glipiZIDE Oral Tablet 2.5 MG (Glipizide) Give 1 tablet by mouth two times a day for DM (diabetes mellitus) Give before meals and hold if BS is <120 (hold if blood sugar is less than 120) -Start Date- 04/10/2024. To be administered at 6:00 Am and 5:00 PM. Review of R275's April Medication Administration Record revealed: *On 4/16/24 R275's blood sugar was 103 and the 6:00 AM glipizide was administered. *On 4/18/24 R275's blood sugar was 97 and the 6:00 AM glipizide was administered. *On 4/21/24 R275's blood sugar was 118 and the 6:00 AM glipizide was administered. During an interview on 4/23/24 at 3:35 PM, Licensed Practical Nurse (LPN) C reported the Director of Nursing (DON) had been working as a floor nurse all the time since the unit manager stepped down from her position. LPN C reported that due to the DON frequently working as a floor nurse, so much has fallen through the crack such as missed laboratory testing, missed treatments, and missed medications. LPN C reported a concern with the lack of follow through and follow up with nursing related concerns including medication errors and medications not administered following the providers orders/parameters. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, (Nurses) are responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Never document that you have given a medication until you have actually given it. Document the name of the medication, the dose, the time of administration, and the route on the MAR. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 610). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition. 37577 Resident #2 (R2) Review of an Admission Record revealed R2 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of diabetes mellitus, chronic kidney disease and is a kidney transplant recipient, and history of falling. During an observation on 04/23/24 at 7:59 AM, Licensed Practical Nurse (LPN) S checked R2's blood sugar, sat the glucometer on top of the medication cart without cleaning it and prepared the Lispro (insulin) pen for administration of 2 units per sliding scale. LPN S did not prime the pen prior to administering the insulin SQ (subcutaneous). When administering the insulin SQ, LPN S did not hold the pen to R2's skin for 5 seconds. Review of the manufacturer guidelines for use of a Lispro insulin pen reflected .priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin .insert the needle into the skin, push the dose knob all the way in, and continue to hold the dose knob in and slowly count to 5 before removing the needle. Resident #43 (R43) Review of an Admission Record revealed R43 was [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of heart failure, recent fall, chronic kidney disease-stage 3, unsteadiness on feet, and muscle weakness. Review of an Emar (electronic medication administration record) for R43, dated 04/01/24 to 04/30/24, revealed an order for Midodrine 5 mg (milligrams) give one tab in the morning for hypotension (low blood pressure) Hold if SBP (systolic blood pressure) is greater than 120. R2's blood pressure the morning of 4/12/24 was listed as 130/71 and the Emar indicates that the medication was administered to the resident, despite the blood pressure being outside ordered parameters. Resident #225 (R225) Review of an Admission Record revealed R225 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of fractured left clavicle (shoulder bone) and left hand, unsteadiness on feet, and muscle weakness. R225 is her own responsible party. During an interview on 04/22/24 at 10:19 AM, R225 reported that two evenings ago (Saturday 4/20/24) LPN R brought in her night time medications, set them down and quickly left the room. R225 stated that LPN R reeked of alcohol and maybe that's why she didn't stay until I took my medications. I think she (LPN R) was drunk. This concern was reported to the Administrator by this surveyor.

Based on interview and record review, the facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse in a facility with a daily average census of more than 60 residents resulting in a lack of consistent clinical services oversight and negative resident outcomes when the DON was a charge nurse for over 110 hours since January 2024. Findings: During an interview on 4/24/24 at 8:32 AM, the Director of Nursing (DON) reported that she has had to work as a charge nurse in the facility. The DON reported that because she is a salaried employee, she is supposed to keep track of the number of hours she works as a charge nurse on a form that is submitted for the Payroll Based Journal (PBJ) report. The DON said that she is getting better about accounting for the number of hours she has to work as a charge nurse. Review of Time Sheet-Exempt Staff forms from January 1, 2024-April 20, 2024, revealed the DON had worked as a charge nurse for over 111 hours. The weeks the DON worked as a charge nurse; she was not able to work Regular hours as the full-time DON. During an interview on 4/23/24 at 3:35 PM, Licensed Practical Nurse (LPN) C reported the Director of Nursing (DON) had been working as a floor nurse all the time since the unit manager stepped down from her position. LPN C reported that due to the DON frequently working as a floor nurse, so much has fallen through the crack such as missed laboratory testing, missed treatments, and missed medications. LPN C reported a concern with the lack of follow through and follow up with nursing related concerns. Review of the Director of Nursing Services job description specified The Director of Nursing plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents. During an interview on 4/24/2024 at 8:32 AM, the DON reported that a part of her oversight included running a report every morning on the Dashboard of missed medications and treatments. The DON could not explain why no follow-through regarding the missed treatments was completed to avoid future missed treatments and to prevent negative outcomes. According to the DON, Skin and Wound Evaluations are used to determine how wounds were progressing and that is what is used by the Interdisciplinary Team (IDT) during Resident at Risk meetings held every week to review concerns such as wounds. Resident at Risk meeting notes were requested at this time. During an interview on 4/25/24 at 1:00 p.m., the Nursing Home Administrator (NHA) reported that she could not find any evidence that R64 or R276 had been reviewed during Resident at Risk meetings pertaining to wounds. An Immediate Jeopardy (IJ) at F-686, Pressure Ulcer Prevention and Care, was identified on 4/24/2024 and began on 12/21/23 when facility licensed nurses failed to accurately assess, provide treatments as ordered, and ensure physician oversite for R276's newly identified pressure injury. R64 experienced the worsening/deterioration of the wound on his right heel due to missed treatments and developed an additional wound to his left heel with a delay in treatment. It was identified during the annual survey that Licensed Practical Nurses were administering IV medications through Peripherally Inserted Central Catheters (PICC) lines. The DON did not have evidence any LPNs who administered these treatments had oversight or specialized training to carry out these orders which was outside the scope of practice for LPNs.

This citation is related to intake #MI00140932 Based on observation, interview, and record review, the facility failed to ensure call lights were within sight and reach for 1 of 3 residents (Resident #70) reviewed for call light placement. Findings: Resident #70 (R70) Review of an Admission Record revealed R70 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of acute respiratory failure with hypoxia (low oxygen levels in the blood), chronic obstructive pulmonary disease (COPD), chronic pain, retention of urine, and severe protein-calorie malnutrition. During an interview on 04/22/24 at 11:06 AM, confidential informant (CI) O reported coming into R70's room multiple times and the call light was not within reach of the resident. During an observation on 04/23/24 at 10:30 AM, R70 laid in bed and the call light was out of sight and out of reach, draped over the footboard. During an observation on 04/23/24 at 11:50 AM, R70 laid in bed resting and the call light remained draped over the footboard, out of reach and out of sight of R70. During an observation on 04/25/24 at 8:05 AM, R70 sat up in the recliner resting with eyes closed and the call light sat curled up at the head of the bed, out of reach of the resident. During an observation on 04/25/24 at 9:00 AM, R70 sat up in the recliner receiving a nebulized breathing treatment and the call light remained curled up at the head of the bed, out of reach. Review of the facility policy Call Lights, last revised 02/15/22, revealed the following .when a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatments and orders were in place to prevent catheter associated urinary tract infections for 1 resident (Resident #64) out of 3 residents reviewed for catheters and urinary tract infections, resulting in the potential for complications from cross contamination and infections. Findings: Resident #64 (R64) Review of an Admission Record reflected R64 admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, pressure ulcer of right heel, stage 3, Methicillin Susceptible Staphylococcus Aureus (MSSA) and obstructive and reflux uropathy. During an on 4/23/24 at 3:37 PM, LPN Q was assisted by LPN C in completing a dressing change and catheter care. LPN Q obtained three 10 milliliter pre-filled normal saline syringes, uncovered R64's lower body, leaned away from R64's catheter to avoid any splashes, separated/disconnected the drainage tubing from the catheter insertion near the urethra at the tip of the penis. LPN Q pinched the open end of the drainage tubing with her left hand, uncapped the prefilled syringe and flushed R64's urethra with all three syringes, one after the next. LPN Q then reattached the drainage tubing to the catheter emerging from R64's urethra. LPN Q and LPN C said they did not know why R64 was having his urethra flushed in this manner twice a day and did not know why the flush was being done with normal saline. LPN Q and LPN C did not don gowns or face shields to protect against contact or droplets. Review of the April 2024 Treatment Administration Record (TAR) reflected an order Sodium Chloride Solution 0.9% Insert 30 cc (cubic centimeters) in the urethra every day and night shift for Cath Flush foley cath with normal saline flushes x3, BID (twice a day)-Start Date-9/20/2023. During an interview on 4/23/24 at 3:20 PM, the Director of Nursing (DON) was asked why there was an order for R64 to have twice daily catheter flushes with normal saline since 9/20/2023. The DON speculated the order came from a hospitalization and reported she would check into the matter. Review of an email dated 4/23/2024 at 3:33 PM indicated the DON had reached out to R64's urologist and were awaiting a return call. During an interview on 4/24/24 at 8:32 AM, the DON said she could not locate any information about where the order for catheter flushes in the manner ordered for R64 originated. During a telephone interview on 4/29/2024 at 2:00 PM, the Medical Assistant (MA) V for Urologist W treating R64, reported their office had been contacted by the facility DON regarding the catheter flushes. The MA V said that Urologist W did not order the catheter flushes and would not recommend them as opening the closed drainage system twice a day is a significant risk for infection.

Based on observation, interview, and record review, the facility failed to ensure best practice standards were followed for residents receiving supplemental oxygen, for 2 of 3 residents reviewed (Resident #67 and Resident #70). Findings: Resident #67 (R67) Review of an Admission Record revealed R67 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of chronic obstructive pulmonary disease and obstructive sleep apnea. Review of a physician order reflected the following for R67: Oxygen 2-3 liters per minute via nasal cannula as needed for shortness of breath. During an observation on 04/22/24 at 11:41 AM R67 received supplemental oxygen via a nasal cannula at 2.5 liters/minute. There was no date on the oxygen tubing indicating when it had last been changed. During an observation on 04/24/24 at 9:46 AM R67 laid in bed with eyes closed, receiving supplemental oxygen at 2.5 liters/minute via nasal cannula. There was no date on the oxygen tubing indicating when it had been changed last. Resident #70 (R70) Review of an Admission Record revealed R70 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of acute respiratory failure with hypoxia (low oxygen levels in the blood) and chronic obstructive pulmonary disease (COPD). Review of an Emar-Etar (electronic medication and treatment administration record) dated April 2024 did not contain an order for the rate of oxygen delivery that R70 received continuous and did not contain a documentation process to capture whether or not nursing staff observed the oxygen delivery regularly to ensure it was set correctly. Review of a Care Plan related to R70's respiratory needs did not contain an intervention of supplemental oxygen use and did not contain any concerns that staff should watch for with a patient who had COPD and received oxygen. During an observation on 04/22/24 at 11:01 AM, R70 received supplemental oxygen via a nasal cannula that was correctly in place. The concentrator delivering the oxygen was set at 3 liters. The oxygen tubing did not have a date on it, indicating when it was last changed. The bottle of water used to humidify the oxygen was not dated. During an interview on 04/22/24 at 11:05 AM, confidential informant (CI) O reported entering R70's room on several occasions and the oxygen had been cranked all the way up. CI O also reported that yesterday there were two nebulizer treatments loaded and ready for use. One sat at the foot of the bed and the other sat on the bedside table. During an observation on 04/23/24 at 8:00 AM, R70 sat up in the recliner, oxygen delivered via nasal cannula at 3 liters, and no date found on the oxygen tubing or bottle of water used to humidify the oxygen. During an observation on 04/24/24 at 8:25 AM, R70 sat up in the recliner receiving a nebulized breathing treatment. The oxygen tubing now had a sticker on it dated 04/18/24. The humidified bottle of water did not have a date on it. During an interview on 04/24/24 at 10:26 AM, the Director of Nursing (DON) could not explain why R70's oxygen tubing now had a date on it, and the date was from 4/18/24. The DON stated that a company comes in weekly and changes out all the necessary tubing on a weekly basis. The company has their own list that they use and will also look into rooms to see if there are any new residents here that require tubing changes.

Based on observation, interview, and record review, the facility failed to maintain safe water temperatures, resulting in the potential for scalding residents, affecting residents using the 200 hall spa, and Room #'s 214 and 204. Findings include: On 4/22/24 at 1:53 PM, the bathroom sink hot water temperature, of room [ROOM NUMBER], was measured using a digital probe thermometer and was found to be 123 degrees F. On 4/22/24 at 1:55 PM, the bathroom sink hot water temperature, of room [ROOM NUMBER], was found to be 127 degrees F. At this time, Resident #52 stated that the water gets very hot. On 4/22/24 at 2:04 PM, the 200 hall spa room hand sink hot water was measured to be 130 degrees F. During an interview on 4/22/24 at 2:12 pm, Maintenance Director U was queried on the hot water temperatures and stated that they turned the water temperature up to 140 degrees last year and discovered some sinks were missing point-of-use mixing valves, which haven't been installed yet. According to the facility's Water Temps, log, dated for April 2024, it notes the following high temperatures, Beauty Shop Hair Sink - 120.5, 107 Shower - 121.4, 109 Shower - 121.6, 300 Spa East Shower 122.3, 300 Spa [NAME] Shower 121.9. The log for March 2024 notes the following high temperatures, Beauty Shop Hair sink - 120.3, 100 Spa - 121, 300 Spa East Shower - 122.4, 300 Spa [NAME] Shower - 122.5. The logs consistently show water temperature levels over 120 degrees back to January 2024.

This citation pertains to intake numbers: MI 452, MI 252 and MI 584 Based on interview and record review, the facility failed to follow safety protocols and care plans to prevent falls for 2 Residents (R2 and R6), resulting in R2 falling and sustaining a [CONDITION(S)] and R6 falling with the potential for serious injury when staff did not follow the facility safety protocols. Findings include: R2 Review of R2's face sheet dated 7/12/22 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: encounter for other orthopedic aftercare (onset date 6/22/22), muscle weakness, unsteady on feet, unspecified fall (onset date 6/17/22), chronic pain, [CONDITION(S)], Dementia with Lewy Bodies, and dysphagia (swallowing difficulties). R2 was not his own responsible party. Review of an incident report for R2 dated 6/17/22 at 7:40 PM revealed, R2 was found on the bathroom floor, under environmental factors noted, Bed alarm not on. Item 12 noted, Alarm being used at the time of the fall? No. Disconnected. Item 13 noted, R2 was last toileted and/or changed or Catheter emptied 6/22/17 AM/PM 19:00 (not the date of incident) soiled, incontinent at the time of fall. Review of R2's Post Fall Evaluation dated 6/17/22 revealed, R2 fell in the bathroom on BM (bowel movement) his bed alarm was not on, he was alert and oriented x 2, forgetful, his bed alarm was disconnected. The root cause of this fall noted, Had to have BM (bowel movement), self-transferred to bathroom slipped in BM (bowel movement) on floor. Review of R2's hospital transfer form dated 6/18/22 at 3:00 AM revealed he was transferred to the hospital due a fall. Review of R2's hospital admission History and Physical note dated 6/18/22 at 3:15 AM revealed, This is a [AGE] year-old male who resides in a nursing facility who apparently got up without signaling the nurse and fell in the bathroom on a hard floor. There was no blood loss. The point of impact was the head, left hip, and left knee. The pain was present in the head, left hip and left knee. The patient was not ambulatory at the scene and no entrapment after the fall. No drug use with the incident. No alcohol with the incident as well. The symptoms were aggravated with activity, painful in his hip and he is having muscle spasms intermittently. In the emergency room , the patient was found to have an impacted left [CONDITION(S)]. Orthopedics was consulted through the emergency room , and they were in agreement that the patient will need operative repair. Review of R2's hospital noted dated 6/19/22 revealed he had hip surgery on 6/19/22, Closed reduction, percutaneous pinning of his left hip. Review of R2's progress noted dated 6/17/22 at 23:29 (11:29 PM) revealed R2 fell at 19:45 (7:45 PM). Was found in BR (bathroom) by CNA (Certified Nurse Aide). He had slipped on bowel movement. He had fallen on buttocks. He said he hit his head on the side of the vanity. Now (sp) injuries found. VSS (vital signs stable). Instituted Neuro checks, cranial nerve checks, Pt (patient) shaking due to [CONDITION(S)] and anxiety. O2 biox = 87% RA (room air). Asked pt to C&BB (unknown). Biox increased to 92%. (Name of physician assistant) notified. A telemedicine visit was obtained. Biox improved to 94%. O2 started at 2L/NC (liters nasal canula). Review of R2's progress note dated 6/17/22 at 12:16 AM revealed, CENA (Certified Nurse Aide) asked me to look at resident today. Noted increased swelling BLE (both lower extremities) and left foot purple and cold. and (sp) LUE (left upper extremity) has discolored area with localized area of swelling and to touch no redness or warmth noted. Left hand is cold. (name of nurse practitioner) assessed. Increase [MEDICATION(S)] (water pill) ordered for LE (left extremity) swelling and feet elevated in wheelchair with foot buddy in wheelchair for safety. also (sp) ordered LUE ultrasound. Review of R2's fall care plan dated 3/2/21 and revised on 6/22/22 revealed, an intervention dated 4/7/21, offer toileting upon arising, before and after meals, before bed and prn. Another intervention dated 5/8/21, Sensor alarms to bed and wheelchair for safety. Check placement and function Q shift as ordered. Review of Certified Nurse Aide) CNA B's Employee Disciplinary Record dated 6/20/22 revealed, Rule Violation: #28 making errors of sufficient magnitude which may jeopardize Guest Safety and Welfare. Supervisor's Remarks: failed to turn on resident alarm when putting him to bed or make sure alarm was functioning before leaving his room. Therefore, causing safety risk. Counseling/Discussion/Agreement: Do not turn off resident alarms. If they are not working properly then you need to alert the nurse for a new alarm and to make sure that he is supervised until alarm is functioning. Written warning. Signed by CNA B on 6/20/22 and Licensed Practical Nurse (LPN) G CNA B supervisor and unit manager. Upon entrance to the facility R2's full investigation for his fall on 6/17/22 was requested to be scanned and emailed to the Surveyors. The facility provided a past non-compliance packet and a facility reported incident investigation. The packet for non-compliance and the facility investigation did not include staff interview statements. Prior to exit the facility did not provide any witness or staff interview statements. Review of the facility past non-compliance packet dated 6/17/22 revealed it was for the incident on 6/17/22 when CNA B left R2 unattended in bed with his fall alarm turned off. There was no mention of the incident where CNA B failed to follow the facility protocol of a two person lift transfer with R6 that resulted in R6 falling during the transfer on 7/4/22. There was no indication in the past non-compliance that the facility was doing an intervention to ensure CNA B was going to comply with the facility safety protocols or properly care for residents. The past non-compliance noted, A CNA was providing care to a guest and had turned off the fall alarm on the bed because it kept sounding. The fall alarm pad was placed too high in the resident's bed and needed to be readjusted. Upon completion of cares to the guest the employee forgot to turn on the alarm before exiting the room. The resident self-transferred to the toilet, fell in the bathroom and sustained a fracture to his left femur. Review of CNA B's Employee Disciplinary Record noted dated 6/27/22 revealed CNA B was given a written warning for failure to respond to patients' needs. In supervisor's remarks was noted, Many residents on your section were left wet when the next shift came on duty, Residents were not checked on every 2 hours and changed/toileted if needed. After Counseling/Discussion/Agreement noted, According to report given many were toiled one time on your shift and was in in the morning. Will be placed on 30 day action plan with continued monitoring and evaluation after 30 day. No action plan was attached. There was no documentation of an action plan. During an interview with CNA B on 7/11/22 at 2:16 PM she confirmed that she left R2 unattended in bed on 6/17/22 and was aware his bed alarm was not functional. CNA B said there was another CNA D in R2's bathroom at the time and CNA D said she would fix R2's alarm when she could not get it to work correctly so she went on to do other care. CNA B said she had taken R2 to the bathroom prior to putting him in bed. CNA B said R2 urinated but did not have a bowel movement. CNA B was not aware CNA D had not fixed the alarm until she found out R2 had fallen in the bathroom. CNA B was asked if she gets the help, she needs or was having any problems with staff or care concerns. CNA B denied any staff or care concerns ongoing. During an interview with CNA D on 7/12/22 at 9:32 AM in a resident room not in use, CNA D recalled the night R2 fell in the bathroom when his bed alarm was not on. CNA D said she was in the bathroom with R2's roommate when CNA B was putting R2 to bed. CNA D said CNA B got upset when R2's bed alarm kept sounding. CNA D said she told CNA B she needed to check the placement of the bed alarm. CNA D denied any knowledge of CNA B turning of R2's bed alarm. CNA D assumed CNA B fixed the problem when the alarm stopped sounding. CNA D said she did not verify R2's alarm was on when she left as she was not the one providing care and CNA B did not indicate there was an ongoing problem. CNA D said she had reported CNA B's failure to turn R2's alarm on the night of the fall to the Nursing Home Administrator (NHA) and the Director of Nursing (DON). CNA D said she also reported CNA B refused to toilet or do peri care for male residents to the NHA and DON. CNA D said she did not think CNA B had taken R2 to the toilet prior to putting him in bed because she was the one that cleaned him up when he fell , and he was covered in urine and poop. CNA D said R2 can usually tell you when he needs to use the bathroom and usually completely empties. During an interview with the Assistant Director of Nursing (ADON) on 7/12/22 at 9:49 AM. The ADON confirmed CNA B received discipline for leaving R2's alarm off when she put him to bed on 6/17/22, was provided discipline for not responding to patients needs/leaving them soiled more than 2 hours on 6/27/22 and received an educational opportunity when she did not have assistance transferring R6 on 7/4/22 and R6 fell during the transfer. The ADON acknowledged CNA B's personnel record did not have any record of the Action Plan that was to be started on 6/30/22 or the education related to not following the facility safety protocol when transferring residents in a lift on 7/4/22. The ADON said she had not started CNA B's action plan as CNA B's supervisor's last day was July 1 and she had been doing her job duties along with CNA B's job duties. An action plan was provided by the ADON after the interview on 7/12/22 at 9:49 AM. The plan was labeled, Educational Opportunity for CNA B dated 6/27/22. The plan noted, Area Addressed: 30-day improvement plan. Discussion: Must show weekly improvement in areas of toileting and resident care. Should do walking rounds with on coming staff. Residents should be dry and all duties completed at end of shift. Plan Will evaluate weekly and at end of 30 days evaluate job status. This form was not signed or dated after the statement I have read and understand the above statements. No indication CNA B knew she had a 30 day improvement plan started. No indication this plan had been implemented. R6 Review of R6's face sheet dated 7/12/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: dementia, symptomatic [CONDITION(S)] and epileptic syndromes with complex partial seizures, pain in left knee, history of falling and neuralgia (nerve pain). R6 was not her own responsible party. Review of facility provided Incident Report with an incident date of 7/4/22 revealed at 12:45 PM R6 was involved in a witnessed fall. R6 fell out of EZ stand (lift equipment). Per the report, CNA B was transporting the resident from shower/bathroom when the resident slipped their arms out of the ez stand. R6 was noted to be in bare feet. The immediate interventions to prevent recurrence were: Educated CNA that resident should have non slip socks on during transfers [and] that EZ stand requires 2 staff. Review of an Educational Opportunity for CNA B dated 7/8/22 revealed, As a minor you may only operate equipment such as, mechanical lifts as a spotter or a second person to assist with transfer. There was no indication CNA B had independently transferred R6 on 7/4/22 with a mechanical lift and it resulted in a fall. This was the second safety violation noted since 6/17/22 for CNA B. There was no indication of discipline or ongoing training or monitoring of CNA after the incident on 7/4/22. CNA B was still working on 7/11/22 and did not indicate any ongoing work performance issues when interviewed while working on 7/11/22 at 2:16 PM. Review of document Root Cause Analysis provided by the facility on 7/12/22 revealed: On 7/4/22 at 12:45 pm, [R6] had a witnessed fall in her room during a transfer. [R6] had just finished being assisted with a Shower and was had (sic) returned to her room. She was being assisted by cena, [CNA B] who was transferring her into bed from the wheelchair using the EZ-Stand lift. Per interview with [CNA B], [R6] became tired and began to let go of the handles of the Ez-Stand and slipped out just as she was about to be lowered to the bed, and slid down the side of the bed and down to the floor. Per interview with [LPN N], who was [R6's] nurse at the time, [R6] also had bare feet for the transfer which also may have contributed to the fall .The nurse verbally educated the cena on how to properly use the lift, including proper foot wear and using the assistance of two staff for mechanical lifts .The contributing factors that led to the fall was the cena using the lift by herself and improper foot wear. [R6] had just had a shower and was fatigued at the time. The cena was provided with a written education on transferring with mechanical lift and she stated understanding.

This citation pertains to intake #: MI 832 Based on observation, interview and record review, the facility failed to meet the emotional and/or behavioral needs for 3 residents when they failed to 1). Identify and assess residents with a history of trauma and/or adjustment difficulty and implement the appropriate treatment and/or services and 2.) identify and implement facility policy for 1 resident (R4) after an actual attempt of suicide (wrapped a call light cord around her neck) and 2 residents that had verbalized thoughts of self-harm and feeling they would be better off dead (R67 and R9), resulting in an Immediate Jeopardy beginning on 1/27/22 when R67 expressed the desire to kill himself and went without safety interventions. This deficient practice resulted in the diminished quality of life for the residents with suicidal ideation and thoughts of self-harm, psychosocial distress, recurrent thoughts of death, and increased depression and the potential for psychosocial disorders to go untreated and to decrease the residents' overall well-being. This deficient practice created the high likelihood of serious harm, injury, and/or death for residents experiencing psychosocial distress. Findings include: Review of the facility policy, Suicide/Self-Harm Attempt last revised 10/14/21 revealed, Most suicide attempts are preceded by warning signs. DO NOT IGNORE WARNING SIGNS. Suicide/self-harm attempts and completed suicides have occurred in nursing facilities. Some warning signs are .Suicide threats or similar statements-often people who commit suicide talk about it first. They may say something very direct, threaten to end their lives, or talk about wanting to be dead .High risk behavior divergent from baseline. Loss in personal life-Death of loved one, loss of independence. PROCEDURE 1. Guest/Residents are screened for psychosocial well-being and mood state through the PHQ9 process admission, quarterly, with significant change and as needed. i. Guest/Residents determined through this process to have thoughts of suicide or self-harm will have a care plan developed with interdisciplinary interventions and medical consultation. 2. If at any time guest/resident shows warning signs such as verbally expressing self-harm or demonstrates, by physical action, a desire to harm self, a licensed practitioner (nurse or social worker) should conduct an interview with the guest/resident in a private environment and notify the physician .3. At such time that signs and/or symptoms of suicide or self-harm are exhibited, the guest/resident is not to be left unattended (immediately place on 1:1 supervision). A charge nurse or other nurse manager should be informed of the risk. 4. As soon as possible, but within 24 hours, the guest's/resident's physician, psychiatrist, or psychotherapist will assess and evaluate the level of risk and further recommended supervision, treatment or emergency hospitalization . 5. A room and body search will be ordered and conducted immediately, following facility policy, to remove potentially dangerous objects .7. If it has been determined that the guest/resident is not in immediate danger for self-harm outside referrals will be made as appropriate and follow up is (sic) needed from appropriate parties as situation determines. This may include physician, psychologist, social services, therapy, and hospice. DOCUMENTATION 1. Update care plan as needed: i. Behavior ii. Planned interventions iii. Safety precautions 2. Key documentation in (Electronic Health Record EHR): i. Document the guest/resident mood/behavior, temperament, activity level exhibited, statements from guest/resident or any other observations identified in the medical record until symptoms have resolved ii. Observations and findings of physician, psychiatrists, and other health care professionals iii. Physician and family responsible party notifications iv. Behavior charting as indicate (sic). Review of The Fundamentals of Nursing (Potter and Perry) 10th edition revealed, Older adults sometimes experience late-life depression, but it is not a normal part of aging. Depression is the most common, yet most undetected and untreated, impairment in older adulthood. It sometimes exists and is exacerbated in patients with other health problems such as stroke, diabetes, dementia, [CONDITION(S)], heart disease, cancer, and pain-provoking diseases such as arthritis. Loss of a significant loved one or admission to a nursing center sometimes causes depression .Of special note, suicide attempts in older adults are often successful. Suicide rates in all age-groups are on the rise over the past several years; the age-group of [AGE] years of age and older has the second highest suicide rate of all age-groups (American Foundation for Suicide Prevention, 2018). Therefore, suicide prevention considerations for older adults are similar to those for the general population. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (pp. 182-183). Elsevier Health Sciences. Kindle Edition. Review of The Fundamentals of Nursing (Potter and Perry) 10th edition revealed, When patients attempt suicide within health care settings, it is typically alleged that nurses failed to provide appropriate individualized care, supervise the patient adequately, and adhere to existing policies and procedures to keep the patient safe. When providing care to patients with mental illnesses and SUDs, consider the scope and standards of nursing care as well as the specific statutes and regulations associated with their care. You also need to know your employer's policies and procedures when caring for patients at risk of harm. Integrate this knowledge to provide evidence-based nursing and to ensure that your documentation reflects the care you provided. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (pp. 309-310). Elsevier Health Sciences. Kindle Edition. Resident #4 (R4) Review of an Admission Record revealed Rr was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) assessment with a reference date of 6/11/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R4 was cognitively intact. R4's MDS assessment with a reference date of 9/9/21 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R4 was cognitively intact. R4's MDS assessment with a reference date of 12/8/21 revealed a BIMS score of 14, out of a total possible score of 15. Review of a MDS assessment for R4, with a reference date of 3/9/22 revealed a Staff Assessment for Mental Status which described R4's cognitive status as Short-term and Long-term Memory Ok, Cognitive Skills for Daily Decision Making Independent-decisions consistent/reasonable, Acute Onset Mental Status Change No. Review of R4's Nurses Note dated 3/8/19 revealed, Resident with suicidal idealization, stated I want to die, I will kill myself, It will happen today I am sick of living like this. Resident had attempted to put call light around neck, then when that was taken attempted to take string from light and was first going to put it around her neck .if I am given the opportunity I will kill myself, there is no use in stopping me . There was no documentation to support immediate interventions to provide safety or mental health wellbeing to the resident. Review of R4's Care Plan initiated on 3/20/19 revealed, (R4) has the potential to demonstrate physical, verbal aggression R/T (related to): Anger, Depression, Ineffective coping skills, Mental Illness, Poor impulse control . Report to physician of imminent danger to self and others. Provide safe environment per physician instructions . (R4's Care Plan did not include using the call light for suicide/self-harm). Review of R4's Nurses Note dated 10/17/20 revealed, .The resident was noted with her call light on and when it was answered it was wrapped around her neck, but resident would not talk . (R4's Care Plan was not updated to reflect her use of the call light for suicide attempt/self-harm and no new interventions were implemented.) Review of R4's Nurses Note dated 7/18/21 revealed, cena (nurse aide) came to this nurse stating that this resident had the call light around her neck 2 times, call light was removed, bell given in replacement of call light, resident refused to take medications, resident then knocked food tray onto the floor, ask resident why she would do that and continues to yell at staff to get the hell out of my room you dirty (B****). 15-minute checks started, will continue to monitor. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe). Review of R4's Care Plan initiated on 3/20/19 pertaining to self-harm revealed a newly added intervention No description provided Date Initiated: 07/18/2021. (Indicating no new care planned interventions were added to R4's Care Plan). Review of R4's Nurses Note dated 7/20/21 revealed, Resident was requesting call light cord to be placed back in her room to use. DON was consulted. Resident states she is not going to harm herself (sic) with the call cord, and shows no sign of wanting to harm herself (sic). Call light cord was given to this (sic) resident and she has been using it appropriately (sic) at this time. (No documentation that she was evaluated by the Physician or Psychiatrist prior to the return of the call light. R4's Care Plan did not reflect new interventions to keep R4 safe). Review of R4's Nurses Note dated 1/5/21 revealed, Staff member went back into residents room to check on her status resident had call light wrapped around her neck. Call light was removed from room and bell given to resident which she threw across the room. Resident is now on 15 minute checks for the remainder of this shift. (R4's Care Plan did not reflect new interventions to keep R4 safe. No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe). Review of R4's Behavior Note dated 3/3/21 revealed, .D/t (due to) safety reasons RN took out call light & placed call bell in room . (Indicating R4 was exhibiting self-harm/suicidal behavior. No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe). Review of R4's Nurses Note dated 3/15/22 revealed, Staff alerted this nurse resident had wrapped the call light cord around her neck three times. This nurse assessed area around residents neck, no signs of injury noted. Asked resident why she had placed the cord around her neck, resident did not verbalize to this (sic) nurse why, eyes noted to be open and respirations even an non labored (sic). I asked resident if she wanted to harm herself and again resident did not respond back to this nurse. I asked patient if she was in pain and no response. No visual s/s (signs or symptoms) of pain present. Resident in bed resting with mat at bedside, w/c(wheelchair) at bedside and bed in lowest position. 15 min checks initiated at 2100 (9pm), call light cord removed and resident provided with a bell. This nurse spoke with on call nurse, informed her of current situation, she will address with social worker to further address as indicated and aware of interventions in place. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe). Review of R4's Social Services Note dated 3/16/22 revealed, SS (social services) met with resident to discuss what happened the evening before, more details in nurses notes dated in 3/15/22. Resident denied having thoughts of being better off dead and denied having a plan to harm herself. The IDT (Interdisciplinary Team) met and determined it was safe for resident (sic) to have the call light. Resident was given it back this afternoon, the bell was taken away. Resident has been resting and watching TV throughout the day. SS to follow up as needed as needed or requested. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe). Review of R4's Late Entry Nurses Note written by Unit Manager (UM) K, created on 3/22/22 at 3:19 P.M., and dated 3/16/2022 revealed, this nurse went in to talk to resident regarding what happened with call light. when asked about the cord being wrapped around her neck, she stated that staff had placed it over her chest and she was attempting to move it behind her head where she likes it and it ended up around her neck. This nurse proceeded to ask about it being wrapped several times around her neck not just once and she stated that she did not wrap it around her neck on purpose. I asked her if she was trying to harm herself and she stated no and again said that it was staff and that she did not intend to purposely put it around her neck. She did not like having to use the bell that was given to her. I informed her that I would give her call light back providing that she did not put it around her neck and make sure she told staff where she likes it to be placed. call cord given back to her. resident was happy and satisfied and ensured this nurse that there would be no further issues. Review of R4's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . I was approached today by nursing that patient has been threatening to end her life and secondary to which we are doing an emergent telehealth visit. Today on my interview the patient denied having any suicidal ideation or any plan to harm herself. She does mention that she has been feeling a little more depressed regarding her general debility . Review of a Nurses Note dated 3/24/22 revealed, on 3/23/22 Administrator spoke to (Nurse Practitioner name omitted) about guest wrapping cord around her neck and that this has occurred (sic) several times. She stated that she would see her when she comes in and if she exhibits any suicidal (sic) ideation send her to ER. During an interview on 3/22/22 at 3:30 P.M., Social Services Director (SSD) J reported that any time a resident reports suicidal idea or exhibits self-harm behavior the facility policy is put into place. SSD J stated, Any time a resident shows warning signs-demonstrating or desire, licensed practitioner should conduct interview and notify physician, search the resident and the room, place resident on a 1:1, and document in the electronic health record. SSD J reported that on 3/15/22 was accidental and R4 was tangled in the call light. SSD J reported that because she reported she did not have a plan, the facility protocol for suicidal ideation/self-harm was not implemented but R4 was placed on 15-minute checks. SSD J reported that she was not aware of any other incidence of R4 wrapping the call light around her neck. SSD J reported that had she know that R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/22/22 at 04:12 P.M., UM K reported that she wrote a Nurses Note on 3/22/22 regarding an interview she had with R4 that occurred on 3/16/22. UM K reported that she was the nurse on call the evening of 3/15/22. UM K reported that R4 reported to her that the call light cord around her neck was an accident. UM K reported she was aware that R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . UM K reported that she had not interviewed her previously about her self-harm/suicidal behavior. UM K reported that immediately following the self-harm/suicidal behavior, the nurse on duty should have contacted the physician and the guardian and implemented the facility policy. UM K reported that R4 could have changed her story with me and reported it was an accident instead of self-harm/suicidal behavior. UM K reported that the Social Worker would be responsible for following up with the psychiatrist and physician regarding the self-harm/suicidal behavior and would monitor the resident closely. Review of R4's Nurses Note dated 3/24/22 revealed, Guest's guardian stated that she would like (psychiatric service name omitted) to see and work with guest. She also stated that she wouldn't be opposed to medication changes to improve mood and behaviors. (Indicating R4's guardian was not notified of the incident on 3/15/22 until 9 days later.) Review of R4's Social Services Note dated 3/25/22 revealed, SS (Social Services) attempted to contact resident's daughter, (name omitted) to get more background information on resident and potentially their relationship and any information that would be beneficial for the facility as they continue to care for resident .SW (Social Work) spoke (with) (daughter) requesting additional background information on (resident) in order to better serve and provide care . (Daughter) suspected, although not confirmed, abuse from (resident) father toward (resident) when (resident) was a child .considerable and daily alcohol use . (Indicating an individualized care plan that addresses the assessed emotional and psychosocial needs of the resident was not completed prior.) Review of R4's Care Plan created on 3/25/22 revealed, (R4) experienced physical abuse from her father throughout childhood. She has a hx (history) of considerable alcohol abuse throughout adulthood according to (daughter) .Goal-Care and current situation will not be influenced by past trauma-Will feel safe in current situation Interventions-Encourage resident/guest to be involved in activities and be engaged with other as possible and desired .Establish and maintain a trusting relationship .Maintain a calm non-threatening relationship by listening to the resident/guest .Provide reassurance to the resident/guest that he/she is safe and the facility is doing what is needed to maintain safety for all. (Indicating the facility failed to acknowledge and assess the underlying causes of the resident's expressions of distress or develop and implement a care plan that addressed this distress prior). Resident #67 (R67) Review of an Admission Record revealed R67 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment for R67, with a reference date of 1/9/22 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R67 was cognitively intact. Review of a MDS assessment for R67, with a reference date of 3/2/22 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R67 was cognitively intact. Review of Resident Mood Interview revealed R67 had Thought that you would be better off dead, or of hurting yourself in some way-Yes-12 to 14 days (nearly every day). Review of R67's Care Plan revealed, (R67) has the potential for fluctuations in mood R/T: DX of [CONDITION(S)], UNSPECIFIED, suicidal ideations Date Initiated: 01/10/2022 Revision on: 3/10/2022 .Behavioral health/psych consults as needed and follow recommendations as indicated. Date Initiated: 01/10/2022 . Should (R67) be expressing a desire to harm self or others provide 1:1 monitoring, follow suicide protocol and report to physician immediately. Date Initiated: 03/10/2022 . R67's Care Plan was not updated with interventions following his suicidal ideation on 1/27/22 until 3/10/22 after his second verbalization of suicidal ideation on 3/2/22. Review of a Nurses Note dated 1/27/22 revealed, During shift change another guest informed off going night nurse that this guest had expressed the desire to kill himself during breakfast. Other guest informed night nurse this guest stated I would do it if I could. Night nurse went and spoke to this guest, informed this writer that he does not have a plan to hurt/kill himself but that due to his medical/physical condition he wants to die. Informed social worker of (R67's) comments. Will check on guest frequently throughout day. No documentation that R67's physician and family were notified of his suicidal ideation or that the facility policy was implemented. Review of R67's Social Services Note dated 1/27/22 revealed, SS (Social Services met with resident regarding the comments he made during breakfast, expressing thoughts of wanting to harm himself. Resident states he is just frustrated at the lack of progress he is making in therapy, and how he sees other residents on 100 hall walking and how he just wants to be able to walk. Resident also upset because he would like to see his family more, but understands that they are working and that they are busy. He jokes: I use to be like that, they probably got it from me. SS informed him that rehab director had ordered the knee extension brace, which staff seemed optimistic that this could lead to progress towards his goal of being able to walk. Resident seemed encouraged by this. He states that progressing in therapy could boost his morale, but when asked if anything else the staff could do to help boost his morale, he stated no. SS and resident both agreed that it was important that he keeps a positive attitude and resident stated he would try his best. When asked if resident had any plans to harm himself at that current moment, he stated no, he was fine. SS once again reiterated to keep a positive attitude. Resident had no unmet needs or wants. SS to follow up as needed or requested. No documentation that R67's physician and family were notified of his suicidal ideation or that the facility policy was implemented. No documentation that R67 had follow up with suicidal ideation from physician, psychologist, family or social services from 1/27/22-3/1/22. Review of R67's Social Services Note dated 3/2/22 revealed, .Resident scored a 6/27, indicating s/s (signs and symptoms) of possible mild depression. Resident states having little interest in doing things and thoughts of wanting to harm himself for 12-14 days. Resident is having an exceptionally hard time transitioning to being a LTC (Long Term Care) resident here at the facility. He states he would like to be up and walking more and is feeling lonely and feeling like a burden on his family. SS (Social Services) spoke with him about having a staff member walk him to the dining room for his meals, he was very open to this idea .SS asked resident if he would be open to speaking with the (contracted psych services) psychologist. He stated he would be very open to that. SS to get that set up. Nursing staff aware . No documentation that R67's physician and family were notified of his suicidal ideation or that the facility policy was implemented. No documentation that R67 had follow up with suicidal ideation from physician, psychologist, family or social services from 3/3/22-3/23/22. During an interview on 3/22/22 at 3:30 P.M., SSD J reported that R67 had expressed feelings of suicidal ideation to her but did not have a plan. SSD J reported that if a resident makes comments of suicidal ideation the physician is immediately notified. SSD J reported that she had not yet obtained a consent for treatment from the contracted psychiatric service. During an interview on 03/23/22 at 10:40 A.M., R67 reported that he was feeling sad and there's nothing I can do about it. R67 stated, If I had a chance to kill myself I would. If I could get a pill I would. R67 reported that he feels suicidal when thinking of his health and not being able to walk, I just can't picture sitting here the rest of my life. R67 reported he was independent until recently and was struggling with the thought of having to sell his and I have to get rid of all of my belongings and there's nothing I can do. R67 stated, If I could just die and get out of here, I'd do it. I wouldn't hesitate. R67 reported that it feels good talking to you. It helps to talk to people. R67 reported that it was also help his depression if he could be given a realistic plan for his recovery and future goals, if I knew the plan, what i could (physically) do, that would help so much. Knowing what my future holds would fix my depression. To know what's going on. I keep mentioning I want to see a doctor and know the plan. R67 stated, so far, I'll I've heard is a bunch of talk. So many people come by, but it's the last I see them. They come in and talk about it (depression/suicidal ideation) and then they're gone. During an interview on 03/23/22 at 10:54 A.M., SSD J was notified of R67's ongoing suicidal ideation. SSD J reported that she would be following up with R67 and would obtain a consent for treatment by the contracted psych service. Review of R67's Social Service Note dated 3/23/22 at 11:58 A.M., revealed, SS met with resident to assess his psychosocial wellbeing. Resident stated he was doing 'okay as I could be'. SS let him know she would (sic) glad to hear that but express (sic) concerned (sic) at his recent statements of suicide. Resident states he feels that way as he is still adjusting to life at the facility and that he is unable to walk like he would like to .SS circled back to the statement about suicide, and resident stated he wanted to try and 'work through it mentally', SS made him aware that that was one way to work through those certain thoughts, there is no shame in starting a medication to help with those thoughts of suicide. Resident agreed. Resident states he is mainly upset at that he needs more help than other resident at times, which SS told him it is nothing to be ashamed of, and that it is always okay to ask for help. Due to resident making statements of wanting to harm himself, resident was placed on a 1:1, and had certain items that he could potentially harm himself. These items were inventoried and scanned into (EHR). Resident was given a bell to use, and was extremely agitated at the staff who removed the items. Email was sent to (contracted psych service) psychologist to see how soon resident can be seen. Waiting to hear back. (name omitted Nurse Practitioner) was notified and would be seeing him today to assess him .The physician was also notified to assess him later today. Resident gave permission to let the staff call his daughter to make her aware of the situation. Mood care plans updated. (Indicating the facility policy was not implemented until approximately 8 weeks after the first suicidal statement). Review of R67's Nurses Note dated 3/23/22 revealed, Spoke with guest and received permission to speak with his daughter. Daughter (name omitted) called and informed about her dads statements of wanting to take a magic pill to end it. She states that he is probably depressed because of his current situation of having to be living in a nursing home; because, prior to this he was living alone even shoveling snow, then the next day being unable to get out of a chair. She states that she doesn't believe that her father would ever hurt himself that he is kind of dramatic. Explained our facility policy and what has taken place and that he is upset and stating that he will not say anything to anyone again. Informed her that we will have the NP and Physician see him today in hopes of getting him on some medication for depression. Will also have guest seen by (contracted psych service). He has been placed on 1:1, all items that could be used to harm himself have been removed per policy. Guest has a bell to ask for assistance at this time. Will continue to observe for further issues. Review of R67's Nurses Note dated 3/23/22 revealed, .New order was obtained for [MEDICATION(S)] 25 mg po qd (by mouth every day) . (Indicating treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9(R9) R9 was admitted to the facility 9/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 13 which indicated the Resident was cognitively intact. Review of the Electronic Medical Record (EMR) did not reflect that R9 was currently prescribed any anti-depressant or anti-psychotic medication. Review of the EMR Progress Note entered by Director of Social Services Social Worker (SW) J on 3/14/22 at 5:38 PM reflected a BIMS evaluation and PHQ 9 had been completed with R9. The documentation of the encounter reflected (R9) stated having little interest in things because I just don't care and having thoughts of being better off dead. The documentation of the encounter also reflected, (R9) states having trouble falling asleep and feeling tired for 7-10 days. Review of page 10 of the Care Plan for R9 reflected a Need that R9 is at risk for decline in cognition and has impaired cognitive function or impaired thought process . An intervention for this care area initiated 9/10/21 reflected, Observe and report to physician any changes in cognitive function including but not limited to decision making ability, changes in baseline (cognitive function) .mental status. And Report to Nurse any changes in cognitive function .sleeplessness/lethargy . Review of the EMR for R9 did not reveal any documentation that the physician or nursing had been notified regarding the Resident's statements of having thoughts of being better off dead or sleeplessness. The EMR did not reflect any further documentation of monitoring or follow up to these statements. No documentation was found that measures were implemented to ensure the safety of R9. No documentation was found that a mental health professional was informed or had completed an evaluation of R9 as soon as possible or within 24 hours as directed by the facility policy. The EMR did not reflect that Care Plan measures in place at the time of the interview by SW J on 3/14/22 were implemented nor was the Care Plan updated. The EMR did not reflect the family or responsible party was notified of the warning signs exhibited by R9. A review was conducted of the PHQ 9 form, a form associated with the MDS process and assists in determining a resident's depression, for R9 completed 3/14/22 by SW J. This PHQ 9 form revealed documentation that R9 had little interest or pleasure in doing things, had 'Trouble falling or staying asleep and having little energy. Question 9a revealed the question Thoughts that you would be better off dead, or of hurting yourself in some way. Question 9a reflected R9 had answered yes. The PHQ 9 form reflected the answer was an MDS trigger. A review was conducted of the associated form titled Assessment Trigger Section PHQ 9 (MDS 3.0). This form repeated the question Thoughts that you would be better off dead, or of hurting yourself in some way and indicated a response of no despite R9 answering yes to this question. On 3/24/22 at 2:15 PM an interview was conducted with the Minimum Data Set Registered Nurse (MDS RN) L . MDS RN L reported that any answers recorded on an MDS form would carry over to the actual MDS. In an interview conducted 3/22/22 at 3:49 PM SW J the EMR Progress Note of 3/14/22 encounter with R9 was reviewed. SW J indicated she did not follow the facility policy when R9 expressed warning signs of self-harm. SW J reported that she did not contact the physician [TRUNCATED]

This citation pertains to intake #: MI 832 Based on observation, interview and record review, the facility neglected the psychosocial needs of its residents when they failed to 1.) ensure staff were educated and qualified to systematically and accurately assess resident mood and behavior, 2.) identify and address signs and symptoms of psychosocial distress and promptly respond to suicidal residents (R4 and R67) and residents who reported suicidal ideation (R9) and clinically significant mood and behavior disorders, 3.) notify the physician, family/responsible party, and psychiatric services of psychiatric crisis, 4.) ensure resident safety, assess resident environment, provide ongoing supervision and monitoring, 5.) implement care planned interventions and ensure care plans are comprehensive and include family/resident involvement and 6.) provide referrals for mental health and psychoactive medication management to behavioral and mental health professionals as needed, resulting in an Immediate Jeopardy beginning on 1/27/22 when R67 expressed the desire to kill himself and went without safety interventions, psychiatric services, and continued monitoring. This deficient practice resulted in the diminished quality of life for the residents with suicidal ideation and thoughts of self-harm, psychosocial distress, recurrent thoughts of death, and increased depression and the potential for psychosocial disorders to go unaddressed and to exacerbate. This deficient practice created the high likelihood of serious harm, injury, and/or death for residents experiencing psychosocial distress. Findings include: Review of the facility policy Abuse Prohibition, Investigation, and Reporting last revised July 2019 revealed, .F. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the facility policy, Suicide/Self-Harm Attempt last revised 10/14/21 revealed, Most suicide attempts are preceded by warning signs. DO NOT IGNORE WARNING SIGNS. Suicide/self-harm attempts and completed suicides have occurred in nursing facilities. Some warning signs are .Suicide threats or similar statements-often people who commit suicide talk about it first. They may say something very direct, threaten to end their lives, or talk about wanting to be dead .High risk behavior divergent from baseline. Loss in personal life-Death of loved one, loss of independence. PROCEDURE 1. Guest/Residents are screened for psychosocial well-being and mood state through the PHQ9 process admission, quarterly, with significant change and as needed. Guest/Residents determined through this process to have thoughts of suicide or self-harm will have a care plan developed with interdisciplinary interventions and medical consultation. 2. If at any time guest/resident shows warning signs such as verbally expressing self-harm or demonstrates, by physical action, a desire to harm self, a licensed practitioner (nurse or social worker) should conduct an interview with the guest/resident in a private environment and notify the physician .3. At such time that signs and/or symptoms of suicide or self-harm are exhibited, the guest/resident is not to be left unattended (immediately place on 1:1 supervision). A charge nurse or other nurse manager should be informed of the risk. 4. As soon as possible, but within 24 hours, the guest's/resident's physician, psychiatrist, or psychotherapist will assess and evaluate the level of risk and further recommended supervision, treatment or emergency hospitalization . 5. A room and body search will be ordered and conducted immediately, following facility policy, to remove potentially dangerous objects .7. If it has been determined that the guest/resident is not in immediate danger for self-harm, outside referrals will be made as appropriate and follow up is (sic) needed from appropriate parties as situation determines. This may include physician, psychologist, social services, therapy, and hospice. DOCUMENTATION 1. Update care plan as needed: i. Behavior ii. Planned interventions iii. Safety precautions 2. Key documentation in (Electronic Health Record EHR): i. Document the guest/resident mood/behavior, temperament, activity level exhibited, statements from guest/resident or any other observations identified in the medical record until symptoms have resolved ii. Observations and findings of physician, psychiatrists, and other health care professionals iii. Physician and family responsible party notifications iv. Behavior charting as indicate (sic). Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) assessment with a reference date of 6/11/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R4 was cognitively intact. R4's MDS assessment with a reference date of 9/9/21 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R4 was cognitively intact. R4's MDS assessment with a reference date of 12/8/21 revealed a BIMS score of 14, out of a total possible score of 15. Review of a MDS assessment for R4, with a reference date of 3/9/22 revealed a Staff Assessment for Mental Status which described R4's cognitive status as Short-term and Long-term Memory Ok, Cognitive Skills for Daily Decision Making Independent-decisions consistent/reasonable, Acute Onset Mental Status Change No. Review of R4's Nurses Note dated 3/8/19 revealed, Resident with suicidal idealization, stated I want to die, I will kill myself, It will happen today I am sick of living like this. Resident had attempted to put call light around neck, then when that was taken attempted to take string from light and was first going to put it around her neck .if I am given the opportunity I will kill myself, there is no use in stopping me . This incident was not added to above MDS for Acute Onset Mental Status Change or to Care Plan for immediate intervention. Review of R4's Care Plan initiated on 3/20/19 revealed, (R4) has the potential to demonstrate physical, verbal aggression R/T (related to): Anger, Depression, Ineffective coping skills, Mental Illness, Poor impulse control . Report to physician of imminent danger to self and others. Provide safe environment per physician instructions . (R4's Care Plan did not include the attempt to use the call light for suicide/self-harm). Review of R4's Nurses Note dated 10/17/20 revealed, .The resident was noted with her call light on and when it was answered it was wrapped around her neck, but resident would not talk . (R4's Care Plan was not updated to reflect her use of the call light for suicide attempt/self-harm and no new interventions were implemented, Social Services did not provide follow up assessments for behavior.) Review of R4's Nurses Note dated 1/5/21 revealed, Staff member went back into residents room to check on her status resident had call light wrapped around her neck. Call light was removed from room and bell given to resident which she threw across the room. Resident is now on 15 minute checks for the remainder of this shift. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe, Social Services did not provide follow up assessments for behavior). Review of R4's Nurses Note dated 7/18/21 revealed, cena (nurse aide) came to this nurse stating that this resident had the call light around her neck 2 times, call light was removed, bell given in replacement of call light, resident refused to take medications, resident then knocked food tray onto the floor, ask resident why she would do that and continues to yell at staff to get the hell out of my room you dirty (B****). 15-minute checks started, will continue to monitor. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe, Social Services did not provide follow up assessments for behavior). Review of R4's Care Plan initiated on 3/20/19 pertaining to self-harm revealed a newly added intervention No description provided Date Initiated: 07/18/2021. (Indicating no new care planned interventions were added to R4's Care Plan). Review of R4's Behavior Note dated 3/3/21 revealed, .d/t (due to) safety reasons RN took out call light & placed call bell in room . (Indicating R4 was exhibiting self-harm/suicidal behavior. No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe). Review of R4's Inpatient Behavioral Health Services Progress Note dated 6/27/21 revealed, admitted /Time 6/19/2021 .Chief Complaint: Major neurocognitive disorder with behavioral disturbances .Staff reports pt (patient) is doing much better-less irritable had a good day yesterday .Thought process was organized; she is difficult to understand at time d/t underlying dysphagia (difficult or garbled speech) .denies depression, anxiety, hallucinations, sleep issues but has poor insight .LESS irritable--on [MEDICATION(S)] And [MEDICATION(S)] increased .Denies SI/HI (Suicidal Ideation and Homicidal Ideation) .Compliant with medications and cooperative with care .appetite is stable-good- improved since admission .Sleep much better now .Hygiene is less than optimal-but is total care-cooperative with care now .Continue [MEDICATION(S)] 20 mg-Continue [MEDICATION(S)] 6 mg at HS(bedtime)-Continue [MEDICATION(S)] dose at HS 50 mg to improve sleep AND MOOD .Continue [MEDICATION(S)] for mood stability 250 mg with dinner-Continue [MEDICATION(S)] 15 mg HS (hour of sleep/bedtime) to improve sleep and appetite .Home in 1-2 days if remains stable-back to ECF (Extended Care Facility) . R4 was discharged back to the facility on [DATE] with improved psychiatric health and on a new drug regimen. Review of R4's June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation as to why the [MEDICATION(S)] was abruptly discontinued and/or why it was discontinued without a tapering dose. There was no documentation that symptoms were monitored from the abrupt stopping of [MEDICATION(S)]. Review of the FDA guidelines for [MEDICATION(S)] revealed, During marketing of [MEDICATION(S)] and other SSRIs and SNRIs (selective serotonin and [MEDICATION(S)] reuptake inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, [CONDITION(S)], and hypomania. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms. Patients should be monitored for these symptoms when discontinuing treatment with [MEDICATION(S)]. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible . During an interview on 03/22/22 at 04:12 P.M., Unit Manager (UM) K reported that any time there is a new admission/readmission the nursing staff were to complete a medication reconciliation and order the medications in the Electronic Health Record. UM K reported that the clinical managers review new admissions/readmissions and review the clinical notes and ordered medications. UM K was not aware that [MEDICATION(S)] was not continued after R4 returned to the facility and reported she was not the Unit Manger at that time. Review of R4's Nurses Note dated 7/20/21 revealed, Resident was requesting call light cord to be placed back in her room to use. DON was consulted. Resident states she is not going to harm herself (sic) with the call cord, and shows no sign of wanting to harm herself (sic). Call light cord was given to this (sic) resident and she has been using it appropriately (sic) at this time. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe, Social Services did not provide follow up assessments for behavior). Review of R4's July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Contracted Psych Service note dated 10/13/2021 revealed, Last seen by (contracted psych service) on 8/25/21 .Inpatient Behavioral Health Services 6/19/2021-6/29/2021 .(Start [MEDICATION(S)] 10 mg, [MEDICATION(S)] 250 mg after dinner, [MEDICATION(S)] 6 mg HS, Stop [MEDICATION(S)]) .Current Psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .LAST GDR (Gradual Dose Reduction) CONSIDERATION 10/13/21-GDR Contraindicated Risk & Benefit statement: Target symptoms have not been sufficiently relieved by non-pharmacological interventions. In my professional opinion, the continued use of the present medication regimen is in accordance with relevant current standards of practice. Any type of dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbation of underlying symptoms, so the resident is NOT a candidate of Gradual Dose Reduction at the present time .ASSESSMENT & PLAN-Major depressive disorder, recurrent, unspecified (unchanged) Plan: Recommend to continue [MEDICATION(S)] 15 mg at HS. [MEDICATION(S)] was started inpatient psych however this was not continued when readmitted to the nursing home facility .Mood disorder due to known physiological condition with mixed features (chronic)-Plan: Recommend to continue [MEDICATION(S)] 50 mg at HS was increased during Geri-Psych stay in June at (hospital name omitted) . (Indicating R4 had an increase in anti-psychotic medication during an inpatient stay due to behaviors/psych status.) .[CONDITION(S)] with behavioral disturbance (chronic)-Plan: Recommend to continue [MEDICATION(S)] 250 mg HS. Noted no VPA level ([MEDICATION(S)] level/[MEDICATION(S)] level), therefore Recommend to check [MEDICATION(S)] level before morning [MEDICATION(S)], Ammonia level, CBC and CMP (indicating medically related social services not being provided/monitored). Review of R4's Contracted Psych Service note dated 11/11/2021 revealed, Last seen by (contracted psych service) on 10/13/21 .Inpatient Behavioral Health Services 6/19/2021-6/29/2021 .(Start [MEDICATION(S)] 10 mg, [MEDICATION(S)] 250 mg after dinner, [MEDICATION(S)] 6 mg HS, Stop [MEDICATION(S)]) .Current Psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . LAST GDR CONSIDERATION 11/11/2021 .Contraindicated Risk & Benefit statement: Target symptoms have not been sufficiently relieved by non-pharmacological interventions. In my professional opinion, the continued use of the present medication regimen is in accordance with relevant current standards of practice. Any type of dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbation of underlying symptoms, so the resident is NOT a candidate of Gradual Dose Reduction at the present time .ASSESSMENT & PLAN-Major depressive disorder, recurrent, unspecified (unchanged) Plan: Recommend to continue [MEDICATION(S)] 15 mg at HS. As previously stated, [MEDICATION(S)] was started inpatient psych however this was not continued when readmitted to the nursing home facility .Mood disorder due to known physiological condition with mixed features (chronic)-Plan: [MEDICATION(S)] 50 mg at HS was increased during Geri-Psych stay in June at (hospital name omitted) .Appears that resident becomes upset when tray is brought to room and staff are unable to assist with feeding when tray is dropped off and resident has to wait. Recommend for staff to bring in tray when they are able to stay and feed resident . [CONDITION(S)] with behavioral disturbance (chronic)-Plan: Recommend to continue [MEDICATION(S)] 125 mg HS. This is a decrease from 250 mg HS (indicating the facility did not follow the providers recommendation to continue dosage and not do a GDR), since readmission to facility. Noted no recent VPA level therefore Recommend to check [MEDICATION(S)] level before morning [MEDICATION(S)], ammonia level, CBC and CMP (indicating medically related social services not being provided/monitored). R4's Care Plan was not updated following the psych providers recommendation for feeding/behavior. Review of R4's Contracted Psych Service note dated 12/22/21 revealed, Last seen by (contracted psych service) on 11/11/21 .Inpatient Behavioral Health Services 6/19/2021-6/29/2021 .(Start [MEDICATION(S)] 10 mg, [MEDICATION(S)] 250 mg after dinner, [MEDICATION(S)] 6 mg HS, Stop [MEDICATION(S)] .Current Psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] & PLAN-Major depressive disorder, recurrent, unspecified (unchanged) Plan: Recommend to continue [MEDICATION(S)] 15 mg at HS. As previously stated, [MEDICATION(S)] was started inpatient psych however this was not continued when readmitted to the nursing home facility .Mood disorder due to known physiological condition with mixed features (chronic)-Plan: Recommend to continue [MEDICATION(S)] 50 mg at HS was increased during Geri-Psych stay in June at (hospital name omitted) . [CONDITION(S)] with behavioral disturbance (chronic)-Plan: Recommend to continue [MEDICATION(S)] 125 mg HS, GDR on 11/4/2021 Noted this is a decrease from 250 mg HS, since readmission to facility. Noted no VPA ([MEDICATION(S)] level/[MEDICATION(S)] level), Ammonia level, CBC and CMP (indicating medically related social services not being provided/monitored and a GDR was completed for [MEDICATION(S)] against the psych providers recommendation). Review of R4's Contracted Psych Service note dated 1/20/2022 revealed, Last seen by (contracted psych service) on 11/11/2021 and chart review on 12/22/2021 .Inpatient Behavioral Health Services 6/19/2021-6/29/2021 .(Start [MEDICATION(S)] 10 mg, [MEDICATION(S)] 250 mg after dinner, [MEDICATION(S)] 6 mg HS, Stop [MEDICATION(S)]) .Current Psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .LAST GDR CONSIDERATION 1/20/2022-GDR Contraindicated Risk & Benefit statement: Target symptoms have not been sufficiently relieved by non-pharmacological interventions. In my professional opinion, the continued use of the present medication regimen is in accordance with relevant current standards of practice. Any type of dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbation of underlying symptoms, so the resident is NOT a candidate of Gradual Dose Reduction at the present time .ASSESSMENT & PLAN-Major depressive disorder, recurrent, unspecified (unchanged) Plan: Recommend to continue [MEDICATION(S)] 15 mg at HS. As previously stated, [MEDICATION(S)] was started inpatient psych however this was not continued when readmitted to the nursing home facility .Mood disorder due to known physiological condition with mixed features (chronic)-Plan: Recommend to continue [MEDICATION(S)] 50 mg at HS was increased during Geri-Psych stay in June at (hospital name omitted) .[CONDITION(S)] with behavioral disturbance (chronic)-Plan: Recommend to continue [MEDICATION(S)] 125 mg HS. VPA < 10 on 11/26/2021, therefore not therapeutic. Review of R4's Contracted Psych Service note dated 3/3/22 revealed, Last seen by (contracted psych service) on 1/20/2022 .Inpatient Behavioral Health Services 6/19/2021-6/29/2021 .(Start [MEDICATION(S)] 10 mg, [MEDICATION(S)] 250 mg after dinner, [MEDICATION(S)] 6 mg HS, Stop [MEDICATION(S)] .Current Psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Note [MEDICATION(S)] 125 mg HS (discontinued on 2/6/2022) .LAST GDR CONSIDERATION 03/03/2022-GDR Contraindicated Risk & Benefit statement: Target symptoms have not been sufficiently relieved by non-pharmacological interventions. In my professional opinion, the continued use of the present medication regimen is in accordance with relevant current standards of practice. Any type of dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbation of underlying symptoms, so the resident is NOT a candidate of Gradual Dose Reduction at the present time .ASSESSMENT & PLAN-Major depressive disorder, recurrent, unspecified (unchanged) Plan: Recommend to continue [MEDICATION(S)] 15 mg at HS .This medication is an appetite stimulant at this dosage (Indicating the dose of [MEDICATION(S)] was not use to treat depression) .As previously stated, [MEDICATION(S)] was started inpatient psych however this was not continued when readmitted to the nursing home facility .[CONDITION(S)] with behavioral disturbance (chronic) Plan: Noted [MEDICATION(S)] 125 mg HS was discontinued . (Indicating [MEDICATION(S)] was discontinued and the psych providers recommendation to not GDR was not followed). Review of R4's Nurses Note dated 3/15/22 revealed, Staff alerted this nurse resident has wrap her call light cord around her neck three times. This nurse assessed area around residents neck, no signs of injury noted. Asked resident why she had placed the cord around her neck, resident did not verbalize to this (sic) nurse why, eyes noted to be open and respirations even an non labored (sic). I asked resident if she wanted to harm herself and again resident did not respond back to this nurse. I asked patient if she was in pain and no response. No visual s/s (signs or symptoms) of pain present. Resident in bed resting with mat at bedside, w/c (wheelchair) at bedside and bed in lowest position. 15 min checks initiated at 2100 (9pm), call light cord removed and resident provided with a bell. This nurse spoke with on call nurse, informed her of current situation, she will address with social worker to further address as indicated and aware of interventions in place. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe). Review of R4's Social Services Note dated 3/16/22 revealed, SS (social services) met with resident to discuss what happened the evening before, more details in nurses notes dated in 3/15/22. Resident denied having thoughts of being better off dead and denied having a plan to harm herself. The IDT (Interdisciplinary Team) met and determined it was safe for resident (sic) to have the call light. Resident was given it back this afternoon, the bell was taken away. Resident has been resting and watching TV throughout the day. SS to follow up as needed as needed or requested. (No documentation that R4's Physician or Guardian were notified of suicide/self-harm or that the facility policy was implemented to keep R4 safe. R4's Care Plan did not reflect new interventions to keep R4 safe, Social Services did not provide follow up assessments for behavior). Review of R4's Late Entry Nurses Note written by Unit Manager (UM) K, created on 3/22/22 at 3:19 P.M., and dated 3/16/2022 revealed, this nurse went in to talk to resident regarding what happened with call light. When asked about the cord being wrapped around her neck, resident stated that staff had placed it over her chest and she was attempting to move it behind her head where she likes it and it ended up around her neck. This nurse proceeded to ask about it being wrapped several times around her neck not just once and she stated that she did not wrap it around her neck on purpose. I asked her if she was trying to harm herself and she stated no and again said that it was staff and that she did not intend to purposely put it around her neck. She did not like having to use the bell that was given to her. I informed her that i would give her call light back providing that she did not put it around her neck and make sure she told staff where she likes it to be placed. Call cord given back to her. Resident was happy and satisfied and ensured this nurse that there would be no further issues. Review of R4's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . I was approached today by nursing that patient has been threatening to end her life and secondary to which we are doing an emergent telehealth visit. Today on my interview the patient denied having any suicidal ideation or any plan to harm herself. She does mention that she has been feeling a little more depressed regarding her general debility . Review of a Nurses Note dated 3/24/22 revealed, on 3/23/22 Administrator spoke to (Nurse Practitioner name omitted) about guest wrapping cord around her neck and that this has occurred (sic) several times. She stated that she would see her when she comes in and if she exhibits any suicidal (sic) ideation send her to ER. (Indicating a delay in physician notification of suicidal behavior). During an interview on 3/22/22 at 3:30 P.M., Social Services Director (SSD) J reported that any time a resident reports suicidal idea or exhibits self-harm behavior the facility policy is put into place. SSD J stated, Any time a resident shows warning signs-demonstrating or desire, licensed practitioner should conduct interview and notify physician, search the resident and the room, place resident on a 1:1, and document in the electronic health record. SSD J reported that on 3/15/22 was accidental and R4 was tangled in the call light. SSD J reported that because she reported she did not have a plan, the facility protocol for suicidal ideation/self-harm was not implemented but R4 was placed on 15-minute checks. SSD J reported that she was not aware of any other incidence of R4 wrapping the call light around her neck. SSD J reported that had she known that R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/22/22 at 04:12 P.M., UM K reported that she wrote a Nurses Note on 3/22/22 regarding an interview she had with R4 that occurred on 3/16/22. UM K reported that she was the nurse on call the evening of 3/15/22. UM K reported that R4 reported to her that the call light cord around her neck was an accident. UM K reported she was aware that R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . UM K reported that she had not interviewed her previously about her self-harm/suicidal behavior. UM K reported that immediately following the self-harm/suicidal behavior, the nurse on duty should have contacted the physician and the guardian and implemented the facility policy. UM K reported that R4 could have changed her story with me and reported it was an accident instead of self-harm/suicidal behavior. UM K reported that the Social Worker would be responsible for following up with the psychiatrist and physician regarding the self-harm/suicidal behavior and would monitor the resident closely.Validation of a behavioral program or a system to follow the psychosocial wellbeing of residents with mental health concerns could not be provided to the surveyors during the time of survey. Review of R4's Nurses Note dated 3/24/22 revealed, Guest's guardian stated that she would like (psychiatric service name omitted) to see and work with guest. She also stated that she wouldn't be opposed to medication changes to improve mood and behaviors. (Indicating R4's guardian was not notified of the incident on 3/15/22 until 9 days later.) Review of R4's Social Services Note dated 3/25/22 revealed, SS (Social Services) attempted to contact resident's daughter, (name omitted) to get more background information on resident and potentially their relationship and any information that would be beneficial for the facility as they continue to care for resident .SW (Social Work) spoke (with) (daughter) requesting additional background information on (resident) in order to better serve and provide care . (Daughter) suspected, although not confirmed, abuse from (resident) father toward (resident) when (resident) was a child .considerable and daily alcohol use . (Indicating an individualized care plan that addresses the assessed emotional and psychosocial needs of the resident was not completed prior.) Review of R4's Care Plan created on 3/25/22 revealed, (R4) experienced physical abuse from her father throughout childhood. She has a hx (history) of considerable alcohol abuse throughout adulthood according to (daughter) .Goal-Care and current situation will not be influenced by past trauma-Will feel safe in current situation Interventions-Encourage resident/guest to be involved in activities and be engaged with other as possible and desired .Establish and maintain a trusting relationship .Maintain a calm non-threatening relationship by listening to the resident/guest .Provide reassurance to the resident/guest that he/she is safe and the facility is doing what is needed to maintain safety for all. (Indicating the facility failed to acknowledge and assess the underlying causes of the resident's expressions of distress or develop and implement a care plan that addressed this distress prior). During an interview on 03/24/22 at 9:38 A.M., Corporate Clinical Care Coordinator (CCCC) R reported that the contracted psych agency would make recommendations for medication changes and GDRs, and the facility provider was responsible for making the recommended changes. CCCC R reported that there have been miscommunications between the providers in the past, and all providers would be educated on the psychiatric medication recommendation process. CCCC R reported that if the facility provider does not agree with a recommendation, a progress note related to the recommendation rejection will be completed. CCCC R reported that if the recommendation is approved, the nursing staff will process the new order. Resident #67 (R67) Review of an Admission Record revealed R67 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment for R67, with a reference date of 1/9/22 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R67 was cognitively intact. Review of a MDS assessment for R67, with a reference date of 3/2/22 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R67 was cognitively intact. Review of Resident Mood Interview revealed R67 had Thought that you would be better off dead, or of hurting yourself in some way-Yes-12 to 14 days (nearly every day). Review of R67's Care Plan revealed, (R67) has the potential for fluctuations in mood R/T: DX of [CONDITION(S)], UNSPECIFIED, suicidal ideations Date Initiated: 01/10/2022 Revision on: 3/10/2022 .Behavioral health/psych consults as needed and follow recommendations as indicated. Date Initiated: 01/10/2022 . Should (R67) be expressing a desire to harm self or others provide 1:1 monitoring, follow suici

This citation pertains to intake #: MI 920 Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development of avoidable pressure ulcers, 2.) complete wound documentation/descriptions and accurately stage resident pressure ulcers, and 3.) promptly identify and provide necessary treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy, Skin Management last revised 7/14/21 revealed, .5. The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairment as follows: In Electronic Health Record (EHR) facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved. Photos may be taken of pressure injury and vascular ulcers .8. The licensed nurses will document preventative measures on the care plan/kardex. 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record .11. A weekly total body skin evaluation is completed for each guest/resident by the licensed nurse. The licensed nurse will document findings of the skin evaluation .12. If a new area of skin impairment is identified, notify the guest/resident, responsible party, attending physician, DON (Director of Nursing)/designee and treatment team, if applicable. 13. Guest's/resident's with pressure injury and lower extremity ulcers will be evaluated, measured and staged weekly (Pressure injury and vascular ulcers only) in accordance with the practice guidelines until resolved. A photo may be initiated unless the guest/resident refuses. 14. The licensed nurse will notify the attending physician with any changes as needed . Review of the February Drill Down revealed, Facility Acquired Pressure Ulcers. One facility acquired pressure ulcer for February. Continue to work on weekly wound documentation. We will now have out 2nd unit manager in place to oversee the wound documentation and treatments. Wound phone with some Internet connectivity issues. Will ensure that weekly measurements and documentation even when a picture cannot be obtained. Resident #13 Review of an Admission Record revealed R#13 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R13, with a reference date of 3/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R13 was severely cognitively impaired. Review of Section M-Skin Conditions revealed R13 had an unstageable pressure ulcer. During an observation on 03/21/22 at 02:02 P.M., R13 was wearing socks, sitting up in a wheelchair with no pressure offloading devices on her heels. During an observation on 03/23/22 at 02:31 P.M., R13 was wearing socks, sitting up in a wheelchair with no pressure offloading devices on her heels. During an observation on 03/24/22 t 08:02 A.M., R13 was wearing socks, sitting up in a wheelchair with no pressure offloading devices on her heels. During an observation on 03/24/22 at 10:23 A.M., R13 was wearing socks, sitting up in a wheelchair with no pressure offloading devices on her heels. During an interview on 03/23/22 at 02:33 P.M., Certified Nursing Assistant (CNA) O reported that R13 only wore heel protection boots while she was in bed and no interventions were in place for when she was up in her wheelchair. During an interview and observation on 03/28/22 at 12:40 P.M., Licensed Practical Nurse (LPN) Q reported that the wound assessment camera was able to measure length and width but was unable to measure depth. If depth was measurable, it would be measured by the licensed nurse. LPN Q reported once the picture was uploaded to the EMR the nurse would then complete a thorough documentation of the description of the wound and the wound treatment. LPN Q reported that R13's left heel wound had worsened and was evaluated by the Nurse Practitioner on Friday (3/25/22), and a new treatment was put in place. An observation of R13's left heel revealed a wound approximately the size of a AAA Battery with a visible measurable depth. The skin surrounding the wound was macerated and the wound bed was pink. During an interview on 03/28/22 at 01:09 P.M., Director of Nursing (DON) reviewed R13's EMR (Electronic Medical Record) wound pictures from 3/22/22 and 3/28/22 and reported that R13's wound should be staged and measured accurately by nursing staff. DON reported that R13's wound depth was measurable and should have been documented with a depth measurement. DON reported that education would be provided to nursing staff. During an interview on 03/24/2022 at 1:24 P.M., Unit Manager (UM) K reported that there was no nurse overseeing all the wound care in the facility, and each UM was responsible for the wounds on their unit. UM K reported that the facility Nurse Practitioner or Physician would follow up with wounds and refer to wound clinic if needed. UM K reported that at that time, there were no residents that received care at a wound clinic. UM K reported that wounds were assessed weekly which would include a picture of the wound with the EMR camera that automatically measures wounds length and width. UM K reported that the camera could not measure depth. UM K reported that the wound pictures were uploaded to the EMR for the physician to review and for the licensed nurse to complete wound description documentation. UM K reported that an incident report was completed by the licensed nurse for any new pressure injuries/wounds and the physician would be notified. Once the incident report is completed the licensed nurse would report the pressure injury/wound to the Unit Manager. UM K reported that the licensed nurses caring for the resident would update the care plan/kardex for new interventions, as required in the incident report. UM K reported that any licensed nurse (LPN/RN) was able to stage the resident pressure injury. UM K reported that if a pressure injury/wound worsened, the licensed nurse would notify the UM and the physician for treatment changes. Review of R13's Total Body Skin assessment dated [DATE] revealed, .Number of new skin conditions: 0. R13's Electronic Medical Record contained a chain of linked Skin & Wound Evaluation's which indicated the assessments were related to the same pressure injury/wound. Review of R13's Skin & Wound Evaluation dated 7/7/21 revealed, 1. Type (Blank) .22. Location: (Blank). 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 3.2cm2 2. Length: 4.0 cm 3. Width: 1.3 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-New . No documentation that the Practitioner and Responsible Party were notified of the skin breakdown. No new treatment in place. Review of R13's History and Physical dated 7/8/21 revealed, .Skin: Negative for any [CONDITION(S)], pressure ulcer or skin breakdown . (Indicating the physician was not aware of skin breakdown/pressure ulcer on left heel.) Review of R13's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Indicating the physician was not aware of skin breakdown/pressure ulcer on left heel.) Review of R13's Skin & Wound Evaluation dated 7/29/21 revealed, 1. Type (Blank) .22. Location: (Blank). 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 4.7 cm2 2. Length: 3.8 cm 3. Width: 2.0 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Improving . Wound area increased in size. No documented treatment in place. (22 days from previous wound assessment). Review of R13's Order dated 7/31/21 revealed, Cleanse bilateral impaired skin to heels, apply [MEDICATION(S)] every day . (Discontinue date 10/29/21 with no new order for wound treatment.) Review of R13's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Indicating the physician was not aware of skin breakdown/pressure ulcer on left heel.) Review of R13's Skin & Wound Evaluation dated 8/12/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 1.3 cm2 2. Length: 2.9 cm 3. Width: 0.8 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Stable . No documented treatment in place. (14 days from previous wound assessment). Review of R13's Dietary Note dated 8/16/21 revealed, .She continues to heal wounds to bilateral heels. Review of R13's Skin & Wound Evaluation dated 8/26/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 1.2 cm2 2. Length: 2.8 cm 3. Width: 1.1 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Improving . No documented treatment in place. (14 days from previous wound assessment). Review of R13's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Indicating the physician was not aware of skin breakdown/pressure ulcer on left heel.) Review of R13's Skin & Wound Evaluation dated 9/9/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.3 cm2 2. Length: 0.8 cm 3. Width: 0.6 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Stable . No documented treatment in place. (14 days from previous wound assessment). Review of R13's Skin & Wound Evaluation dated 9/16/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: (Blank) 2. Length: (Blank) 3. Width: (Blank). 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Improving . No documented treatment in place. Review of R13's Skin & Wound Evaluation dated 9/23/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.5 cm2 2. Length: 1.2 cm 3. Width: 0.6 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Improving . No documented treatment in place. (14 days from last wound measurement). Review of R13's Skin & Wound Evaluation dated 9/30/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: (Blank) 2. Length: (Blank) 3. Width: (Blank). 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Stable . No documented treatment in place. Review of R13's Skin & Wound Evaluation dated 10/7/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.6 cm2 2. Length: 1.0 cm 3. Width: 0.7 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Improving . No documented treatment in place. (14 days from last wound measurement). Review of R13's Skin & Wound Evaluation dated 10/21/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.5 cm2 2. Length: 1.1 cm 3. Width: 0.7 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) . G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Stable . No documented treatment in place. (14 days from previous wound assessment). (Previous Order dated 7/31/21 revealed, Cleanse bilateral impaired skin to heels, apply [MEDICATION(S)] every day . (Discontinue date 10/29/21 with no new order for wound treatment.) Review of R13's Resident at Risk dated 10/25/21 revealed, .Wounds almost healed . (Indicating ongoing skin breakdown/pressure ulcer). Review of R13's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Indicating the physician was not aware of skin breakdown/pressure ulcer on left heel.) Review of R13's Skin & Wound Evaluation dated 11/4/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.2 cm2 2. Length: 0.8 cm 3. Width: 0.4 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) .G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Stable . No documented treatment in place. (14 days from last wound measurement). Review of R13's Skin & Wound Evaluation dated 11/16/21 revealed, 1. Type (Blank) .22. Location: Left Heel. 23. Acquired: (Blank). 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.3 cm2 2. Length: 0.7 cm 3. Width: 0.6 cm. 4. Depth: Not Applicable .C. Wound Bed (Blank) .D. Exudate (Blank) .E. Periwound (Blank) .F. Wound Pain (Blank) .G. Orders (Blank) .H. Treatment (Blank) .I. Progress-Stable . No documented treatment in place. (14 days from last wound measurement). Review of R13's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Indicating the physician was not aware of skin breakdown/pressure ulcer on left heel.) Review of R13's Skin & Wound Evaluation dated 11/25/21 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? Unknown .B. Wound Measurements-1. Area: 1.6 cm2 2. Length: 1.1 cm 3. Width: 1.7 cm. 4. Depth: Not Applicable .C. Wound Bed: (Pink or red) .D. Exudate None .E. Periwound Normal in color .Induration: None present .[CONDITION(S)]: No swelling or [CONDITION(S)] .F. Wound Pain-PAIN AD Score 0 .G. Orders-Goal of Care: Healable .H. Treatment None-No dressing applied .I. Progress-Improving . (Indicating the worsening of the wound size). Review of R13's Skin & Wound Evaluation dated 12/2/21 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? Unknown .B. Wound Measurements-1. Area: 0.2 cm2 2. Length: 0.5 cm 3. Width: 0.5 cm. 4. Depth: Not Applicable .C. Wound Bed: (Blank) .D. Exudate None .E. Periwound (Blank) .Induration: None present .[CONDITION(S)]: (Blank) .F. Wound Pain-(Blank) .G. Orders-Goal of Care: Healable .H. Treatment (Blank) .I. Progress-Improving . No documented treatment in place. (No documentation that the wound had healed). Review of R13's Skin & Wound Evaluation dated 2/18/22 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 1.2 cm2 2. Length: 1.3 cm 3. Width: 1.2 cm. 4. Depth: Not Applicable .C. Wound Bed: (Blank) .D. Exudate: (Blank) .E. Periwound (Blank) .Induration: (Blank) .[CONDITION(S)]: (Blank) .F. Wound Pain-(Blank) .G. Orders-Goal of Care: Healable .H. Treatment (Blank) .I. Progress-Monitoring . No documented treatment in place. (Approximately 11 weeks from previous assessment). Review of R13's Order dated 2/24/22 revealed, cleanse open area to left heel with NS (Normal Saline) apply [MEDICATION(S)] and cover with [MEDICATION(S)] daily . (there were no treatment orders from 10/29/21 through 2/18/22). Review of R13's Skin & Wound Evaluation dated 2/25/22 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.2 cm2 2. Length: 1.0 cm 3. Width: 0.4 cm. 4. Depth: Not Applicable .C. Wound Bed: (Blank) .D. Exudate: (Blank) .E. Periwound (Blank) .Induration: (Blank) .[CONDITION(S)]: (Blank) .F. Wound Pain-(Blank) .G. Orders-Goal of Care: Healable .H. Treatment (Blank) .I. Progress-(Blank) . Review of R13's Wound Picture dated 2/25/22 revealed that the picture was not taken directly over the wound. The wound was opened but the wound bed was not visible from the picture. Review of R13's Skin & Wound Evaluation dated 3/8/22 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.4 cm2 2. Length: 0.7 cm 3. Width: 0.7 cm. 4. Depth: Not Applicable .C. Wound Bed-Granulation 50% of wound filled .D. Exudate: Light .E. Periwound (Blank) .Induration: (Blank) .[CONDITION(S)]: (Blank) .F. Wound Pain-(Blank) .G. Orders-Goal of Care: Healable .H. Treatment (Blank) .I. Progress-Deteriorating . No documented treatment in place. (11 days from previous assessment.) Review of R13's Wound Picture dated 3/8/22 revealed the picture had glare of light over the wound which made it difficult to assess. Review of R13's wound assessment and suggested treatment plan from a contracted agency (name omitted) dated 3/16/22 revealed, Wound-Left Heel .Exudate-Moderate .Thickness-Full Thickness .Etiology-Pressure Ulcer-Stage III .Size (LxW cm) 0.70 x 0.70 .Depth <0.2 .Debridement-Autolytic . (Indicating a measurable depth to the wound). Review of R13's Skin & Wound Evaluation dated 3/22/22 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.8 cm2 2. Length: 1.1 cm 3. Width: 0.9 cm. 4. Depth: Not Applicable .C. Wound Bed: (Blank) .D. Exudate: (Blank) .E. Periwound (Blank) .Induration: (Blank) .[CONDITION(S)]: (Blank) .F. Wound Pain-(Blank) .G. Orders-Goal of Care: Healable .H. Treatment (Blank) .I. Progress-(Blank) . No documented treatment in place. (14 days from previous wound assessment). Review of R13's Wound Picture dated 3/22/22 revealed an open area on the left heel with a red wound bed. The depth of the wound was measurable. Review of R13's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Area with pink wound bed and mild amount of sloughing surrounding. No drainage noted. Previous dressing change with [MEDICATION(S)] and [MEDICATION(S)]. Today will change to silver optical pad and covered with border dressing to help dry the area. Denies pain to the heel. Heel boot protectors on bil (bilateral) in bed. No other changes or apparent distress . Review of an Order dated 3/25/22 revealed, Cleanse left heel with NS (Normal Saline), pat dry, apply silver alginate to wound bed and cover with border gauze daily. Review of R13's Skin & Wound Evaluation dated 3/28/22 revealed, 1. Type: Pressure .Stage 1: Non-blanchable [CONDITION(S)] of intact skin .22. Location: Left Heel. 23. Acquired: In-House Acquired. 24. How long as the wound been present? (Blank) .B. Wound Measurements-1. Area: 0.6 cm2 2. Length: 1.1 cm 3. Width: 0.7 cm. 4. Depth: Not Applicable .C. Wound Bed: None .D. Exudate: Light-Serous .E. Periwound-Edges: Attached: Edge appears flush with wound bed or as a sloping edge-Macerated: Wet, white, waterlogged tissue .Induration: None present .[CONDITION(S)]: No swelling or [CONDITION(S)] .F. Wound Pain-(5/10) .G. Orders-Goal of Care: Healable I. Progress-Stable . Review of R13's Wound Picture dated 3/28/22 revealed an open area on the left heel with a red wound bed. The depth of the wound was measurable. The wound appeared macerated with white edges around the wound. Review of the requested Timeline for R13's left heel wound revealed: 7/7/21 4.04 cm x 1.27 cm black eschar 7/29/21 3.85 cm x 1.98 cm improving 8/12/21 2.88 cm x 0.81 cm 8/26/21 2.84 cm x 1.12 cm 9/9/21 0.76 cm x 0.57 cm 9/16/21 no measurements, picture taken, small dry scab 9/23/21 1.2 cm x 0.57 cm 9/30/21 no measurements, picture taken, open 10/7/21 1.03 cm x 0.71 cm 10/21/21 1.08 cm x 0.65 cm 11/4/21 0.77 cm x 0.41 cm 11/16/21 0.68 cm x 0.65 cm 11/25/21 1.07 cm x 1.73 cm skin intact 12/2/21 0.55 cm x 0.4 cm, flaky scab 2/16/22 a fragile area noted to the left heel, skin prep ordered, continued with bilateral boots in bed for protection. Wound evaluation closed out r/t being healed. (Review of R13's progress notes, wound evaluation, and physician notes did not reflect the left heel wound evaluation was closed nor that the left heel had healed. The wound assessment thread was not completed and then restarted). 2/18/22 black eschar noted to left heel with open center 1.77 cm x 1.2 cm 2/23/22 0.7 cm x 0.69 cm 2/24/22 new order to cleanse with normal saline, apply [MEDICATION(S)] daily 3/8/22 0.7 cm x 0.69 cm 3/22/22 1.11 cm x 0.87 cm 3/25/22 new order for silver alginate daily A list of residents with current pressure ulcers/wounds was requested. Review of the handwritten list revealed, (R13) pressure-unstageable (Left) heel (Facility Acquired) . (NPUAP definition of unstageable-full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a category/ stage III or IV.) Review of R13's Care Plan revealed the Need was not revised to specifically reflect the pressure ulcer on R13's Left Heel until 3/21/22, (R13) has actual impaired skin integrity related to pressure ulcer to left heel. Review of R13's Care Plan for skin integrity revealed the initial care planned interventions were created on 7/14/21, Conduct skin assessments weekly and measure area(s) and document characteristic .Follow RAR protocol .Observe for signs of infection related to area(s) .Obtain labs as ordered and report abnormal findings to physician .Refer to Dietician as needed .Refer to potential for skin impairment care plan for interventions . A revision to R13's Care Plan was completed on 12/14/21 Elevate heels while in bed. Blue boot to bilateral feet while in bed and on 3/21/22 Treatment to left heel as ordered . No other revisions for R13's left heel pressure ulcer documented. Resident #11(R11) R11 was admitted to the facility 12/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] reflected R11 was at risk for developing pressure sores but did not have any pressure sores on admission. The MDS reflected R11 had Moisture Associate Skin Damage (MASD) at an unspecified location. Review of the Care Plan for R11 reflected a Care Plan problem or Need that (R11) has an actual impaired integrity related to dark red area to coccyx MASD and left forearm skin tear. The Goal of the Need reflected Area to Coccyx will resolve by review date. Both the Need and Goal were initiated on 12/13/21. This active Care Plan was last revised 12/23/21. No other active skin related Need was identified in the Care plan of R11. The Electronic Medical Record (EMR) for R11 revealed a Skin and Wound Evaluation completed on 1/5/22 at 3:06 PM. This evaluation reflected an In-House Acquired MASD area on the Coccyx of R11. The Evaluation reflected the MASD was Incontinence Associated [CONDITION(S)] and, although no dressing was applied additional care implemented included Incontinence Management, Moisture Barrier, and Turning/repositioning program. Review of the photograph of the coccyx and surrounding area also dated 1/5/22 revealed a healed wound on the coccyx. Inferior to the coccyx at the left of the gluteal cleft what appears to be a small open area not identified on the Skin and Wound evaluation. Otherwise, the mid and lower buttock area is free of MASD, open areas, or other skin integrity issues. Review of the Doctor's Orders (DO) revealed an active order entered 1/5/22 for Wound assessment /picture of coccyx wound weekly. Review of the EMR Nurse Practitioner (NP) Progress Note dated 1/31/22 at 00:00 reflected Skin: Negative for any [CONDITION(S)], pressure ulcer or skin breakdown. Review of the Skin and Wound Evaluations dated 2/2/22 and 3/2/22 reflected MASD of the coccyx with a documented area of less than (>) 1 centimeter (cm) squared (sq). However, no photographs were in the EMR despite the active physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin and Wound Evaluation dated 3/9/22 reflected MASD on the coccyx with a measurement of total area of 19.2 cm sq. but that the skin was intact. The photograph of the buttocks of R11 revealed a darkened area at the coccyx and intact skin without new MASD or new skin integrity issues on the buttocks. Review of the Skin and Wound Evaluation dated 3/23/22 revealed MASD on the coccyx with a total measured area of 1.7 cm sq. The photograph of the 3/23/22 evaluation displayed a slightly reddened coccyx area. However, this photograph revealed a large measurable open area on the mid to lower right buttocks and three smaller but measurable open areas on the left buttocks and general overall redness. No documentation was found in the EMR that indicated an assessment of the characteristics of the new areas or that the medical provider was notified of the new areas of altered skin integrity. Review of the medical record reflected NP documentation on 3/22/22, 3/24/22, 3/26/22 that indicated coccyx without redness at present, and skin warm and dry. On 3/28/22 at approximately 12:00 PM the Assistant Director of Nursing (ADON) was asked to arrange for a visual review by the surveyor of the area on R11. The ADON subsequently reported that R11 declined the review but would allow a new photograph to be taken. On 3/28/22 at 1:28 PM the photographs of the buttocks of R11 of 3/9/22 and 3/23/22 were reviewed with the Director of Nursing (DON). The DON acknowledged the new areas are measurable, likely had depth, and should have been measured during the 3/23/22 Skin and Wound Evaluation. The DON reported each open area should have been photographed separately. The DON reported a new photograph was currently being taken. Neither this photograph nor further information were provided by the time of survey exit. Resident #59(R59) R59 was admitted to the facility 1/12/20 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] reflected R59 has a pressure sore and diabetic foot ulcers. Review of the EMR Progress Note dated 8/17/21 at 7:20 PM reflected, Wound on left outer heel noted to be opening more. No drainage, (signs or symptoms) of infection noted and skin prep applied. The Progress Note entry did not reflect the physician was notified of the change or opening of the area of the left outer heel. Further review of previous Progress Notes did not reveal this area was open prior to the Progress Note entry of 8/17/21. Review of the Progress Note dated 8/31/21 at 11:04 AM reflected a treatment was initiated for the open area on the left lateral (outer) foot. This assessment identified that when the R59 was up in his wheelchair pressure was being placed on the open area. Measures were implemented to off-load this pressure. However, the Progress Note entry did not reflect the physician was notified of the open area or that a new treatment was implemented. Review of the Progress Note dated 9/17/21 at 4:22 PM reflected the left foot of R59 was very swollen and the toes were red. The entry reflected the physician was contacted, provided a picture of the swollen foot, and antibiotic therapy was initiated for the infection. Although the area of the left outer heel was first documented as identified on 8/17/21 and a treatment was put in place on 8/31/21 the medical record revealed a delay of physician notification and Care Plan initiation until 9/17/21 when antibiotic therapy was required to treat the area.

This citation pertains to intake numbers: MI 446 and MI 152 Based on interview and record review, the facility failed to implement fall care plans and provide interventions for increased supervision and assistance for 2 residents with fall histories and repeated falls (R 9 and R10), resulting in the facility not meeting R 9 and R 10's safety needs. Findings include: R 9 Review of R 9's face sheet dated March 16. 2021, revealed she was an [AGE] year-old female admitted to the facility on [DATE], she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was listed as her own responsible party. Review of R 9's Brief Interview of Mental Status (BIMS) score dated 9/21/20 revealed she scored 8/15 (moderate cognitive impairment). Review of R 9's admission hospital paperwork revealed she was taken to the emergency roiagnom on [DATE] at 8:00 PM because of progressive weakness, inability to stand up from the toilet. She was limited as a historian due to dementia. Review of R 9's, 72-hour admission conference note dated 9/17/20 at 13:55 (1:55 PM), revealed the box for responsible party/family was checked. Notes do not indicate family name or any family participation in the care conference. There was no indication of any safety concerns or preferences discussed at this care conference. The goal was for R9 to return home with her husband. There was concern about home care because the resident said they could not afford home care. Review of R 9's ADL (activities of daily living) care plan dated 9/15/20 revealed she required extensive assistance of 2 for transfers, bed mobility and toilet use. She required encouragement to use her call light for assistance. On 3/18/21 at 12:35 PM an interview was completed with Social Worker (SW) P. R 9's 72 hours admission conference note dated 9/17/20 at 13:55 (1:55 PM) was reviewed with SW P, SW P was not sure if R 9's family participated in the care conference as a family name was not indicated in the note. She confirmed they did not discuss resident preferences or any safety concerns, and a written care plan was not provided to the resident or family at the time of the care conference on 9/17/20. The facility provided 3 incident and accident reports that document 3 unwitnessed falls for R9, 9/19/20 at 6:20 AM, 9/26/20 at 4:30 AM and 10/1/20 at 8:45 AM. There was no indication what staff were working at the times of these falls, no indication how they determined the last time care was provided. There was no indication what the resident was like prior to the fall. There was no indication if the resident had been self-transferring. There was no indication how they were able to determine what the unmet need was when these falls occurred due to the lack of information in the incident reports. There was no indication what R 9 normal wake/sleep time, bowel/bladder schedule or what her tolerance was to being out of bed. The Surveyor was not able to verify the information that was provided as staff working at the time of the falls was not indicated in the information provided. The Director of Nursing (DON) provided a fall timeline for R 9 on 3/18/21 at 1:00 PM. R 9 had 3 falls since admission 9/19/20 at 6:20 AM, 9/26/20 at 4:30 AM and 10/1/20 at 8:45 AM. The first fall on 9/19/20 at 6:20 AM, R 9 was found on the floor between the wall and her bed. She was observed in bed 30 minutes prior. It was not clear if she was sleeping or restless. She had been assisted to the toilet less than an hour prior to that fall. The intervention to prevent further falls was to move the bed next to the wall. The next fall on 9/26/20 at 4:30 AM indicated she again fell out of bed and this time she needed to use the toilet. It was about 2.5 hours since she was last assisted to the toilet. The intervention was to change cardiac medications and do a urinalysis to check for a urinary tract infection. The DON reviewed her notes and said they did not increase R 9 supervision or assistance after the 2nd fall, she was unable to find any normal routine scheduling to meet R 9's ADL needs. The next fall was on 10/1/20 at 8:45 AM when she was found on the bathroom floor. It was not clear when she was last assisted to the toilet as the report said, just prior to breakfast. There was no indication of a bowel and bladder schedule being assessed for her needs. R9 was sent to the hospital after this fall where it was determined she had a left wrist fracture. R 9 did not return to the facility. Review of R 9's fall care plan dated 9/15/20, revealed she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was incontinent and weak. There were no interventions to increase R 9 supervision and assistance related to her need to use the toilet after her fall on 9/26/20 when the facility determined the unmet need was to use the toilet. R 9 fell again on 10/1/20 in the bathroom and sustained a left wrist fracture. R 9 did not return to the facility after she went to the emergency room to treat her fractured wrist on 10/1/20. Review of R9's hospital radiology report dated 10/1/20 revealed R9 had an acute distal radial fracture on the left side (left wrist fracture). R 10 Review of R 10's Face sheet dated March 17, 2021 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not her own responsible party. Review of R 10's Nursing Comprehensive Evaluation dated 12/31/20 revealed she was continent of bowel and bladder, required one person assistance to transfer, use the toilet and walk (using a device). She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of this assessment R 10 was only orient to self not time or place. She was considered a wander risk due to confusion and was issued a wander guard device. During an interview with SW P on 3/18/21 at 12:35 PM, R 10's 72-hour care conference was review. The care conference was dated 1/4/21 (4 days after admission, not 72 hours). No written care plan for this date was located. R 10's DPOA participated. The note revealed the DPOA was having difficulty providing care prior to this last hospitalization . At home she required supervision walking with a walker about 125 feet. She had frequent falls, she was known to get up and walk without her walker. There was no indication of wake/sleep time, frequency of toilet needs or what worked to compensated for being blind. There was no indication if she required naps or how they supervised her at home. Review of R 10's ADL (activities of daily living) care plan dated canceled 1/7/21, revealed she required encouragement to use her call light. The ADL goal was, Will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score through the review date. The care plan did not give any indication how much assistance R 10 required for her ADL's. Review of R 10's fall care plan revealed she had a goal of being free from injury related to falls. All interventions were resolved on 1/7/21 and there was no indication when they were started. Interventions included: keep the resident's environment as safe as possible with even floors, free from spills and/or clutter; adequate lighting: call light within reach, commonly used items in reach, avoid repositioning furniture and keep bed in appropriate position, left side of bed against the wall, provide resident with activities that minimize the potential for falls while providing diversion and distraction (no idea what activities she could do as she was legally blind), and PT/OT evaluate and treat as ordered. There was no indication what special needs she had for safety as she was legally blind. There was no indication how much assistance she required with her ADL's in the ADL care plan or the fall care plan. The facility provided incident and accident forms for R 10's 3 unwitnessed falls dated, 1/2/21 at 1300 (1:00PM), 1/3/21 at 1415 (2:15 PM) and 1/6/21 at 5:45 AM), there was not information as to what staff were working at the time of the fall. It was not clear who found the resident after she fell . It was not clear if the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON provided a timeline for R 10's falls on 3/18/21 and reviewed the fall with the surveyor. The first fall on 1/2/21 at 1300 revealed R 10 was found on the floor of her bathroom. She obtained a skin tear and a hematoma on her left hand. She said she was putting on a sweater (no indication she was actually putting on a sweater) There was no indication when R 10 was last assisted with any care or the use of the toilet. R 10 had an increased agitation. R 10 was sent to the emergency room after this fall and it was determined she had a urinary tract infection. The DON said the root cause of the fall was weakness. The DON could not locate any increase supervision or assistance care planned or provided to R 10 after this fall. The next fall was on 1/3/21 at 1415 (2:15 PM) almost 24 hours after the first fall. R 10 was found on her room floor next to her bed she stated she was going to fix her TV. There was no indication she was using her visual device. The intervention was to move her bed and the cable that was hanging down from the TV. The DON was not able to locate any increased supervision or assistance provided after this fall. There was no indication when R 10's last ADL assistance with provided. The next fall was on 1/6//21 at 5:45 AM. R 10 was found on the floor in her room in front of her chair with her walker next to her. She had a hematoma and a laceration on her forehead. R 10 had a been assisted to the toilet a 5:00 am. It was not clear if she had gone back to bed or stayed up. It was not clear if she was agitated and had been known to self-transfer. It was not clear if she ever used her call light. R 10 was transferred to the hospital after this fall and did not return. No staff interviews were provided to the Surveyor. The surveyor was not provided names of staff providing care at the time of these falls so information in this timeline could not be verified. There was no indication in the timeline or the care plan that the facility increased R 10's supervision and assistance related to these falls. There was no indication that diversional activities were being provided or her environment was adapted accommodate her being blind. Review of R 10's Emergency Department (ER) notes date 1/6//21 revealed she was being seen because she had an unwitnessed fall at the nursing home. She had a hematoma and laceration to her right forehead. R 10 had a CT scan of her head which revealed a right orbital fracture (bones around the right eye). According to the ER note, they discussed discharge plans with R 10's DPOA (durable power of attorney) and since she had 2 previous falls in the nursing home she may be better managed at home. R 10's DOPA took her home from the hospital.

This citation pertains to intake numbers: MI 446 and MI 152 Based on interview and record review the facility failed to implement increased supervision and assistance to prevent falls for 2 Residents (R9 and R 10) of 5 Residents reviewed for falls, resulting in R9 and R 10 falling multiple times and sustaining fractures. Findings include: R 9 Review of R 9's face sheet dated March 16. 2021, revealed she was an [AGE] year-old female admitted to the facility on [DATE], she had diagnoses that included: Alzheimer's Disease, dementia, [CONDITION(S)], moderate protein-calorie malnutrition, diabetes Mellitus II, weakness, adult failure to thrive, dizziness and giddiness, overactive bladder, difficulty in walking and unspecified fall, subsequent encounter. She was listed as her own responsible party. Review of R 9's Brief Interview of Mental Status (BIMS) score dated 9/21/20 revealed she scored 8/15 (moderate cognitive impairment). Review of R 9's admission hospital paperwork revealed she was taken to the emergency roiagnom on [DATE] at 8:00 PM because of progressive weakness, inability to stand up from the toilet. She was limited as a historian due to dementia. Review of R 9's, 72-hour admission conference note dated 9/17/20 at 13:55 (1:55 PM), revealed the box for responsible party/family was checked. Notes do not indicate family name or any family participation in the care conference. There was no indication of any safety concerns or preferences discussed at this care conference. The goal was for R9 to return home with her husband. There was concern about home care because the resident said they could not afford home care. Review of R 9's ADL (activities of daily living) care plan dated 9/15/20 revealed she required extensive assistance of 2 for transfers, bed mobility and toilet use. She required encouragement to use her call light for assistance. On 3/18/21 at 12:35 PM an interview was completed with Social Worker (SW) P. R 9's 72 hours admission conference note dated 9/17/20 at 13:55 (1:55 PM) was reviewed with SW P, SW P was not sure if R 9's family participated in the care conference as a family name was not indicated in the note. She confirmed they did not discuss resident preferences or any safety concerns, and a written care plan was not provided to the resident or family at the time of the care conference on 9/17/20. The facility provided 3 incident and accident reports that document 3 unwitnessed falls for R9, 9/19/20 at 6:20 AM, 9/26/20 at 4:30 AM and 10/1/20 at 8:45 AM. There was no indication what staff were working at the times of these falls, no indication how they determined the last time care was provided. There was no indication what the resident was like prior to the fall. There was no indication if the resident had been self-transferring. There was no indication how they were able to determine what the unmet need was when these falls occurred due to the lack of information in the incident reports. There was no indication what R 9's normal wake/sleep time, bowel/bladder schedule or what her tolerance was to being out of bed. The Surveyor was not able to verify the information that was provided as staff working at the time of the falls was not indicated in the information provided. The Director of Nursing (DON) provided a fall timeline for R 9 on 3/18/21 at 1:00 PM. R 9 had 3 falls since admission 9/19/20 at 6:20 AM, 9/26/20 at 4:30 AM and 10/1/20 at 8:45 AM. The first fall on 9/19/20 at 6:20 AM, R 9 was found on the floor between the wall and her bed. She was observed in bed 30 minutes prior. It was not clear if she was sleeping or restless. She had been assisted to the toilet less than an hour prior to that fall. The intervention to prevent further falls was to move the bed next to the wall. The next fall on 9/26/20 at 4:30 AM indicated she again fell out of bed and this time she needed to use the toilet. It was about 2.5 hours since she was last assisted to the toilet. The intervention was to change cardiac medications and due a urinalysis to check for a urinary tract infection. The DON reviewed her notes and said they did not increase R 9 supervision or assistance after the 2nd fall, she was unable to find any normal routine scheduling to meet R 9's ADL needs. The next fall was on 10/1/20 at 8:45 AM when she was found on the bathroom floor. It was not clear when she was last assisted to the toilet as the report said, just prior to breakfast. There was no indication of a bowel and bladder schedule being assessed for her needs. R9 was sent to the hospital after this fall where it was determined she had a left wrist fracture. R 9 did not return to the facility. Review of R 9's fall care plan dated 9/15/20, revealed she had a history of dementia and falls, she had changes in cognition with behaviors. She was incontinent and weak. There were no interventions to increase R 9 supervision and assistance related to her need to use the toilet after her fall on 9/26/20 when the facility determined the unmet need was to use the toilet. R 9 fell again on 10/1/20 in the bathroom and sustained a left wrist fracture. R 9 did not return to the facility after she went to the emergency room to treat her fractured wrist on 10/1/20. Review of R9's hospital radiology report dated 10/1/20 revealed R9 had an acute distal radial fracture on the left side (left wrist fracture). R 10 Review of R 10's Face sheet dated March 17, 2021 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: heart failure, chronic kidney disease, stage 4 (severe), diabetes mellitus II, muscle weakness, difficulty in walking, unsteady on feet and [CONDITION(S)]. She was not her own responsible party. Review of R 10's Nursing Comprehensive Evaluation dated 12/31/20 revealed she was continent of bowel and bladder, required one person assistance to transfer, use the toilet and walk (using a device). She had a history of falls and urinary urgency. The summary included information on a visual device R 10 kept around her neck which allowed her to see the call light and push the button. At the time of this assessment R 10 was only orient to self not time or place. She was considered a wander risk due to confusion and was issued a wander guard device. During an interview with SW P on 3/18/21 at 12:35 PM R 10's 72-hour care conference was review. The care conference was dated 1/4/21 (4 days after admission, not 72 hours). No written care plan for this date was located. R 10's DPOA participated. The note revealed the DPOA was having difficulty providing care prior to this last hospitalization . At home she required supervision walking with a walker about 125 feet. She had frequent falls, she was known to get up and walk without her walker. There was no indication of wake/sleep time, frequency of toilet needs or what worked to compensated for being blind. There was no indication if she required naps or how they supervised her at home. Review of R 10's ADL (activities of daily living) care plan dated canceled 1/7/21, revealed she required encouragement to use her call light. The ADL goal was, Will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score through the review date. The care plan did not give any indication how much assistance R 10 required for her ADL's. Review of R 10's fall care plan revealed she had a goal of being free from injury related to falls. All interventions were resolved on 1/7/21 and there was no indication when they were started. Interventions included: keep the resident's environment as safe as possible with even floors, free from spills and/or clutter; adequate lighting: call light within reach, commonly used items in reach, avoid repositioning furniture and keep bed in appropriate position, left side of bed against the wall, provide resident with activities that minimize the potential for falls while providing diversion and distraction (no idea what activities she could do as she was legally blind), and PT/OT evaluate and treat as ordered. There was no indication what special needs she had for safety as she was legally blind. There was not indication how much assistance she required with her ADL's in the ADL care plan or the fall care plan. The facility provided incident and accident forms for R 10's 3 unwitnessed falls dated, 1/2/21 at 1300 (1:00 PM), 1/3/21 at 1415 (2:15 PM) and 1/6/21 at 5:45 AM), there was no information as to what staff were working at the time of the fall. I was not clear who found the resident after she fell . It was not clear if the resident had a history of self-transfers. It was not clear if R 10 was using her visual device when the fall occurred or even if the visual devise was helping her as she had known confusion. The DON provided a timeline for R 10's falls on 3/18/21 and reviewed the fall with the surveyor. The first fall on 1/2/21 at 1300 revealed R 10 was found on the floor of her bathroom. She obtained a skin tear and a hematoma on her left hand. She said she was putting on a sweater (no indication she was actually putting on a sweater). There was no indication when R 10 was last assisted with any care or the use of the toilet. R 10 had an increased agitation. R 10 was sent to the emergency room after this fall and it was determined she had a urinary tract infection. The DON said the root cause of the fall was weakness. The DON could not locate any increased supervision or assistance care planned or provided to R 10 after this fall. The next fall was on 1/3/21 at 1415 (2:15 PM) almost 24 hours after the first fall. R 10 was found on her room floor next to her bed she stated she was going to fix her TV. There was no indication she was using her visual device. The intervention was to move her bed and the cable that was hanging down from the TV. The DON was not able to locate any increased supervision or assistance provided after this fall. There was no indication when R 10's last ADL assistance with provided. The next fall was on 1/6/21 at 5:45 AM. R 10 was found on the floor in her room in front of her chair with her walker next to her. She had a hematoma and a laceration on her forehead. R 10 had a been assisted to the toilet a 5:00 am. It was not clear if she had gone back to bed or stayed up. It was not clear if she was agitated and had been known to self-transfer. It was not clear if she ever used her call light. R 10 was transferred to the hospital after this fall and did not return. No staff interviews were provided to the Surveyor. The surveyor was not provided names of staff providing care at the time of these falls so information in this timeline could not be verified. There was no indication in the timeline or the care plan that the facility increased R 10's supervision and assistance related to these falls. There was no indication that diversional activities were being provided or her environment was adapted accommodate her being blind. Review of R 10's Emergency Department (ER) notes date 1/6/21 revealed she was being seen because she had an unwitnessed fall at the nursing home. She had a hematoma and laceration to her right forehead. R 10 had a CT scan of her head which revealed a right orbital fracture (bones around the right eye). According to the ER note, they discussed discharge plans with R 10's DPOA (durable power of attorney) and since she had 2 previous falls in the nursing home she may be better managed at home. R 10's DOPA took her home from the hospital.

Based on observation, interview and record review, the facility failed to develop and implement care plans for 2 residents (Residents #33 and #38) out of 19 residents reviewed for care planning, resulting in a fall with fracture (Resident #33), and the potential for complications for a resident diagnosed with [REDACTED].#38). Findings include: Resident #33 According to a facility face sheet dated 12/18/19, Resident #33 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. On 12/17/19 at 9:53 AM, Resident #33 was observed with staff. She was seated in her wheelchair with a gait belt (a belt placed around the waist to assist the staff ambulating with her) on. Resident #33 was assisted to stand to use a 2 wheeled walker. Resident #33 stated, I have a problem with this (touching right leg). My leg hurts. Record review of progress notes dated, 9/23/2019 11:50 Nurses Notes Note Text: This nurse was at nurse station and heard a loud noise down the hallway. (Name of Resident #33) was found in room [ROOM NUMBER] with another guest, on knees, with other guest attempting to help (Name of Resident #33) onto her feet. Noted a bedside chair turn onto side. Room was darkened with window shade closed and room light was off. (Name of Resident #33) was unable to verbalize what had happened just repeating I'm fine when asked. The other guest stated, she just stood up, leaned on the chair armrest, and fell . Assisted to chair x 2 (times 2) staff. ROM WNL (Range of Motion within normal limits). Neuro (neurological)checks WNL. VS (vital signs) 98.1 (temperature), 82 (heart rate), 18 (respirations), 119/68 sitting BP (Blood pressure) standing 122/76. SaO2 (oxygen saturation) 97% RA (room air). 0.3 CM (centimeter) skin tear noted with small amount of bleeding noted to inside of right 4th finger where a silver ring is in place. Area was cleansed with soap and water with band aid placed. (Name of family member) aware of fall. Message left for (name of physician) to return call to (Initials of facility name). According to progress notes dated, 10/19/2019 02:30 Nurses Notes Note Text: 0215 (2:15 AM) heard a loud noise ran to room. patient sitting on floor leaning on RT (right) hip and elbow. walker tipped over and dining room chair tipped over. patient states she was going to the bathroom. was observed 15 min prior sitting in wingback chair with legs elevated on dining chair. patient had one shoe on and one off. attempted to get up alone and was told to wait for help. assisted with 2 assist up and to BR (bathroom). no injuries noted skin check done. accucheck (blood sugar) 83. neuros (neurological checks) intact. (Name of family member) notified of incident. (Name of physician) notified. will continue to monitor According to progress notes and provided timeline dated on 10/19/19, Note Text: At 1010 (10:10 AM) the guest was noted to be sitting on her buttocks with her back against the bed and front of body facing the entrance of the room. When asked if having pain, the guest originally stated no. When the guest shifted a little, the guest then complained of having right hip pain. The guest was placed in a lying position r/t (related to) not tolerating the position she was in and trying to get up. When lying, the guest's right foot was noted to be turned outward. The guest denied any pain elsewhere and no other visible injuries were noted. An ambulance was called at 1013 (10:13 AM) r/t the guest having c/o's (complaints) of right hip pain and the foot being turned outward. The guest's daughter, (Name of family), was notified of the fall and of an ambulance being called via phone at 1015 (10:15 AM). The guest's granddaughter, (Name of family), was also notified of the fall via the phone and requested that the guest be sent to (Name of Hospital) for eval(uation). This nurse gave report to (Name of nurse) at (Name of hospital) via the phone at 1035 (10:35 AM). When the guest was asked what had happened, the guest stated that she was getting up to go to the nurses' desk to see what was going on and had fell . The guest stated that she had been on the bed prior to getting up and falling. On 12/18/19 at 1:49 PM, during an interview and record review of incident accident reports and care plans of Resident #33 with the Director of Nursing (DON) she revealed: 1) On 6/14/19, Resident #33 was observed in the hall, fell backwards and was observed by friend and nurse. Resident #33 had a small open area on back of head. Resident #33 was sent to hospital and was tested for a (Urinary Tract Infection) UTI and was positive. Intervention developed was to increase supervision to walk with assist until UTI was treated. 2) On 8/10/19 she reported a fall to her daughter, Resident #33 felt the fall was that day. The intervention that the facility developed related to the fall was to move Resident #33 closer to the nurse's station, but her daughter declined. Resident #33 suffered a right forearm discoloration, bleeding on head with small bump. The DON stated the facility reviewed all interventions and felt room change was all they wanted to attempt at that time. No new intervention was implemented to prevent another fall related to what was occurring. 3) On 8/23/19 a CNA knocked on Resident #33's door, Resident #33 said just a minute and was seen walking into the bathroom. When seen in bathroom, Resident #33 was observed to be sitting on the floor of the bathroom. The intervention developed was a toileting plan. 4) On 8/27/19 Resident #33 was ambulating in the hall with walker with CN[NAME] Resident #33 fell and bumped back of right hand of wheelchair close to her. Intervention implemented was to obtain labs including a UA (Urinalysis). The DON confirmed that the facility did not develop an immediate intervention related to why the fall occurred to prevent another fall. 5) On 9/14/19 Resident #33 had an unwitnessed fall in room her room. She stated she bumped her head. Resident #33's room door was closed at the time of the fall. The intervention developed was to encourage Resident #33 to keep the room door open. 6) On 9/23/19 observed on knees in friends' room [ROOM NUMBER]. The person present observed her standing up from chair and chair tipped over. Resident #33 got a skin tear right 4th finger. Intervention developed was to have residents visit in a common area. 7 and 8) On 10/19/19 Resident #33 had 2 falls: 7) at 2:15 AM Resident #33 was sitting in her room in chair with feet propped up by staff. When staff returned, Resident #33 was observed sitting on the floor leaning on her right elbow. Resident #33 stated she was getting up to go to the bathroom. Intervention developed was supervision throughout the night. The DON was unable to state how the supervision was implemented or how staff knew to increase supervision. There was no documentation provided as to how this supervision was done. 8) at 10:10 AM in Resident #33's room, Resident #33 was sitting on her bottom, back against the bed. Resident #33 had no pain at first then complained of right hip pain. Resident #33 was getting up to go to the nurse's station to see what was going on. Resident #33 suffered a [MEDICAL CONDITION]. Neurological checks were started and Resident #33 was transferred to the hospital. Review of a facility policy titled, Fall Management dated revised 10/2019 reflected, The facility will identify hazards and guest/resident risk factor and implement interventions to minimize falls and risk of injury related to falls. Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices and or functional programs as appropriate to minimize the risk for falls Guests/residents will be evaluate by the interdisciplinary team (IDT) for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review .When a fall occurs, the licensed nurse will evaluate the guest/resident for injury .The first responder (the first person to identify that the guest/resident has fallen) will summon a nurse after ensuring the guest/resident is safe, and then ask the guest/resident what they were attempting to do. A fall huddle will be held to determine the root cause of the fall. The licensed nurse will complete: incident accident report, review and or revise care plan and guest/resident kardex .The IDT will review all guest/resident falls within 24 to 72 hours at the stand up/clin ops meeting to evaluate/investigate the circumstances and probable cause of the fall, review/modify the plan of care to minimize repeat falls and update the guest/resident kardex as needed .The DON/designee will document any changes in the care plan at the meeting . Resident #38 A review of Resident #38's Admission Record, dated 12/19/19, revealed Resident #38 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #38's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/27/19, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed Resident #38 was severely cognitively impaired. A review of Resident #38's Nurses Notes, dated 12/17/19, revealed, Continues on ABX (antibiotics) for UTI (urinary tract infection) with no ADR (adverse drug reaction). No urinary symptoms voiced. A review of Resident #38's medical record failed to reveal a care plan for urinary tract infections. A review of Resident #38's (MONTH) 2019 Medication Administration Record [REDACTED]. On 12/19/19 at 11:30 AM, Assistant Director of Nursing (ADON) was notified a urinary tract infection care plan could not be located in Resident #38's medical record. A copy of Resident #38's urinary tract infection care plan was requested from ADON J, if one could be located. On 12/19/19 at 2:13 PM, ADON J provided a urinary tract care plan for Resident #38, dated 12/19/19 (4 days after Resident #38 received the first scheduled dose of [MEDICATION NAME] and 6 hours after Resident #38 received the last scheduled dose of [MEDICATION NAME]). ADON J failed to provide any additional evidence that a urinary tract care plan had been developed prior to 12/19/19.

Based on observation, interview and record review, the facility failed to propel 3 residents in wheelchairs with foot rests (Residents #18, 21 and 33), failed to place a coffee thermos out of reach of wandering/ambulating residents potentially affecting 5 residents in the 200/300 Hall and failed to prevent a fall with fracture for one resident (Resident #33), resulting in the potential for injury during wheelchair propelling, hot [MEDICAL CONDITION] choking hazard from hot coffee and a [MEDICAL CONDITION] resulting from a fall. Findings include: Resident #33 According to a facility face sheet dated 12/18/19, Resident #33 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. On 12/17/19 at 9:53 AM, Resident #33 was observed with staff. She was seated in her wheelchair with a gait belt (a belt placed around the waist to assist the staff ambulating with her) on. Resident #33 was assisted to stand to use a 2 wheeled walker. Resident #33 stated, I have a problem with this (touching right leg). My leg hurts. On 12/17/19 at 11:08 AM it was observed that a member of the family was propelling resident #33 in her wheelchair without footrests in the hall going toward her room. On 12/17/19 at 11:12 AM during an interview, Resident #33's family member verified he knew he should use the footrests while propelling Resident #33 but stated she's doing better so she's was able to self-propel herself so the foot rests weren't on. Record review of progress notes dated, 9/23/2019 11:50 Nurses Notes Note Text: This nurse was at nurse station and heard a loud noise down the hallway. (Name of Resident #33) was found in room [ROOM NUMBER] with another guest, on knees, with other guest attempting to help (Name of Resident #33) onto her feet. Noted a bedside chair turn onto side. Room was darkened with window shade closed and room light was off. (Name of Resident #33) was unable to verbalize what had happened just repeating I'm fine when asked. The other guest stated, she just stood up, leaned on the chair armrest, and fell . Assisted to chair x 2 (times 2) staff. ROM WNL (Range of Motion within normal limits). Neuro (neurological)checks WNL. VS (vital signs) 98.1 (temperature), 82 (heart rate), 18 (respirations), 119/68 sitting BP (Blood pressure) standing 122/76. SaO2 (oxygen saturation) 97% RA (room air). 0.3 CM (centimeter) skin tear noted with small amount of bleeding noted to inside of right 4th finger where a silver ring is in place. Area was cleansed with soap and water with band aid placed. (Name of family member) aware of fall. Message left for (name of physician) to return call to (Initials of facility name). According to progress notes dated, 10/19/2019 02:30 Nurses Notes Note Text: 0215 (2:15 AM) heard a loud noise ran to room. patient sitting on floor leaning on RT (right) hip and elbow. walker tipped over and dining room chair tipped over. patient states she was going to the bathroom. was observed 15 min prior sitting in wingback chair with legs elevated on dining chair. patient had one shoe on and one off. attempted to get up alone and was told to wait for help. assisted with 2 assist up and to BR (bathroom). no injuries noted skin check done. accucheck (blood sugar) 83. neuros (neurological checks) intact. (Name of family member) notified of incident. (Name of physician) notified. will continue to monitor According to progress noted dated, Note Text: At 1010 (10:10 AM) the guest was noted to be sitting on her buttocks with her back against the bed and front of body facing the entrance of the room. When asked if having pain, the guest originally stated no. When the guest shifted a little, the guest then complained of having right hip pain. The guest was placed in a lying position r/t (related to) not tolerating the position she was in and trying to get up. When lying, the guest's right foot was noted to be turned outward. The guest denied any pain elsewhere and no other visible injuries were noted. An ambulance was called at 1013 (10:13 AM) r/t the guest having c/o's (complaints) of right hip pain and the foot being turned outward. The guest's daughter, (Name of family), was notified of the fall and of an ambulance being called via phone at 1015 (10:15 AM). The guest's granddaughter, (Name of family), was also notified of the fall via the phone and requested that the guest be sent to (Name of Hospital) for eval(uation). This nurse gave report to (Name of nurse) at (Name of hospital) via the phone at 1035 (10:35 AM). When the guest was asked what had happened, the guest stated that she was getting up to go to the nurses' desk to see what was going on and had fell . The guest stated that she had been on the bed prior to getting up and falling. On 12/18/19 at 1:49 PM, during an interview and record review of incident accident reports and care plans of Resident #33 with the Director of Nursing (DON) she revealed: 1) On 6/14/19, Resident #33 was observed in the hall, fell backwards, and was observed by friend and nurse. Resident #33 had a small open area on back of head. Resident #33 was sent to hospital and was tested for a (Urinary Tract Infection) UTI and was positive. Intervention developed was to increase supervision to walk with assist until UTI was treated. 2) On 8/10/19 she reported a fall to her daughter, Resident #33 felt the fall was that day. The intervention that the facility developed related to the fall was to move Resident #33 closer to the nurse's station, but her daughter declined. Resident #33 suffered a right forearm discoloration, bleeding on head with small bump. The DON stated the facility reviewed all interventions and felt room change was all they wanted to attempt at that time. No new intervention was implemented to prevent another fall related to what was occurring. 3) On 8/23/19 a CNA knocked on Resident #33's door, Resident #33 said just a minute and was seen walking into the bathroom. When seen in bathroom, Resident #33 was observed to be sitting on the floor of the bathroom. The intervention developed was a toileting plan. 4) On 8/27/19 Resident #33 was ambulating in the hall with walker with CN[NAME] Resident #33 fell and bumped back of right hand of wheelchair close to her. Intervention implemented was to obtain labs including a UA (Urinalysis). The DON confirmed that the facility did not develop an immediate intervention related to why the fall occurred to prevent another fall. 5) On 9/14/19 Resident #33 had an unwitnessed fall in room her room. She stated she bumped her head. Resident #33's room door was closed at the time of the fall. The intervention developed was to encourage Resident #33 to keep the room door open. 6) On 9/23/19 observed on knees in friends' room [ROOM NUMBER]. The person present observed her standing up from chair and chair tipped over. Resident #33 got a skin tear right 4th finger. Intervention implemented was to have residents visit in a common area. 7 and 8) On 10/19/19 Resident #33 had 2 falls: 7) at 2:15 AM Resident #33 was sitting in her room in chair with feet propped up by staff. When staff returned, Resident #33 was observed sitting on the floor leaning on her right elbow. Resident #33 stated she was getting up to go to the bathroom. Intervention implemented was supervision throughout the night. The DON was unable to state how the supervision was done or how staff knew to increase supervision. There was no documentation provided as to how this supervision was done. 8) at 10:10 AM in Resident #33's room, Resident #33 was sitting on her bottom, back against the bed. No pain at first then right complained of hip pain. She was getting up to go to the nurse's station to see what was going on. Resident #33 suffered a [MEDICAL CONDITION]. Neurological checks were started and Resident #33 was transferred to the hospital. Review of a facility policy titled, Fall Management dated revised 10/2019 reflected, The facility will identify hazards and guest/resident risk factor and implement interventions to minimize falls and risk of injury related to falls. Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices and or functional programs as appropriate to minimize the risk for falls Guests/residents will be evaluate by the interdisciplinary team (IDT) for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review .When a fall occurs, the licensed nurse will evaluate the guest/resident for injury .The first responder (the first person to identify that the guest/resident has fallen) will summon a nurse after ensuring the guest/resident is safe, and then ask the guest/resident what they were attempting to do. A fall huddle will be held to determine the root cause of the fall. The licensed nurse will complete: incident accident report, review and or revise care plan and guest/resident kardex .The IDT will review all guest/resident falls within 24 to 72 hours at the stand up/clin ops meeting to evaluate/investigate the circumstances and probable cause of the fall, review/modify the plan of care to minimize repeat falls and update the guest/resident kardex as needed .The DON/designee will document any changes in the care plan at the meeting . Resident #21 According to a Minimum Data Set assessment dated [DATE], Resident #21 was an [AGE] year old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. On 12/17/19 at 12:23 PM Resident #21 was observed being propelled by wheelchair by Certified Nurse's Aide (CNA) [NAME] with one foot on a footrest, the other foot hanging, skimming the floor. On 12/18/19 at 9:33 AM during an interview with CNA [NAME] when asked if Resident #21's foot should have been from the footrests during propelling into the dining room yesterday she stated, no. Review of a facility policy titled, Wheelchairs dated 3/05 reflected, Wheelchairs will be accessible as needed, to provide transportation for guest while maintaining their safety and comfort .Procedure: .11. Return leg rests to appropriate position, and gently position guest's legs and feet . According to Mosby's Textbook for Long-Term Care Nursing Assistants 7th edition, in the Wheelchair Safety Section, Make sure the person's feet are on the foot plates (wheelchair footrests or pedals) before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving. Never push a person in a wheelchair without feet resting on the footplate's (footrests or foot pedals). 200/300 pantry area On 12/18/19 05:15 PM during an observation of the 300 Pantry area, it was observed there was a pump carafe sitting on the counter. The Certified Dietary Manager (CDM) A stated it contained coffee and the temperature was obtained before the carafe was taken to the unit. The CDM A stated that usually CNA's obtained the coffee for residents. The CDM A was asked how they would be sure that a resident with dementia would not burn themselves by pushing the carafe top. CDM A stated the carafe was also available to visitors. The CDM A was asked how the facility assured that mug covers or thickened liquids were being provided if coffee was obtained for residents by visitors. She stated family was educated about resident's needs. When asked about how a visitor or family member would know the resident's special requirements if the visitors and family had not yet obtained coffee for residents, she stated she understood the concern. During an observation on 12/17/19 at 11:45 AM, a coffee carafe was observed on a counter in a public area on a unit where residents with dementia and other debilities lived. The temperature of the coffee dispensed from the carafe was 150 degrees. The carafe was not supervised and was in an area readily accessible to vulnerable residents at risk [MEDICAL CONDITION] choking/aspiration. During an interview on 12/17/19 at 11:50 AM, two Certified Nurse Aides (CNA's) reported that the coffee is left on the unit throughout the day for visitors and residents and that CNA's get residents the coffee upon request. According to the Michigan Department of Community Health: Scalding Injuries Caused By Excessive Hot Water, Food and Hot Beverage Temperatures (Revised (MONTH) 5, 2008), it can take less than 1 second for a second degree burn to develop in water that is 150 degrees Fahrenheit. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin [MEDICAL CONDITION] depth more quickly. Resident #18 According to a facility Admission Record dated 12/19/2019, Resident #18 had [DIAGNOSES REDACTED]. During an observation on 12/18/19 at 9:33 AM, Resident #18 was observed being pushed in her wheelchair without foot pedals by a family member. Resident #18 was wearing rubber soled sneakers and her feet hovered just above the floor. Licensed Practical Nurse (LPN) N had just been given a holiday card by the resident and observed her being pushed without foot pedals and did not advise the family member of the safety concerns related to propelling a resident in a wheelchair without foot pedals in place. According to the facility policy for Wheelchairs dated 3/2005 reflected leg rests were to be used when assisting a resident in a wheelchair.

The following statement of deficiencies contains 2 Deficient Practice Statements. Deficient Practice Statement A: Based on observation, interview and record review the facility failed to access for safety with hot liquids to prevent a hot liquid burn for 1 of 3 residents (Resident #10) reviewed for hot liquid assessment resulting in Resident #10 sustaining 2nd degree burns to his thighs with pain and discomfort. The facility was placed in Immediate Jeopardy (IJ) as a result of the facility's failure to assess for hot liquid safety and implement appropriate interventions to prevent burns from hot liquid spills. This deficient practice placed all residents at the facility at risk for hot liquid spills and serious injury. On 7/20/17 at 12:30 PM the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on 7/2/17 at approximately 8:50 AM, due to the facility's failure to assess timely and implement appropriate interventions to prevent hot liquid spill burns. On 7/21/17, the surveyors verified the following corrective action plan had been implemented: Resident identified to be affected by the alleged deficient practice. 1. Resident #10 was assessed by nursing staff on 7/2/17 and a physician order [REDACTED]. 2. Resident #10's care plan was reviewed and updated by the DON on 7/2/17. Care plan was updated to include an immediate intervention of a covered cup when the resident drank with hot fluids. 3. Physician and Responsible Party Notification occurred on 7/2/17 at approximately 9:05 am. 4. Resident #10 no longer resides at Laurels of Carson City. He was discharged home on[DATE]. Residents with the potential to be affected by the alleged deficient practice. 1. An audit was completed on 7/3/17 to ensure that any resident requiring adaptive equipment has a current care plan and care card. 2. On 7/3/17 CNA's were queried to further facilitate communication. All were able to correctly recite those residents who use adaptive devices for hot beverages. 3. On 7/3/17 all residents were screened by the therapy department and those requiring interventions had their care plans and care cards audited by the nursing department. Systemic Measures 1. On 7/20/17 Facility Administrator, Director of Nursing and Rehab Services Director reviewed and approved Therapy Process for Screening with Hot Liquids. (Please see attached Therapy Process for Screening with Hot Liquids) 2. On 7/20/17 Facility Licensed Speech Therapist and Licensed Occupational Therapist will be educated on facility's internal Therapy Process for Screening with Hot Fluids. 2 out of 2 Occupational Therapists have been educated on 7/20/17 and 2 out of 3 Speech Therapists will be educated on 7/20/17 with the 3rd being educated prior to returning to work. 3. Director of Nursing or Designee will maintain a list of guests who require adaptive equipment. This list will updated as appropriate and kept in each dining area for staff to access. 4. Director of Nursing or Designee will review this list weekly during the NAR meeting to ensure accuracy. Quality Assessment and Assurance 1. The Facility Director of Nursing or designee will complete audits of new admissions weekly for four weeks and then monthly for three months to ensure proper evaluation/communication has occurred as outlined in the Therapy Process for Screening, Communication for the follow. Results of the audits will be presented for Quality Assurance for further review and recommendations. The Immediate Jeopardy was removed on 7/20/17. The corrective action plan was verified as being implemented, however the facility remained out of compliance with a scope of isolated and severity of Actual harm that is not immediate jeopardy as sustained compliance could not be verified. Findings include: The facility provided a policy for Assistive/Adaptive Devices dated 4/2010 for review. The policy reflected, 1. Guests shall be evaluated by therapy or per facility policy to identify the need for an assistive feeding device. A physician's orders [REDACTED]. 2. Suitable and acceptable devices shall be offered to the guest. 3. Notification of the nutritional intervention shall be sent to the Dietary Department in a timely manner utilizing the Diet Communication form .4. The diet card/cardex (care guide) and care plan shall be maintained to reflect the current status of the guest .6. Assistive devices shall be returned to the Dietary Department after each meal service per facility policy. 7. Assistive devices include, but are not limited to the following: divided plates, plate guard, rocker knives, built-up silverware, sippy cups, nosey cups, dycem placemats. Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #10 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents moderate cognitive impairment. Resident #10 required staff assistance with activities of daily living. According to the Accident/Incident Report, dated 7/2/17 at 8:50 AM, Resident #10 spilled hot coffee on his lap which resulted in pain and burns to both legs. According to the Wound and Skin Condition Records, dated 7/2/17, the following findings were noted: -an open blister to the right upper inner thigh 17 x 5 x <0.1 cm -a blister to the right upper inner thigh 9.5 x 5 cm -an open blister to the left upper inner thigh 11 x 3 x <0.1 cm On 7/19/17 at 2:50 PM an interview was conducted with Certified Nurse Assistant (CNA) F related to the incident. CNA F stated that on 7/2/17 at approximately 8:50 AM, she was standing near the nurse's desk and observed Resident #10 in the dining area spill his coffee on his lap. CNA F immediately assisted Resident #10 across the hall to his room, applied cool, wet compresses to his lap, removed his pants, and summoned the nurse for further evaluation and treatment. On 7/19/17 at approximately 5:55 PM, CNA C was interviewed about the incident via telephone. CNA C stated that she started her shift at 6 AM on 7/2/17 and she observed Resident #10 along with another resident, sitting in the dining area drinking coffee from a regular mug with no lid. At approximately 8:45, Resident #10 asked CNA C for a refill and CNA C refilled his mug with coffee. CNA C stated just after that she went to assist another resident, CNA F reported that she observed Resident #10 spilling the coffee into his lap. CNA C stated that after the burn occurred the staff reviewed Resident #10's care guide and it did not reflect the need for a lid on cups or mugs. CNA C stated, I asked after it happened how the night shift would even know (that Resident #10 needed a lid on cups). There wasn't anything on the care guide. The night shift had provided the coffee (to Resident #10) before we even started shift at 6 AM. They (midnight staff) wouldn't even know if he needed a lid or thicken liquids because the care guide didn't say. CNA C stated that she remembered Resident #10 eating his breakfast and he did not have any cups with lids for his breakfast beverages. On 7/19/17 at 4:30 PM an interview and record review of the care guide and care plans was done with the Director of Nursing (DON) B. The care plan, dated 7/2/17 (date of burn), reflected the intervention of Lidded mugs for hot liquids until re-evaluation by therapy. The DON B stated the intervention was placed on the care plan and the care guide after the burn incident on 7/2/17. When asked how the facility determines if a resident needs adaptive devices for eating/drinking, the DON B stated, Usually OT (Occupational Therapy) does an assessment within the first 24 hours and makes the recommendation and sends it to the dietary to notify them, then it's placed in three places- the meal ticket, care guide and care plan. During an interview and record review on 7/20/17 at 8:45 AM Occupational Therapist (OT) I stated that he completed Resident #10's initial assessment on 6/22/17 and determined that he would require moderate assistance with eating/drinking to maintain his alertness during meals, as well as supervision and cueing. OT I stated that he told the aides and nursing. Record review of the assessment did not reflect the recommendations. When asked if the communication to nursing and aides was documented anywhere, OT I stated, No, but now we evaluate for hot liquid in the findings section. All findings, needs or no needs, will be in the evaluation, then we will complete a communication notice, and a physician's orders [REDACTED].#10 later in the day and found that he needed cups with lids as well. An interview was conducted on 7/19/17 at 5:00 PM with the Speech Therapist (ST) E as well as a record review of the evaluation, dated 6/28/17 and revised on 7/5/17. ST E stated that she assessed Resident #10 on 6/22/17 and determined that he needed to use a lidded cup called a Kennedy cup. When asked if she communicated that to anyone, ST T stated that she verbally told the Dietary Manager (DM) J that he (Resident #10) needed a Kennedy cup (a cup with a lid for cold beverages). When asked if Resident #10 was assessed for hot liquid safety, ST T stated, No. When asked if the facility had a system to assess for hot liquid management, ST T stated, Yes, but it wasn't followed. ST T stated that the facility will have OT do the 24-hour evaluation, document it, send a formal communication notice to nursing, then nursing will place it on the care guide and care plan, obtain a physician's orders [REDACTED]. ST T stated that she was given a written discipline for not communicating recommendations to the appropriate disciplines. Deficient Practice Statement B: Based on observation, interview and record review the facility failed to prevent falls for 1(Resident #6) of 4, residents reviewed for falls, resulting in Resident #6 sustaining 14 falls from 1/7/17 through 6/4/17, resulting in skin tears, abrasions and possible intercranial hemorrhage, without interventions being updated or implemented into the resident's care plan. Findings: Record review of facility 'Fall Awareness Program' policy, dated 10/2010, revealed that guests at risk for falls will be monitored by staff. (5.) The fall awareness program is overseen by the behavior management committee, Occurrences related to falls are reviewed by the committee. Care Plans will be reviewed with appropriate update of interventions within 24-72 hours of each new occurrance. Resident #6: Record review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old male with moderately impaired cognitive skills of daily living, cues and supervision required. Medical [DIAGNOSES REDACTED]. Admission assessment, dated 12/24/16, for Resident #6 revealed a fall assessment score of 23, with a total score of 10 or above deeming that the guest is at risk and to initiate a care plan. Record review on 7 of Resident #6's Accident/Incident reports from January 2017 with Registered Nurse (RN) unit manager S are as follows: Fall-1/7/17 at 6:00 AM an unwitnessed/found on floor fall in room in front of closet, resulting in skin tear to elbow. Intervention to move Resident #6 to common area prior to 6:00 AM. Record review of 1/7/17 neurological flowsheet was incomplete with assessment blank spots noted. Review of the Resident #6's 'Admission Care Plan dated 12/24/16 revealed that on 1/9/17 intervention to be up for day in common area prior to 6:00 AM. Fall-1/9/17 at 1:05 PM witnessed fall from wheelchair in dining room. No injury noted. Intervention: staff to be seated next to resident at table in dining room. Review of the Resident #6's 'Admission Care Plan dated 12/24/16 revealed that the intervention was not added to the care plan. Fall- 1/25/17 at 11:10 AM unwitnessed/found on floor fall in the main dining room. No injury noted. Intervention: educate activity staff on supervision. Record review of 1/25/17 neurological flowsheet was incomplete with assessment blank spots noted. Review of the Resident #6's 'Admission Care Plan dated 12/24/16 revealed that on 1/25/17 no intervention was added. Fall- 2/3/17 at 4:30 PM unwitnessed/found on floor fall in the 300 hall living room in front of recliner. No injury noted. Intervention: none noted. Record review of 2/3/17 neurological flowsheet was incomplete with assessment blank spots noted. Review of the Resident #6's 'Admission Care Plan dated 12/24/16 revealed that on 2/9/17 bed side floor mat intervention was added. Fall- 2/10/17 at 6:30 PM witnessed fall, stood up in wheelchair fell over foot pedals. No injury noted. Intervention: to remove foot pedals after transport to dining room. Review of the Resident #6's 'Admission Care Plan dated 12/24/16 revealed that on 2/13/17 remove foot pedals after transport to dining room intervention was added. Fall- 3/17/17 at 6:45 PM witnessed fall in common area. Right shoulder pain noted. Intervention: to walk to and from meals. Review of the Resident #6's Care Plan dated 2/13/17 revealed that on staff to walk resident to and from meals intervention was not added. Fall- 4/23/17 at 1:05 PM unwitnessed/found on floor fall in the 300 hall. Intercranial hemorrhage injury noted possibly from fall. Intervention: will be re-evaluated upon return noted. No neurological assessment done due to resident sent to hospital. Resident re-admitted on [DATE]. Review of the Resident #6's Admission Care Plan dated 4/26/17 revealed that on 4/27/17 a Wanderguard intervention was added. Fall- 5/8/17 at 6:40 AM unwitnessed/found on floor at bedside. Skin tear to left upper arm injury noted. Intervention: no new interventions noted. Record review of 5/8/17 neurological flowsheet was incomplete with assessment blank spots noted. Review of the Resident #6's Admission Care Plan, dated 4/26/17, revealed that no intervention was added. Fall- 5/12/17 at 3:55 PM witnessed from bed to mat. No injury noted. Intervention: no new interventions noted. Record review of 5/8/17 neurological flowsheet was incomplete with assessment blank spots noted. Review of the Resident #6's Admission Care Plan dated 4/26/17 revealed guest may roll out of bed onto mat was an intervention. Fall- 5/18/17 at 5:15 AM unwitnessed/found on floor in hallway in front of resident room. Abrasion to left elbow injury noted. Intervention: Guest to be assisted into recliner at last bed check between 4-5 AM interventions noted. Record review of 5/28/17 neurological flowsheet was incomplete with blank spots noted. Review of the Resident #6's Admission Care Plan dated 4/26/17 revealed that no intervention was added. Fall- 5/28/17 at 6:55 PM unwitnessed/found on floor in resident room. Skin tear to left upper elbow 0.1 cm X 0.5 cm injury noted. Intervention: Guest to be assisted into recliner after meals interventions noted. Record review of 5/28/17 neurological flowsheet was incomplete with blank spots noted. Review of the Resident #6's Admission Care Plan dated 4/26/17 revealed that no intervention was added. Fall- 6/3/17 at 11:27 PM witnessed fall in hall while walking. Right shoulder pain noted. Intervention: medication review, possible room change and encourage call light use noted. Review of the Resident #6's Admission Care Plan dated 4/26/17 revealed no interventions were added. Fall- 6/4/17 at 6:05 AM unwitnessed/found on floor in resident room. No injury noted. Intervention: Guest moved to room closer to nurses station, toileting program initiated interventions noted. Record review of 5/28/17 neurological flowsheet there was none found for the fall. Review of the Resident #6's Admission Care Plan dated 4/26/17 revealed that no toileting program intervention was added. Fall- 6/16/17 at 00:50 AM unwitnessed/found on floor in resident room. No injury noted. Intervention: Bed in lowest position intervention noted. Record review of 5/28/17 neurological flowsheet was incomplete with blank spots noted. Review of the Resident #6's Admission Care Plan dated 6/16/17 revealed that bed in low position intervention was added. Observation of Resident #6 during survey from 7/20/17 and 7/21/17 revealed that the resident's foot pedals on his wheelchair were not removed after transport to dining room as care planned.

This citation pertains to intake #MI 552 Based on interview and record review, the Facility failed to provide the necessary care and services to maintain the highest practicable physical and mental well-being by not assessing, monitoring and providing intravenous hydration as ordered for an acute change of condition of condition in 1 of 3 sampled Residents (#101) reviewed for quality of care, from a total of 3, resulting in Resident #101 being admitted to the hospital with [REDACTED]. Findings include: Resident #101 Review of Resident #101's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. According to Resident #101's Cumulative [DIAGNOSES REDACTED].#6, Diabetes Mellitus, [MEDICAL CONDITIONS] (Stroke) and [MEDICAL CONDITION]. According to Resident #101's facility history and physical examination [REDACTED]. According to Resident #101's Brief Interview For Mental Status (BIMS) dated 6-6-12, Resident #101's score was 6 of 15 (severely cognitively impaired). A second BIMS score for resident #101, dated 6-12-12 was 13/15 (cognitively intact). Resident #101 was listed as her own responsible party and a full code. Review of Resident #101's nurse's notes for 7-6-12, at 10:00 PM, revealed that Resident #101 was found on the floor in her room and sent to the emergency room for treatment for [REDACTED]. Review of Resident #101's nurses' notes for 7-7-12 at 2:45 AM revealed the Resident returned to the facility after receiving emergency care and her vital signs were stable. Review of the prescriber's telephone orders for Resident #101 dated 7-7-12, no date and signed by Licensed Practical Nurse (LPN) #1 documented, ice to right knee as needed, monitor suture to upper lip, cleanse with normal saline, remove sutures in 5 days, monitor laceration to eye brow every and nose every shift, monitor hematoma to left eye brow every shift, Neurological checks every 2 hours for 24 hours. Review of prescriber's telephone orders for Resident #101 dated 7-8-12 at 12:30 PM and signed by LPN #3 documented, start IV (intravenous insertion site), run 50 ml/hour with normal saline until lab draw. Review of Resident #101's Intake/Output Data Collection Sheet for 7-7-12 documented that Resident #101 only had 460 ml of fluid intake (very low fluid intake); for 7-8-12, Resident had 850 ml of fluid intake (low fluid intake); and for 7-9-12, 350 cc of IV intake and 120 oral intake (low fluid intake which may cause dehydration) was documented.. During a telephone interview with LPN #1 on 7-31-12 at 1:40 PM, LPN #1 was asked about Resident #101's low fluid intake, especially as of 7-8-12, Resident #101 was receiving IV fluids per the prescriber ' s order. If IV fluids were started on 7-8-12 at 12:30 PM as order and ran until 7-9-12 at 11:15 AM (when resident #101's family requested an evaluation at a local hospital emergency room ), Resident #101 would have received approximately 1150 ml of normal saline. According to the Intake/Output record Resident #101 received 350 ml of normal saline. LPN #1 explained that on 7-8-12, Resident #101 removed her IV. The Surveyor asked if LPN #1 notified Resident #101's physician that her IV was removed. LPN #1 explained she did not call the physician because a Registered Nurse would have to be called in to start the IV if the physician wanted it. During a telephone interview with LPN #1 on 8-1-12 at 10:15 AM the Surveyor asked LPN #1 if she called Resident #101's physician when Resident #101 returned from the emergency roiagnom on [DATE] and she wrote orders on the prescriber's telephone orders. LPN #1 said she did not call the physician and that she just wrote the orders from the hospital. The Surveyor asked LPN #1 how long Residents were normally monitored for neurological checks in the facility when they hit their head and LPN#1 explained that they are normally taken for days. The Surveyor asked if Resident #101's physician would have been aware of the change to 24 hours the hospital made and LPN #1 explained she did not notify the physician of the hospital orders. Review of the facility Neurological Check Policy dated 03/05, documented that a licensed nurse is to monitor a Residents neurological status after a traumatic event for every 15 minutes for the first hour, every 30 minutes for the second hour, hourly for the next 5 hours, then every 4 hour x 4; than 8 hours x 3. (72 hours total). Review of the Neurological Assessment Flow sheet showed that Resident #101's Neurological checks were done for 24 hours after her return to the facility. Neurological checks for 7-7-12 at 2:45 PM and 4:45 PM documented very low blood pressure readings at 88/44 and 82/44 (possible sign of dehydration). Review of nursing notes for 7-7-12 revealed no evidence that Resident #101's physician was called notifying of a change in condition (low blood pressure). During an interview with LPN #3 on 8-1-12 at 10:17 AM, LPN #3 explained she was assigned to care for Resident #101 on 7-7-12. LPN #3 said Resident #101 was very confused and did not recall falling on 7-6-12. LPN #3 explained that Resident #101 was not eating on 7-7-12 and had very little to drink. LPN #3 said she was assigned to Resident #101 again on 7-8-12 and she (#101) remained lethargic and was not drinking. LPN #3 explained she called Resident #101's physician on 7-8-12 at 12:30 PM and told the physician that Resident #101 was not drinking much and the physician ordered intravenous fluid (IV). LPN #3 explained that the IV fluid was not started until 6:00 PM because the IV had to be started by a Registered Nurse (RN) and an RN was not available until 6:00 PM. The Surveyor asked LPN #3 what she (LPN #3) would do if Resident #101 pulled out her IV when she was assigned to care for her. LPN #3 said she would have to call the Registered Nurse on call because she (LPN #3) has not had anyone remove their IV when she was working. Review of Nurses Progress Notes for Resident #101 dated 7-9-12 at 10:45 AM documented Resident #101 family requested an emergency room evaluation. Resident #101's vital signs were documented as pulse 68, Respirations 20 and blood pressure 92/46 (low blood pressure). Review of Nurses Progress Notes for Resident #101, dated 7-9-12 at 11:15 AM documented that emergency medical services were at the facility to transfer Resident #101 to the emergency room . Review of the Hospital emergency room History and Physical for Resident #101, dated 7-9-12 documented that Resident #101 was admitted with a very low blood pressure 89/40, and [DIAGNOSES REDACTED] (low blood sugar). A Urinalysis was positive for bacteria (Urinary Tract Infection). Review of the Hospital Clinical Report for Resident #101, dated 7-9-12 revealed the following Diagnoses: [REDACTED]. Review of hospital laboratory results for Resident #101 dated 7-9-12 revealed that Resident #101 had the following abnormal lab values: high Blood Urea Nitrogen (BUN) level of 42 and a high Creatinine level of 2.40 (can be caused by dehydration). Review of hospital laboratory results for Resident #101 dated 7-12-12 revealed Blood Urea Nitrogen (BUN) level of 12 (normal) and a creatinine level of .8 (normal) (Kidney function returned to normal after hospital treatment). ( )

This complaint pertains to intake number MI 795. Based on interview and record review the facility failed to provide adequate supervision and assistance in 1 of 4 sampled Residents Resident (#101) from a total of 4 sampled Residents resulting in Resident #101 falling on two occasions then sustaining a left hip fracture. Findings include: Review of the Face Sheet revealed Resident #101 was an [AGE] year old male admitted to the facility on [DATE]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #101 had the following Diagnoses: [REDACTED]. According to the MDS dated [DATE] Resident #103 required the assistance of one person for ambulation and transfers. According to the Brief Interview of Mental Status (BIMS) dated 6-10-11 Resident #101 scored 11/15, indicating Resident #101's cognition was moderately impaired. Review of the Incident Report dated 7-14-11 at 2:50 AM revealed Resident #101's, "Fall alarm rang. Entered patient's room. Viewed patient falling backward against wall and bed. Patient assisted to bed. Patient assessed, neurological check completed. On call nurse called. Doctor called. Orders given to send patient to (name of hospital). The Incident Report indicated Resident #101 sustained a "Bruise/abrasion/purple read-circle over left side of face. Bump- circle over back of head. Hematoma, large open area bleeding - circle over left elbow. Small skin tears - line to end of fingers on left hand. Bruise - circle over right lower leg. Interventions included placing a left enable bar to assist with bed mobility and transfers and for facility staff to "observe for signs of pain". Review of the Incident Report dated 7-17-11 at 12:27 AM revealed Resident #101 had an unwitnessed fall and was found on the floor in his bathroom with his pants around his ankles and the walker underneath him. Resident #101 complained of pain in his left leg. The Incident Report indicated Resident #101 stated, "he had to use restroom but forgot to use call light". Resident #101 was transferred to the hospital for evaluation and treatment. During an interview on 9-8-11 at 1 PM, Social Worker (SW) #1 reported that Resident #101's cognition was moderately impaired and that people with moderate impairment can not always remember to use a call light when they need help. Review of the Social Work Progress Notes dated 7-7-11 revealed Resident #101, "Remains moderately impaired, mood stable with minimal signs and symptoms of depression related to adjustment to placement. Mood easily altered. Guest would still like to return home if able, at this time not safe to return home alone due to confusion. Nursing and physician continue to address confusion related to medication use." Review of the Hospital Physician Clinical Report dated 7-17-2011 revealed, Resident #101 "fell while in the Nursing home in bathroom. Stated he may have had a loss of consciousness." An X-ray revealed Resident #101 sustained a left displaced hip fracture. During a telephone interview on 9-8-11, at 3:20 PM, Licensed Practical Nurse (LPN) #1 stated Resident #101 needed help to get to the bathroom and with getting out of bed, but he would not use his call light when he needed help. LPN #1 said she tried to educate Resident #101 on using the call light. LPN #1 reported Resident #101 was confused at times and that she had observed him talking to the wall, thinking he was still on the farm, and thinking he had to go to work. LPN #1 stated on 7-17-2011, she found Resident #101 on the bathroom floor and his fall alarm was not sounding. LPN #1 said she knew right away by his position that his hip was broken so she did not move him, but called the physician and ambulance to transfer Resident #101 to the hospital. This surveyor asked LPN #1 if the facility could have done anything else to keep Resident #101 safe, LPN #1 stated, "We do not have enough staff to get to the fall alarms before Residents get out of bed. On the night shift there are 2 caregivers and one medication nurse for 30 Residents". During a telephone interview on 9-14-11 at 9:00 AM, Certified Nursing Assistant (CNA) #1 said Resident #101 "never" used his call light and she had to run every time she heard his fall alarm. CNA #1 said 50% of the time Resident #101 was standing or walking before she could get to him when his fall alarm was sounding and many times would not use his walker. CNA #1 said Resident #101 was very unsafe walking and had observed him stumble and loose his balance. CNA #1 said Resident #101 had increased confusion at night and would be very emotional (he would frequently cry). CNA #1 said the night Resident #101 fell and broke his hip (7/17/11), she was not aware the other caregiver was on break and CNA #1 was on the other part of the hall assisting another resident when Resident #101 fell . CNA #1 said she would have stayed on Resident #101's side of the hall if someone would have told her the other caregiver was on break. CNA #1 said more staff is needed to get to fall alarms in time. Review of a typewritten document with Resident #101's name dated 7-18-2011, provided by the Director of Nursing when this surveyor requested the facility investigations for Resident #101's falls, revealed documentation indicating, "Guest is noted with recent falls at home and was admitted a fall risk." The document indicated Resident #101 "has increased confusion throughout the day and night" and that his "Alarm to be checked every shift for proper function and placement." Resident #101 was to be "toileted every 2 hours and per request, [DIAGNOSES REDACTED].#101 was visualized by 5 staff between 8 PM and 12 AM on 7/17/11. There was no documentation to indicate that any of the staff listed as having observed Resident #101 on the evening of 7/17/11, offered to take him to the bathroom prior to him being found on the bathroom floor at 12:27 AM. The typewritten investigation concluded with, "The guest (Resident #101) has history of transferring self at home, at the hospital, and in present facility. Guest did not comply with alarm. He did not comply with asking for assistance. He 'forgot' to use call light on several occasions. He frequently attempted to transfer self to and from the bed/wheelchair and toilet without assistance." ( )

THIS CITATION PERTAINS TO INTAKE MI 795. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 1 (#201) OF 4 SAMPLED RESIDENTS, FROM A TOTAL SAMPLE OF 4 RESIDENTS, WHEN RESIDENT #201, WHO WAS ON COUMADIN (A BLOOD THINNING MEDICATION), DID NOT HAVE A SENSOR ALARM IN HER WHEELCHAIR, HAD AN UNWITNESSED FALL OUT OF HER WHEELCHAIR, AND SUSTAINED A 12 CENTIMETER LACERATION ON HER RIGHT LEG. FINDINGS INCLUDE: REVIEW OF RESIDENT #201'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE WHO WAS RE-admitted to the facility on [DATE] AFTER A HOSPITAL STAY FOR URINARY TRACT INFECTION, WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS COGNITIVELY INTACT WITH NO MEMORY PROBLEMS, AND REQUIRED MAXIMUM ASSISTANCE OF TWO PERSONS FOR TRANSFERS. FACILITY NURSES NOTES FOR RESIDENT #201 DATED 10/26 DOCUMENTED THAT RESIDENT #201 WAS TO HAVE SENSOR ALARMS TO HER BED AND HER CHAIR. PHYSICIAN ORDERS [REDACTED].#201 WAS ON ASPIRIN 81 MG ONCE DAILY AND COUMADIN 2.5 MG ONCE DAILY (BOTH MEDICATIONS INCREASE BLEEDING, DECREASE CLOTTING, AND THIN THE BLOOD). REVIEW OF FACILITY BEHAVIOR MANAGEMENT MONTHLY MEETING DOCUMENTATION DATED 10/26/11 REVEALED RESIDENT #201 HAD A BIMS OF 15 (BRIEF SCREENER THAT AIDS IN DETECTING COGNITIVE IMPAIRMENT - 15 IDENTIFIED TO BE COGNITIVELY INTACT), HAD A FALL ASSESSMENT OF 16 (INDICATES HIGH RISK FOR FALLS) WITH FALL INTERVENTIONS OF SENSOR ALARMS IN HER BED AND CHAIR, BILATERAL ENABLER BARS, AND THAT ALL INTERVENTIONS WERE EFFECTIVE AT THAT TIME. CARE PLAN FOR RESIDENT #201 IDENTIFIED HER TO BE AT RISK FOR FALLS, BUT DID NOT DOCUMENT ALARMS AS AN INTERVENTION. THE CARE PLAN ALSO IDENTIFIED RESIDENT #201 TO BE AT RISK FOR ABNORMAL BLEEDING RELATED TO ANTICOAGULATION USE (BLOOD THINNING MEDICATION TO PREVENT CLOTTING), WITH INTERVENTIONS LISTED TO INCLUDE CAUTION AGAINST BUMPING, SHAVING, ETC. FACILITY DEVICE AUDIT SHEETS FOR 11/4/11 1ST AND 3RD SHIFT, 11/5/11 1ST AND 3RD SHIFT, AND 11/6/11 2ND SHIFT DO NOT SHOW THAT RESIDENT #201 WAS TO HAVE ALARMS ON HER BED OR WHEELCHAIR. FACILITY INCIDENT REPORT DATED 11/6/11 AT 6:00 PM DOCUMENTED THAT CERTIFIED NURSE AIDE (CNA #7) ANSWERED RESIDENT #201'S CALL LIGHT AND OBSERVED RESIDENT #201 WITH HER WHEELCHAIR TIPPED FORWARD AND BUTTOCKS ON THE EDGE OF HER WHEELCHAIR WITH A LACERATION NOTED TO RIGHT LOWER EXTREMITY. FACILITY NURSE'S NOTES FOR RESIDENT #201 DATED 11/6/11 AT 6:00 PM REVEALED THAT RESIDENT #201 WAS OBSERVED ON THE FLOOR IN THE UPRIGHT POSITION IN FRONT OF HER WHEELCHAIR. NURSE'S NOTES REVEALED THAT RESIDENT #201 STATED SHE fell MAYBE 15 MINUTES AGO. NURSE'S NOTES DOCUMENTED RESIDENT #201 WAS ASSISTED WITH A LIFT AND UPON ASSESSMENT A 6 CENTIMETER X 2.5 CENTIMETER X 2 CENTIMETER LACERATION TO RIGHT LOWER LEG WITH MUSCLE, TENDON AND BONE EXPOSED WAS OBSERVED WITH A PRESSURE DRESSING APPLIED AT 6:10 PM. NURSE'S NOTES STATED THAT RESIDENT #201 WAS SENT TO THE HOSPITAL BY AMBULANCE. FACILITY NURSE'S NOTES DOCUMENTED RESIDENT #201 WAS REadmitted to the facility on [DATE]. HOSPITAL OPERATIVE REPORT DATED 11/7/11 REVEALED THAT RESIDENT #201 SUSTAINED AN UNWITNESSED FALL AND HAD A LACERATION OF THE DISTAL RIGHT TIBIAL AREA (RIGHT LOWER LEG) 12 CENTIMETERS IN LENGTH AND 8 CENTIMETERS IN TOTAL WIDTH. THE OPERATIVE REPORT ALSO REVEALED THAT RESIDENT #201'S HEMOGLOBIN (PROTEIN IN RED BLOOD CELLS THAT CARRIES OXYGEN FROM THE LUNGS TO THE BODY'S TISSUES) WAS 9.2 AND SHE WAS TRANSFUSED WITH 2 UNITS OF PACKED RED BLOOD CELLS PRIOR TO A SURGICAL REPAIR OF THE LACERATION. IN AN INTERVIEW ON 11/16/11 AT 3:10 PM, CNA #7 STATED THAT ON 11/6/11, DURING THE DINNER MEAL, SHE WAS PASSING TRAYS ON THE 200 HALL. CNA #7 STATED SHE WAS THE ONLY STAFF MEMBER COVERING 200 AND 300 EAST HALLS DURING DINNER TIME, AND THIS WAS THE NORMAL ROUTINE. CNA #7 STATED WHEN SHE FINISHED PASSING TRAYS ON 200 HALL, SHE WENT AROUND THE NURSE'S STATION AND TURNED THE CORNER TO GO DOWN 300 HALL AND NOTICED RESIDENT #201'S CALL LIGHT WAS ON, SO SHE WENT TO THE ROOM. CNA #7 STATED WHEN SHE ARRIVED AT RESIDENT #201'S ROOM, THE DOOR WAS CLOSED, WHICH WAS UNUSUAL, SO SHE PUSHED THE DOOR OPEN AND SAW RESIDENT #201 WITH HER WHEELCHAIR TIPPED FORWARD AND RESIDENT #201 HAD FALLEN HALF WAY OUT OF HER CHAIR AND WAS PINNED BETWEEN THE SIDE OF HER BED, HER WHEELCHAIR AND HER BEDSIDE STAND, WITH HER BEDSIDE TABLE OVER TOP OF HER. CNA #7 STATED RESIDENT #201 WAS PINNED AND WOULDN'T MOVE AND THERE WAS BLOOD ON THE FLOOR BY RESIDENT #201'S RIGHT LEG. CNA #7 SAID RESIDENT #201 TOLD HER THAT SHE (RESIDENT #201) WAS LEANING TO THE RIGHT IN HER WHEELCHAIR, TRIED TO ADJUST HERSELF BY PUSHING ON HER BEDSIDE TABLE, THE TABLE TIPPED, AND SHE fell OUT OF THE WHEELCHAIR. CNA #7 STATED THERE WAS NO ALARM SOUNDING WHEN SHE ENTERED THE ROOM. CNA#7 STATED SHE WENT INTO THE BATHROOM AND PULLED THE EMERGENCY STRING, AND THEN PEAKED HER HEAD OUT IN THE HALL AND HOLLERED FOR HELP. CNA #7 STATED LICENSED PRACTICAL NURSE (LPN #4) WAS THE NURSE ON THE DIVERSIONAL HALL (300 WEST), AND CAME TO RESIDENT #201'S ROOM. CNA #7 STATED ONCE LPN #4 ARRIVED, SHE (CNA #7) RAN TO THE DINING ROOM TO GET LPN # 3 BECAUSE HE WAS RESIDENT #201'S NURSE AND THEN RETURNED TO RESIDENT #201'S ROOM. CNA #7 STATED THERE WAS A LOT OF BLOOD ON THE FLOOR BY RESIDENT #201'S RIGHT LEG, THAT RESIDENT #201'S RIGHT PANT LEG WAS SOAKED WITH BLOOD AND THERE WAS WHAT CNA #7 STATED LOOKED LIKE A "BIG CLOT" OF BLOOD ON THE FLOOR BY RESIDENT #201'S RIGHT LEG. CNA #7 STATED A LIFT WAS USED TO ASSIST RESIDENT #201 BACK INTO HER BED, AND LPN #3 PULLED BACK RESIDENT #201'S PANT LEG AND CNA #7 OBSERVED A BIG CUT. CNA #7 STATED SHE COULD SEE MUSCLE AND BONE EXPOSED IN THE CUT ON RESIDENT #201'S LEG. CNA #7 STATED LPN #3 PLACED GAUZE ON THE CUT, AND THE RESIDENT WENT BY AMBULANCE TO THE HOSPITAL. CNA #7 STATED IT WAS VERY HARD TO SUPERVISE RESIDENTS ON BOTH HALLS DURING A MEAL BY HERSELF. DURING AN INTERVIEW ON 11/16/11 AT 10:15 AM, IN RESIDENT #201'S ROOM, WITH RESIDENT #201 PRESENT, LPN #4 DEMONSTRATED THE POSITION SHE FOUND RESIDENT #201 IN ON 11/6/11 WHEN SHE WAS INJURED. THE FACILITY ADMINISTRATOR HAD PROVIDED THE EXACT WHEELCHAIR WHICH WAS BEING USED BY RESIDENT #201 AT THE TIME OF THE INCIDENT, WHICH WAS A WIDER WHEELCHAIR, WITH BILATERAL FOOT RESTS. THE LEFT FOOT REST HAD A PADDED CRADLE WHERE THE RESIDENT'S LEFT CALF WOULD REST. LPN #4 STATED THAT THE WHEELCHAIR WAS TIPPED FORWARD AND RESTED ON THE FRAME OF THE RESIDENT'S BED, JUST INSIDE THE DOOR OF THE ROOM, WITH A BEDSIDE TABLE BETWEEN THE WHEELCHAIR AND THE BED. LPN #4 STATED RESIDENT #201'S BOTTOM WAS ON THE EDGE OF THE WHEELCHAIR SEAT, THE RESIDENT WAS SUSPENDED IN THE AIR, WITH HER FEET ON THE BOTTOM BAR OF THE BEDSIDE TABLE. LPN #4 STATED THE BEDSIDE STAND AND A PILLOW WERE DIRECTLY TO THE RIGHT OF THE RESIDENT, AND AN OXYGEN CONCENTRATOR WAS TO THE RIGHT AN BEHIND THE RESIDENT. LPN #4 STATED RESIDENT #201 WAS PINNED INTO THE VERY SMALL AREA AND IT REQUIRED SEVERAL PEOPLE TO REMOVE HER. LPN #4 STATED A LARGE LACERATION WAS OBSERVED ON RESIDENT #201'S RIGHT LOWER LEG, AND THAT SHE (LPN #4) CALLED AN THE AMBULANCE FOR TRANSPORT TO THE HOSPITAL. LPN #4 STATED THE PILLOW ON THE FLOOR WAS PROBABLY FROM POSITIONING RESIDENT #201 BECAUSE SHE ALWAYS LEANS TO THE RIGHT. ON 11/16/11 AT 10:15 AM, THE SURVEYOR ASKED RESIDENT #201 IF SHE COULD EXPLAIN WHAT HAPPENED. RESIDENT #201 STATED SHE HAD BEEN PLACED IN HER ROOM BY SOMEONE, FACING THE TELEVISION, WITH HER BEDSIDE TABLE IN FRONT OF HER, AND THE TABLE PUSHED AGAINST HER BED. RESIDENT #201 STATED THERE WAS HOT COFFEE ON HER BEDSIDE TABLE, AND SHE WAS PUSHED SO CLOSE TO THE TABLE AND THE BED, THAT THE TABLE KEPT TIPPING. RESIDENT #201 STATED THE FOOTRESTS ON HER WHEELCHAIR WERE FORWARD, BUT NOT LOCKED, SO THEY KEPT SWAYING OUT, AND SOMEONE HAD PLACED A PILLOW BEHIND HER BACK AND ONE ON HER RIGHT SIDE, BECAUSE SHE ALWAYS LEANS TO THE RIGHT. RESIDENT #201 STATED THE PILLOW WAS HANGING OVER THE SIDE OF THE WHEELCHAIR, HER RIGHT ARM WAS STUCK UNDER THE PILLOW AND SHE COULDN'T GET HER ARM UP. RESIDENT #201 STATED SHE TRIED TO USE HER FOOT TO PUSH BACK AWAY FROM THE TABLE SO THE COFFEE WOULDN'T SPILL ON HER, BUT THE OXYGEN CONCENTRATOR WAS IN THE WAY. RESIDENT #201 STATED SHE WAS BLOCKED IN, SO SHE TRIED TO PUSH ON THE TABLE A LITTLE AND THEN SHE fell FORWARD OUT OF HER CHAIR. RESIDENT #201 STATED SHE FELT HERSELF TIPPING SO SHE TURNED HER CALL LIGHT ON BEFORE SHE WENT DOWN. RESIDENT #201 STATED SHE YELLED FOR HELP, BUT NOBODY CAME, SO SHE JUST LAID HER HEAD AGAINST SOME PAPERS AND WAITED FOR SOMEONE TO COME. WHEN THE SURVEYOR ASKED HOW LONG IT WAS BEFORE SOMEONE CAME TO HELP HER, RESIDENT #201 STATED IT WAS ABOUT 15 MINUTES. RESIDENT #201 STATED SHE WAS SURE CNA #7 CAME AS SOON AS SHE SAW HER CALL LIGHT AND THAT SHE WAS A GOOD GIRL, BUT THERE IS ONLY ONE PERSON ON 200 AND 300 HALL DURING DINNER, SO SHE PROBABLY DIDN'T SEE MY LIGHT RIGHT AWAY. RESIDENT #201 STATED SHE KNEW SHE WAS SUPPOSED TO HAVE AN ALARM ON HER CHAIR AND ON HER BED, AND THAT THERE WAS NO ALARM SOUNDING WHEN SHE fell OUT OF HER CHAIR ON 11/6/11. IN A TELEPHONE INTERVIEW ON 11/16/11 AT 10:45 AM, LPN #3 STATED HE WAS CALLED TO RESIDENT #201'S ROOM AND WHEN HE ARRIVED IN HER ROOM, HE OBSERVED HER ON THE FLOOR. LPN #3 STATED THAT LPN #4 WAS IN THE ROOM AND INFORMED HIM THAT INITIALLY RESIDENT #201'S BOTTOM HAD BEEN ELEVATED IN THE AIR. LPN #3 STATED THERE WAS BLOOD ON THE FLOOR, AND RESIDENT #201 WAS ASSISTED TO THE BED USING A LIFT. LPN #3 STATED ONCE RESIDENT #201 WAS IN THE BED, HE NOTICED A LACERATION, "IT WAS A GOOD ONE", LPN #3 STATED. LPN #3 STATED THERE WAS LOTS OF BLOOD AND HE COULD SEE MUSCLE AND BONE. LPN #3 STATED RESIDENT #201 WAS ON COUMADIN, AND THAT HE APPLIED A STERILE PRESSURE DRESSING AND IMMEDIATELY CALLED AN AMBULANCE. LPN #3 STATED THE WOUND WAS ACTIVELY BLEEDING. LPN #3 STATED HE HAD OBSERVED RESIDENT #201 A SHORT TIME BEFORE THE FALL, THAT SHE HAD HER CALL LIGHT PINNED TO HER SHIRT AND A PILLOW TUCKED INTO HER RIGHT SIDE BECAUSE SHE ALWAYS LEANED TO THE RIGHT. LPN #3 STATED ONLY ONE CNA ALWAYS COVERED 200 AND 300 EAST HALL DURING DINNER TIME. DURING AN INTERVIEW ON 11/16/11 AT 2:45 PM, THE SURVEYOR DISCUSSED SUPERVISION AND SAFETY DEVICE CONCERNS WITH THE FACILITY DIRECTOR OF NURSING AND ADMINISTRATOR. THE FACILITY ADMINISTRATOR STATED THAT RESIDENT #201 COMPLAINS ABOUT HER CARE A LOT. THE SURVEYOR INFORMED THE ADMINISTRATOR THAT RESIDENT #201 HAD NOT EXPRESSED ANY CONCERNS ABOUT THE CARE SHE HAD RECEIVED AT THE FACILITY AND HAD IN FACT MADE STATEMENTS ABOUT HOW MUCH SHE LIKED THE GIRLS THAT PROVIDED HER CARE. THE FACILITY DIRECTOR OF NURSING STATED THAT THE UNIT MANAGER HAD DISCONTINUED THE SENSOR ALARM FROM RESIDENT #201'S BED. THE FACILITY ADMINISTRATOR THEN STATED, "BUT SHE WAS IN HER CHAIR". THE DIRECTOR OF NURSING THEN STATED, "I KNOW". #