Every finding on record at The Laurels of Fulton

Based on interview and record review, the facility failed to provide medication according to professional standards of practice for 1 resident (R2) of 12 residents reviewed. Findings include:Review of an admission Record revealed R2 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, hypertension, anxiety, and history of falls. Review of R2's Physician's Orders revealed an active order for amlodipine besylate 10mg (a prescription medication used to treat high blood pressure), give 1 tablet my mouth one time a day, Hold if SBP (systolic blood pressure, the top number in a blood pressure reading, measuring the force in your arteries when your heart beats and pushes blood out) is less than 120, with a start date of 7/21/2025. Review of R2's Electronic Medical Record (EHR) on 12/18/2025 at 1:42 PM revealed nursing staff were not documenting blood pressure checks prior to administration of amlodipine since the medication start date of 7/21/2025. R2's amlodipine was documented on the Medication Administration Record (MAR) as administered at 0800 each morning, with no documentation in the EHR that the blood pressure was checked prior to ensure it was within the physician's ordered parameters. In an interview on 12/18/2025 at 2:49 PM, the Assistant Director of Nursing (ADON) N reported she reviewed the EHR and was unable to find documentation that nursing staff had completed any blood pressure checks prior to administrations of R2's amlodipine since the medication start date of 7/21/2025. ADON N reported the order was not placed into the EHR correctly. When placed correctly, the EHR prompts staff to check and document the blood pressure at the time of medication administration.

Based on observations, interviews and record review, the facility failed to provide meaningful activities for 2 Residents (R2 and R6) of 12 residents sampled.Findings include:R2Review of R2's admission record dated, 12/18/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] he had diagnoses that included: wandering, vascular dementia and cognitive communication deficit. R2 was not his own responsible party.R2 was observed in bed on 12/17/25 at 8:32 AM awake in bed, breakfast tray on bedside table in front of him with all his food eaten.R2 was observed in bed on 12/17/25 at 9:23 AM with his breakfast tray in front of him. His eyes were closed, and he appeared to be sleeping.R2 was observed in bed on 12/17/25 at 9:34 AM. His walker was within eyesight but out of reach approximately 3 feet away from his bed. R2 was asked what activities he liked to do here, and he responded, I have not tried any yet.R2 was observed in bed again on 12/17/25 at 10:43 AM, he did not have a television, books or any meaningful activities visible in his room. He was still awake.Review of R2's Activity care plan dated 6/25/25 revealed, R2 enjoys a variety of activities but does not self-initiate leaving his room.he loves to chat; former bar owner and very involved in his community - able to independently choose what activities he wishes to participate in - would need reminders and encouragement - would need some assistance during r/t (related to) cognition. Interventions included: escort R2 to activities, invite and remind R2 of available and upcoming activities.Review of R2's electronic medical record reveals many activity tasks were listed. Some of the tasks listed included: women's club, busy hands, cooking club. R2's task documentation for women's club, busy hands and cooking club, was reviewed for the last 30 days and there was no indication that he attended any of these activities or any other activities.During an interview with the Activities Director (AD) W on 12/17/25 at 12:49 PM, AD W was asked about R2's activity preferences, and she said he does not like group activities. AD W stated R2 likes to sit and watch people by the nurse's station. AD W was asked how often R2 should be offered activities, and she said daily. AD W was asked for R2's records on what activities he was offered this month, and AD W ran a report on her computer that revealed 8 days this month he was not offered any activities, and no refusals were documented. AD W could not validate what activities R2 had participated in. AD W was asked for a copy of R2's activity attendance report. AD W was asked again for any documentation of R2 activity attendance on 12/18/25 at 9:00 AM. Upon exit the facility did not provide any documentation of R2's activities attendance.During an interview with Activity Aide (AA) X on 12/17/25 at 1:01PM, AA X said she works on Wednesdays and the weekends. AA X was asked about R2's activity preferences. AA X was not aware of R2's preferences and confirmed she had not assisted him with any activities this month.R6Review of R6's admission record dated 12/17/25 revealed she was admitted on [DATE] and had diagnoses that included spastic quadriplegic cerebral palsy, and developmental disorder of speech and language. It also revealed she was not her own responsible party.R6 was observed in bed in her room on 12/16/25 at 10:43 AM. The television was on cartoons with no audible sound. R6 did not answer any questions but looked at the Surveyor when she was speaking.R6 was observed in her room up in a wheelchair on 12/17/25 at 8:35 AM. She was connected to her tube feeding pump. She had cartoons on her television, but the volume was in a very low hardly auditable setting. R6 did not respond to any questions but did look at the Surveyor when she was asked questions.During an interview with Registered Nurse (RN) B on 12/17/25 at 9:20 AM in R6's room, RN B was asked if R6's television volume should be adjusted so R6 could hear the cartoons and RN B confirmed R6 liked cartoons and should have the volume adjusted. RN B was asked if R6 was assisted out of her room daily and RN B said when she was up in her wheelchair she should be assisted out of her room. RN B was asked how she could confirm staff were assisting her out of her room daily and she did not have any way to verify this was happening. The Surveyor expressed concern as R6 was left in her room this morning when she was out of bed and had now returned to her bed. The Surveyor had not observed R6 out of her room at all on 12/17/25.Review of R6's care plan dated 8/18/25 revealed, R6 shows little awareness of programing surrounding. She would benefit from small group awareness and/or sensory stimulation r/t (related to) dx (diagnosis) of DD (developmental disorder), non-verbal -enjoys the company of favored staff and co-guests AEB (as evidenced by) smiling and blowing kisses -seems to enjoy watching tv (cartoons) and engaging with her manipulatives and stuffed animals - requires staff to anticipate what activities she would enjoy - requires staff to get her to and from - would benefit from mostly sensory activities.Review of R6's medical record revealed she had several activity tasks listed, they included gardening, games, happy hour, cooking club and arts and crafts. Review of R6's activities task documentation for gardening, games, happy hour, cooking club and arts and crafts was reviewed for the last 30 days and there was no indication that she attended any of these activities.During an interview with AD W on 12/17/25 at 1:08 PM, AD W was asked to verify that R6 was being offered daily activities. AD W ran a report for December 2025 and said R6 was missing activity documentation for 8 days this month. AD W could not say what activities were offered and had no explanation for the lack of daily documentation. AD W had no way to verify R6 was being assisted out of her room daily, or if anyone was assisting R6 with the television volume. The Surveyor requested a copy of R6 activity record for December 2025. On 12/18/25 at 9:00 AM a second request for R6 activity records was made and upon exit the facility did not provide any activities records for R6.During an interview with AD W on 12/17/25 at 2:46 PM, the Surveyor asked about R2 and R6's tasks in the electronic medical records that indicated they should be offered activities like busy hands, cooking club and several other things that did not seem appropriate for residents on tube feeding, men going to a woman's group, and residents who lacked movement in all 4 extremities going to a busy hands group. AD W said all residents on admission are given these canned tasks and she has not had time to remove the ones that are not appropriate. She was still not able to provide any documentation of which activities had been offered to R2 and R6 or evidence of any attendance to any activity.

Based on interview and record review, the facility failed to evaluate one cognitively impaired resident and document the rationale for use of an antipsychotic, define target behaviors, and establish goals for treatment in accordance with regulatory requirements and facility policy for one Resident (R3) of five residents reviewed for the use of psychotropic medication.Findings include:R3 was admitted to the facility 8/1/25 with pertinent diagnoses that included Dementia and Alzheimer's Disease. Review of the Minimum Data Set (MDS) dated [DATE] reflected R3 was severely cognitively impaired. The medical record reflected the spouse of R3 was the designated Responsible Party.Review of the Electronic Medical Record (EMR) Progress Notes revealed a Medical Provider entry dated 8/5/25 at 8:00 AM that R3 is pleasantly confused, has been noted to be exit seeking but is easily redirectable and there were No acute clinical concerns.Review of the EMR Progress Note dated 8/7/25 at12:46 AM reflected R3 is pleasantly confused wandering, and allowed redirection with a pleasant attitude.Review of the EMR Progress Note entry dated 8/7/25 at 2:23 PM reflected staff were having a hard time redirecting resident and that R3 is becoming agitated. The entry did not reflect what, if any, non-pharmacological interventions or diversions were attempted or implemented to calm or redirect R3.Review of Hospice documentation dated 8/8/25 reflected Hospice had received a call from a Facility Nurse that R3 is exit seeking and having increased agitation. The entry reflected a Doctor's Order for Ativan (also known as Lorazepam, a benzodiazepine anxiolytic (antianxiety) psychoactive medication) was implemented. The documentation reflected Hospice suggested the facility consider some ideas to help keep (R3) entertained.Review of the EMR Medical Provider entry of 8/12/25 reflected R3 was evaluated for back pain and prescribed Tylenol. The Medication section of this entry reflects the addition of Lorazepam 0.5 mg as needed for anxiety/agitation to the Resident's medication regimen. However, this entry did not reveal R3 had exhibited or had been evaluated for anxiety. No documentation was found that provided a historical review, justification or rational, or specific goals of prescribing a psychoactive anxiolytic to R3.Review of the medical record did not reveal documentation the responsible party for R3 had been informed of the indications for use, the rationale, the risks and benefits, or the goal of a psychoactive medication until 9/10/25. Nor did the medical record reveal the responsible party had been informed of any measures that had been attempted for behavior modification prior to initiating the Lorazepam on 8/12/25.Review of the Care Plan for R3 revealed plans of care for Wandering and Behavior had been initiated 8/1/25 at the time of admission. Both plans of care were without revision until 8/20/25 despite documentation of behaviors and the initiation of antipsychotic medication for behavior modification on 8/12/25. No documentation was found the facility attempted to personalize the plan for care for R3 to avoid the use of antipsychotic medication. Further review of the entire Care Plan revealed an Activities plan of care was not initiated until 8/21/25 well after admission to the facility and the initiation of pharmacological intervention. Additionally, review of the entire Care Plan did not reveal a plan for care for antipsychotic medications had been initiated to date since the initial Doctor's Order for Lorazepam on 8/12/25 or after the Doctor's Order on 11/25/25 for Depakote for behavior modification.The policy provided facility titled Psychoactive Medication Management last revised 9/7/25 was reviewed. The policy reflected Policy: The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/ functional programs as appropriate and safety interventions to minimize the use of psychotic medications in managing behaviors when non- pharmacological interventions have failed. And Procedure.4. Residents receiving psychoactive medications upon admission, those with new psychoactive medications orders or an increase in the dose of the medication, will have a psychotropic medication informed consent completed. Before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for the antipsychotic medications in advance of such initiation or increase. And A resident requiring a psychoactive medication will be monitored by the interdisciplinary team (IDT). The policy reflects the IDT will review behaviors .and interventions attempted. And Non- pharmacological approaches should be used before prescribing the medication.and documented in the medical record.On 12/18/25 at 11:12 AM an interview was conducted with Assistant Director of Nursing (ADON) N. ADON N was unable to identify from the medical record Medical Provider documentation of rational or a specific goal for the use of a psychoactive medication for R3. ADON N acknowledged the consent for the medication was dated 9/10/25 after the medication had been initiated. No additional documentation was provided. On 12/18/2025 at 1:18 PM an interview was conducted with Social Worker (SW) G. SW G was informed documentation of the determination for the use of psychoactive medication had not been identified in the medical record. SW G reported the facility had a team approach to behavior management and tried not to jump straight to an antipsychotic. SW G reiterated the facility used a team approach to ensure consents, care plans and evaluations had been completed but was unable to provide any documentation to support this claim for R3.As of survey exit no additional documentation was provided by the facility.

Based on interview and record review, the facility failed to maintain an accurate Electronic Health Record (EHR) for 1 resident (R45) of 12 residents reviewed for accuracy of medical records. Findings include: Review of an admission Record revealed R45 admitted to the facility on [DATE] with pertinent diagnoses which included alzheimer's disease, dementia, and visual hallucinations. Review of R45's Resident Code Status, signed 12/10/2025, revealed his status was Do Not Resuscitate (DNR). Review of R45's Physician's Orders, active 12/16/2025 at 1:00 PM, revealed no order for DNR or hospice. Further review of the EHR revealed no alert for DNR. In an interview on 12/16/2025 at 1:10 PM, Registered Nurse (RN) D reported R45 was DNR status. RN D reviewed R45's EHR and reported there was no alert or Physician's Order for DNR. RN D reported a resident who was DNR should have a Physician's Order and alert in their EHR. In an interview on 12/17/2025 at 10:21 AM, Assistant Director of Nursing (ADON) N reviewed R45's EHR and reported there was no Physician's Order for DNR or hospice care, and there was no alert for DNR status. ADON N reported R45's DNR status was signed 12/10/25. ADON N reported the Physician's Order and alert should have been placed in the EHR at that time. ADON N reported R45 signed into the care of hospice when he admitted to the facility on [DATE] and he should also have a Physician's Order for hospice. In an interview on 12/18/2025 at 1:00 PM, the Director of Nursing (DON) reported R45 had been on 1 on 1 observation for his safety from within 24 hours of his admission to the facility on [DATE]. The DON reported R45's 1 on 1 intervention was not documented in the EHR until it was placed in the Care Plan on 12/13/2025. The DON reported there was no documentation to show staff had been completing 1 on 1 observation of resident. Regional Clinical Nurse A reported the facility should have documented the 1 on 1 intervention on R45's Care Plan when this was initiated. Regional Clinical Nurse A further reported the facility should have been documenting the 1 on 1 under tasks. Review of the facility policy/procedure Medical Records Management, revised 1/31/2022, revealed .The facility must maintain medical records on each guest/resident, in accordance with accepted professional standards and practice and state and federal law. Medical records must be complete, accurately documented, readily accessible, systematically organized, and maintained. The electronic medical record is defined as containing the following items. Active, discontinued, and completed physician orders. Care plans, including resolved and cancelled.

Based on interview and record review, the facility failed to inform the responsible party of the initiation of a psychotropic medication for one cognitively impaired Resident (R3) of six residents reviewed for psychotropic medications.Findings include:R3 was admitted to the facility 8/1/25 with pertinent diagnoses that included Dementia and Alzheimer's Disease. Review of the Minimum Data Set (MDS) dated [DATE] reflected R3 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated the Resident was severely cognitively impaired. The medical record reflected the spouse of R3 was the designated responsible party.Review of the Electronic Medical Record (EMR) Doctor's Orders reflected on 8/12/25 a telephone order for Lorazepam (Ativan), (a benzodiazepine anxiolytic (antianxiety) medication) 0.5 milligram (mg) to be administered every 4 hours as needed for anxiety/agitation.The EMR for R3 revealed the document titled Psychotropic Medication Informed Consent dated 9/10/25 and was reviewed. The document reflected the Guardian for R3 had been informed of the risks and benefits and given consent for the administration Lorazepam on 9/10/25 after the initial Doctor's Order dated 8/12/25. On 12/17/25 at 3:52 PM an interview was conducted with the Director of Nursing (DON). The DON acknowledged that the responsible party for R3 had not given informed consent for the initiation of Lorazepam. The policy provided by the facility titled Psychoactive Medication Management, last revised 9/7/25 was reviewed. The policy reflected Procedure.4. Residents receiving psychoactive medications upon admission, those with new psychoactive medications orders or an increase in the dose of the medication, will have a psychotropic medication informed consent completed. Before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for the antipsychotic medications in advance of such initiation or increase.

Based on interview and record review, the facility failed to timely inform the party responsible of a fall sustained by a cognitively impaired (R3) of five residents reviewed for accidents.Findings include:Resident (R3) was admitted to the facility 8/1/25 with diagnoses that included Dementia and Alzheimer's Disease and was severely cognitively impaired. The medical record reflected the spouse of R3 was the designated responsible party and emergency contact.On 12/16/25 at 2:27 PM a telephone interview was conducted with the spouse of R3. The spouse reported that several months prior his wife had fallen, and he was not contacted for several days following the incident. The spouse reported he was upset that he had not been contacted and complained to the facility.Review of the incident report provided by the facility dated 8/16/25 at 2:15 AM reflected R3 had sustained a fall. The document reflected the responsible party was not contacted until 8/18/25 at 6:21 PM.The policy provided by the facility titled Fall Management last revised 7/8/25 was reviewed. The policy reflected Practice Guidelines: .6. The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record.Review of the Electronic Medical Record (EMR) Progress Notes reflected an entry on 8/16/25 at 3:46 AM that R3 had been found on the floor. The Progress Note reflected the medical provider had been notified but not the responsible party. Review of later Progress Notes did not reveal the responsible party for R3 had been notified of the fall on 8/16/25.On 12/17/25 at 3:52 PM an interview was conducted with the Director of Nursing (DON). The DON reported that if a resident was not their own person the responsible party would be contacted if a fall occurred. The DON reported that if the fall occurred during the night and there was no injury the responsible party would be notified at a reasonable time. The DON acknowledged the responsible party for R3 should have been notified sooner of the fall sustained by R3.

Based on observation, interview, and record review, the facility failed to implement their abuse policy and have a policy for reporting and investigating abuse for 2 Residents (Resident #2 and #24) out of 12 sampled residents.Findings included: Review of the facility Abuse Prohibition Policy last revised 9/9/22 revealed, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the guest's/resident's medical symptoms. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guests/residents care and treatments on an ongoing basis. It is the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and report to the appropriate state agencies, physician, families, and/or representative. The subject of abuse should be routinely and openly discussed. Guests/residents will be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents on admission and at least annually thereafter.Further review of the facility Abuse Prohibition Policy revealed there were no examples of abuse allegations, no information on who to report abuse to, and no information on the reporting process to the State Agency.R2Review of R2's admission record dated, 12/18/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: wandering, vascular dementia, and cognitive communication deficit. R2 was not his own responsible party.Review of R2's care plan dated 8/18/25 revealed, wandering/exit seeking: (R2) is at risk for exit seeking/wandering r/t (related to) dx (diagnosis) of dx TIA (stroke), cognitive communication deficit, UTI (urinary tract infection) hearing loss, adjustment disorder with mixed disturbance of emotions and conduct, delirium d/t (due to) a recent placement -noted with short term and long term memory deficits-confusion noted to increase starting in evening/afternoon - noted to sleep in open beds that are not assigned to him at times. The last updated intervention was dated 10/6/25.Review of R2's progress note dated 12/17/25 at 17:00 (5:00 PM) revealed, Resident wandering in hallway and went a short way into another resident's room, his pants had fallen to his knees. Pants were pulled up and resident redirected.R24Review of R24's admission record dated 12/17/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: muscle weakness, lack of coordination, and weakness. R24 was not her own responsible party.Review of R24's progress notes for 12/17/25 revealed no note of a resident entering her room or any emotional distress.Review of R24's progress note dated 12/18/25 at 5:00 AM revealed, Patient resting comfortably with eyes closed. Slept throughout night. No c/o (complaints of) pain. No concerns voiced.Review of R24's progress note dated 12/18/25 at 8:47 AM revealed, Alerted to resident room for new complains of right ear pain. Upon assessment (R24) reports that it is not her ear that hurts it is her throat that hurts from screaming. Ear is without abnormalities, no redness or warmth noted. Offered warm tea with lemon to sooth throat. She declined offer stating she only wanted her AM meds with Tylenol in it.Review of R24's progress note dated 12/18/25 at 10:57 AM, Social Services Note: SS (social services has interacted with guest four times this morning r/t (related to) her needs and allegation she made 12/17/25 r/t (related to) another guest exposing himself to her.R24 was observed in her room on 12/18/25 at 8:00 AM. R24 was very distressed about a man coming into her room the previous day after her second smoke break with his pants down. She said at first, she was not afraid because there had been another confused man that would wander into her room when she was in the bathroom, and she knew that man was just confused. When she found out it was not the same person, she was very upset. She complained of yelling so loud and for so long yesterday about this man in her room that her right ear was very painful at this time. The Nursing Home Administrator (NHA) was in the hall at this time. The Surveyor asked the NHA to come into R24's room and she repeated the story again. Certified Nurse Aide (CNA) R came into R24's room at this time with R24's breakfast tray. CNA R reported that during shift report she was told that R2 had been in R24's room with his pants down the previous day. R24 was so upset at this time that at first, she refused to eat. With encouragement she did allow CNA R to set up her breakfast tray.During a telephone interview on 12/18/25 at 8:23 AM, Licensed Practical Nurse (LPN) C confirmed she put the note in R2's medical record on 12/17/25 at 5:00 PM about him being in another resident's room with his pants down. LPN C confirmed that R2 was the resident in R24 room with his pants down. LPN C said CNA S informed her about the incident. LPN C said the Director of Nursing (DON) was in the building at the time of this report and she reported it to the DON. The DON told her to talk to them and document in R2's progress note. She confirmed she did not write any notes in R24's progress note. LPN C reported she did talk to R24, and she was very upset, but she was able to calm her down.During an interview on 12/18/25 at 8:45 AM, LPN U reported she started working on R24's nursing unit on 12/17/25 at 11:00 PM and it was reported to her that R24 was alleging the incident with R2 was almost rape. LPN U was still working on R24's unit at this time and was aware that R24 was still very upset about R2 being in her room with his pants down.During an interview on 12/18/25 at 8:33 AM, the DON confirmed LPN C had reported to her the previous day that R2 had been in R24's room and R2 had exposed himself to R24. The NHA and DON confirmed that this event was not documented in R24's medical record. R2 and R24's representatives were not notified. No investigation or witness statements had been taken at this time. R2 and R24 were not assessed. No interventions were implemented to ensure R24's safety.

Based on observation, interview, and record review the facility failed to investigate and report an allegation of abuse to the State Agency for 2 Residents (R2 and R24) of 12 residents sampled.Findings included:R2Review of R2's admission record dated, 12/18/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: wandering, vascular dementia, and cognitive communication deficit. R2 was not his own responsible party.Review of R2's care plan dated 8/18/25 revealed, wandering/exit seeking: (R2) is at risk for exit seeking/wandering r/t (related to) dx (diagnosis) of dx TIA (stroke), cognitive communication deficit, UTI (urinary tract infection) hearing loss, adjustment disorder with mixed disturbance of emotions and conduct, delirium d/t (due to) a recent placement -noted with short term and long term memory deficits-confusion noted to increase starting in evening/afternoon - noted to sleep in open beds that are not assigned to him at times. The last updated intervention was dated 10/6/25.Review of R2's progress note dated 12/17/25 at 17:00 (5:00 PM) revealed, Resident wandering in hallway and went a short way into another resident's room, his pants had fallen to his knees. Pants were pulled up and resident redirected.R24Review of R24's admission record dated 12/17/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: muscle weakness, lack of coordination, and weakness. R24 was not her own responsible party.Review of R24's progress notes for 12/17/25 revealed no note of a resident entering her room or any emotional distress.Review of R24's progress note dated 12/18/25 at 5:00 AM revealed, Patient resting comfortably with eyes closed. Slept throughout night. No c/o (complaints of) pain. No concerns voiced.Review of R24's progress note dated 12/18/25 at 8:47 AM revealed, Alerted to resident room for new complains of right ear pain. Upon assessment (R24) reports that it is not her ear that hurts it is her throat that hurts from screaming. Ear is without abnormalities, no redness or warmth noted. Offered warm tea with lemon to sooth throat. She declined offer stating she only wanted her AM meds with Tylenol in it.Review of R24's progress note dated 12/18/25 at 10:57 AM, Social Services Note: SS (social services has interacted with guest four times this morning r/t (related to) her needs and allegation she made 12/17/25 r/t (related to) another guest exposing himself to her.R24 was observed in her room on 12/18/25 at 8:00 AM. R24 was very distressed about a man coming into her room the previous day after her second smoke break with his pants down. She said at first, she was not afraid because there had been another confused man that would wander into her room when she was in the bathroom, and she knew that man was just confused. When she found out it was not the same person, she was very upset. She complained of yelling so loud and for so long yesterday about this man in her room that her right ear was very painful at this time. The Nursing Home Administrator (NHA) was in the hall at this time. The Surveyor asked the NHA to come into R24's room and she repeated the story again. Certified Nurse Aide (CNA) R came into R24's room at this time with R24's breakfast tray. CNA R reported that during shift report she was told that R2 had been in R24's room with his pants down the previous day. R24 was so upset at this time that at first, she refused to eat. With encouragement she did allow CNA R to set up her breakfast tray.During a telephone interview on 12/18/25 at 8:23 AM, Licensed Practical Nurse (LPN) C confirmed she put the note in R2's medical record on 12/17/25 at 5:00 PM about him being in another resident's room with his pants down. LPN C confirmed that R2 was the resident in R24's room with his pants down. LPN C said CNA S informed her about the incident. LPN C said the Director of Nursing (DON) was in the building at the time of this report and she reported it to the DON. The DON told her to talk to them and document in R2's progress note. She confirmed she did not write any notes in R24's progress note. LPN C reported she did talk to R24, and she was very upset, but she was able to calm her down.During an interview on 12/18/25 at 8:45 AM, LPN U reported she started working on R24's nursing unit on 12/17/25 at 11:00 PM and it was reported to her that R24 was alleging the incident with R2 was almost rape. LPN U was still working on R24's unit at this time and was aware that R24 was still very upset about R2 being in her room with his pants down.During an interview on 12/18/25 at 8:33 AM, the DON confirmed LPN C had reported to her the previous day that R2 had been in R24's room and R2 had exposed himself to R24. The NHA and DON confirmed that this event was not documented in R24's medical record. R2 and R24's representatives were not notified. No investigation or witness statements had been taken at this time. R2 and R24 were not assessed. No interventions were implemented to ensure R24's safety. The NHA said he would start the investigation now and report it to the State Agency.

Based on interview and record review, the facility failed to complete and maintain an Acute Transfer Log and provide this log to the Ombudsman in a timely manner. Findings include: In an interview on 12/18/2025 at 12:13 PM the Nursing Home Administrator (NHA) reported that Social Worker (SW) G completes the Acute Transfer Log (a log that is maintained with residents that are transferred to an acute care facility) and emails the log to the State Ombudsman. In an interview on 12/18/2025 at 12:18 PM, SW G reported that the NHA completes the Acute Transfer Log and emails the log to the State Ombudsman. Review of an email received from Ombudsman V on 12/18/2025 at 12:44 PM revealed the State Ombudsman office had not received an Acute Transfer Log from the facility since September of 2023.

Based on observation, interview, and record review, the facility failed to develop, implement, and update individualized care plans for 2 residents (R8 and R6) of 12 residents reviewed. Findings include:R6 Review of R6's admission record dated 12/17/25 revealed she was admitted on [DATE] and had diagnoses that included spastic quadriplegic cerebral palsy, hydronephrosis with renal and ureteral calculous obstruction (enlarged kidney and kidney stones in the ureter), malignant neoplasm of the lateral wall of bladder (bladder cancer) and developmental disorder of speech and language. She was not her own responsible party. Review of R6's Catheter care plan dated 3/21/25 revealed, R6 is at risk for UTI (urinary tract infection) and catheter related trauma r/t (related to) urostomy and history of MDRO's (multidrug resistant organisms). Interventions included: Ensure catheter tubing is secured. R6 was observed on 12/17/25 receiving care. When the CNA's turned R6 on side the foley bag was secured to the side of the bed and the tubing was observed to be stretched tight. RN B was in the room at this time. It was observed that R6 did not have the catheter tubing secured to her leg. RN B was asked if R6 should have the tubing secured and she said it was the facility policy. R8 Review of an admission Record revealed R8 admitted to the facility on [DATE] with pertinent diagnoses which included acute respiratory failure with hypoxia, speech disturbances, dysphagia, malignant neoplasm of larynx, tracheostomy, and major depressive disorder. Review of R8's Cognition Care Plan dated 8/14/2025 revealed R8 with intact cognition per BIMS. Review of a current Respiratory Care Plan dated 8/13/2025 revealed R8 has a potential for difficulty breathing and risk for respiratory complications relate to the use of Trach and dx of acute respiratory failure w/hypoxia. In an observation and interview on 12/16/2025 at 10:45 AM in R8's room R8 shrugged her shoulders when asked where the facility keeps the backup tracheostomy tube. R8 presented the cap to her stoma but could not locate the backup tracheostomy tube in her room. In an observation and interview on 12/16/2025 at 10:46 AM with Registered Nurse (RN) D in the East Hallway at the medication cart RN D revealed the backup tracheostomy tube for R8 was in the medication cart. RN D opened the bottom drawer to the medication cart and presented a box with R8's name on it. RN D stated the backup tracheostomy tube should be at the bedside but is kept in the medication cart. RN D stated she did not know why the backup tube was being stored in the medication cart. In an interview and record review on 12/16/2025 at 11:30 AM the Regional Nurse A revealed that R8 had a laryngectomy tube not a tracheostomy tube. Regional Nurse A provided two procedure guidelines for 1. Laryngectomy stoma and tube care and 2. tracheostomy tube cannula and stoma care describing the care of both. Regional Nurse A reported that the backup laryngectomy tube was being stored in the medication cart because R8 had behaviors including throwing things away like her laryngectomy tube. In an interview on 12/17/2025 at 9:30 AM the Assistant Director of Nursing (ADON) N revealed the backup laryngectomy tube was in the medication cart related to R8's behaviors of playing with it and removing it. ADON N revealed the nurses were aware that the backup tube was in the medication cart. In an interview on 12/18/2025 at 7:59 AM the Director of Nursing (DON) was asked if R8's care plan should match R8's current medical condition and the DON stated yes. Current care plans for R8 did not direct nursing to the placement of R8's laryngectomy tube and throughout the care plan R8's laryngectomy tube was referred to as a tracheostomy. R8's Care plans did not reveal the behaviors that caused staff to change the location of the backup laryngectomy tube from the bedside to the nurse medication cart. Review of facility policy/procedure Care Planning, issued 03/03/2025 revealed .every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights. The care plan must be specific, resident centered, individualized and unique to each resident.

Based on interview and record review, the facility failed to revise the Care Plan for one cognitively impaired Resident (R3) with behaviors and who was prescribed psychoactive medications without documented Care Plan revisions to attempt to prevent or minimize the use of psychoactive medications of five residents reviewed for Care Plan revisions.Findings include:Resident (R)3 was admitted to the facility 8/1/25 with pertinent diagnoses that included Dementia and Alzheimer's Disease. Review of the Minimum Data Set (MDS) dated [DATE] reflected R3 was severely cognitively impaired. The medical record reflected the spouse of R3 was the designated Responsible Party.Review of the Electronic Medical Record (EMR) Progress Notes revealed a Medical Provider entry dated 8/5/25 at 8:00 AM that R3 is pleasantly confused, has been noted to be exit seeking but is easily redirectable and there were No acute clinical concerns.Review of the EMR Progress Note dated 8/7/25 at12:46 AM reflected R3 is pleasantly confused wandering, and allowed redirection with a pleasant attitudeReview of the EMR Progress Note entry dated 8/7/25 at 2:23 PM reflected staff were having a hard time redirecting resident and that R3 is becoming agitated. The entry did not reflect what, if any, non- pharmacological interventions or diversions were attempted to calm or redirect R3.Review of Hospice documentation dated 8/8/25 reflected Hospice had received a call from a Facility Nurse that R3 is exit seeking and having increased agitation. The entry reflected a Doctor's Order for Ativan (also known as Lorazepam, a benzodiazepine anxiolytic (antianxiety) psychoactive medication) was implemented. The documentation reflected Hospice suggested the facility consider some ideas to help keep (R3) entertained.Review of the EMR Medical Provider entry of 8/12/25 reflected R3 was evaluated for back pain and prescribed Tylenol. The Medication section of the Medical Provider entry reflects the addition of Lorazepam 0.5 mg as needed for anxiety/agitation to the Resident's medication regimen. However, this entry did not reveal R3 had exhibited or had been evaluated for anxiety. No documentation was found that provided a basis for the use of psychoactive medication.The policy provided facility titled Psychoactive Medication Management last revised 9/7/25 was reviewed. The policy reflected Policy: The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/ functional programs as appropriate and safety interventions to minimize the use of psychotic medications in managing behaviors when non- pharmacological interventions have failed. And The .team works with the resident and/or family /legal representative to determine an appropriate plan of care. And Non-pharmacological interventions are the first choice in management of behavioral symptoms. And Behavioral interventions are individualized, non-pharmacological approaches to care.Review of the Care Plan for R3 revealed plans of care for Wandering and Behavior had been initiated 8/1/25 at the time of admission. Both plans of care were without revision until 8/20/25 despite documentation of behaviors and the initiation of antipsychotic medication for behavior modification on 8/12/25. No documentation the facility attempted to personalize the plan for care for R3 prior to use of antipsychotic medication to avoid use of these medications in accordance with facility policy could be located.Review of the Behavior Care Plan for R3 reflected the Intervention to Provide a program of activities that is of interest and accommodates (R3)'s status/cognition. However, review of the entire Care Plan revealed an Activities plan of care was not initiated until 8/21/25 well after admission to the facility and the initiation of pharmacological intervention. Additionally, review of the entire Care Plan did not reveal a plan for care for antipsychotic medications had been initiated to date since the initial Doctor's Order for Lorazepam on 8/12/25 or after the Doctor's Order on 11/25/25 for Depakote for behavior modification.On 12/18/25 at 11:12 AM an interview was conducted with Assistant Director of Nursing (ADON) N. ADON N was informed a review of the Care Plan for did not reveal personalized efforts were made to address the behaviors of R3 and prevent the use psychoactive medications. ADON N was unable to provide documentation the Care Plan had been revised and no further information was provided by the facility.On 12/18/2025 at 1:18 PM an interview was conducted with Social Worker (SW) G. SW G was informed documentation had not been discovered of revisions to the Care Plan of R3 to manage behavioral symptoms prior to and after initiating psychoactive medications. SW G reported the facility had a team approach to behavior management and tried not to jump straight to an antipsychotic. SW G reiterated the facility used a team approach to ensure consents, care plans and evaluations had been completed but was unable to provide any documentation to support this claim for R3.

Based on observations, interview and record review, the facility failed to ensure one resident (R24) of 12 residents sampled was receiving all her activities of daily living to maintain her ability to walk.Findings included:Review of R24's admission record dated 12/17/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: muscle weakness, lack of coordination, and weakness. R24's admission Record also revealed she was not her own responsible party.During an observation of cares for R24 on 12/17/25 at 8:45 AM, R24 required physical assistance to stand and transfer from her bed to her wheelchair. R24 had a wheeled walker in her room. Certified Nurse Aide (CNA) M was asked if R24 could walk. CNA M said she requires assistance, and she would ask if she wanted to walk. R24 said she did not want to walk because her right shoulder was sore. CNA M could not recall the last time she had seen R24 walk.Review of R24's Kardex (caregiver guide for care) dated 1217/24 revealed, ambulation/walking: R24 is able to ambulate w/4WW (with a wheeled walker), She uses a wheelchair for long distance locomotion/mobility. She is able to use her feet to propel herself short distances but may need staff assistance for longer distances. Encourage walk-to-dine.Review of R24's task for Walk 10 feet - encourage walk to dine from 11/18/25 to 12/16/25 revealed R24 was assisted to walk one time on 11/25/22, one-time on12/7/25 and one time on 12/9/25. There was no indication of how far she walked. It was documented that she refused to walk one time on 11/20/25, one time on 12/2/25, one time on 12/3/25, one time on 12/4/25, one time on 12/6/25, one time on 12/7/25, one time on 12/9/25, one time on 12/10/25, one time on 12/11/25, one time on 12/14/25, one time on 12/15/25, and one time on 12/16/25. There were no progress notes for these dates to show why R24 was only assisted one time on some days. In addition, on the days R24 refused to walk to dine there was no indication a licensed nurse was aware of R24's refusals to walk. There was also no documentation on why she was not assisted or encouraged to walk to dine on 11/18/25, 11/19/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/26/25, 11/27/25, 11/28/25, 11/29/25, 11/30/25, 12/1/25, 12/5/25, 12/8/25, 12/12/25, and 12/13/25.During an interview with the Director of Nursing (DON) on 12/17/25 at 1:30 PM, the DON was asked how she ensured residents like R24 were receiving walking assistance. The DON reviewed R24's electronic medical record and said R24 finished physical therapy on 12/2/25 and the note indicated she was back to walking at her prior level of function. The DON said she did not have any documentation that showed R24 had been assisted to walk or refused to walk since 12/2/25 when she was seen by physical therapy. The DON confirmed the CNAs should be assisting R24 to walk daily and if she refuses, they should document the refusal in her medical record, and a license nurse should document why R24 was refusing to walk. Prior to exit the facility provided documentation of R24's refusal to walk but did not provide any documentation that the licensed nurses or her physician was aware of the refusals or any follow up to determine the reason R24 was refusing to walk.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the fall of 1 resident (R45) of 4 residents reviewed for falls. Findings include:Review of an admission Record revealed R45 admitted to the facility on [DATE] with pertinent diagnoses which included alzheimer's disease, dementia, and visual hallucinations. Review of a current fall Care Plan intervention for R45, initiated 12/13/2025, revealed resident required one on one supervision in anticipation of care needs. In an observation on 12/16/2025 at 11:10 AM in R45's room, R45 was observed resting in bed with a Certified Nursing Assistant (CNA) sitting at his bedside providing 1 on 1 supervision. Review of R45's Nurses Notes in the Electronic Medical Record (EMR), dated 12/13/2025 at 7:55 AM, revealed .Resident was sitting in (wheelchair) at nurse's station under 1:1 supervision. Foot pedals were in place and (wheelchair) was locked. (Resident) was noted to be in front of (wheelchair) on hands and knees, face first by this nurse. In an observation and interview on 12/17/2025 at 12:27 PM in R45's room, R45 was in bed with CNA I sitting at his bedside and providing 1 on 1 supervision of R45. CNA I reported R45 had a recent incident when he was found on the floor while in 1 on 1 supervision. CNA I reported she was not working at the time, but she was aware that it was shift change when the incident occurred. Review of R45's fall incident report, dated 12/13/2025 at 6:30 AM, revealed .Resident was sitting in wheelchair at nurses' station while 1:1 staff was charting. Was noted by nurse to be in front of chair on the floor on hands and knees, face first. In an interview on 12/17/2025 at 12:58 PM, CNA J reported she was providing 1 on 1 supervision to R45 when he was found on the floor the morning of 12/13/2025. CNA J reported R45 was in his wheelchair at the nursing station while she was documenting at a computer when he was found on the floor. In an interview on 12/17/2025 at 1:05 PM, the Assistant Director of Nursing (ADON) N reported CNA J was provided written counseling regarding how to provide 1 on 1 supervision of residents. Review of Educational Opportunity provided to CNA J, dated 12/17/2025, revealed .When assigned to a resident 1 on 1, you must be with the resident at all times to intervene. This means in close proximity enough to physically assist them and deter a fall. If you are going on break, you need to hand the resident off to another staff. Review of facility policy/procedure Fall Management, effective 7/8/2025, revealed .Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls.

This citation pertains to intake 2636578Based on interview and record review, the facility failed to implement measures to prevent the elopement from the facility for one resident known to be at risk for elopement (R101) of four residents reviewed resulting in an Immediate Jeopardy that began on 9/21/25 when R101 left the facility unbeknownst to staff which created a high likelihood for serious harm, injury, and/or death. Findings include: Review of the admission Record reflected R101 originally admitted to the facility 9/19/23 and had pertinent diagnoses that included Alzheimer's Disease, Dementia with Mood Disturbance and Major Depressive Disorder - recurrent and severe with Psychotic Symptoms. Review of the annual Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) dated 8/22/25 reflected R101 was cognitively moderately impaired and could not complete the Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status). Section GG (Functional Abilities) revealed that R101 was independently ambulatory without assistive devices.Review of the Facility Incident Report (FRI) dated 9/22/25 reflected an unauthorized leave of absence by R101 occurred: on 09/21/2025 at approximately 5:00PM. The reported reflected R101 was identified at risk (for elopement) but did not have a [brand name of alarming device] in place. The [brand name of device] is a device worn by a resident that would initiate audible alarms and trigger doors to lock when in proximity doors, Activation of this device would thereby alert staff and prevent an unsafe exit through a door. Review of the Electronic Medical Record (EMR) Progress Notes for R101 reflected an entry on 8/27/25 at 8:04 PM that a Doctor's Order had been received to transfer the Resident from the facility for a psychiatric evaluation and treatment. The Progress Notes reflected R101 readmitted to the facility on [DATE] following in-patient psychiatric treatment.Review of the EMR Reentry Nursing Comprehensive Evaluation dated 9/16/25 at 3:40 AM reflected an Elopement Risk assessment was completed for R101. The documentation revealed R101 had verbalized a desire to leave the facility and had scored 13 on the elopement assessment. The assessment form reflected a score of 11 or higher indicated a resident was at risk for elopement. The documentation reflected (R101) is at risk for wandering with exit seeking as (R101) states is here in error and wants to leave.noted to happen more frequently starting in the afternoon. The documentation revealed that the intervention for a personal alarm was not implemented.On 10/8/25 at 12:20 PM a telephone interview was conducted with Certified Nurse Aide (CNA) G who reported she was scheduled to work on Sunday 9/21/25 at 6:00 PM. CNA G reported on that day she had gone to work early and was traveling east on the rural road that led to the facility. CNA G reported about 5:00 PM she saw someone walking down the road and it was (name of R101). CNA G reported she stopped beside the Resident and rolled down the window. CNA G reported R101 told her she was going to Tennessee. CNA G reported she told R101 that that was quite a distance and asked her to get into the car so that she could call her sister. CNA G reported that R101 got into her car, drove to the facility where she called inside and asked staff to come out and get the Resident. CNA G reported that three or four staff came out and escorted the Resident into the facility. On 10/8/25 at 10:40 AM a telephone interview was conducted with Licensed Practical Nurse (LPN) D. LPN D reported on the afternoon of Sunday 9/21/25 she was getting ready to pass medications and the CNAs were getting residents ready for dinner. LPN D reported she answered a phone call from a night CNA (CNA G) who was coming in early and had picked up (name of R101) down the road from the facility. LPN D indicated she did not know R101 had left the facility. LPN D reported she went out to the parking lot with several other staff members and walked R101 into the facility. LPN D reported that R101 had said that her mom told her to go get some medicine. On 10/8/25 at 10:38 AM a telephone interview was initiated with CNA F who reported she had worked on Sunday 9/21/25. CNA F reported that R101 had been at the Nurse's station a few minutes prior when CNA G called on the telephone and reported that the Resident was outside in her car. CNA F indicated she did not know R101 had left the facility or why R101 did not have a [brand name of alarming device] on. CNA F reported the Resident had recently returned from a psychiatric facility and should have been wearing a [brand name of alarming device]. CNA F reported a [brand name of alarming device] would have locked the front doors when close to them and would have prevented R101 from leaving the building.On 10/8/25 at 10:08 AM an interview was conducted with LPN E who reported she worked on Sunday 9/21/25. LPN E reported she had seen R101 chatting at the front desk and a short while later a CNA coming into work had called and said, I have (name of R101). LPN E reported she went out to the parking lot and helped escort the Resident back into the facility. LPN E reported she immediately assessed and put a [brand name of alarming device] on R101, then entered the Resident into the facility elopement book.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.The Immediate Jeopardy that began on 9/21/25 was removed on 9/22/25 when the facility 1) Re-assessed the elopement risk for R101 and implemented measures to prevent recurrence.2) Performed a resident count to ensure no other residents had eloped.3) Assessed all facility residents for risk of elopement for any previously unidentified residents at risk and ensured appropriate safety measures were in place.The Deficient Practice was corrected on 9/22/25 when the facility:1) Reviewed and updated the facility Missing Guest/Elopement book.2) Re-education of the Elopement policy was initiated for all staff. 3) Re-education of the Missing Guest Procedure for all staff was initiated4) The Nursing Home Administrator was re-educated on the facility elopement policy and the expected information to be ascertained to ensure compliance with the facility policy across disciplines. The facility was able to demonstrate monitoring of the corrective action and maintained compliance as of 9/22/25.

This citation pertains to intake #MI00148210 Based on interview and record review, the facility failed to provide enhanced supervision and assistance to residents with acute medical changes and significant medication changes, for two of five residents (Resident #32 and Resident #16) reviewed, resulting in a fractured left arm and a brain bleed for Resident #32 and a fractured right arm for Resident #16. Findings: Resident #32 (R32) Review of an Admission Record revealed R32 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnosis of seizure disorder, stroke with impaired speech, congestive heart failure, morbid obesity, impaired vision, muscle weakness, and pain in both knees. R32 required staff assistance for ambulation, bathing, and bed mobility (resident required substantial/maximal assistance x 1 to roll side to side, lying to sitting on side of bed, and sitting to lying), getting dressed, using the bathroom, and to transfer in and out of bed. Review of a Care Plan for R32 reflected the following relevant needs and interventions: (A) R32 is at risk for side effects from pain medications, initiated 03/14/24, with the following interventions: (1) monitor for respiratory depression-obtain respiratory rate, depth, and effort after administration of pain medications, (2) observe for altered mental status .dizziness, sedation, (3) observe for increased risk of falls .(B) R32 is at risk for adverse side effects from diuretic therapy for congestive heart failure, initiated 10/21/24, with the following intervention: (1) may cause dizziness, postural hypotension (a drop in blood pressure when changing positions), fatigue, and increased risk for falls .(C) R32 is at risk for falls and fall related injuries due to encephalopathy (any brain disease or disorder that affects the brain's structure or function. It can be caused by a number of things, including injury, disease, drugs, or chemicals. Encephalopathy can be temporary or permanent, and can lead to serious complications), impaired mobility, muscle weakness, heart failure, morbid obesity, seizure disorder, diuretic and opiod (pain medicine) use, initiated 07/14/22, with the following interventions: (1) anticipate and meet needs as needed and complete fall risk per protocol. Review of a Nursing Comprehensive-Quarterly Fall Assessment for R32, dated 10/11/24, reflected that there was No Risk for falls for this resident. Review of an Electronic Medication Administration Record (Emar) for R32, dated November 2024, revealed the following medications were prescribed: (a) Phenobarbital 97.2 MG (milligrams) at bedtime for seizure disorder (this medication is a hypnotic and causes sedation), (b) Lasix (a diuretic known to cause dizziness and a drop in blood pressure) 40 MG twice daily for swelling due to congestive heart failure (this is an increase from 20 MG twice daily, made on 11/03/24), and (c) Oxycodone (a powerful opiod pain medication) 10 MG twice daily from 11/1/24 to the morning of 11/5/24 and then doubled to 20 MG twice daily from the evening on 11/5/24 until the time of the fall on 11/11/24, as well as an additional order for Oxycodone 5 MG every 6 hours as needed for breakthrough pain, and (d) Clindamycin (antibiotic) 300 MG every 6 hours for infection for 10 days-start date 11/05/24 (This antibiotic can cause dizziness, fainting, or light headedness when getting up .(Mayo clinic Micromedex US L.P. 1973, [DATE]). The same Emar revealed no orders for staff to monitor and check orthostatic blood pressures (used to assess for a drop in blood pressure with position changes), or to monitor for side effects, including dizziness and sedation, following increased doses of Oxycodone and Lasix and the recent start of Clindamycin. Review of a facility Investigation, completed for an unwitnessed fall sustained by R32 on 11/11/24 at approximately 6 AM, revealed that R32 was found by staff on the floor face down in her room, and had sustained a right sided head injury and complained of left shoulder pain. X-rays completed at the facility showed a left upper arm fracture. Review of the last blood pressure obtained before R32's fall the morning of 11/11/24 was 108/80 (obtained 11/10/24 at 3:43 PM). The last recorded blood pressure for R32 with a systolic blood pressure below 110 was recorded on 02/19/24. Per the EHR (electronic health record), following the lower than usual blood pressure reading of 108/80 on 11/10/24 at 3:43 PM, R32 was administered a dose of Oxycodone 20 MG at bedtime and then another dose of Oxycodone 5 MG at 3:54 AM on 11/11/24. No indication of monitoring for side effects following those two doses of Oxycodone could not be located in the EHR. Review of an EMS (emergency medical services) ambulance run record, dated 11/11/24, revealed the following findings regarding R32: (a) EMS arrived at the facility at 1:34 PM, (b) were advised that an earlier x-ray showed a left arm fracture, (c) noted bruising to R32's right side of her face, and (d) was told by facility staff that the staff believed R32 tried to stand up from the bed and fell . Review of an emergency room Record dated 11/11/24 revealed R32 had sustained an acute intraventricular hemorrhage in the right lateral ventricle (a brain bleed) and confirmed the earlier findings of a fractured left arm. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year old female, originally admitted to the facility on [DATE] with pertinent diagnoses of muscle weakness, anxiety disorder, developmental disorder, congestive heart failure, and dementia. Review of a Post Fall Evaluation dated 11/13/24 at 10:15 AM showed R16 fell in her room and fractured her right arm. Resident was weak from pneumonia. Review of an Emar for R16, dated November 2024, revealed the resident was started on Clindamycin (an antibiotic) 300 MG one tab twice daily for pneumonia starting 11/08/24. R16 was also prescribed Invega 3 MG one tab at bedtime and Abilify 15 MG one tab in the morning ( both medications are antipsychotic and can cause blurred vision, confusion, sedation, orthostatic hypotension, and restlessness). Review of a task monitoring form for R16, that documented the amount of staff assistance needed to walk to and from the bathroom, revealed that on 11/7/24 through 11/10/24 R16 was independent to ambulate in her room. Documentation from 11/11/24 through the time of the fall on 11/13/24 showed R16 requested staff assistance to ambulate that ranged from partial to moderate assistance needed to complete dependence on staff. Review of a Provider Encounter Progress Note dated 11/11/24 revealed: Nursing called to report (R16) not getting better as expected. Very pale, lethargic, diminished lung sounds, and oxygen saturations were in the 70's (%) range while receiving 5 liters of oxygen. Review of a Fall Risk Care Plan for R16 reflected that no new safety interventions were put in place once the resident was (a) diagnosed with pneumonia, (b) started on an antibiotic, (c) requested staff assistance to ambulate to and from the bathroom, and (d) was reported to be lethargic and not doing better. During an interview on 11/20/24 at 3:48 PM, Certified Nurse Aide (CENA) H stated that after R16 was diagnosed with pneumonia, R16 had not been doing well, was weak, and was unsteady on her feet.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for one resident (Resident #8) out of 13 residents reviewed for quality care, resulting in hospitalization for a fracture sustained after a fall from staff use of the incorrect lift device. Findings: Resident #8 (R8) Review of an Admission Record reflected R8 admitted to the facility with diagnoses that included generalized osteoarthritis, hemiplegia and hemiparesis (weakness and partial paralysis) of the left non-dominant side following a stroke, history of traumatic brain injury and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15. R8 was coded as using a wheelchair for mobility, did NOT walk, and was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed - to- chair transfers. Review of a Discharge assessment - return anticipated MDS dated [DATE] reflected R8 was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed - to- chair transfers. During an observation and interview on 11/18/2024 at 11:23 AM, R8 was sitting up in bed, a sling in place on her left arm. R8 reported her left hip and shoulder were painful due to an accident that occurred at the facility during a transfer, resulting in a broken arm. R8 said that before the accident occurred, she told staff she felt weak and tired from recent low blood pressures and thought she had another urinary tract infection when she slipped out of a sit-to-stand lift. Review of a Fall incident report dated 9/1/2024 reflected Incident Description: This nurse was called to room. Nurse aides were standing around resident (R8) who was sitting on the floor, with an aide behind her. She slipped out of sit-to-stand during a transfer. The report indicated When resident goes outside, she is to be transferred via Hoyer (a full mechanical lift) to bed instead of sit-to-stand. She is tired from being outside and its hard for her to hold on. The report indicated R8 had a left shoulder injury and 10/10 pain level. Details in the report were limited and the complete fall investigation was requested. Review of a Verification of Investigation form dated 9/01/2024 reflected Resident (R8), who is AxOx3 (alert and oriented times 3, person, place, situation), fell when she let go of a sit-to-stand. She was a two person assist, and her CNAs (Certified Nurse Aides) (CNA H and CNA K) both testified that they had taken (R8) to the restroom, and were bringing her back to bed in the EZ sit-to-stand, when (R8) let go of the sling on the left side, and slid down to the floor through the lift sling (she was dragged down by her girth). (R8's) grey dress pullover was pulled up over her head. (R8's) shoulder hit the side of her bed when she went down. (R8) stated I was tired from the day, and I just let go. Current care plan includes a 2 person assist for transfers, and the care plan was followed. The care plan included with the investigation did not address R8's transfer status. A statement from CNA H indicated that R8's left arm was flaccid (limp) and R8 let go of the lift device with her right hand when she fell . Review of a Care Plan initiated on 11/28/2019, revised on 7/03/2024 indicated that R8 was at risk for fall related injury related to history of falls, hemiplegia/paresis left side, TBI (traumatic brain injury), needs assistance with ambulation with use of walker . The goal was that R8 would remain free from injury related to falls. Interventions included Encourage the resident to wear appropriate footwear as needed; ensure gait belt is on for all transfers . This care plan, in place at the time of R8's fall, conflicts with the MDS data which indicate R8 does not ambulate or use a walker for ambulation. Review of a Care Plan initiated 3/15/2024 and in place prior to R8's fall on 9/01/2024 reflects (R8) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): weakness d/t (due to) CVA (stroke) with left sided weakness, PVD (peripheral vascular disease), GERD (gastro-esophageal reflux disease), seizures, RLS (restless leg syndrome), HTN (high blood pressure), and OA (osteoarthritis). This care plan indicates R8 is unable to walk or ambulate and was dependent on staff for transfers. The care plan does NOT specify the number of staff or assistive devices required to transfer R8. During an interview on 11/20/2024 at 11:31 AM, Physical Therapy Assistant (PTA) L said R8 was on the therapy case load to evaluate R8 due to deconditioning and had been cut from services on 8/30/2024 due to lack of progress prior to being hospitalized after the fall and broken arm on 9/01/2024. PTA L reported that R8 was a max (maximum) assist with a sit-to-stand for transfers and required a Hoyer lift as needed. PTA L said she does not update care plans but gives transfer status recommendations to nursing staff in the form of a communication and education to staff. PTA L said that the intervention Hoyer as needed has been long standing. PTA L emphasized that staff can always use more support than required, but cannot offer less support than what is typical for a resident. The transfer status recommendations and communication forms were requested from PTA L at this time. Review of Therapy Communication Forms dated 3/14/2022 indicated that R8 was to be transferred via EZ-stand for transfers <> (to and from) bed to wheelchair . The recommendation made over two years prior was not found in a comprehensive review of the care plan that was in place prior to R8's fall from the sit-to-stand device. During an interview on 11/20/2024 at 11:47 AM, the Director of Nursing (DON) reviewed the care plan that had been in place prior to R8's fall with fracture on 9/01/2024. The DON said that they were present at the facility on the day R8 fell . R8 had been outside most of the day, coming inside every few hours to be cared for, which likely weakened R8 and contributed to the fall. The DON confirmed that no specific directions pertaining to how R8 was to be transferred was documented in the care plan for self-care/mobility and confirmed that R8 did not walk using a walker anymore. Review of a hospital History of Physical Notes dated 9/2/2024 reflected History of Present Illness: (R8) is a 60 y.o. (year old) female who presents with past medical history notable for hypertension, hyperlipidemia, hemorrhagic CVA with residual left-sided weakness and obstructive sleep apnea who presents to the emergency room after a fall while being transferred from the wheelchair to a bed via a sit and stand device. The patient said that her blood pressures have been low and she apparently passed out briefly. Patient landed on her left side resulting in severe pain in the left arm. She was confirmed to have a fracture at the facility and was brought to the emergency room for evaluation/treatment. In the ED (Emergency Department) the patient was afebrile with low blood pressures documented around 87/68. Nontachycardic (no increased pulse). After IV (intravenous) fluids in the ER blood pressures have improved to systolic blood pressure close to 100. Currently she is asymptomatic but does want to go back to sleep. Further review of hospital records indicated R8 had a CT (computed tomography, an imaging exam) scan of the left shoulder without contrast which showed R8 had a Comminuted (a broken bone that has separated into three or more pieces; usually caused by a severe impact, such as a car accident or a serious fall), displaced, and angulated fracture of the surgical neck of the humerus. The hospital record also revealed R8 was diagnosed with Metabolic Encephalopathy and Sepsis without shock due to a UTI.

Based on observation, interview, and record review, the facility failed to 1.) implement the facility policy for pressure injury/wound management, 2.) ensure pressure injury/wound assessments were comprehensive and accurate, and 3.) ensure treatments were promptly ordered and completed, for 2 of 13 residents (Resident #17 and #1) reviewed for alterations in skin integrity, resulting the development of preventable pressure injuries and the worsening of wounds. Findings: Resident #17 (R17) Review of an Admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic respiratory failure, chronic heart failure, and diabetes. R17 was dependent on staff for all activities of daily living. According to the Nurse Notes, R17 was hospitalized from 11/3/24-11/7/24 for a UTI (urinary tract infection). Review of R17's Care Plan revealed the following concerns and interventions: (a) R17 is at risk for urinary tract infection and catheter-related trauma with the following intervention-Ensure catheter tubing is secured-Initiated: 08/25/2023, (b) R17 is at risk for impaired skin integrity/pressure injury R/T: weakness, mobility issues, low proteins, and incontinence of bowel, presence of catheter and tubing, non ambulatory, COPD, hoyer lift, fragile skin of sacrum r/t previously healed pressure ulcer and MASD (moisture associated skin damage), unable to reposition self with the following interventions-put barrier between skin and catheter tubing to avoid skin irritation and/or abrasion-initiated: 04/05/2024 .turn and reposition every two hours and PRN (as needed)-initiated: 03/26/2021 .Added to the care plan on 11/15/24 was MASD to right buttocks related to incontinence. Review of R17's readmission Nursing Comprehensive Evaluation dated 11/7/24 revealed: groin and perineal area reddened. No measurements were noted. Review of R17's Order Summary revealed that no new order for skin impairment treatment, noted on the admission assessment dated [DATE], were put into place until 11/11/24. Review of R17's Minimum Data Set, dated dated dated [DATE] (completed after returning from the hospital stay 11-3-24 to 11-7-24) revealed R17 did not have one or more unhealed pressure ulcer(s) at Stage 1 or higher and R17 was at risk of developing pressure ulcer. Review of R17's Electronic Medical Record revealed (a) no treatment order for a catheter securement device, (b) no comprehensive wound assessment following the skin breakdown identified on 11/7/24, (c) the guardian was not notified of the skin break down identified on 11/7/24, and (d) the physician was not notified of the skin concerns identified on 11/7/24. Review of R17's provider Progress Note dated 11/12/24, did not reflect a new/worsening pressure injury or skin impairment. Review of R17's Order Summary with a start date of 11/15/24 revealed changes (increased care required) to the order initiated on 11/11/24 for the right buttocks wound care. Review of R17's Electronic Medical Record revealed no comprehensive wound assessment following the identification of the skin breakdown and/or worsening of the skin breakdown which resulted in a treatment order change dated 11/15/24 or guardian and physician notification of the skin breakdown and treatment changes. On 11/21/24 at 12:43 PM, R17's Skin & Wound Evaluation dated 11/17/24 was documented as complete. The wound now measured 0.8 cm (length) x 1.0 cm (width) x 0.1 cm (depth). The surrounding tissue was fragile and at risk for breakdown. It was documented that the guardian and the provider were notified on 11/21/24 of the skin breakdown. During an observation on 11/19/24 at 12:50 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 01:07 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 02:10 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 02:53 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 03:41 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 03:55 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 08:13 AM, R17 was sitting up in a broda chair in the dining room attempting to feed herself. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 08:42 AM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 09:26 AM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 10:45 AM, R17 was sitting up in a broda chair in the activity room. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 11:58 AM, R17 was sitting up in a broda chair in the activity room. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 12:34 PM, R17 was sitting up in a broda chair in the dining room attempting to feed herself. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation and interview on 11/20/24 at 01:04 PM, Certified Nursing Assistant (CNA) E brought R17 to her room to provide pericare. CNA E reported R17 got up before breakfast but had not provided pericare since that time. During an interview on 11/20/24 at 01:20 PM, R17 reported pain her buttocks. During an observation and interview on 11/20/24 at 01:25 PM, CNA E and CNA F were providing incontinence care for R17. R17 did not have a securement device in place and her urinary catheter tubing was under her thigh/buttocks. R17 was rolled to the left side exposing her buttocks and posterior thighs. On her right groin/upper posterior thigh there were 2 areas of deep ruddy red indentations where the incontinence brief and urinary catheter tubing had been pressing into her skin. CNA F reported R17 should have had a securement device in place for her urinary catheter and did not know how long she had been without it. R17 had dried stool (bowel movement) that was not easily wiped away noted on her buttocks that had contaminated the dressing on R17's right gluteal wound. The dressing border had lifted and there was stool under the dressing. Licensed Practical Nurse (LPN G) entered the room to perform a dressing change and reported she did not know how long R17 had been without the securement device. Review of R17's Skin & Wound Evaluation dated 11/20/24 at 2:11 PM revealed a Medical Device Related Pressure Injury Stage I on the Right Ischial Tuberosity, Medial identified as in-house acquired on identified on 11/20/24. The wound measured 5.5 cm (length) x 1.8 cm (width) . ensure catheter tubing anchor is in place and tubing in proper position . Confirming the presence of a new avoidable pressure injury. Review of R17's contracted wound consultants Progress Note dated 11/20/24 revealed, . is being seen today for evaluation of a new wound site to the right groin/medial Ischial tuberosity, in addition to a follow-up of her right gluteal incontinence-associated dermatitis .On evaluation today after lunch, (R17) was alert. She reported pain at the newly observed wound site without other reports of pain during assessment or other wound interventions .Notes: Pain to groin area where the new wound is located .Indwelling Foley urinary catheter and incontinence brief associated devices appear to have created skin breakdown in the form of a Stage 1, non-blanching, medical device-related pressure wound along the right groin/medial ischial tuberosity. Positive for tenderness on palpation of the wound, erythema and ecchymosis. The wound site measures about 5.5 cm in length by about 1.8 cm in width, but without depth .a 3.5 x 2.5 cm area (without depth) that is red-pink, dermatitis noted to the right gluteus. An area of redness and bruising, 5.5 cm x 1.8 cm, was noted on the right posterior ischium area medially, where the incontinence brief and urinary catheter tubing had been laid onto the skin, showing skin that is reddened and non-blanching, with indentations and bruising in the shape of the incontinence brief edge, and urinary catheter tubing, pressure injury, which is tender on palpation .(Problem 1) .Skin moisture secondary to chronic urinary incontinence associated dermatitis located to the right gluteus, measuring 3.5 cm x 2.5 cm, no depth .(Note the resident had an indwelling foley catheter at the time of the assessment) .(Problem 2) .Contusion that is pink-red with ecchymosis, no edema or signs of infection noted to the right interior thigh, distal to the groin, appearing to be a medical device associated skin injury from chronic indwelling foley catheter and incontinence brief edge contact with the skin that likely caused friction injury. Nonblanching, the skin remains closed/intact. - Measured 5.5 cm x 1.8 cm, without depth . During an interview on 11/21/2024 at 8:54 AM, Assistant Director of Nursing (ADON) A reported that the provider and guardian should be notified at the time the skin breakdown is identified and documented in the Skin & Wound Evaluation. ADON A reported that the standard of practice was for R17's catheter securement device to be in place at all times. Review of the facility policy Skin Management last revised 8/14/24 revealed, Practice Guidelines (1.) Upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record .(3.) Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. 4. Residents admitted with any skin impairment will have: (a) Appropriate interventions implemented to promote healing, (b) A physician's order for treatment, and (c) Skin impairment location, measurements and characteristics documented. Review of the facility policy/procedure Indwelling urinary catheter (Foley) care and management last reviewed 11/20/24 revealed, .make sure the catheter is secured properly. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Medical device- related pressure injuries (MDRPIs) are injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes .Pay particular attention to areas located over bony prominence's; next to and around medical devices . Consider adults with medical devices (e.g., tubes, drainage systems, and oxygen devices) to be at risk for pressure injuries. Confirm that devices are not placed directly under an individual who is bedridden or immobile . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pgs. 1247-1260). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Early identification of high-risk patients helps prevent pressure injuries . Interventions aimed at prevention include turning and positioning to relieve pressure. Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 845). Elsevier Health Sciences. Kindle Edition. 29073 Resident #1 (R1) Review of an Admission Record indicates R1 admitted to the facility with diagnoses that included schizoaffective disorder, muscle weakness, dependence on wheelchair, chronic venous insufficiency, peripheral vascular disease, and cerebral palsy. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14/15. R1 had Functional Limitation in Range of Motion on one side of the upper extremities and impairment on both lower extremities. R1 needed Substantial/maximal assistance with rolling to the left and right, sitting to lying, lying to sitting and was Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity for sitting to standing, chair/bed-to-chair transfer and toileting. Section M - Skin Conditions indicated R1 was at risk of developing pressure ulcers and did not have any pressure ulcers at the time of the assessment. During an interview on 11/19/24 at 2:00 PM, R1 was seated in his wheelchair and reported he had a very sore bottom, and it felt like he sat on a nail. R1 said he would be willing to have his skin observed the next time he got transferred to bed. During an observation and interview on 11/19/24 at 2:19 PM, Certified Nurse Aide (CNA) B and CNA C transferred R1 using a mechanical lift into the bed. CNA B said R1 was last assisted/repositioned prior to lunch at 11:00 AM (three hours prior to the observation). R1's brief was dry, and the resident used the urinal before the CNA's rolled R1 to his right side, exposing his buttocks. Serosanguinous drainage was noted on the brief under R1's right coccygeal area, as well as reddened and blanchable skin. There was no evidence a barrier cream had been applied and CENA B said they would apply A & D ointment because that's all I have. The surveyor requested a nurse observe the wound at this time. During an observation and interview on 11/19/24 at 2:39 PM, the Director of Nursing (DON) assessed the open area and scab on R1's right coccygeal area. The DON verbalized her assessment as blanchable, reddened skin around an open area that measured 2.0 centimeters (cm) x 2.0 cm x 0.1 cm in depth with bloody drainage. The non-blanchable scab measured 0.8 cm x 0.8 cm with no measurable depth. The wound was cleaned with wound cleanser and chalmosyn (a barrier cream) was applied. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] reflected R1's skin was intact. Review of a Nurses Notes dated 11/9/24 reflects (R1) has a dark scabbed area on right side of coccyx, approx. (approximately) 2.5 x 1 cm (centimeter). No drng (drainage) noted. (Medical Director) faxed, voice mail left for guardian, DON (Director of Nursing) notified. A corresponding Skin & Wound - Total Body Skin Assessment was not associated with the findings. Review of a Total Body Skin Assessment note dated 11/10/2024 reflected Pt (patient) buttocks red with open area noted to right side. Pt. BLE (bilateral lower extremities) are red/dry no open areas noted. Lotion/creams applied, reposition q (every) 2 hours and PRN. Up in w/c wheelchair for meals. Incont (incontinent) of b&b (bowel and bladder), wears briefs. The documentation did not reflect physician and other notifications had been made, measurements, or wound description had been documented upon discovery of an open area. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] reflected R1 had no new wounds, despite a progress note that indicated R1 had a new open area. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] reflected Enter the # of New Wounds - 6. New Wounds - yes. The form did not indicate the number of new wounds. Review of R1's November 2024 Treatment Administration Record (TAR) reflected Apply chamosyn (a skin protectant ointment that can be used to treat a variety of skin conditions, including diaper rash, minor burns, and cuts) to coccyx BID (twice a day), monitor site until healed two times a day for wound-Start Date- 11/10/24-D/C (discontinue) Date-11/13/2024. Another order for the same treatment was initiated on 11/13/24 and changed the time from 8 AM and 8 PM to every day and night shift for skin management. Review of a Care Plan initiated 1/27/2020 reflected R1 was at risk for impaired skin integrity/pressure injury related to diagnoses. The Goal of the care plan focus area was to minimize the risk of developing a pressure injury. Interventions included conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; follow facility policies and protocols for the prevention and treatment of impaired skin integrity; observe skin with showers/cares, notify nurse immediately of any new areas of skin breakdown; refer to treatment POC (plan of care); turn and reposition (R1) every 2 hours and PRN (as needed) as allows. The interventions did not address R1's preference for sitting up in his wheelchair for most of the day and the requirement to offload pressure. Further review of the entire Care Plan did not reflect a focus, goals, or interventions related to R1's actual skin impairment/pressure injury identified on 11/09/2024 and 11/10/2024. During an interview on 11/20/24 at 9:50 AM, the Assistant Director of Nursing (ADON) A reported the open area discovered on R1 was classified as a stage 2 pressure ulcer. ADON A reported R1 has a history of stage 2 pressure ulcers, was incontinent and delusional. ADON A said R1 was not on a toileting schedule to address incontinence and did not like to lie down to relieve pressure. ADON A reported there was not a care plan intervention to off-load pressure while up in the wheelchair.

Based on interview and record review, the facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected. Findings: Review of the April 2024 infection surveillance revealed there was no Employee Infection Log completed and no Infection Prevention Committee Meeting notes. Review of the May 2024 infection surveillance revealed there was no Employee Infection Log completed and no Infection Prevention Committee Meeting notes. Review of the June 2024 infection surveillance revealed there was no Employee Infection Log completed and no Infection Prevention Committee Meeting notes. Review of the July 2024 infection surveillance revealed there was no Employee Infection Log completed. Review of the Infection Prevention Committee Meeting notes dated August 2024 revealed, Review of data for Month/Year July 2024 .6. Employee health-employee outbreaks, exposures to blood and body fluids or communicable diseases was left blank. Review of the November 2024 Staff Case List (employee illness tracking) revealed 6 staff members were listed: On 11/5/24 a staff member was documented to have a Bacterial infection with a status of Resolved. The unit the staff member worked, residents that they came into contact with, the date last worked, the date the infection resolved, and the date they returned to work was not listed. On 11/11/24 a staff member was listed with no Infection Type with a status of Resolved. The symptoms, the unit the staff member worked, residents that they came into contact with, the date last worked, the date the infection resolved, and the date they returned to work was not listed. On 11/15/24 a staff member was listed with no Infection Type with a status of Resolved. The symptoms, the unit the staff member worked, residents that they came into contact with, the date last worked, the date the infection resolved, and the date they returned to work was not listed. On 11/15/24 a staff member was listed with no Infection Type with a status of Resolved. The symptoms, the unit the staff member worked, residents that they came into contact with, the date last worked, the date the infection resolved, and the date they returned to work was not listed. Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and schizophrenia. R23 had been diagnosed with a UTI in the Emergency Department and discharged with an antibiotic. Review of the August and September 2024 Infection Surveillance Monthly Report revealed R23 was not listed. Additionally, R23's laboratory documentation revealed, mixed flora. No Significant pathogens isolated and therefore no culture and sensitivity testing was completed. R23's symptoms, onset of symptoms, laboratory results/confirmed diagnosis, and antibiotic use was not included for the purpose of tracking and trending infections. During an interview on 11/21/2024 at 8:32 AM, Infection Control Preventionist (ICP) A reported that she was not the active ICP from April-July and could not speak to why employee infection surveillance had not been completed. ICP reported the employee illness/call-offs should be tracked in real time to prevent the spread of an infection/outbreak. ICP A confirmed there was no Employee Infection Log completed from April-July 2024. ICP A reported that residents prescribed an antibiotic are included on the Infection Surveillance Monthly Report however, residents with symptoms of infection but do not get prescribed antibiotics are not included. ICP A reported that identified residents that may have infection by reviewing daily charting notes completed by the floor nurses, reviews the dashboard in the Electronic Health System, and reviews the staff/provider chat system. ICP A reported the expectation was for the floor nurses to document signs/symptoms of infection and report those symptoms to the management team. During an interview on 11/21/24 at 12:15 PM, Director of Nursing (DON) and ICP A reported that residents exhibiting symptoms of an infection are not listed on the Infection Surveillance Monthly Report but instead are tracked using a Resident at Risk list and discussed weekly in the Resident at Risk Meeting. Residents ordered antibiotics were to be listed on the Infection Surveillance Monthly Report. Review of the facility policy Infection Prevention Program Overview last revised 10/11/23 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 residents, staff, contractors, consultants, volunteers, visitors and others who provided care and services to the residents on behalf of the facility, and students in the facility's nurse aide training program or from affiliated academic institutions . 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 . DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION ACTIVITIES . A. Infection Preventionist (IP) *The IP serves as the coordinator of an Infection Control program. The designated IP should have primary training in either nursing, medical technology, microbiology, or epidemiology or other related field and must possess additional training in infection prevention and control. *Responsibilities may include: *Collecting, analyzing, and providing infection data and trends to nursing staff and healthcare practitioners *Consulting on infection risk assessment, prevention, and control strategies *Providing education and training; Implementing evidence based infection control practices including those mandated by regulatory and licensing agencies . REPORTING MECHANISMS FOR INFECTION PREVENTION A. 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 .

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews were maintained in the resident's clinical record with documentation of the physician's response for 1 resident (R1) of 5 residents reviewed for medication regimen reviews. Findings include: Resident #1 (R1) Review of an Admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder. Review of R1's Order Summary revealed: QUEtiapine Fumarate (antipsychotic medication) Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth one time a day for Delusions/Hallucinations (Dated 10/23/24) QUEtiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for mood (Dated 6/19/24) VENLAFAXINE HCL ER (antidepressant medication) 37.5 MG CAP{90 EA} Give 1 capsule by mouth in the morning for depression (Dated 5/13/24) VENLAFAXINE HCL ER 75 MG CAP{90 EA} Give 75 mg by mouth in the morning for depression (Dated 6/27/23) Depakote (mood stabilization medication) Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for psychosis with delusions Review of R1's pharmacy Consultation Report dated 3/12/24 revealed, (R1) has orders for labs, but at the time of this review they were not available in the medical record. The missing lab values include: cbc (complete blood count), cmp (comprehensive metabolic panel), HgbA1C (glycohemoglobin) q (every) 3 months (Feb, May, Aug, Nov)-Lipids, hepatic panel, keppra, tsh, free t-4, ammonia & valporic Acid level Q (every) 6 mo (months) (Feb, Aug). Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. The consultation report was signed indicating facility staff received/reviewed the recommendations with Nurses please order all tests handwritten on the report. Review of R1's Laboratory Results from March to present revealed that only a BMP (basic metabolic panel) had been obtained/resulted following the pharmacist recommendations (on 3/26/2024, 4/11/2024, 5/15/2024, 7/5/2024, and 7/25/2024) despite R1's dosage increase in venlafaxine in May and quetiapine in June. Review of R1's Order Summary revealed an order for CBC, CMP, HgbA1c Q-3 mo (Feb, May, Aug, Nov) Lipids, Hepatic Panel, Keppra, TSH, Free T-4, Ammonia & Valporiric (sic) Acid level Q6-mo (Feb, Aug) but was discontinued on 7/20/24. There was no physician rationale for the discontinuation of the labs noted in R1's Electronic Medical Record. Review of R1's Electronic Medical Record (EMR) revealed a monthly Medication Regimen Review (MRR) was completed on 4/15/24, 6/13/24, 8/12/24, and 11/11/24 with noted irregularities and/or recommendations. There were no Consultation Reports available for review in R1's EMR. A request for the pharmacy Consultation Reports/MRRs dated 4/15/24, 6/13/24, 8/12/24, and 11/11/24 were requested on 11/20/24 at 4:11 PM via email and received on 11/21/24 at 12:28 PM. Review of R1's pharmacy Consultation Report dated 4/15/24 revealed, (R1) has orders for labs, but at the time of this review they were not available in the medical record. The missing lab values include: CBC, CMP, HgbA1c Q-3mo (Feb, May, Aug, Nov)-Lipids, Hepatic Panel, Keppra, TSH, Free T-4, Ammonia & Valpoiric (sic) Acid level Q-6 mo (Feb, Aug). Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. There was no signature/initials of the provider on the report to indicate they were notified of the recommendations. Review of R1's pharmacy Consultation Report dated 6/13/24 revealed, (R1) has orders for labs, but at the time of this review they were not available in the medical record. The missing lab values include: HgbA1c Q-3mo (Feb, May, Aug, Nov)-Lipids, Hepatic Panel, Keppra, TSH, Free T-4, Ammonia & Valproic Acid level Q-6 mo (Feb, Aug). Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. Ok for labs was handwritten on the consultation report indicating the nursing staff were to ensure laboratory testing was completed. Review of R1's EMR revealed the recommended labs were not completed at that time. Review of R1's pharmacy Consultation Report dated 8/12/24 revealed, (R1) has orders for labs, but at the time of this review they were not available in the medical record. The missing lab values include: HgbA1c Q-3mo (Feb, May, Aug, Nov)-Lipids, Hepatic Panel, Keppra, TSH, Free T-4, Ammonia & Valproic Acid level Q-6 mo (Feb, Aug). Recommendation: Unless otherwise indicated, please ensure that ordered labs are obtained. Please disregard recommendation if these labs have been recently obtained. There was no signature/initials of the provider on the report to indicate they were notified of the recommendations. Review of R1's Psychiatric Consultation dated 10/17/24 revealed, Quetiapine 100mg one PO BID (by mouth twice a day) increased 06/19/24 .Start Quetiapine 50mg one PO QD (by mouth every day). Confirming quetiapine was increased on 6/19/24 and again on 10/17/24. Review of R1's pharmacy Consultation Report dated 11/11/24 revealed, (R1) receives Divalproex Sodium DR but does not have a trough concentration documented in the medical record with the previous 6 months. Recommendation: Please monitor a valproic acid trough concentration on the next convenient lab day, 1 week after any dosage changes, every 6 months thereafter, and as clinically indicated. During an interview on 11/21/24 at 12:28 PM, Director of Nursing (DON) confirmed the MMRs dated 4/15/24, 6/13/24, 8/12/24, and 11/11/24 were not in R1's EMR and were obtained from the pharmacy. DON confirmed R1 had not had the recommended laboratory tests completed. DON reported that she was not aware that the laboratory testing was to be ongoing while R1 was on psychotropic medications. DON reported that pharmacy recommendations should be reviewed by the provider once received with documentation by the provider that the recommendations were reviewed/instituted. DON confirmed that there was no documentation/rationale regarding the discontinuation of the routine laboratory tests by the provider or a rationale for why the pharmacist recommendations were not followed/implemented. Review of the FDA prescribing information for Seroquel revealed, Neuroleptic Malignant Syndrome (NMS): Manage with immediate discontinuation and close monitoring (5.4) o Metabolic Changes: Atypical antipsychotics have been associated with metabolic changes. These metabolic changes include hyperglycemia, dyslipidemia, and weight gain (5.5) o Hyperglycemia and Diabetes Mellitus: Monitor patients for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Monitor glucose regularly in patients with diabetes or at risk for diabetes o Dyslipidemia: Undesirable alterations have been observed in patients treated with atypical antipsychotics. Appropriate clinical monitoring is recommended, including fasting blood lipid testing at the beginning of, and periodically, during treatment o Weight Gain: Gain in body weight has been observed; clinical monitoring of weight is recommended o Tardive Dyskinesia: Discontinue if clinically appropriate .Leukopenia, Neutropenia and Agranulocytosis: Monitor complete blood count frequently during the first few months of treatment in patients with a pre-existing low white cell count or a history of leukopenia/neutropenia and discontinue SEROQUEL at the first sign of a decline in WBC in absence of other causative factors .Clinical trials with quetiapine demonstrated dose-related decreases in thyroid hormone levels .both TSH and free T4, in addition to clinical assessment, should be measured at baseline and at follow-up .Nevertheless, the presence of factors that might decrease pharmacokinetic clearance, increase the pharmacodynamic response to SEROQUEL, or cause poorer tolerance or orthostasis, should lead to consideration of a lower starting dose, slower titration, and careful monitoring during the initial dosing period in the elderly. Review of the FDA prescribing information for depakote revealed, .Valproate is metabolized almost entirely by the liver .Adverse reactions that have been reported with all dosage forms of valproate . Thrombocytopenia and inhibition of the secondary phase of platelet aggregation .laboratory test results include increases in serum bilirubin and abnormal changes in other liver function tests. These results may reflect potentially serious hepatotoxicity . Abnormal thyroid function tests . Hyperammonemia, hyponatremia, and inappropriate ADH secretion .Depakote or Depakene may cause other serious side effects including: Low blood count .High ammonia levels .low body temperature . Review of the FDA prescribing information for venlafaxine revealed, .ADVERSE REACTIONS .Abnormal Bleeding .Renal Impairment *Hepatic Impairment .Hyponatremia . Effexor XR was associated with mean final increases in serum cholesterol concentrations . Effexor XR was associated with mean final on-therapy increases in fasting serum triglycerides . SSRIs and SNRIs, including Effexor XR, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse event . Venlafaxine is well absorbed and extensively metabolized in the liver . Review of the facility policy Psychoactive Medication Management last revised 10/20/23 revealed, Policy-The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize the use of psychotropic medications in managing behaviors when non- pharmacological interventions have failed. Overview-Residents receiving psychoactive medications to treat behavioral symptoms are evaluated, monitored, and managed by the interdisciplinary team including, but not limited to, facility clinical staff, practitioner, and a pharmacist. The facility will provide appropriate treatment and services for residents who display or are diagnosed with a mental disorder or psychological adjustment difficulty, or who have a history of trauma and/or post-traumatic stress disorder (or substance use disorders) .Monitor medication for efficacy, side effects and adverse consequences of the medication. Notify the practitioner of adverse consequences or side effects noted .When evaluating the residents progress, the practitioner reviews the total plan of care, orders, the resident's response to medication(s) and determines whether to continue, modify or stop a medication .

Based on interview and record review, the facility failed to 1.) implement and operationalize an antibiotic stewardship program and 2.) ensure accurate monitoring and documentation of infections for 3 residents (Resident #23, #30, and #192) out of 6 residents reviewed for antibiotic use and treatment. Findings: Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and schizophrenia. R23 had been diagnosed with a UTI in the Emergency Department and discharged with an antibiotic. Review of R23's provider Progress Note dated 8/29/24 revealed, .Per nursing report, patient wandering into other patients rooms and grabbing things and putting in mouth .Patient incont (incontinent) now and not attending to self care needs. Recent Ua negative . There were no additional genitourinary symptoms and/or infectious process symptoms documented prior to the start of the antibiotic. Review of R23's Nurses Note dated 8/29/2024 revealed, res (resident) returned back from ER with DX (diagnosis) of UTI order to start macrobid in AM X 5 DAYS came back at approx 1645 (4:45 PM). There was not documentation that the provider was notified of the order for the antibiotic, that McGeer Criteria was initiated/followed, or that the culture result was reviewed on 8/30/24. Review of R23's Order Summary dated 8/29/24 revealed, Nitrofurantoin Macrocrystal Oral Capsule 100 MG Give 1 capsule by mouth two times a day until 09/04/2024. Review of R23's Microbiology Report dated 8/30/24 revealed, mixed flora. No Significant pathogens isolated and therefore no culture and sensitivity testing was completed. The report was signed by the provider on 9/5/24 following the completion of the antibiotic. Review of R23's Electronic Medical Record revealed no documentation of UTI symptoms, onset of symptoms, McGeer Criteria, or a rationale for the use of the antibiotic prescribed in the Emergency Department. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: overactive bladder and multiple sclerosis. Review of R30's Nurses Note dated 8/13/2024 revealed, Resident brief is soaked with blood and numerous blood clots in brief. Abdomen is nondistended, painful when palpated .order for resident to be sent to ER. Review of R30's provider Progress Note dated 8/13/2024 revealed, Patient with large vaginal bleeding and clots that persisted for > 6 hours. Also with low abdominal pain. Patient sent to ER for further evaluation. Review of R30's Electronic Medical Record revealed no documentation McGeer Criteria or a rationale for the use of the antibiotic prescribed in the Emergency Department prior to culture results. Review of R30's Nurses Note dated 8/14/2024 revealed, .denies pain with no noted blood in urine. Started on antibiotic for UTI, receiving Keflex 500mg BID (twice a day) . Review of R30's Nurses Note dated 8/16/2024 revealed, Resident began Augmentin today r/t (related to) treatment-resistant infection Review of R30's Nurses Note dated 8/16/2024 revealed, Husband notified of new antibiotic order d/t resistance of previous ATB. Review of R30's Order Summary 8/13/24 revealed Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth two times a day for infection for 10 Days. Review of R30's Order Summary 8/13/24 revealed Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth two times a day for Cystitis until 8/23/24. Review of R30's Microbiology Report dated 8/15/24 revealed the bacteria from R30's urine was resistant to Keflex. Review of R30's Medication Administration Record revealed R30 received 6 doses of Keflex from 8/13/24-8/16/24 prior to the start of a susceptible antibiotic. Resident #192 (R192) Review of an Admission Record revealed R192 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: lupus and history of kidney stones. Review of R192's Nurses Note dated 9/8/2024 revealed, Resident out via EMS d/t (due to) c/o (complaints of) pain 9/10 Rt (right) flank area, states it is kidney stones as she has experienced before. VSS (vital signs stable) .UA (urinalysis) from yesterday not returned yet. Provider notified, order obtained to send to ER. Review of R192's Nurses Note dated 9/8/2024 revealed, Returned from ER, CT neg for kidney stones, UA pos for UTI with Cipro started. Resident restinq (sic) quietly at this time, states pain 5/10. Provider notified. Review of R192's Electronic Medical Record revealed no documentation McGeer Criteria or a rationale for the use of the antibiotic prescribed in the Emergency Department prior to culture results. Review of R192's provider Progress Note dated 9/8/2024 revealed, .Notified by nursing that resident was sent to ER per her request d/t c/o intolerable flank pain, hx (history) of kidney stones. Nurse later updated that pt was sent back, no kidney stones, but + UTI, was started on Cipro .no previous u/A Cx (urinalysis/culture) available. Macrobid BID x 5 days ordered. Nurse to follow up on cx results . Review of R192's Nurses Note dated 9/8/2024 revealed, Macrobid ordered, awaiting urine c/s (culture and sensitivity) result. Review of R192's Microbiology Report dated 8/15/24 revealed the bacteria from R192's urine was resistant to Macrobid. Review of R192's Order Summary dated 9/8/24 revealed, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI for 5 Days. Review of R192's Medication Administration Record revealed R192 received 4 doses of Macrobid from 9/8/24-9/10/24 prior to the start of a susceptible antibiotic. During an interview on 11/21/2024 at 8:32 AM, Infection Control Preventionist (ICP) A reported that the facility utilizes the McGeer Criteria for antibiotic stewardship. ICP A reported that if a resident is started on an antibiotic for a UTI while in the Emergency Department, follow up calls are made to ensure a copy of the culture and sensitivity are obtained and the appropriate antibiotic is ordered. ICP A reported that antibiotics are not initiated prior to the culture and sensitivity reports unless a rationale/risk vs benefit is completed by the provider. During an interview on 11/21/24 at 12:15 PM, Director of Nursing (DON) and ICP A reported that residents were often discharged from the emergency room with a diagnosis of a UTI and an order for antibiotics. DON reported that management nurses needed to ensure cultures were followed up on in a timely manner and appropriate antibiotics were administered. ICP A reported that residents exhibiting symptoms of an infection are not listed on the Infection Surveillance Monthly Report but instead are tracked using a Resident at Risk list. ICP A reported that McGeer Criteria was used for antibiotic stewardship as a guideline but was not completed in the Electronic Medical Record. ICP A reported licensed nurses and providers are expected to follow McGeer Criteria. ICP A reported if a resident triggers for symptoms of infection nurses are expected to document the progression of the symptoms in order for management to follow up daily and review at the weekly Resident at Risk meeting. DON reported that R23 had new mental status changes, was newly incontinent, and was not eating well which was why she was sent to the emergency department and the antibiotic was continued upon her return. DON and ICP A confirmed that R23, R30, and R192's symptoms were not documented in the Electronic Health Record and agreed that the symptoms documented did not meet McGeer Criteria. On 11/21/24 at 9:17 AM a request for R23, R30, and R192's McGeer Criteria documentation, risk versus benefit and/or provider rationale for the initiation of antibiotics prior to culture results was requested via email. No supporting documentation was received prior to survey exit. Review of the facility policy Infection Control Antibiotic Stewardship & MDROs (Multi Drug Resistant Organisms) last revised 9/9/22 revealed, .2. The medical director and director of nursing will use his/her influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. 3. The infection preventionist will be responsible for promoting and overseeing antibiotic stewardship activities in the facility. Responsibilities include educating employees about the importance of antibiotic stewardship, and adhering to programs that prevent the spread of infection and improve antibiotic use .9. Healthcare acquired (nosocomial) infections and use of antimicrobial agents will be tracked and trended. Infection surveillance and trending of infections will be a key component of our QAPI process. The facility has adopted the McGeer's criteria for infection surveillance definitions. 10. The facility will communicate with the physician based on guest/resident history, evaluation, signs and symptoms, and diagnostic tests if applicable of suspected guest/resident infections to determine the best course of treatment. 11. Laboratory and diagnostic testing will be used judiciously. Positive urine tests do not always warrant an additional culture and sensitivity in the absence of clinical signs and symptoms of infection. When a culture is positive, antibiograms and lab results will be utilized to help prescribers select the best antibiotic for each guest/resident based on the guidelines for prescribing protocols. 12. When antibiotics are prescribed, compliance with dosing is essential. Guests/residents should be educated to take the full dose for the period of time prescribed by the physician. Licensed nurses will monitor for possible side effects of prescribed antibiotics . Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, .resistance to key antibiotics are becoming more common in all health care settings .The increased resistance is associated with the frequent and sometimes inappropriate use of antibiotics over the years in all settings (i.e., acute care, ambulatory care, clinics, and long-term care) .A culture result may show growth of an organism in the absence of infection. For example, in the older adult bacterial growth in urine without clinical symptoms does not always indicate the presence of a UTI .Many laboratory studies are often necessary when a patient is suspected of having an infectious or communicable disease (Box 28.14). You collect body fluids and secretions suspected of containing infectious organisms for culture and sensitivity tests. After a specimen is sent to a laboratory, the laboratory technologist identifies the microorganisms growing in the culture. Additional test results indicate the antibiotics to which the organisms are resistant or sensitive. Sensitivity reports determine which antibiotics used in treatment are effective and need to be ordered for treatment. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pgs. 425-443). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, UTIs are characterized by location (i.e., upper urinary tract [kidney] or lower urinary tract [bladder, urethra]) and have signs and symptoms of infection. Bacteriuria, or bacteria in the urine, does not always mean that there is a UTI. In the absence of symptoms, the presence of bacteria in the urine as found on a urine culture is called asymptomatic bacteriuria and is not considered an infection and should not be treated with antibiotics. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1152). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to prevent facility acquired pressure injuries and provide pressure injury preventative care consistent with professional standards of practice for 3 residents (Resident #94, #37, and #193) reviewed for the risk of and/or the development of pressure injuries, resulting in the development of an avoidable pressure injury, the worsening of a pressure injury, and the potential for skin breakdown and overall deterioration in health status. Findings: Resident #94 (R94) Review of an Admission Record reflected R94 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, respiratory failure and a urinary tract infection. R94 was identified as having a gastrostomy (tube feeding) and a tracheostomy (breathing tube). Review of a Care Plan initiated on 10/23/2023 reflected that R94 was at risk for impaired skin integrity/pressure injury related to his condition. The goal of the care plan was to minimize risk (of skin impairment/pressure injury) in an effort to reduce the likelihood of pressure injury development .as evidenced by no new pressure injury. Interventions to meet this goal included Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Further review of the Care Plan reflected that on 11/08/2023 (more than two weeks after R94 admitted to the facility) reflected (R94) was admitted with a stage 2 (intact blister) on coccyx area and red areas on his buttocks. The goal was to heal the pressure injury without complications. The only intervention listed to meet this goal was, Assess skin as needed. Incontinence care promptly after incontinence episodes. Treatments as ordered; nutrition supplements as needed. Additionally, the care plan reflected that on 10/23/23 an incomplete care plan focus area had been initiated as follows: [Preferred Name] (R94's name had not been added to the care plan) has actual impairment to skin integrity r/t (related to). The care plan focus area was incomplete and did not specify contributing factors of R94's skin break down, the location or extent of the skin injury. The interventions listed included Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to physician. The care plan and the interventions listed were RESOLVED on 11/08/2023. Review of a Nursing Comprehensive Evaluation dated 10/23/2023 indicated R94 had actual skin impairments to his coccyx/buttock inner coccyx, buttock with redness, fragile non-blanchable. Intact blister noted to left inner buttock. Review of a facility History and Physical dated 10/24/23 documented by Physician (MD) D reflected R94's skin was assessed as Positive: warm, dry, wound, Erythema (redness) and Negative: Rash or bruising. The ASSESSMENTS AND PLANS included in the History and Physical did not include orders for wound care. Review of a Skin& Wound - Total Body Skin assessment dated [DATE] (one week after admission) reflected R94's skin was intact with no new wounds. Review of Progress Notes - View All accessed from the Electronic Medical Record (physician progress notes, nursing notes, dietary notes, Resident at Risk notes, encounter notes, etc.) for the date range 10/23/23-11/7/23 did not reflect any additional documentation pertaining to R94's wound. Review of the entire October 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any orders or treatments had been initiated for R94's pressure injury that had been identified on admission. Review of the entire November 2023 MAR and TAR revealed no treatments had been ordered for R94's pressure injury/skin impairment until 11/8/2023 and 11/9/23. Review of a Skin and Wound Evaluation dated 11/9/2023 reflected R94 had a Stage 3: Full thickness skin loss pressure injury that was present on admission (this assessment conflicts with the original admission assessment documenting R94 with an intact blister/stage 2 pressure injury). The wound measured 2.2 centimeters (cm) in area, by 3.3 cm long by 1.0 cm wide with a depth of 0.6 cm. Absent from the assessment was a description of the wound bed, exudate, the condition of the skin around the wound (periwound), a pain assessment, orders, treatments or provider notification. The assessment indicated R94's wound was stable. During an interview on 11/08/2023 at 2:00 PM, R94's Power of Attorney (POA) reported she was concerned about an area of skin impairment on R94's buttock. During an interview on 11/8/2023 at 4:10 PM, the surveyor requested the opportunity to observe R94's skin. The Director of Nursing (DON), Assistant Director of Nursing (ADON) B and Regional DON E reported the wound care Nurse Practitioner (NP) C would be available to facilitate the observation in the morning on 11/9/2023. The surveyor was assured that the observation of R94 and another resident (R37) would be completed with the surveyor at that time. During an observation and interview on 11/9/2023 at 7:45 AM, R94 was lying in bed. POA F was at R94's bedside and reported NP C and ADON B had already completed the wound assessment and treatment and declined consent to observe the documented stage 3 pressure injury. Direct observation of the wound was not made possible as previously assured. On 11/9/23 at 8:00 AM, ADON B and wound care NP C reported they had already completed the assessment and treatment of R94's pressure injury and wound care. During an interview on 11/9/2023 at 10:02 AM, wound care NP C reported she was first notified of R94's pressure injury was on 11/08/2023 when it was already a stage 3 pressure injury. Resident #37 (R37) Review of an Admission Record reflected R37 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbances, abnormal posture, alcohol abuse in remission and a history of a traumatic brain injury. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R37 had short- and long-term memory problems, was not at risk for developing pressure ulcers and was not admitted with any unhealed pressure ulcers or skin alterations. Review of a Nursing Comprehensive Evaluation dated 8/9/2023 reflected that upon admission to the facility R37 was NOT assessed as having any alterations to his coccyx. The assessment noted scabbed areas to R37's right elbow, hand and knee and a scabbed area on the left side of his forehead. The assessment noted a 3cm round purple bruise on R37's left buttock. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] reflected that there were no skin impairments and no new wounds noted on R37. Review of a Skin & Wound Evaluation dated 11/2/2023 reflected R37 had an abrasion that was discovered on 11/01/23 by nursing staff that measured 1.4 cm 2 (centimeters squared) by 2.5 cm long by 0.9 cm wide with a depth of 0.1 cm. The Notes section of the assessment indicated Identified abrasion on lt (left) inner buttock measuring 2.5 X 0.9 X 0.1 cm. Wound dk (dark) pink with scant amount of bloody drainage. Surrounding skin intact, fragile. Tx (treatment) order in place. Will continue monitoring resident. Notifications were made to the wound care NP, R37's POA and the dietician. Review of a Progress Note dated 11/2/2023 documented by NP C reflected the reason for the evaluation of R37 was Wound Care. The History of Present Illness indicated that R37 was referred to wound care for an area of compromised skin integrity noted by staff that presents as a stage III (3) pressure ulcer to the coccyx. This wound was present on admission to the facility (the presence of the wound was not noted on admission to the facility). The note indicated the wound was 1. Coccyx, Stage III-This wound measures 1.64 (cm) x 1.14 (cm) with a depth of 0.1 (cm). This wound if full thickness. There is a moderate amount of serosanguanious drainage from this area. Wound bed consists of 20% granulation tissue, 10% slough and 70% dermal tissue. Edges are attached and there is no eschar, tunneling, undermining or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection. The treatment was Cleanse with wound wash or saline. Pat dry. Apply calcium alginate sheet to site. Cover with gentle optifoam. Perform daily. Label appropriately. Review of November 2023 MAR and TAR did not reflect an order had been entered and treatments were administered to the documented stage 3 pressure injury identified by NP C on 11/2/23. During an interview on 11/8/2023 at 4:10 PM, the surveyor requested the opportunity to observe R37's skin. The Director of Nursing (DON), Assistant Director of Nursing (ADON) B and Regional DON E reported the wound care Nurse Practitioner (NP) C would be available to facilitate the observation in the morning on 11/9/2023. The surveyor was assured that the observation of R37 and another resident (R94) would be completed with the surveyor at that time. On 11/9/23 at 8:00 AM, ADON B and wound care NP C reported they had already completed the assessment and treatment of R37's pressure injury and wound care. R37 was lying in his room in bed and was agreeable to an observation of the wound. The ADON B and wound care NP C positioned R37 and the wound was observed. Wound care NP C described the wound location and stage consistently with the assessment documented from 11/02/2023. During an interview on 11/9/2023 at 10:02 AM, wound care NP C reported she was first notified of R37's pressure injury on 11/02/2023 and staged the area as a stage 3 pressure injury. According to NP C, the location and extent of the injury could not be an abrasion and had to be classified as a stage 3 pressure injury. 39056 Resident #193 (R193) Review of an Admission Record revealed R193 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: tracheostomy (surgical opening into windpipe), traumatic brain injury, and quadriplegia. Prevention Review of R193's Care Plans revealed the following: (R193) is at risk for worsening/new impaired skin integrity. Was admitted with a stage 3 sacral ulcer, and is at risk for new skin impairments related to impaired mobility, vegetative state, and incontinence .Turn/reposition resident every 2 hours and PRN (as needed) Date Initiated: 09/09/2023. (R193) has Actual impairment to skin integrity r/t (related to) stage 3 coccyx wound .Turn and Reposition Date Initiated: 09/09/2023. Review of R193's Hospital Discharge Record dated 11/6/23 revealed, Clinical Impressions as of 10/26/23 .Skin ulcer of sacrum with necrosis of muscle .Wound Services: Asked to see patient regarding coccyx pressure injury. Patient known to wound services .turn pt q 2hr (turn patient every 2 hours) .Wound team to apply vac as ordered . (Vacuum Assisted Wound Closure) . During an observation on 11/08/23 at 08:50 AM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/08/23 at 12:25 PM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/08/23 at 03:18 PM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/09/23 at 08:34 AM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/09/23 at 11:07 AM, R193 was in bed on his back with no offloading devices in place. Review of R193's Wound Care Progress Note dated 11/9/23 revealed, .Patient was discharge to facility with negative wound vacuum therapy. However, based on assessment, this wound-bed has necrotic tissue and yellow adherent slough noted; therefore, negative pressure vacuum therapy is contraindicated. Additionally, this wound has a malodorous smell . During an interview on 11/09/23 at 09:37 AM, Wound Care Provider (WCP) C reported that R193's wound had necrotic tissue with foul smelling drainage. WCP C reported the wound vac had to be discontinued because of the deterioration of the wound. WCP C reported that R193 should have been repositioned at least every 2 hours especially with a wound vac in place. Treatment Review of R193's Wound Care Progress Note dated 9/21/23 revealed, .stage II pressure wound to left iliac crest .2. Left iliac crest stage II .Treatment: Cover with bordered foam for pressure support. Institute offloading from this site . Confirming the presence of a new pressure injury requiring treatment. Review of R193's Treatment Administration Record revealed no documentation that the treatment was ordered or completed. Care Plan Updating Review of R193's Care Plans (all revisions since admission) did not reflect the pressure injury of the iliac crest or the wound providers order to Institute offloading from this site. Review of R193's Care Plans revealed, (R193) has Actual impairment to skin integrity r/t (related to) stage 3 coccyx wound .Cleanse the stage 3 coccyx area with Wound Cleanse, pat dry, apply Medi Honey for autolytic debridement of slough and cover with border foam daily. every day shift for wound management Date Initiated: 09/11/2023 . Review of R193's Order Summary revealed, Sacrum wound- Cleanse site with saline or wound wash. Pat dry. Apply medihoney to wound site. Cover with border foam dressing. Perform daily and as needed if soiled. Label appropriately was discontinued on 9/14/23. Confirming R193's Care Plans were not updated with changes in condition and/or treatment changes. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016) .Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition.

Based on observations, interviews, and record review, the facility failed to prevent accidents and injuries related to transfers and falls for 3 Residents (R19. R26 and R41) resulting in R19 having multiple falls causing a fracture, bruises/lacerations, R26 sustaining multiple abrasions, and R41 having falls with potential for injury. Findings included: Review of the facility Fall Management policy dated effective 8/18/22, revealed, The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Overview. Each guest/resident is assisted in attain/maintain 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 of falls. Guests/residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to manage the process for prediction, risk evaluation, treatment, evaluation, and monitoring of guest/residents falls. In the Practice Guideline section 4. The licensed nurse will complete: Incident/Accident Report. Review and/or revise care plan and guest/resident Kardex. Document in the medical record and on the 24-Hour Report/dashboard. Initiate the Post-Fall evaluation. Document in the progress notes for 72-hours follow the fall. 9. The IDT (interdisciplinary team) will assure the Post-Fall Evaluation is competed within 24-72 hours. R19 Review of R19's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: unsteady on feet, muscle weakness, chronic pain and [CONDITION(S)]. R19 was not her own responsible party. Review of R19's care plan revealed a care plan for Ambulation, R19 unable to ambulate independently R/T (related to): unsteady gait, decreased safety awareness, impaired cognition, needs assistive device, weakness, ataxia (impaired coordination). Initiated 6/11/19 and revision on 6/10/22. Interventions included: ambulate with FWW (front wheeled walker) and 1 person assistance, encourage large, even steps, and limit distractions. Review of R19' care plan revealed a care plan for R19 is at risk for fall related injury and falls R/T (related to): history of falls, HOH (hard of hearing), impaired vision, dementia, guest self-transfers without using call light. Date initiated: 6/10/19 and Revision on 9/24/21. The goal was, Will be free from injury related to falls through the review date: Date Initiated 6/10/19. Target date: 11/20/22. Interventions included: anticipate and meet needs, encourage guest to wear non-skid socks at all times, assist guest as needed 5/25/21, Encourage resident to rest in chair or bed when she appears fatigued 6/21/22, pressure alarms to bed and chair upon return from Hospital, 8/14/22. Review of R19 incident report dated 12/4/21 at 9:45 AM revealed, R19 had an unwitnessed fall and was found on the floor at her bedside. R19 was injured noting a skin tear, hematoma/bruise. The intervention to prevent recurrence was to move her closer to the nurse's station. Review of the Post Fall Evaluation for the fall on 12/4/21 at 9:45 AM revealed, the root cause was R19 got tangled in her bedding. R19 did not use her call light and already had a fall alarm. Review of R19's incident report dated 2/9/22 at 03:00 AM revealed she had an unwitnessed fall in the bathroom when she self-transferred to the bathroom. R19's physician was notified she had a fracture at 12:30 PM. No indication of new intervention place to increase supervision or assistance. Review of R19's progress note dated 2/9/22 at 12:42 PM revealed Radiology report received from (name of company) show acute fracture of left superior pubic ramus. Review of R19's incident report dated 2/13/22 at 5:40 pm, revealed she had a witnessed fall getting out of bed. R19's bed alarm was turned off. The intervention was to turn the alarm on. There was no indication if staff saw the fall or what they attempted to do to prevent the fall. The root cause revealed boxes were checked for mood or mental status, amount of assistance in effect, alarm and footwear. Review of R19's incident report dated 7/7/22, no time, revealed R19 self-transferred and stated she was going to use the bathroom. The note documented R19's fall alarm was sounding. There was no indication the fall was witnessed or how long the alarm was sounding before she was found on the floor. The new interventions were encouraged call light use, and place on 2-hour toilet plan. 2-hour toilet assistance is the standard of care. No increased supervision or assistance was placed after this fall. Review of a Post Fall Evaluation for R19 dated 7/7/22 at 10:07 AM repeated the information found for the incident report date 7/7/22 with no time. There was no indication R19 was provided any increase supervision or assistance after this fall. The root cause area was not completed. The New Interventions after IDT (interdisciplinary team) review was not completed. Review of R19's incident report dated 8/14/22 at 6:00 PM revealed R19 had an unwitnessed fall and was found on the floor next to her bed. Review of a Post Fall Evaluation for R19 dated 8/14/22 at 6:00 PM revealed R19 had an alarm on, and it was sounding at the time of the fall. The root cause and new intervention section of the form were not completed. No indication R19 was provided any increased supervision or assistance. Review of R19's incident report dated 8/28/22 at 2:30 AM revealed R19 was found on the floor after her roommate called for assistance. R19 sustained multiple skin tears and bruises. There was no indication increased supervision or assistance was provided after this fall. Review of a Post Fall Evaluation for R19 date 8/28/22 at 2:30 AM revealed the root cause was footwear. The new intervention was grippy socks. Review of R19 care plan revealed R19 was to have grippy socks in place at all times since 5/21/22. No new interventions for increased supervision or assistance were noted. Review of R19's incident report dated 9/14/22 at 5:00 AM revealed she was found on the floor in her bedroom. R19 was on her way back to bed after using the bathroom. R19 sustained a laceration to her head and a skin tear to her left upper arm and was sent to the emergency room . There was no indication any interventions were placed for increased supervision or assistance. There was no investigation or root cause noted. Review of R19's incident report dated 10/14/22 at 8:15 PM revealed R19 was found on the floor next to her bed. R19's alarm was sounding, and her roommate was calling out. There was no indication how long the alarm was sounding or when the roommate started calling for assistance. There was no indication of any new interventions placed. Review of Post Fall Evaluation for R19 dated 10/14/22 at 8:15 PM revealed the same information in the incident report with the same date and time. The root cause and new intervention section of the form were not completed. No new interventions to increase supervision or assistance was located for this fall. On 10/18/22 at 11:55 AM, R19's 8 falls from 12/4/21 to 10/14/22 were reviewed with the Director of Nursing (DON), the DON did not have any investigation or additional information to provide about the 8 falls. The DON did not have any information that indicated the facility had assessed R19's wake/sleep cycle, toilet needs or times she required additional supervision. The DON confirmed the facility policy was not followed for doing a root cause after each fall. The DON could not locate any information on how often R19 was attempting to self-transfer, or any interventions placed that would have increased R19's supervision and assistance after her last 7 falls. R41 Review of R41's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: nontraumatic subarachnoid hemorrhage (brain injury), lack of coordination, unsteady on feet, and cognitive communication deficit. R41 was not his own responsible party. Review of R41's base line care plan dated 10/4/22 provided no indication that R41's fall history was reviewed. Review of R41's care plan for Activities of Daily Living (ADL) dated 9/29/22 revealed he required assistance of 2 people for bed mobility, transfers, bathing and toilet use. He was to use a wheelchair for mobility as he was not able to walk. As of 10/10/22 he was to have his bed against the wall in low position and a mattress with a concave parameter. Review of R41's care plan for falls dated initiated 9/30/22 and revision on 10/10/22 revealed interventions that included: lock wheels on wheelchair prior to transfers, observe for fatigue and unsteadiness and encourage rest periods as need, observe for ineffectiveness and side effects R/T (related to) [CONDITION(S)] drug use, report abnormal findings, offer to get dressed in morning as allows, put call light in reach, assist and anticipate needs. (no interventions were noted for any times supervision was needed. Review of R41's incident report dated 9/30/22 at 12:43 PM revealed, oriented to person, confused, was ambulating in his room without assistance, was admitted within the last 72 hours and slid to the floor, There was no witness to the event. Review of a Post Fall Evaluation dated 9/30/22 at 12:45 PM revealed he had an unwitnessed fall and was found sitting on the floor facing the window. Prior to being found on the floor he had been in his wheelchair. R41 had been observed 15 minutes prior to being found on the floor. The root cause was environmental factors/items out of reach and mood or mental status. The section for interventions were left blank. Review of R41's progress note dated 10/12/22 at 3:18 PM revealed he was standing as he turned toward his bed, lost his balance. R41 was observed during medication pass. The morning of 10/12/22, R41 was in a gown, and he took himself in his wheelchair to the nurse's station. He was returned to his room to get dressed and brought back out of his room. Review of R41's incident report for 10/12/22 at 2:30 PM revealed he was standing at his closet, turned towards the bed and lost his balance and hit his head on the overbed table. The immediate action taken was to assist R41 with dressing during am care, prior to breakfast as tolerate. The fall was at 2:30 pm and according to the progress note written on 10/12/22 at 3:18 PM he was dressed prior to the fall. Standard care would be to do morning care and assist a resident get dressed. There was no indication of any increased supervision or assistance placed after this fall. No Post Fall Evaluation was provided for this fall. During an interview with Certified Nurse Aide (CNA) A on 10/18/22 at 3:54 PM, CNA A said she routinely cares for R41. CNA A said R41 self-transfers throughout the day. CNA A was questioned as to why he was care planned to need assistance of 2 people if he was strong enough to self-transfer. CNA A said R41 gets physically aggressive with care and 2 staff are needed as he grabs and pinches them. CNA A was asked if the facility had a program or place for residents that do not have any safety awareness and are at risk of falling. CNA A, responded, no we just do our best to do frequent checks. CNA A was asked if she documents R41's self-transfers or unsafe behavior and she said she does not have a place to document that kind of information. During an interview with the DON on 10/18/22 at 4:18 PM the DON was asked if they had any assessments for R41 that would indicate when he was awake/sleeping, needed to use the toilet, times of self-transferring or other means of anticipating his needs for assistance. The DON said they do not document/assess these areas. R41's incident reports were reviewed, and the DON confirmed no increase in assistance or supervision was provided after both falls. R41's care plan was reviewed, and it did not provide any specific information on how to supervise him to prevent falls. R41 was observed on multiple occasions on 10/18/22 (10:49 AM) and 10/19/22 (7:45 AM, 8:45 AM, 3:45 PM) alone in his room up in his wheelchair. Staff in hall and at the nurse's station were not able to see R41 when he was in his room up in his wheelchair. R 26 Review of face sheet and electronic medical record for R26 revealed he initially admitted to the facility on [DATE] with diagnosis that included: [CONDITION(S)], dementia, traumatic brain injury, diabetes mellitus type 2, anxiety, depression, chronic pain, contractures, pseudobulbar affect (sudden involuntary outbursts of laughing or crying) and symptomatic [CONDITION(S)]. R26 was not their own responsible party. Per facility provided wound timeline and facility matrix, R26 had a facility acquired Stage IV pressure ulcer that was first discovered on 9/20/21. On 10/17/22 at 10:55 AM an interview was completed with R26 and their responsible party in their room. R26's responsible party confirmed R26 had wounds on his bottom and he was going to a wound clinic. R26 was not viewed to have any pressure offloading pillows or cushions near his trunk area and was laying on his back with his bed slightly inclined. His feet appeared to be up on pillows and were against the foot board. R26's responsible party stated R26 was not a good historian due to a traumatic brain injury and he has very limited short term memory. R26 and R26's responsible party stated he is able to get up into his wheelchair. On 10/18/22 at 10:00 AM a care observation was made with R26 in their room. CNA (certified nursing assistant) H and CNA I turned R26 side to side and did peri care. CNA I stated she turns him with wedges every 4 hours, CNA H said she tries to turn him every 2 hours. The positioning wedges remained on the empty bed next to resident, and they were also observed on the bed next to the resident at 7:00 AM on 10/18/22. There were dressings on both R26's lower legs in their shin area with no date. The CNAs were not sure when these dressings were started. Scabs were viewed on all toes of R26's right foot. There was a large scab on the left forefoot about 1 inch by 1/4 inch on a boney area. The CNAs stated the resident is bed bound and has been bed bound for at least 2 months as he would yell when up in his wheelchair. An additional care observation of R26 was made on 10/18/22 at 10:42 AM. R26 was viewed in his bed on his back. R26 was viewed on his back since he was observed at 7:00 AM during a facility tour. The dressing on R26's coccyx was viewed to be dated 10/17/22 and looked soiled at the end of gluteal fold, when removed there was bright red blood, the calcium alginate was soaked with bright red blood. LPN (Licensed Practical Nurse) J removed the dressing and the DON (Director of Nursing) rolled R26 on his right side. LPN J took a photo with the DON's phone that works with the electronic medical record system. A 4x4 inch dressing was viewed on both R26's legs in the mid shin area, the right leg was a dime size wound and on the left leg a quarter size. The dressings were viewed to be soaked with fluid and tissue, fluid was viewed from the outside of dressing. The DON and LPN J stated there were no orders for dressings on the legs and had no idea when they were placed or who placed dressing on both legs. R26 was not aware of when dressings were place or cause. It was also observed R26's right foot had scabbed areas on every toe and his left mid foot anterior side had a 1 inch by 1/8-inch scab. R26 and the DON did not know what caused the scabs/injuries. A request was made for any incident or accident reports related to R26 and they were received by email on 10/18/22 at 3:14 PM. The incidents were reviewed. Review of facility provided Incident and Accident Report for R26 with the date 8/24/22 was revealed to a be a one page handwritten document. The time of day of the injury was not noted, the location was checked as resident room and was an abrasion on the left lower extremity. In the section Describe the nature of the accident/incident and if injuries sustained, location of injuries: a handwritten note was input: left lower extremity- 2 abrasions- top- 1 cm x 2 cm bottom 2 cm x 2 cm. The witness section was marked no. The physician was notified at 1700 (5:00 PM) on 8-24-22 the responsible party was notified on 8-24-22 at 950 (9:50 AM). The interventions implemented were new tx (treatment). The employee signature completing the report appeared to be signed by LPN M and was dated 8-24-22. The NHA (nursing home administrator) and the DON signed the report on 8/26/22. Review of R26's documents in their electronic medical records revealed a note to the physician dated 8/25/22 when they were informed: Guest scraped leg (with?) 1 cm x 2 cm & 3 cm x 2 cm abrasion- new treatment started. Review of wound clinic notes from 8/24/22 revealed the resident was seen by the wound clinic on 8/24/22 at 2:15 PM. There was not any reference to a leg injury. Review of R26's progress notes showed no progress note on 8/24/22. A nurses note on 8/25/22 at 9:47 AM authored by LPN M revealed: called to res room and res noted to have 2 small abrasions on LLE (left lower extremity) top one is 1 cm x 2 cm and bottom is 3 cm x2 cm, dr notified and mom notified, new treatment ordered cleanse with NS wipe, blot dry and apply [MEDICATION(S)] and change every 3 days and PRN (as needed). A total body skin assessment is documented on 8/25/22 at 10:15 AM. With the dates and times of these various documents, it is not clear how and when the wound occurred and was initially discovered. Review of facility provided Incident and Accident Report for R26 with the date 9/18/22 was revealed to a be a one page handwritten document. The document revealed at 2100 (11:00 PM) in the resident room R26 sustained an abrasion L (left) 5th toe & top L foot 1 cm (illegible writing). The incident was described a: when rolling resident to change brief, foot scraped on foot board. The interventions implemented revealed: foam dressing applied over wounds and maintenance to look at bed for extender. The employee signature was not legible for who completed it, but was dated 9/19/22. The DON, Administrator and the physician did not sign that they reviewed the document. Review of the electronic medical record progress notes revealed notes regarding the incident as well as notifications. A note from Unit Manager M on 09/19/22 at 9:56 AM revealed Bed cannot accomodate (sp) extenders related to APM and bariatric bed/mattress. New order to pad footboard to protect feet. Review of wound clinic notes from 10/5/22 reveal two additional open wounds both described with original cause of wound was not known. The date acquired was: 9/21/2022. The wound has been in treatment for 2 weeks. Wound #4 is described as Partial thickness wound with etiology of Skin Tear and is located on the Right, Dorsal Foot . and Wound #5 is a Partial Thickness wound with etiology of Skin Tear and is located on the Left, Anterior Lower Leg. Neither of these wounds match the description of the 9/18/22 incident and it is unclear where they came from since the facility provided no further incident reports matching the wound clinic notes injuries. A review of progress notes for R26 shows no note on 9/21/22 and a skin assessment documented on 9/22/22 at 10:15 AM with number of new skin conditions: 0. No other new injury or incident is documented in the progress notes in the date range of 9/21/22. Review of facility provided document dated 10/6/22 at 5:01 AM revealed a computer generated report titled Slid Out of Bed. The incident description revealed: two cenas were changing sheet and rolled guest to side and cena unable to hold him and both cenas lowered to floor. Abrasion to both shins from head board. Red mark to left back shoulder. No other injury. Hoyer (mechanical lift) used to get guest back into bed . The Immediate Action Taken section revealed Full assessment done, no injury except abrasion to shin .Maintenance to check proper functioning and inflation of mattress. Injuries were noted to right lower leg (front) and left lower leg (front). A handwritten Post Fall Evaluation was also included. The date and time of fall was written as 10/5 at 1900 and PM was circled. The description was rolled to floor during bed change. There were several sections of the document not completed including: Re-enactment of fall (to be done if root cause is not determined), Fall Huddle (What was different this time?), Root Cause of this Fall: Review of Contributing Factors (Check all that apply), Describe initial intervention to prevent future falls, and New Interventions after IDT review. The nurse signed the document on 10/5/22 and the section IDT Signatures was blank. Also attached were handwritten witness statements from the two CNAs (certified nursing assistants) involved in the incident with R26. CNA L's statement indicated the incident occurred on [DATE]th at 7:05. The statement was not very detailed and concluded Not sure what happened, but I couldn't stop him from falling. The handwritten statement from CNA K indicated the incident happened on [DATE]th at 7 pm the event account was brief and difficult to read due to incomplete sentences and either misspellings or penmanship. There was also an attached note from Director of Maintenance dated 10-6-22 which stated The Air Mattress on bed [R26's bed] is currently functioning properly and has foam support as well as the air pressure system therefore the mattress should not deflate while on and operating properly. There was no other additional root cause or intervention documented as being explored after the mattress malfunctioning was ruled out. There was no nursing note on 10/5/22 or 10/6/22 regarding the fall. A skin assessment was documented on 10/6/22 at 10:15 AM with no new conditions noted. A progress note on 10/7/22 at 4:06 AM indicated no new injury or pain s/p (status post) lowered to floor from bed. Denies pain. There were two follow up notes on 10/8/22 stating there were no new injuries from being lowered to the floor. There was not another progress note until a skin assessment on 10/13/22 at 10:15 AM which indicated no new skin conditions. The next note was a physician note by Doctor E on 10/18/22 at 10:20 AM. There is no reference to a recent fall or the new injuries. On 10/18/22 at 3:33 PM an email was sent to the DON with questions regarding the incident accident reports: For the 8/24 injury, how did it occur? For the 9/18 injury, was a bed extender obtained, if not how else was this resolved? The 10/6 incident is confusing to me, how was his leg injured on the head board? When the bed was found to be functioning properly, what else was reviewed to find a root cause? On 10/18/22 at 5:53 PM and email was received from the DON: The injury from 8/24/22 was noted by staff upon return from the wound clinic. Guest is transported via [ambulance company] for those appointments. In regards to the incident on 9/19/22 the foot board is to be padded. Maintenance is addressing that tonight. As for the Incident Report on 10/6/22, head board was a documentation error, it should read foot board. His Careplan and Kardex were updated to reflect that more assistance may be required during linen changes. Therapy is screening Guest for bed mobility, transfers and positioning. A follow up interview was completed with the DON on 10/19/22 at 9:05 AM regarding R26. The injury from 8/24/22 was discussed. The DON stated the injury was reported as soon as R26 returned from the wound clinic. She stated that they did not know if the injury occurred from transport in and out of the ambulance (R26's transportation to the wound clinic) or if it occurred at the wound clinic, but they do know for sure the injury was not there before R26 left the building. The DON was asked if R26 had a full body skin assessment prior to leaving the building on 8/24/22 and the DON reviewed the electronic medical record and stated his last skin assessment was 8/19/22. The DON was asked if she called the wound clinic or the ambulance company to obtain interviews or information about the injury and she stated that was not done to her knowledge. The DON was asked if she could say with certainty how and where the injury occurred, and she stated that she could not. The DON agreed this would be an injury of unknown origin and an investigation should have been initiated by the facility to determine when and how it occurred. The 10/6/22 incident was discussed with the DON, she admitted that the incident report and the witness statements were confusing. The DON stated she completed follow up interviews with the staff involved to get a better understanding of the events. The DON admitted the clarifying follow up interviews were not part of the incident report. The DON stated the event occurred because R26 was not properly centered on the bed when staff were changing his sheets and the staff member could not hold him by themselves when he started to fall. The DON confirmed they have enough staff on day shift and second shift to be able to accommodate more than 2 workers assisting with future sheet changes. The DON stated this intervention had not been added to the care plan but was added as of 10/18/22. On 10/19/22 at 9:15 AM, an observation was made of R26 in his room. R26 was in bed on his back with positioning wedges in place and the foot of his bed was viewed to be padded. During an interview with the NHA (nursing home administrator) on 10/19/22 at 1:00 PM, the absence of a thorough investigation and mode of injury for R26 on 8/24/22 was discussed. The NHA stated the unit manager had called the wound clinic and they confirmed the injuries occurred there. The NHA was informed this was not in the incident report, the medical record and the DON was not aware of this conclusion. The NHA flipped through a personal notebook and stated she wrote herself a note on 8/26/22 that the unit manager had made calls and it happened at the wound clinic. The NHA later followed up on 10/19/22 at approximately 1:45 PM and provided a nurses note from 8/26/22 at 9:41 AM: IDT (interdisciplinary team) team met and reviewed abrasion to LLE (left lower extremity). Per [name of staff], LPN area was noted upon return from appointment on 8/24/2022. Area is due to repositioning and turning on gurney with paramedics. It was noted to the NHA and they admitted the note did not say how and when the information was obtained and does not indicate a complete investigation. During the interview with the NHA on 10/19/22 at 1:00 PM, incident and accident interventions were further discussed. The NHA stated when an incident occurs, the nurse on duty fills out the incident paperwork and then the clinical team reviews it later and ensures everything is in place for interventions. If the incident occurred after regular business hours, a call is made to the DON and the nurse is instructed to put the new information into the resident medical record and put in the interventions immediately. The NHA stated that all nurses are not used to putting in solutions on the spot and they have had to educate nurses to think outside the box for potential solutions. The incident reports received for R26 were not consistent in how they were documented and what forms were used. The NHA admitted there is not a current process in place for the team to circle back an ensure that appropriate and thorough interventions were identified and put in place. It was discussed the incidences with R26 where the 9/19/22 incident intervention had not yet been put into place and the initial potential root cause for the 10/6/22 incident was noted to be there was an issue with bed inflation, but there was not further documentation of an additional area to be addressed when the bed was found to be in proper repair. The NHA stated this would be addressed further with the QAPI (Quality Assurance and Performance Improvement) committee. Review of R26's care plan revealed a need related to them being at risk for impaired skin integrity interventions include: conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown .; with an initiated date on 4/16/2019. An additional need is listed as Bed Mobility Program: [R26 is unable to independently move from a lying position to a sitting position .R/T (related to) [CONDITION(S)], impaired cognition, muscle weakness interventions include: assist resident in repositioning, observe skin integrity when turning guest, report red/open areas to nurse, physical assist of: 2 persons, .turn guest every 2 hours, all with initiated dates of 4/16/2019. Another need is listed as R26 has an actual impaired skin integrity related to Pressure injury on coccyx, Stage IV with an initiated date of 12/23/2021. No additional wounds or skin impairments are noted. An additional need area is listed as an ADL (activities of daily living) deficit and requires total assistance with ADL's, transfers and mobility . with a created date of 4/16/2019. Another intervention was revised on 10/18/2022 titled BED MOBILITY: Resident requires total assistance of 2-3 staff to reposition and turn in bed. May require increased assistance with linen changes. The care plan printed 10/17/2022 revealed BED MOBILITY: Resident requires total assistance of 1-2 staff to reposition and turn in bed. The care plan was not changed with identified interventions related to the 10/6/22 incident until 10/18/2022. Review of facility policy Fall Management with a last revised date of 7/14/21 revealed: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Under the section Practice Guidelines: When a fall occurs .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 .The IDT will review all guest/resident falls within 24-72 hours .to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls and update the guest/resident kardex as needed .A 'Guest/Resident at Risk' meeting will be conducted at least monthly by the Interdisciplinary Team. Guests/residents reviewed during the meeting are as follows: Guests/residents that had a fall since the previous meeting .The DON/designee will document any changes in the care plan and kardex at the meeting .The Director of Nursing or designee will print the monthly report .to track and trend falls in the facility. This data .will be analyzed and presented to the QAPI committee for ongoing recommendations .

Based on observations, interviews and record review, the facility failed to develop, implement and initiate new interventions in a timely manner for 2 residents (R2 and R26) reviewed for careplans, resulting in unmet and unrecognized care needs, inadequate care and the potential for injury. Findings include: R2 Review of face sheet and electronic medical record for R2 revealed she initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was not her own responsible party. On initial tour of the facility on 10/17/22, a sign titled Enhanced Barrier Precautions was viewed on R2's door. On 10/17/22 at 10:45 AM, an interview was completed with the Director of Nursing (DON) regarding the noted precautions on the door of R2 and other residents. The DON stated R2 was on enhanced barrier precautions due to having a feeding tube. The DON stated that while providing direct care to the resident staff should be wearing a gown and gloves. Further review of sign Enhanced Barrier Precautions revealed Providers and Staff Must .wear gloves and a gown for the following High-Contact Resident Care Activities .Device care or use .feeding tube . On 10/17/22 at 11:13 AM, R2 was observed in her room. She was laying in bed and her tube feed was viewed to not be running. An interview was attempted with R2, but she was not understandable. R2 responded with some vocalization and made eye contact but was not able to be understood. On 10/18/22 at approximately 9:00 AM, R2's PEG tube insertion site was viewed. The dressing around the site was dry, but undated. Review of R2's progress notes revealed drainage around the resident's PEG (feeding) tube documented on several occasions as well as notes related to tube malfunction. On 9/17/22: Feeding tube has come apart 3 times during shift. Needs to be taped to stay together; 9/19/22: continued to monitor tube feeding equipment repeated malfunction, notified provider & admin ordered new connector; 9/21/22: Cont. with 200cc bolus feeds q (every) 4 hr until replacement tube put in; 9/25/22: Leaking large amount liquid around feeding tube after bolus feedings. Dressing around tube saturated within 2 hours. Discussed using pump instead of bolus (feedings) with nurse on call .; 09/26/22: No further excessive leaking noted around feeding tube; 10/14/22: resident was found to have completely saturated dressing on PEG tube this morning. Drainage was dark brown/black in color. [Dr E] was notified at 0626 and states, 'keep an eye on it for now.' No further orders received. Scant bloody drainage noted when assessed at 1000; 10/17/22: small amount of brownish drainage noted around peg tube each day over the weekend. Review of physician notes authored by Doctor E revealed a note on 9/20/22 at 8:54 AM that included .There has been a malfunction of her feeding system and replacement parts have been ordered. OK for bollus (bolus) feeding until repairs are completed . The same note was included in a physician note on 10/18/22 at 10:27 AM. There was no notation this this concern was resolved and no corresponding orders were viewed in R2's EMR. It was not clear to what extent Doctor E completed a physical examination of R2 during either visit. Observations were made of R2 on 10/18/22 at approximately 4:00 PM and 10/19/22 at approximately 9:00 AM, she was viewed to be in bed with tube feed running on continuous feed. On 10/19/22 at 9:45 AM an interview was completed with the DON regarding R2. The DON was asked if R2 had a continued malfunction of her PEG tube due to the 9/20/22 and 10/18/22 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated R2 did have a PEG tube malfunction, but it was fixed. The DON stated R2's PEG tube had been popping apart during the tube feeds. The DON was asked when the concern was corrected and she reviewed R2's progress notes. The DON stated she could not find the note where the tubing was fixed, but thought it was fixed around 9/22/22. The DON stated she would try to contact the unit manager who fixed the tubing. The DON stated the unit manager should have entered a progress note when the tube was fixed. On 10/19/22 at 10:05 AM, care was observed for R2. Upon entering the room the Enhanced Barrier Precautions sign was still viewed on the door. There was not a PPE (personal protective equipment) station hanging on the room door. A PPE station was viewed on the outside of the room door along with the Enhanced Barrier Precautions sign on another room on the same hall as R2's room. A PPE station was not immediately located in R2's room. Registered Nurse (RN) D entered the room to provide care for R2 feeding tube and already had gloves with them and was not viewed to obtain the PPE while in R2's room. RN D was observed to flush R2's feeding tube and remove the dressing around R2's feeding tube. RN D was wearing a surgical mask and gloves while providing care and did not don a surgical gown. During care, RN D pushed 50 cc of water into the PEG tube site, RN D was asked if they should push water or use gravity flow. RN D stated it was hard to drain with gravity so she does a gentle push. Review of the PEG tube site revealed a dressing dated 10/18, the dressing was fully saturated with brown liquid. Upon removal, the skin surrounding the insertion of the PEG tube was bright red approximately an inch around the insertion site. R2 was viewed to be uncomfortable as evidenced by her grimacing, squirming and making panicked moaning noises. Per review of the electronic medical record with RN D, it was documented that the dressing was last changed at 12:22 AM on 10/19/22. RN D agreed the amount of drainage on the dressing in less than 10 hours was concerning. RN D was informed that the DON would be alerted to the observations made with R2's PEG tube. On 10/19/22 at 10:15 AM an interview was completed with the DON regarding the concerns with R2's PEG tube. The DON was alarmed to hear there was excessive drainage and excoriation to the skin surrounding R2's PEG tube. The DON reviewed the electronic medical record with the surveyor and reviewed R2 had previously been followed for redness around the PEG tube site, but it was healed at of 08/12/22. The DON stated she would contact Doctor E since he was contacted by staff on 10/14/22 related to the drainage, but gave no new orders. The DON stated they had not yet been able to determine the exact date the PEG tube was fixed in September. She believed it was approximately 9/22/22 but it was not documented. The orders for bolus to continuous feed changed on 9/22/22, so it was likely fixed at that time. The DON stated at the time that the PEG tube malfunctioned they did not have additional equipment in house to immediately rectify the issue, the facility now has 3 lumen tubes in stock if a future malfunction occurs. On 10/19/22 at 11:40 AM an interview with completed with the DON. A review of tube feeding medication policy was completed and the DON confirmed all flushes and meds are given via gravity. The DON was asked if they had a policy or any reason to push the tube feeding flush for R2. The DON confirmed R2 is a gravity flush. The DON also noted doctor E is now treating the excoriated skin at the tube feeding site with antibiotics and they are monitoring the skin breakdown. The DON was not sure if the skin breakdown is related to pushing fluids through tube feed. On 10/19/22 at 02:57 PM a follow up interview was completed with the DON, they spoke to the unit manager and they could not definitely recall when they fixed the peg tube. On 10/19/22 at 3:30 PM a follow up interview was completed with the DON. R2's tube feeding orders were reviewed and it was determined R2's PEG tube orders were changed from 9/20/22-9/22/22 so this was likely when the equipment was on order to fix the malfunction and then it was fixed on 9/22/22 at some point. R22 remained on bolus feeds (a type of feeding where formula is administered directly in a shorter amount of time versus using a gradual pump) until 9/26/22 due to their normal formula not being available until 9/26/22. Review of facility provided policy: Medications Administration- Enteral with a last revised date of 6/24/22 revealed instructions for medication administration for a resident with a feeding tube. The DON indicated this was the only policy they could locate that referred to the process for water flush and gravity flow versus syringe push through a PEG tube. Step 11 of the procedure section included .instill at least 15 ml of water into the tube through the syringe to check for patency via Gravity Flow. If water flows in easily, tube is patent. IF it flows in slowly, raise the syringe to increase pressure. If water does not flow properly, stop the procedure and notify the physician. Review of R2's care plan revealed she is at risk for impaired skin integrity .r/r (related to) .PEG tube. Interventions include weekly head to toe skin assessments, document and report abnormal findings to the physician with a initiated date of 2/5/19. Another need is related to use of a PEG tube, goals include: will remain free of side effects or complications related to tube feeding and will be free of s/sx (signs and symptoms) of infection at insertion site both with an initiated date of 7/26/19. Interventions included: flush tube feed per physician orders, and provide care to tube site as ordered and observe for s/sx of irritation or infection. Report abnormal findings to physician as ordered. Another area of need with a last revised date of 7/20/22 was related to R2 has actual impairment to skin integrity related to MASD (moisture associated skin damage) near PEG Tube insertion site with interventions that included conduct weekly head to toe skin assessments and report new/abnormal findings to physicians as needed, observe for s/sx of infection of area .and report to physician as needed, and treatment per order. R26 Review of face sheet and electronic medical record for R26 revealed he initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R26 was not their own responsible party. Per facility provided wound timeline and facility matrix, R26 had a facility acquired Stage IV pressure ulcer that was first discovered on 9/20/21. On 10/17/22 at 10:55 AM an interview was completed with R26 and their responsible party in their room. R26's responsible party confirmed R26 had wounds on his bottom and he was going to a wound clinic. R26 was not viewed to have any pressure offloading pillows or cushions near his trunk area and was laying on his back with his bed slightly inclined. His feet appeared to be up on pillows and were against the foot board. R26's responsible party stated R26 was not a good historian due to a traumatic brain injury and he has very limited short term memory. R26 and R26's responsible party stated he is able to get up into his wheelchair. On 10/18/22 at 10:00 AM a care observation was made with R26 in their room. CNA (certified nursing assistant) H and CNA I turned R26 side to side and did peri care. CNA I stated she turns him with wedges every 4 hours, CNA H said she tries to turn him every 2 hours. The positioning wedges remained on the empty bed next to resident, and they were also observed on the bed next to the resident at 7:00 AM on 10/18/22. There were dressings on both R26's lower legs in their shin area with no date. The CNAs were not sure when these dressings were started. Scabs were viewed on all toes of R26's right foot. There was a large scab on the left forefoot about 1 inch by 1/4 inch on a boney area. The CNAs stated the resident is bed bound and has been bed bound for at least 2 months as he would yell when up in his wheelchair. An additional care observation of R26 was made on 10/18/22 at 10:42 AM. R26 was viewed in his bed on his back. R26 was viewed on his back since he was observed at 7:00 AM during a facility tour. The dressing on R26's coccyx was viewed to be dated 10/17/22 and looked soiled at the end of gluteal fold, when removed there was bright red blood, the calcium alginate was soaked with bright red blood. LPN (Licensed Practical Nurse) J removed the dressing and the DON (Director of Nursing) rolled R26 on his right side. LPN J took a photo with the DON's phone that works with the electronic medical record system. A 4x4 inch dressing was viewed on both R26's legs in the mid shin area, the right leg was a dime size wound and on the left leg a quarter size. The dressings were viewed to be soaked with fluid and tissue, fluid was viewed from the outside of dressing. The DON and LPN J stated there were no orders for dressings on the legs and had no idea when they were placed or who placed dressing on both legs. R26 was not aware of when dressings were place or cause. It was also observed R26's right foot had scabbed areas on every toe and his left mid foot anterior side had a 1 inch by 1/8-inch scab. R26 and the DON did not know what caused the scabs/injuries. A request was made for any incident or accident reports related to R26 and they were received by email on 10/18/22 at 3:14 PM. The incidents were reviewed. Review of facility provided Incident and Accident Report for R26 with the date 8/24/22 was revealed to a be a one page handwritten document. The time of day of the injury was not noted, the location was checked as resident room and was an abrasion on the left lower extremity. In the section Describe the nature of the accident/incident and if injuries sustained, location of injuries: a handwritten note was input: left lower extremity- 2 abrasions- top- 1 cm x 2 cm bottom 2 cm x 2 cm. The witness section was marked no. The physician was notified at 1700 (5:00 PM) on 8-24-22 the responsible party was notified on 8-24-22 at 950 (9:50 AM). The interventions implemented were new tx (treatment). The employee signature completing the report appeared to be signed by LPN M and was dated 8-24-22. The NHA (nursing home administrator) and the DON signed the report on 8/26/22. Review of R26's documents in their electronic medical records revealed a note to the physician dated 8/25/22 when they were informed: Guest scraped leg (with?) 1 cm x 2 cm & 3 cm x 2 cm abrasion- new treatment started. Review of wound clinic notes from 8/24/22 revealed the resident was seen by the wound clinic on 8/24/22 at 2:15 PM. There was not any reference to a leg injury. Review of R26's progress notes showed no progress note on 8/24/22. A nurses note on 8/25/22 at 9:47 AM authored by LPN M revealed: called to res room and res noted to have 2 small abrasions on LLE (left lower extremity) top one is 1 cm x 2 cm and bottom is 3 cm x2 cm, dr notified and mom notified, new treatment ordered cleanse with NS wipe, blot dry and apply [MEDICATION(S)] and change every 3 days and PRN (as needed). A total body skin assessment is documented on 8/25/22 at 10:15 AM. With the dates and times of these various documents, it is not clear how and when the wound occurred and was initially discovered. Review of facility provided Incident and Accident Report for R26 with the date 9/18/22 was revealed to a be a one page handwritten document. The document revealed at 2100 (11:00 PM) in the resident room R26 sustained an abrasion L (left) 5th toe & top L foot 1 cm (illegible writing). The incident was described a: when rolling resident to change brief, foot scraped on foot board. The interventions implemented revealed: foam dressing applied over wounds and maintenance to look at bed for extender. The employee signature was not legible for who completed it, but was dated 9/19/22. The DON, Administrator and the physician did not sign that they reviewed the document. Review of the electronic medical record progress notes revealed notes regarding the incident as well as notifications. A note from Unit Manager M on 09/19/22 at 9:56 AM revealed Bed cannot accomodate (sp) extenders related to APM and bariatric bed/mattress. New order to pad footboard to protect feet. Review of wound clinic notes from 10/5/22 reveal two additional open wounds both described with original cause of wound was not known. The date acquired was: 9/21/2022. The wound has been in treatment for 2 weeks. Wound #4 is described as Partial thickness wound with etiology of Skin Tear and is located on the Right, Dorsal Foot . and Wound #5 is a Partial Thickness wound with etiology of Skin Tear and is located on the Left, Anterior Lower Leg. Neither of these wounds match the description of the 9/18/22 incident and it is unclear where they came from since the facility provided no further incident reports matching the wound clinic notes injuries. A review of progress notes for R26 shows no note on 9/21/22 and a skin assessment documented on 9/22/22 at 10:15 AM with number of new skin conditions: 0. No other new injury or incident is documented in the progress notes in the date range of 9/21/22. Review of facility provided document dated 10/6/22 at 5:01 AM revealed a computer generated report titled Slid Out of Bed. The incident description revealed: two cenas were changing sheet and rolled guest to side and cena unable to hold him and both cenas lowered to floor. Abrasion to both shins from head board. Red mark to left back shoulder. No other injury. Hoyer (mechanical lift) used to get guest back into bed . The Immediate Action Taken section revealed Full assessment done, no injury except abrasion to shin .Maintenance to check proper functioning and inflation of mattress. Injuries were noted to right lower leg (front) and left lower leg (front). A handwritten Post Fall Evaluation was also included. The date and time of fall was written as 10/5 at 1900 and PM was circled. The description was rolled to floor during bed change. There were several sections of the document not completed including: Re-enactment of fall (to be done if root cause is not determined), Fall Huddle (What was different this time?), Root Cause of this Fall: Review of Contributing Factors (Check all that apply), Describe initial intervention to prevent future falls, and New Interventions after IDT review. The nurse signed the document on 10/5/22 and the section IDT Signatures was blank. Also attached were handwritten witness statements from the two CNAs (certified nursing assistants) involved in the incident with R26. CNA L's statement indicated the incident occurred on [DATE]th at 7:05. The statement was not very detailed and concluded Not sure what happened, but I couldn't stop him from falling. The handwritten statement from CNA K indicated the incident happened on [DATE]th at 7 pm the event account was brief and difficult to read due to incomplete sentences and either misspellings or penmanship. There was also an attached note from Director of Maintenance dated 10-6-22 which stated The Air Mattress on bed [R26's bed] is currently functioning properly and has foam support as well as the air pressure system therefore the mattress should not deflate while on and operating properly. There was no other additional root cause or intervention documented as being explored after the mattress malfunctioning was ruled out. There was no nursing note on 10/5/22 or 10/6/22 regarding the fall. A skin assessment was documented on 10/6/22 at 10:15 AM with no new conditions noted. A progress note on 10/7/22 at 4:06 AM indicated no new injury or pain s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . There were two follow up notes on 10/8/22 stating there were no new injuries from being lowered to the floor. There was not another progress note until a skin assessment on 10/13/22 at 10:15 AM which indicated no new skin conditions. The next note was a physician note by Doctor E on 10/18/22 at 10:20 AM. There is no reference to a recent fall or the new injuries. On 10/18/22 at 3:33 PM an email was sent to the DON with questions regarding the incident accident reports: For the 8/24 injury, how did it occur? For the 9/18 injury, was a bed extender obtained, if not how else was this resolved? The 10/6 incident is confusing to me, how was his leg injured on the head board? When the bed was found to be functioning properly, what else was reviewed to find a root cause? On 10/18/22 at 5:53 PM and email was received from the DON: The injury from 8/24/22 was noted by staff upon return from the wound clinic. Guest is transported via [ambulance company] for those appointments. In regards to the incident on 9/19/22 the foot board is to be padded. Maintenance is addressing that tonight. As for the Incident Report on 10/6/22, head board was a documentation error, it should read foot board. His Careplan and Kardex were updated to reflect that more assistance may be required during linen changes. Therapy is screening Guest for bed mobility, transfers and positioning. A follow up interview was completed with the DON on 10/19/22 at 9:05 AM regarding R26. The injury from 8/24/22 was discussed. The DON stated the injury was reported as soon as R26 returned from the wound clinic. She stated that they did not know if the injury occurred from transport in and out of the ambulance (R26's transportation to the wound clinic) or if it occurred at the wound clinic, but they do know for sure the injury was not there before R26 left the building. The DON was asked if R26 had a full body skin assessment prior to leaving the building on 8/24/22 and the DON reviewed the electronic medical record and stated his last skin assessment was 8/19/22. The DON was asked if she called the wound clinic or the ambulance company to obtain interviews or information about the injury and she stated that was not done to her knowledge. The DON was asked if she could say with certainty how and where the injury occurred, and she stated that she could not. The DON agreed this would be an injury of unknown origin and an investigation should have been initiated by the facility to determine when and how it occurred. The 10/6/22 incident was discussed with the DON, she admitted that the incident report and the witness statements were confusing. The DON stated she completed follow up interviews with the staff involved to get a better understanding of the events. The DON admitted the clarifying follow up interviews were not part of the incident report. The DON stated the event occurred because R26 was not properly centered on the bed when staff were changing his sheets and the staff member could not hold him by themselves when he started to fall. The DON confirmed they have enough staff on day shift and second shift to be able to accommodate more than 2 workers assisting with future sheet changes. The DON stated this intervention had not been added to the care plan but was added as of 10/18/22. On 10/19/22 at 9:15 AM, an observation was made of R26 in his room. R26 was in bed on his back with positioning wedges in place and the foot of his bed was viewed to be padded. During an interview with the NHA (nursing home administrator) on 10/19/22 at 1:00 PM, the absence of a thorough investigation and mode of injury for R26 on 8/24/22 was discussed. The NHA stated the unit manager had called the wound clinic and they confirmed the injuries occurred there. The NHA was informed this was not in the incident report, the medical record and the DON was not aware of this conclusion. The NHA flipped through a personal notebook and stated she wrote herself a note on 8/26/22 that the unit manager had made calls and it happened at the wound clinic. The NHA later followed up on 10/19/22 at approximately 1:45 PM and provided a nurses note from 8/26/22 at 9:41 AM: IDT (interdisciplinary team) team met and reviewed abrasion to LLE (left lower extremity). Per [name of staff], LPN area was noted upon return from appointment on 8/24/2022. Area is due to repositioning and turning on gurney with paramedics. It was noted to the NHA and they admitted the note did not say how and when the information was obtained and does not indicate a complete investigation. During the interview with the NHA on 10/19/22 at 1:00 PM, incident and accident interventions were further discussed. The NHA stated when an incident occurs, the nurse on duty fills out the incident paperwork and then the clinical team reviews it later and ensures everything is in place for interventions. If the incident occurred after regular business hours, a call is made to the DON and the nurse is instructed to put the new information into the resident medical record and put in the interventions immediately. The NHA stated that all nurses are not used to putting in solutions on the spot and they have had to educate nurses to think outside the box for potential solutions. The incident reports received for R26 were not consistent in how they were documented and what forms were used. The NHA admitted there is not a current process in place for the team to circle back an ensure that appropriate and thorough interventions were identified and put in place. It was discussed the incidences with R26 where the 9/19/22 incident intervention had not yet been put into place and the initial potential root cause for the 10/6/22 incident was noted to be there was an issue with bed inflation, but there was not further documentation of an additional area to be addressed when the bed was found to be in proper repair. The NHA stated this would be addressed further with the QAPI (Quality Assurance and Performance Improvement) committee. Review of R26's care plan revealed a need related to them being at risk for impaired skin integrity interventions include: conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown .; Provide total assistance to reposition frequently as needed; all with an initiated date on 4/16/2019. An additional intervention with the initiated date of 12/23/2021 is turn/reposition resident every 2 hours and PRN (as needed). An additional need is listed as Bed Mobility Program: [R26 is unable to independently move from a lying position to a sitting position .R/T (related to) [CONDITION(S)], impaired cognition, muscle weakness interventions include: assist resident in repositioning, observe skin integrity when turning guest, report red/open areas to nurse, physical assist of: 2 persons, .turn guest every 2 hours, all with initiated dates of 4/16/2019. Another need is listed as R26 has an actual impaired skin integrity related to Pressure injury on coccyx, Stage IV with an initiated date of 12/23/2021. No additional wounds or skin impairments are noted. An additional need area is listed as an ADL (activities of daily living) deficit and requires total assistance with ADL's, transfers and mobility . with a created date of 4/16/2019. An intervention was added on 10/18/2022 [R26 is to be repositioned between his right side and left side, using positioning wedges, at least every 2 hours. Place positioning wedges above and below his coccyx wound, to offload weight. Avoid positioning [R26] on his back, as he will allow. Review of care plan printed on 10/17/2022 did not reveal this intervention. Another intervention was revised on 10/18/2022 titled BED MOBILITY: Resident requires total assistance of 2-3 staff to reposition and turn in bed. May require increased assistance with linen changes. The care plan printed 10/17/2022 revealed BED MOBILITY: Resident requires total assistance of 1-2 staff to reposition and turn in bed. The care plan was not changed with identified interventions related to the 10/6/22 incident until 10/18/2022. An additional need is listed as R26 had actual impairment to skin integrity r/t [NAME] (sp) pressure ulcer on coccyx .abrasions to left lower extremity with a last revised date of 8/26/2022 by the DON and initiated interventions on that same date: follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the task tab in the electronic medical record on 10/18/22 at 12:25 PM revealed a task of Bed mobility: Turn and Reposition every 2 hours and PRN while in bed and up in wheelchair. A look back of the last 30 days revealed only 5 times this task was documented on 9/26/22 for 20 minutes, 9/29/22 for 20 minutes, 9/30/22 for 25 minutes, 10/6/22 for 25 minutes and 10/12/22 for 15 minutes. Review of notes from the wound specialist dated 8/24/2022 reveal: Off-Loading Wound #1 Coccyx .Keep weight off area of wound at all times. Review of facility policy Fall Management with a last revised date of 7/14/21 revealed: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Under the section Practice Guidelines: When a fall occurs .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 .The IDT will review all guest/resident falls within 24-72 hours .to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls and update the guest/resident kardex as needed .A 'Guest/Resident at Risk' meeting will be conducted at least monthly by the Interdisciplinary Team. Guests/residents reviewed during the meeting are as follows: Guests/residents that had a fall since the previous meeting .The DON/designee will document any changes in the care plan and kardex at the meeting .The Director of Nursing or designee will print the monthly report .to track and trend falls in the facility. This data .will be analyzed and presented to the QAPI committee for ongoing recommendations .

Based on observations, interviews and record review, the facility failed to prevent the development of a Stage IV pressure ulcer, failed to develop and implement interventions to prevent and heal pressure ulcers and failed to monitor further skin integrity concerns for 1 resident (R26) reviewed for alterations in skin integrity, resulting in the potential for further skin breakdown, delayed wound healing, infection, and overall deterioration in health status. Findings include: Review of face sheet and electronic medical record for R26 revealed he initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R26 was not their own responsible party. Per facility provided wound timeline and facility matrix, R26 had a facility acquired Stage IV pressure ulcer that was first discovered on 9/20/21. On 10/17/22 at 10:55 AM an interview was completed with R26 and their responsible party in their room. R26's responsible party confirmed R26 had wounds on his bottom and he was going to a wound clinic. R26 was not viewed to have any pressure offloading pillows or cushions near his trunk area and was laying on his back with his bed slightly inclined. His feet appeared to be up on pillows and were against the foot board. R26's responsible party stated R26 was not a good historian due to a [CONDITION(S)] and he has very limited short term memory. R26 and R26's responsible party stated he is able to get up into his wheelchair. On 10/18/22 at 10:00 AM a care observation was made with R26 in their room. CNA (certified nursing assistant) H and CNA I turned R26 side to side and did peri care. CNA I stated she turns him with wedges every 4 hours, CNA H said she tries to turn him every 2 hours. The positioning wedges remained on the empty bed next to resident, and they were also observed on the bed next to the resident at 7:00 AM on 10/18/22. There were dressings on both R26's lower legs in their shin area with no date. The CNAs were not sure when these dressings were started. Scabs were viewed on all toes of R26's right foot. There was a large scab on the left forefoot about 1 inch by 1/4 inch on a boney area. The CNAs stated the resident is bed bound and has been bed bound for at least 2 months as he would yell when up in his wheelchair. An additional care observation of R26 was made on 10/18/22 at 10:42 AM. R26 was viewed in his bed on his back. R26 was viewed on his back since he was observed at 7:00 AM during a facility tour. The dressing on R26's coccyx was viewed to be dated 10/17/22 and looked soiled at the end of gluteal fold, when removed there was bright red blood, the calcium alginate was soaked with bright red blood. LPN (Licensed Practical Nurse) J removed the dressing and the DON (Director of Nursing) rolled R26 on his right side. LPN J took a photo with the DON's phone that works with the electronic medical record system. A 4x4 inch dressing was viewed on both R26's legs in the mid shin area, the right leg was a dime size wound and on the left leg a quarter size. The dressings were viewed to be soaked with fluid and tissue, fluid was viewed from the outside of dressing. The DON and LPN J stated there were no orders for dressings on the legs and had no idea when they were placed or who placed dressing on both legs. R26 was not aware of when dressings were place or cause. It was also observed R26's right foot had scabbed areas on every toe and his left mid foot anterior side had a 1 inch by 1/8-inch scab. R26 and the DON did not know what caused the scabs/injuries. A request was made for any incident or accident reports related to R26 and they were received by email on 10/18/22 at 3:14 PM. The incidents were reviewed. Review of facility provided Incident and Accident Report for R26 with the date 8/24/22 was revealed to a be a one page handwritten document. The time of day of the injury was not noted, the location was checked as resident room and was an abrasion on the left lower extremity. In the section Describe the nature of the accident/incident and if injuries sustained, location of injuries: a handwritten note was input: left lower extremity- 2 abrasions- top- 1 cm x 2 cm bottom 2 cm x 2 cm. The witness section was marked no. The physician was notified at 1700 (5:00 PM) on 8-24-22 the responsible party was notified on 8-24-22 at 950 (9:50 AM). The interventions implemented were new tx (treatment). The employee signature completing the report appeared to be signed by LPN M and was dated 8-24-22. The NHA (nursing home administrator) and the DON signed the report on 8/26/22. Review of R26's documents in their electronic medical records revealed a note to the physician dated 8/25/22 when they were informed: Guest scraped leg (with?) 1 cm x 2 cm & 3 cm x 2 cm abrasion- new treatment started. Review of wound clinic notes from 8/24/22 revealed the resident was seen by the wound clinic on 8/24/22 at 2:15 PM. There was not any reference to a leg injury. Review of R26's progress notes showed no progress note on 8/24/22. A nurses note on 8/25/22 at 9:47 AM authored by LPN M revealed: called to res room and res noted to have 2 small abrasions on LLE (left lower extremity) top one is 1 cm x 2 cm and bottom is 3 cm x2 cm, dr notified and mom notified, new treatment ordered cleanse with NS wipe, blot dry and apply [MEDICATION(S)] and change every 3 days and PRN (as needed). A total body skin assessment is documented on 8/25/22 at 10:15 AM. With the dates and times of these various documents, it is not clear how and when the wound occurred and was initially discovered. Review of facility provided Incident and Accident Report for R26 with the date 9/18/22 was revealed to a be a one page handwritten document. The document revealed at 2100 (11:00 PM) in the resident room R26 sustained an abrasion L (left) 5th toe & top L foot 1 cm (illegible writing). The incident was described a: when rolling resident to change brief, foot scraped on foot board. The interventions implemented revealed: foam dressing applied over wounds and maintenance to look at bed for extender. The employee signature was not legible for who completed it, but was dated 9/19/22. The DON, Administrator and the physician did not sign that they reviewed the document. Review of the electronic medical record progress notes revealed notes regarding the incident as well as notifications. A note from Unit Manager M on 09/19/22 at 9:56 AM revealed Bed cannot accomodate (sp) extenders related to APM and bariatric bed/mattress. New order to pad footboard to protect feet. Review of wound clinic notes from 10/5/22 reveal two additional open wounds both described with original cause of wound was not known. The date acquired was: 9/21/2022. The wound has been in treatment for 2 weeks. Wound #4 is described as Partial thickness wound with etiology of Skin Tear and is located on the Right, Dorsal Foot . and Wound #5 is a Partial Thickness wound with etiology of Skin Tear and is located on the Left, Anterior Lower Leg. Neither of these wounds match the description of the 9/18/22 incident and it is unclear where they came from since the facility provided no further incident reports matching the wound clinic notes injuries. A review of progress notes for R26 shows no note on 9/21/22 and a skin assessment documented on 9/22/22 at 10:15 AM with number of new skin conditions: 0. No other new injury or incident is documented in the progress notes in the date range of 9/21/22. Review of facility provided document dated 10/6/22 at 5:01 AM revealed a computer generated report titled Slid Out of Bed. The incident description revealed: two cenas were changing sheet and rolled guest to side and cena unable to hold him and both cenas lowered to floor. Abrasion to both shins from head board. Red mark to left back shoulder. No other injury. Hoyer (mechanical lift) used to get guest back into bed . The Immediate Action Taken section revealed Full assessment done, no injury except abrasion to shin .Maintenance to check proper functioning and inflation of mattress. Injuries were noted to right lower leg (front) and left lower leg (front). A handwritten Post Fall Evaluation was also included. The date and time of fall was written as 10/5 at 1900 and PM was circled. The description was rolled to floor during bed change. There were several sections of the document not completed including: Re-enactment of fall (to be done if root cause is not determined), Fall Huddle (What was different this time?), Root Cause of this Fall: Review of Contributing Factors (Check all that apply), Describe initial intervention to prevent future falls, and New Interventions after IDT review. The nurse signed the document on 10/5/22 and the section IDT Signatures was blank. Also attached were handwritten witness statements from the two CNAs (certified nursing assistants) involved in the incident with R26. CNA L's statement indicated the incident occurred on [DATE]th at 7:05. The statement was not very detailed and concluded Not sure what happened, but I couldn't stop him from falling. The handwritten statement from CNA K indicated the incident happened on [DATE]th at 7 pm the event account was brief and difficult to read due to incomplete sentences and either misspellings or penmanship. There was also an attached note from Director of Maintenance dated 10-6-22 which stated The Air Mattress on bed [R26's bed] is currently functioning properly and has foam support as well as the air pressure system therefore the mattress should not deflate while on and operating properly. There was no other additional root cause or intervention documented as being explored after the mattress malfunctioning was ruled out. There was no nursing note on 10/5/22 or 10/6/22 regarding the fall. A skin assessment was documented on 10/6/22 at 10:15 AM with no new conditions noted. A progress note on 10/7/22 at 4:06 AM indicated no new injury or pain s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . There were two follow up notes on 10/8/22 stating there were no new injuries from being lowered to the floor. There was not another progress note until a skin assessment on 10/13/22 at 10:15 AM which indicated no new skin conditions. The next note was a physician note by Doctor E on 10/18/22 at 10:20 AM. There is no reference to a recent fall or the new injuries. On 10/18/22 at 3:33 PM an email was sent to the DON with questions regarding the incident accident reports: For the 8/24 injury, how did it occur? For the 9/18 injury, was a bed extender obtained, if not how else was this resolved? The 10/6 incident is confusing to me, how was his leg injured on the head board? When the bed was found to be functioning properly, what else was reviewed to find a root cause? On 10/18/22 at 5:53 PM and email was received from the DON: The injury from 8/24/22 was noted by staff upon return from the wound clinic. Guest is transported via [ambulance company] for those appointments. In regards to the incident on 9/19/22 the foot board is to be padded. Maintenance is addressing that tonight. As for the Incident Report on 10/6/22, head board was a documentation error, it should read foot board. His Careplan and Kardex were updated to reflect that more assistance may be required during linen changes. Therapy is screening Guest for bed mobility, transfers and positioning. A follow up interview was completed with the DON on 10/19/22 at 9:05 AM regarding R26. The injury from 8/24/22 was discussed. The DON stated the injury was reported as soon as R26 returned from the wound clinic. She stated that they did not know if the injury occurred from transport in and out of the ambulance (R26's transportation to the wound clinic) or if it occurred at the wound clinic, but they do know for sure the injury was not there before R26 left the building. The DON was asked if R26 had a full body skin assessment prior to leaving the building on 8/24/22 and the DON reviewed the electronic medical record and stated his last skin assessment was 8/19/22. The DON was asked if she called the wound clinic or the ambulance company to obtain interviews or information about the injury and she stated that was not done to her knowledge. The DON was asked if she could say with certainty how and where the injury occurred, and she stated that she could not. The DON agreed this would be an injury of unknown origin and an investigation should have been initiated by the facility to determine when and how it occurred. The 10/6/22 incident was discussed with the DON, she admitted that the incident report and the witness statements were confusing. The DON stated she completed follow up interviews with the staff involved to get a better understanding of the events. The DON admitted the clarifying follow up interviews were not part of the incident report. The DON stated the event occurred because R26 was not properly centered on the bed when staff were changing his sheets and the staff member could not hold him by themselves when he started to fall. The DON confirmed they have enough staff on day shift and second shift to be able to accommodate more than 2 workers assisting with future sheet changes. The DON stated this intervention had not been added to the care plan but was added as of 10/18/22. On 10/19/22 at 9:15 AM, an observation was made of R26 in his room. R26 was in bed on his back with positioning wedges in place and the foot of his bed was viewed to be padded. During an interview with the NHA (nursing home administrator) on 10/19/22 at 1:00 PM, the absence of a thorough investigation and mode of injury for R26 on 8/24/22 was discussed. The NHA stated the unit manager had called the wound clinic and they confirmed the injuries occurred there. The NHA was informed this was not in the incident report, the medical record and the DON was not aware of this conclusion. The NHA flipped through a personal notebook and stated she wrote herself a note on 8/26/22 that the unit manager had made calls and it happened at the wound clinic. The NHA later followed up on 10/19/22 at approximately 1:45 PM and provided a nurses note from 8/26/22 at 9:41 AM: IDT (interdisciplinary team) team met and reviewed abrasion to LLE (left lower extremity). Per [name of staff], LPN area was noted upon return from appointment on 8/24/2022. Area is due to repositioning and turning on gurney with paramedics. It was noted to the NHA and they admitted the note did not say how and when the information was obtained and does not indicate a complete investigation. During the interview with the NHA on 10/19/22 at 1:00 PM, incident and accident interventions were further discussed. The NHA stated when an incident occurs, the nurse on duty fills out the incident paperwork and then the clinical team reviews it later and ensures everything is in place for interventions. If the incident occurred after regular business hours, a call is made to the DON and the nurse is instructed to put the new information into the resident medical record and put in the interventions immediately. The NHA stated that all nurses are not used to putting in solutions on the spot and they have had to educate nurses to think outside the box for potential solutions. The incident reports received for R26 were not consistent in how they were documented and what forms were used. The NHA admitted there is not a current process in place for the team to circle back an ensure that appropriate and thorough interventions were identified and put in place. It was discussed the incidences with R26 where the 9/19/22 incident intervention had not yet been put into place and the initial potential root cause for the 10/6/22 incident was noted to be there was an issue with bed inflation, but there was not further documentation of an additional area to be addressed when the bed was found to be in proper repair. The NHA stated this would be addressed further with the QAPI (Quality Assurance and Performance Improvement) committee. Review of R26's care plan revealed a need related to them being at risk for impaired skin integrity interventions include: conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown .; Provide total assistance to reposition frequently as needed; all with an initiated date on 4/16/2019. An additional intervention with the initiated date of 12/23/2021 is turn/reposition resident every 2 hours and PRN (as needed). An additional need is listed as Bed Mobility Program: [R26 is unable to independently move from a lying position to a sitting position .R/T (related to) [CONDITION(S)], impaired cognition, muscle weakness interventions include: assist resident in repositioning, observe skin integrity when turning guest, report red/open areas to nurse, physical assist of: 2 persons, .turn guest every 2 hours, all with initiated dates of 4/16/2019. Another need is listed as R26 has an actual impaired skin integrity related to Pressure injury on coccyx, Stage IV with an initiated date of 12/23/2021. No additional wounds or skin impairments are noted. An additional need area is listed as an ADL (activities of daily living) deficit and requires total assistance with ADL's, transfers and mobility . with a created date of 4/16/2019. An intervention was added on 10/18/2022 [R26 is to be repositioned between his right side and left side, using positioning wedges, at least every 2 hours. Place positioning wedges above and below his coccyx wound, to offload weight. Avoid positioning [R26] on his back, as he will allow. Review of care plan printed on 10/17/2022 did not reveal this intervention. Another intervention was revised on 10/18/2022 titled BED MOBILITY: Resident requires total assistance of 2-3 staff to reposition and turn in bed. May require increased assistance with linen changes. The care plan printed 10/17/2022 revealed BED MOBILITY: Resident requires total assistance of 1-2 staff to reposition and turn in bed. The care plan was not changed with identified interventions related to the 10/6/22 incident until 10/18/2022. An additional need is listed as R26 had actual impairment to skin integrity r/t [NAME] (sp) pressure ulcer on coccyx .abrasions to left lower extremity with a last revised date of 8/26/2022 by the DON and initiated interventions on that same date: follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the task tab in the electronic medical record on 10/18/22 at 12:25 PM revealed a task of Bed mobility: Turn and Reposition every 2 hours and PRN while in bed and up in wheelchair. A look back of the last 30 days revealed only 5 times this task was documented on 9/26/22 for 20 minutes, 9/29/22 for 20 minutes, 9/30/22 for 25 minutes, 10/6/22 for 25 minutes and 10/12/22 for 15 minutes. Review of notes from the wound specialist dated 8/24/2022 reveal: Off-Loading Wound #1 Coccyx .Keep weight off area of wound at all times.

This citation pertains to MI 145 Based on observation, interviews, and record review, the facility failed to notify the physician of an unusual occurrence for one resident (Resident #14), out of 12 residents reviewed for notification, resulting in a delay in treatment of [REDACTED]. Findings include: According to a facility face sheet dated 5/22/18 at 5:03 PM, Resident # 14 was a [AGE] year old female admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. Review of a facility recap of an incident for Resident #14 dated 5/19/18 at 11:47 AM reflected, On (MONTH) 18, (YEAR) at 10:49 AM, guest (Resident #14) with complaints of pain to her left arm. Upon assessment 3 to 4 plus (meaning a large amount) [MEDICAL CONDITION] ([MEDICAL CONDITION] is swelling from fluid. Pitting denotes that you can push the area with your finger and an indentation remains) noted in the left hand and 3 plus [MEDICAL CONDITION] noted to the arm up to the humerus (upper arm). During an interview and observation with Resident #14 on 06/27/18 at 01:53 PM, she stated her left arm wasn't in the Hoyer sling (a mechanical lift used to transfer totally dependant residents) correctly during a transfer on 5/9/18. Resident #14 revealed the left arm was put in the sling maybe a little too much force was used. No one did anything on purpose. Resident #14 stated she told the staff that it hurt when they were putting the left arm in the sling. Resident #14 didn't remember the staff that was working with her. Resident #14 confirmed there were two staff completing the Hoyer lift transfer. Resident #14 stated the left arm was x rayed in facility. It was observed that Resident #14 had a plastic splint to her upper left arm and a compression glove to her left hand (elastic glove to help decrease the swelling). Resident #14 stated tomorrow she sees the doctor at the hospital. Resident #14 stated the left arm was painful, some times. Resident #14 stated she received pain pills and these helped. On 06/28/18 at 09:25 AM, an observation and interview of Resident #14 was made in the hall near her room in her wheelchair. Resident #14's left arm was supported by a pillow. Resident #14 was observed to have a compression glove on her left hand. Resident #14 stated she was going to the doctors. Physical Therapy staff told Resident #14 she will look at her left upper arm splint in the gym before she went to her appointment. On 06/28/18 at 01:05 PM, during an interview and observation of Resident # 14 Hoyer lift mechanical transfer by Certified Nurses Aides (CNA's) T, U and V, Resident #14 had a Hoyer sling under her in her wheelchair. CNA U fastened Resident #14's left arm sling to cradle her left arm. CNA's T, U and V said in agreement that the blue piping around the edge of the sling is the size Resident #14 required. CNA's T, U, and V stated they used the blue loop on top of the sling and the green loop on the bottom of the sling to hook to the lift to keep Resident #14 seated upright correctly as they hooked up the sling to the lift. Resident #14 was lifted by the mechanical lift by 2 CNA's, one at the lift, one with the Resident behind the wheelchair. Resident #14's arms and legs were monitored. It was observed that the sling cradled the back of Resident #14 but the sides left the sides of the Resident #14 exposed and the right elbow could be seen out the right side of Resident #14. Resident #14 was guided to the bed by 2 CNA's and placed upon the bed. It was observed that Resident #14 had bilateral pedal (foot) [MEDICAL CONDITION]. Resident #14 was observed to be wearing a brief. On 06/28/18 at 02:18 PM, during review of Resident #14's progress notes dated 5/9/2018 at 17:27 (5:27 PM), the notes reflected, Nurses Notes Note Text: guest c/o of pain to left upper arm. stated was holding it during transfer and it slipped (out of the Hoyer sling). pain gel applied and effect noted. will monitor. On 06/28/18 at 02:20 PM during a review of Resident #14's progress notes dated, 5/15/2018 at 06:30 AM (6 days after her flaccid arm fell out of the Hoyer sling) reflected, Nurses Notes Late Entry: Note Text: Res with noted increased [MEDICAL CONDITION] from baseline to L (left) arm with redness. Passed on to day shift nurse to have doc (physician) see res (Resident #14) as it his normal day to make rounds. Res (Resident #14) aware that doc (physician) would be in to see during the day. Res (Resident #14) stated understanding and was ok with this. On 06/28/18 at 02:21 PM during a review of Resident #14's progress notes dated 5/15/2018 at 17:46 (5:46 PM) reflected, Nurses Notes Note Text: DR. (Physician AA) in today. Looked at left arm. Swelling, warmth and redness/discoloration noted. Started on Bactrim DS (an antibiotic) and ordered ultrasound. (of the left arm for blood clots) On 06/28/18 at 02:24 PM during a review of Resident #14's progress notes dated 5/17/2018 at 01:46 PM reflected, Nurses Notes Note Text: no adverse effects of ab (antibiotic) therapy observed this shift. resting in bed on back with eyes closed. Left arm propped on pillow. No c/o (complaints of) break through pain observed. On 06/28/18 at 02:26 PM during review of Resident #14's progress notes dated 5/18/2018 at 10:49 AM (9 days after Resident #14's arm fell out of the Hoyer sling) reflected, eMar (electronic medical record)- Shift Level Administration Note Note Text: Patient voiced concerns about pain in left arm. On Assessment noted [MEDICAL CONDITION] pitting +3-4 in the left hand +3 in arm up to humerus. Nurse noted she has been on antibiotic for 6 doses with out changes or improvement. On assessment guest states that It hurts so bad in the elbow that I want to pass out when you bend it Noted colors abnormal from yellow -pink- red . entire extremity in warm to touch. Noted order to x ray arm. No adverse reaction from antibiotic use. On 06/28/18 at 02:28 PM during review of Resident #14's progress notes dated 5/18/2018 at 23:44 (11:44 PM) reflected, Nurses Notes Note Text: At about 9:10 (PM) this evening, the x-ray tech asked this nurse for assistance in getting the x-ray board behind the resident's left shoulder and arm area. This nurse assisted. Res (Resident #14) was laying comfortably in bed, HOB (head of bed) was raised up to about 80 degrees and x-ray board was positioned. About 10 min later the x-ray tech showed me what appeared to be a fractured left humerus. (Name of Administrator A) was contacted and message left. (Name of transport company) was then contacted and transport was sent . Res (Resident #14) left the building at about 9:40 PM and was sent to (Name of local hospital). On 06/28/18 at 02:57 PM during review of progress notes for Resident #14 dated 5/20/2018 at 09:00 AM reflected, Nurses Notes Late Entry: Note Text: Contacted (Name of Physician AA) in regards to further orders and orthopedic consult. No new orders at this time. On 06/28/18 at 02:58 PM during review of Resident #14's progress notes dated 5/20/2018 at 09:20 AM reflected, Nurses Notes Note Text: continues Bactrim ds (antibiotic) r/t (related to) [MEDICAL CONDITION] (skin infection) of L (left) arm. Tolerating well no s/s (signs or symptoms) of adverse reactions noted. No increased c/o (complaints of) pain. When asked if res (Resident #14) is having pain. States, Yes. When asked where pain is res (Resident #14) responds All over. Will continue to monitor. On 06/28/18 at 03:00 PM during review of Resident #14's Physician AA progress notes dated 5/22/2018 at 10:02 AM reflected, Physician Note Note Text: Resident (#14) was actually seen and evaluated by me on 5/15/18 for left arm [MEDICAL CONDITION] (swelling) and increased discomfort in the arm in general, but nonspecific. There was [MEDICAL CONDITION] of the entire arm, and about the upper forearm there was warmth, [DIAGNOSES REDACTED] (redness) and increased density to the skin consistent with [MEDICAL CONDITION]. Therefore antibiotic was started and an ultrasound was ordered to rule out further vascular (blood flow) abnormality. Ultrasound was negative for pathology. Subsequently she developed pain above the elbow which was discovered when trying to move her arm. X-ray was then ordered and fracture was found and ortho (orthopaedic physician) referral has been done. 06/28/18 at 03:01 PM during review of Resident #14's progress notes dated 5/24/2018 at 01:47 AM reflected, Nurses Notes Note Text: Continues on [MEDICATION NAME] for ear infection. No s/s of adverse reaction noted. Has splint to L upper arm r/t fracture. Skin remains intact. Neurological checks to extremity WNL (Within normal limits) for res. Will continue to monitor and observe. On 06/28/18 at 03:07 PM review of a report dated 5/18/18 at 22:15 (10:15 PM) x ray results for Resident #14 reflected, PR[NAME]EDURE: HUMERUS MINIMUM 2V (views) STATUS: Final INTERPRETATION: Reason for Study: M79.622 PAIN IN LEFT UPPER ARM Principal Result Interpreter: (name) Technician: (name) Transcription Technician: LE HUMERUS MINIMUM 2V HUMERUS MINIMUM 2V, LEFT Results: There is a displaced [MEDICAL CONDITION] (end furthest from the body) shaft of the humerus (upper arm bone). Conclusion: Fracture humerus. On 07/02/18 at 08:38 AM, during an interview with Registered Nurse (RN) J and DON B, DON B confirmed that an Incident Report was not completed on 5/9/18 after an unusual occurrence. DON B stated she did not talk to the CNA's after the reported incident. DON B was asked if a Resident complained of pain after their arm fell from a Hoyer sling would this require an incident report and DON B stated the nurse did range of motion on Resident #14 after the CNA's reported this to her after Resident #14's Hoyer transfer. DON B revealed, We probably should have done an incident report. DON B confirmed that Physician AA was not notified of this occurrence on 5/9/18. It's not documented in the notes DON B confirmed and family wasn't called. On 5/14/18 RN Jstated Physician AA. was informed of increased [MEDICAL CONDITION], redness, pain. RN J stated Physician AAsaw Resident #14 on 5/15/18. DON B revealed that Bactrim DS (an antibiotic) was started on 5/15/18 for Resident #14 and an ultrasound of the left arm for a blood clot was ordered. DON B stated Physician AA did an assessment of Resident #14 and thought she had a blood clot or [MEDICAL CONDITION] (skin infection) of the left arm. Resident #14 had increased complaints of pain on 5/18/18 and an x ray was done, at 9:20 PM. DON B stated. DON B revealed the facility got the results of fracture when the portable X-ray was done in the facility. Before the x ray technician left, the x ray technician alerted the nurse on a visible injury (displaced fracture). Physician AA was called when technician notified the nurse of this. Interviews were then started about an injury of unknown origin revealed DON B. During a interview on 07/02/18 at 09:06 AM with CNA S, she stated she was working with CNA T during the occurrence with Resident #14 on 5/9/18. CNA S stated they got Resident #14 in her Hoyer sling in bed. CNA S stated they hooked Resident #14 up, raised the Hoyer. both arms were by her side in bed. CNA S stated she brought Resident #14's left arm to the resident's belly and Resident #14 held on to the left hand with her right hand. CNA S stated they raised Resident #14 fully in sling/lift and CNA T was pulling the Hoyer lift backward. CNA S stated she was behind the Resident #14 and the resident's arm flopped down out of the (Hoyer) sling. CNA S stated she moved Resident #14 to the side and raised Resident #14's arm and that's when the Resident #14 said, ow. CNA S stated then CNA S was holding Resident #14's left arm at left elbow and forearm. CNA S stated she just held Resident #14's left arm until CNA S and T put her into her bed. CNA S stated Licensed Practical Nurse (LPN) N came and checked Resident #14's arm. CNA S stated that CNA T told the LPN N Resident #14's arm had fallen out of her Hoyer sling. CNA S revealed that Resident #14 didn't say it hurt. CNA S stated she then put Resident #14's arms back on her belly, held her arms in place and Hoyer lifted Resident #14 back into her wheelchair. CNA S stated the occurrence with Resident #14 was before breakfast. CNA S stated Resident #14 had no more complaints of pain during her shift. CNA S denied any force being used to move Resident #14's left arm during the occurrence. CNA S stated Resident #14's arm is always kind of swollen. CNA S stated Resident #14 required the blue sling. During an interview on 07/02/18 at 09:20 AM with LPN N, she revealed that CNA S came to her and told her what happened during a hoyer lift transfer for Resident #14. Resident #14 told LPN N that her left arm slipped and that it hurt. When Resident #14 got into bed LPN N said she assessed the left arm of Resident #14. LPN N stated that Resident #14 did not say her left arm hurt. LPN N stated she did palpation (feeling) of the arm and limited ROM (range of motion). LPN N stated Resident #14's skin wasn't changed (no injury, bruising, no skin changes) and there was no change in position of the left arm. LPN N revealed that no incident report hand been completed, no one had me do one. LPN N was asked if she had called the physician and she stated, I don't believe so. Just made a progress note. LPN N denied Resident #14 had any complaints during her shift. On 07/02/18 at 14:28 PM during a phone interview with Physician AA, he stated Resident #14 was having pain in her left arm and it was red and swollen (the left upper arm). Physician AA felt the redness and swelling looked like [MEDICAL CONDITION] so an ultrasound was ordered which was negative for a blood clot. Physician AA stated there was an increase in pain in Resident #14's right arm and so then an x ray was ordered. Physician AA stated he couldn't isolate the pain anywhere specific in the left arm. Physician AA couldn't say when he was notified of the left arm, (I) can't be sure. Physician AA also stated he can't be sure if he was notified of a possible injury to Resident #14's left arm on 5/9/18. Physician AA stated if the notification was by fax or phone call, he won't have documentation of this. Physician AA stated he wrote a note on 5/22/18 but that was after the fact. Physician AA stated he's not sure if the fracture was related to the occurrence on 5/9/18. Physician AA stated there was no severe pain after the occurrence for Resident #14. According to a facility policy dated 6/17 titled, Incident Reporting reflected, An incident is an unexpected occurrence which is not consistent with the routine operation of the facility or in the routine care of a particular guest. It may be an accident or an usual occurrence which may or may not result in an injury. Incidents are to be reported in a timely fashion to administration .The employee who identifies that an incident has occurred will immediately notify a supervisor. Any non non nursing supervisor will notify the appropriate charge nurse. A licensed nurse will assess the guest including taking all vital signs. Additional assessments will be completed as appropriate to determine a course of action. After the nurse's assessment, if injury is noted, the physician will be notified immediately for further direction. If no injury is present, the physician may be notified by fax, office notification, or voicemail . Review of a facility policy dated revised 11/16 titled, Physician Notification reflected, The licensed nurse will report changes in the guest's condition due to illness, exacerbation of existing condition, or accidents and incidents to the physician, nurse practitioner, or physician assistant, follow the established interact protocols for immediate, no immediate, or routine notification .notify the physician of a change in the guest's condition. document the time and date that the physician as notified, the physician's response, and any treatment ordered in the Progress Notes .Accidents/Incidents: time; observation of injury (bruises, abrasions); cause or suspected cause.

This citation pertains to intake # MI 073 and MI 489 Based on observation, interviews, and record review, the facility failed to prevent avoidable falls and provide adequate supervision and assistance for 2 Residents (#8 and #10), of 2 Residents reviewed for falls, of a total sample of 11 Residents, resulting in Resident #8 having multiple falls with injuries that included a clavicle fracture, a laceration/bruises and Resident #10 falling and sustaining a laceration. Findings include: Resident #8 Review of Resident #8's face sheet dated 2/27/18, revealed Resident #8 was an [AGE] year old female, admitted on [DATE] and had the following Diagnoses: [REDACTED]. Resident #8 was not her own responsible party. Review of Resident #8's Fall care plan dated 1/12/17 revealed the following interventions to prevent falls: 11/7/17 toilet guest after all meals, 1/2/17 evaluate for different chair and cushion related to falls, 11/10/17 shoulder x-ray, 11/10/17 therapy evaluation, 12//4/17 therapy evaluation /adjust wheel chair, 11/10/17 consult urologist, 1/12/17 observe for fatigue and encourage rest periods,12/31/17 non skid material to wheel chair. Review of Resident #8's Nursing Care Card, dated updated 2/7/18 revealed, Resident #8 was a fall risk and had the following equipment in place: pad alarm to bed, pad alarm to wheel chair, mat to floor right side and non skid material in wheel chair. Under comments documented 6/19/17 Encourage rest periods when guest appears fatigued, 7/12/17 toiled guest and put to bed after meals, as guest will allow Resident #8 had 10 falls documented from 5/29/17 to 12/3/17. All 10 falls were reviewed in order with Director of Nursing (DON) B on 2/28/17 and were reviewed for root cause of the fall, care plan compliance and implementation of adequate assistance and supervision post fall. Multiple investigations of falls did not verify Resident #8's fall care plan was being followed at the time of the fall, several falls lacked a root cause or cause of the fall, several falls lacked any increase supervision or assistance care plan post fall. After review of all the information DON B provided about all 10 falls, DON B said she understood the concerns and confirmed the lack of investigation and documentation to determine a root cause for the falls. DON B confirmed interventions given in the documentation the facility provided in their full investigation of the falls were not being implemented. DON B confirmed she was not able to determine if Resident #8's care plan was being followed at the time of the falls. Fall 11/9/17 at 1:05 PM, investigation indicated this was an unwitnessed fall in Resident #8's bathroom. There was no indication Resident #8 had been assisted to the bathroom after lunch 11/9/17 as care planned and as documented as needed in the fall investigations on 5/29/17, 7/11/17 and 10/6/17. Resident #8's wheel chair alarm was not sounding when she was found on the floor, but the alarm was on the chair and functioning prior to lunch 11/9/17. Resident #8's x-ray post fall revealed a left clavicle fracture. Review of complete medical record of all falls for Resident #8 revealed the following: Fall 5/29/17 at 2:10 PM, documentation revealed Resident #8 was found (unobserved fall) on the floor in the doorway of her room. No witness statement found and no root cause analysis located. Under immediate interventions documented, change alarms to pressure alarms instead of clip alarms and toilet after all meals Toilet after all meals was not found on the fall care plan until 11/7/17. There was no indication that Resident #8's care plan was being followed at the time of this fall. Fall 6/18/17 at 7:15 PM, investigation indicated Resident #8 was attempting to get into bed (unobserved) and was found on the floor next to her bed. No staff statements or root cause was located. There was no indication if the care plan was being followed and the new intervention was to encourage rest periods when fatigued. (There was no indication how long Resident #8 had been up in her wheel chair and no documentation to support that Resident #8 was showing signs/symptoms of fatigue prior to the fall. Fall 7/11/17 at 6:30 PM, investigation indicated Resident #8 was (unobserved) attempting to put her self to bed after dinner. Fall on 5/29/17 documented Resident #8 was going to be assisted to the toilet after all meals (not care planned). There was no indication Resident #8 was assisted to the toiled after dinner on 7/11/17 and the new intervention again was to toilet after meals and put in bed. There was no indication this was care planned at this time. Fall 10/6/17 at 6:30 PM, investigation indicated Resident #8 was unobserved and found in the assisted dinning room on the floor next to a table. There were no witness statements of information provided to determine a root cause for the fall. There was no indication when Resident #8 had completed her dinner or that she was offered assistance to the toilet or bed as documented in the fall investigation on 7/11/17. The fall on 7/11/17 happened at the same time of day 6:30 PM (this indicated the care plan was not being followed). Resident #8's injury from this fall was a bruised right eye. The new intervention was to have Resident #8 go to an activity after dinner. Fall 10/9/17 at 10:45 AM, investigation indicated an unwitnessed fall that resulted in Resident #8 hitting her head. There were no witness statements or indications what was happening prior to the fall. There were no new interventions placed post fall to increase Resident #8's supervision or assistance to prevent another fall. Fall 11/6/17 at 2:30 PM was an unwitnessed fall. There were no witness statements or documentation to support that Resident #8's fall care plan was being followed at the time of the fall. The new intervention was encourage Resident to toilet after meals. This intervention was indicated in the fall investigations on 5/29/17, 7/11/17 and 10/6/17. This intervention was found on the care plan dated 11/7/17 (one day after this fall). Fall 12/3/17 at 2:00 PM, investigation indicated Resident #8 slid out of her wheel chair unobserved. There was no indication of what was happening prior to the fall or any root cause. Resident #8 was referred to therapy. There were no new interventions indicated to increase Resident #8's supervision or assistance. Fall 12/29/17 at 11:40 AM, investigation indicated Resident #8 was observed falling forward out of her wheel chair in the dining room. Resident #8's injuries included 2 hematoma's, a skin tear and bruises on her left shin and left cheek. There was no root cause analysis or investigation that could determine the cause of the fall. No witness statement. There was no care plan interventions found to increase Resident #8's supervision or assistance to prevent another fall. Fall 12/31/17 at 1:00 PM was unwitnessed and Resident #8 obtained a laceration to her left brow (size and treatment was not provided on the investigation). There were no staff statements or indication of care/condition prior to the fall. The root cause was documented as On (MONTH) 31, (YEAR) at 1300 (1:00 PM) guest was noted to be sitting in her wheelchair by the nurse's station when she stood up and immediately fell to the floor. She did hit her head causing a laceration to her left eyebrow. name of resident was sent to the emergency room for evaluation and treatment. It is not clear how this root cause was determined because there were no witness statements, it was documented as unwitnessed and there were no staff statement to indicate what was happening prior to the fall. Resident #10 Review of Resident #10's face sheet dated 2/27/18 revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #10 was not in the facility at the time of the investigation. Resident #10 sustained a fall and was sent to the hospital on [DATE] and did not return. Review of Resident #10's Incident Report dated 2/15/18 at 5:00 PM documented Resident #10 had an unwitnessed fall in the east hall and had a 3 cm x 0.5 cm laceration to his head. Resident #10 was sent to the emergency room due to Resident #10 hitting his head, initially being found unresponsive but then became responsive with first aid by facility staff. Resident #10 was sent to the emergency room with a resulting subdural hematoma. Review of Resident #10's Certificate of Death, dated 2/17/18 at 12:51 AM, documented Resident #10's cause of death were, intracrainial hemorrhage, brain herniation, acute [MEDICAL CONDITION] and coma. Review of Resident # 10's Nursing Care Card (care giver instructions) dated 1/31/18 and updated 2/7/18, revealed he was a fall risk. He was oriented to person, place and time. He required the assistance of one person for transfers and walking with a walker. There was no indication he wandered and the box for the wanderguard (device used to ensure resident to do not wander out of the facility without assistance) was not marked. Review of Resident #10's Baseline Care Plan dated 1/31/18 revealed, under Falls/Safety/Elopement Risks/Devices: Evaluate for unsteady gait, ambulation device as necessary walker, observe cognitive status for ability to ask for assistance, observe guest footwear for fit and non-skid soles, device type: walker, Refer to Behavior Management as needed, Fall Risk Score 4, Guest chooses to ambulate and transfer without assistance. Review of Resident #10's Baseline Care Plan dated 1/31/18 revealed under, ADL (activities of daily living/ Rehab Potential documented, bathing /hygiene w/assist of 1, Dressing/grooming with assist of 1, Toileting w/assist of 1, ambulation/transferring with assist of 1 and skilled therapy as ordered. Review of Resident #10's Baseline Care Plan dated 1/31/18 revealed under, Infection Alert, Type UTI (urinary tract infection), observe for S/S (signs and symptoms) of infection and report to physician as needed, treat as ordered [MEDICATION NAME] (name of antibiotic), 2/6/18 UA with C& S if indicated (urinalysis with culture and sensitivity) test to determine if resident had a UTI. Review of Resident #10's Baseline Care Plan dated 1/31/18 revealed under, Cognitive Loss/[MEDICAL CONDITION], Orient PRN (as needed) to person, place and time, introduce self, approach in calm manner, explain what you intend to do while providing care, anticipate needs and observe for non-verbal cue, Rule out infection. Review of Resident #10's Baseline Care Plan dated 1/31/18 revealed under, Admission Diagnoses: [REDACTED]. Review of Resident #10's Baseline Care Plan dated 1/31/18 revealed under Guest Goals: Participate in therapy and Return home with wife. Review of Resident #10's Minimum Data Set (MDS) nursing assessment, dated 2/7/18 revealed a Brief Interview of Mental Status (BIMS) score of 8/15. Moderate cognitive impairment. Resident #10 required extensive assist of one person for transfers and limited assistance of one person to walk. Review of Resident #10's Minimum Data Set (MDS) nursing assessment, dated 2/13/18 revealed significant improvement in his mental status BIMS of 15/15 (normal cognition), transfer status remained the same, but declined in ability to walk in his room (now extensive assist to walk in his room). Review Resident #10's progress note dated 2/15/18 at 6:00 AM, signed by Licensed Practical Nurse (LPN) M documented, Res (resident) self transferring during N[NAME] (night). Staff attempted to redirect res without success. Res was asking to go home. Late in the evening asking where the church was, Later requested to go upstairs. Staff applied gait belt to res each time and walked with resident and attempted to redirect res with each encounter. Res was pleasant with staff, No agitation or aggression noted. Review of a skilled note dated 2/14/18 at 9:00 PM, revealed Resident #10 was oriented to person and place but not time, had vital signs within normal limits, was restless and had an abnormal sleep pattern. Under comments documented, Res ambulating with walker independently,. Staff educated and encouraged res to allow staff to assist. Stated understanding. This note was signed by LPN M. Note by same nurse at end of shift 6:00 AM documented confused behaviors with examples of wanting to go upstairs and to church. Resident was not demonstrating cognitive function to understand safety. There was no indication the physician was notified. During a telephone interview with LPN M on 2/27/18 at 12:24 PM, LPN M confirmed she worked with Resident #10 on the night of 2/14/18 into the day of 2/15/18. LPN M said she works 6:00 PM to 6 AM. LPN M Resident #10 was not his normal self that night. LPN M said Resident #10 had always slept at night in the past. LPN M Resident #10 kept getting up to walk so she had the staff walk with him than try to put him to bed but he kept getting up. LPN M said Resident #10 was confused and recalled he made statements that did not make sense. LPN M was asked if she changed Resident #10's safety care plan and she said no she just educated him on using the call light. LPN M was asked if Resident #10 was using the call light and she said, No. Staff just assisted him when they saw him up. Review of Resident #10's Skilled Note dated effective 2/15/18 at 5:00 AM, signed at 3:23 PM, documented, Guest has short term memory and is also not compliant with directions at time. Vital signs were within normal limits. Boxes for oriented to person, place, time, restless, forgetful, delusions, abnormal sleep pattern, and confused were all maker. Under Specify documented, both incontinent and continent, urine dark yellow and UA sent to Lab for C & S (test to detect urine infection). Guest is more confused. also taking to people that are not there. Needs one assist with ADL's Under comments documented, Guest wife here almost every afternoon to visit. Today guest did not recognize his wife. Guest alert to self and able to ambulate with wheeled walker; guest monitored 1:1: with walker. Feeds himself but is one assist with ADL's (activities of daily living). Note was signed by LPN K. During a telephone interview with LPN K on 2/27/18 at 12:18 PM, LPN K said she worked 2/15/18 and Resident #10's wife was at the nurses station that day concerned about Resident #10 being more confused and she obtained orders for a urinalysis which LPN K documented in Resident #10's progress note on 2/15/18 at 2:40 PM. LPN K could not recall the details of what was happening that day and did not recall making any changes to Resident #10's safety care plan. LPN K denied any awareness of unsafe behaviors that day. LPN K was interviewed on the phone again on 2/27/18 at 3:03 PM, after the Skilled Note was located and reviewed. LPN K was read the note she made that said, Guest alert to self and able to ambulate with wheeled walker; guest monitored 1:1: with walker. Feeds himself but is one assist with ADL's (activities of daily living). LPN K was asked who was providing the 1:1 care as indicated in the note. LPN K said I was at the medication cart. LPN K was asked can you provide 1:1 care and pass medications and LPN K said, No. LPN K asked what the facility policy/procedure for placing a resident on 1:1 care and if there would be a staffing report or documentation to locate who provided the 1:1 care. LPN K said she did not know and again had no recall of who she would have assigned to the 1:1 care. During a telephone interview with Certified Nurses Aide (CNA) F on 2/27/18 at 11:18 AM, CNA F recalled working with Resident #10 on 2/15.18 prior to his fall. CNA F was asked what Resident #10 was like that day prior to the fall and CNA F CNA F said Resident #10 was very confused. CNA F said Resident #10's wife was walking with him and staying in his room that day. CNA F was asked if she reported Resident #10 being more confused that day and CNA F said the nurses knew. CNA F was asked if Resident #10 was to walk by him self or with his wife and she did not know. CNA F was asked if the nurses updated Resident #10's care plan for safety that day due to his confusion and CNA F said, no. CNA F said she was there when Resident #10 fell but she did not see him. CNA F did not know when Resident #10's wife went home. During a telephone interview with Resident #10's wife Q on 2/27/18 at 11:23 AM. Q said she had been at the facility on 2/15/18 prior to Resident #10 falling. Q said Resident #10 was talking crazy making statements like 2 drunk men were there, he was seeing bugs. he was trying to leave the building out the laundry room door. Q said she told the nurse and requested to have Resident #10 checked for a UTI. Q said she put Resident #10 in bed around 4:30 PM and thought he would sleep but she got a call later that he had got up and fell . Q said she did not think the facility had enough help. Review of the facility investigation for Resident #10's fall 2/15/18 revealed there were no written witness statements. The facility provided a typed 3 page investigation for Resident #10 dated 2/15/18. Documented in this investigation Guest was in the hallway and had a fall causing a laceration to the back of his head, 3 cm x 0.5 cm). Actions taken by facility: First aid was administered immediately and pressure applied to the laceration to the back of his head. 911 was called to transfer guest to the hospital for evaluation and treatment. Investigation item #4 documented, Detail from witnesses to alleged incident interviews: RN N was interviewed by DON B at 6:47 PM, 2/15/18. RN N stated that she was standing in the hallway administering medications when she heard a thud in the hallway. RN N stated she turned and noted guest lying on his right side in the hallway. RN H immediately called for help. First aid was administered . Family and 911 called. Investigation item #4 documented, Interview with CNA F with DON B on 2/15/18 at 6:55 PM, CNA F stated that the last interaction that she had with the guest was approximately 4:30 PM when she assisted guest and his wife back to guest room. Investigation item #4 documented, Interview with RN H by DON B on 2/15/18 at 7:05 PM RN Hstated that she she heard RN N call out for help and she immediately responded and applied pressure to the guest's laceration on the back of his head. Upon initial assessment RN H said guest was unresponsive. Upon turning the guest to his back by RN H and RN N he gasped for air and opened his eyes and started to speak nonsensically. Full body assessment was completed and he was able to move all extremities. Guest left facility per (name of ambulance company) at 5:30 PM with family present. Upon assessing environment RN Hstated guest had gripper socks on and they were dry, his walker was in his room, and no fluid was observed on the floor in the hallway or in his immediate surroundings. Investigation item #13 documented, Name of Resident #10 is alert and oriented x 4, he was admitted for short term rehabilitation to return home with his wife. Guest had been educated and encouraged to use the call light and ask for assistance when needed. name of Resident #10 has the [DIAGNOSES REDACTED]. He receives [MEDICATION NAME] and Asprin routinely (medication that thin the blood). Guest was noted on (MONTH) 15th to be exiting his room and when he visually seen a staff member in the hallway he went back into his room and turned his call light on. Staff member met him at his door and assist guest to therapy room. Description given in item #13 do not match the documentation in Resident #10's medical record or interview of the staff that cared for Resident #10 starting the night of 2/14/18. Documentation and interviews indicated Resident #10 had a significant change in condition. Resident #10 was not responding to education to use his call light, he was having hallucinations of bugs and people that were on present. He was telling staff he wanted to go to church and upstairs during the night. The medical record documented that the licensed nurses caring for Resident #10 the night of 2/14/18 and day of 2/15/18 were aware of the Resident #10's change in condition and one licensed nurse indicated Resident #10 was placed on 1:1 care but this could not be verified and was not in place at the time of the fall. There was no indication in Resident #10's medical record that the nurses up dated Resident #10 care plan for the need for increased supervision when he was clearly more confused and walking without assistance. (care plan to have assistance and wheel walker with ambulation). The investigation report document Resident #10 was not observed leaving his room and walking down the hall without his walker. (Found more than 20 feet from his bed where he was last seen at 4:30 PM). During an interview with Resident #10's physician R on 2/27/18 at 2:55 PM. Physician R reviewed Resident #10's electronic medical record and said he had assessed Resident #10 on 2/6/18 and had not seen Resident #10 since that time. Physician R was asked if he was notified that Resident #10 was confused on 2/15/18. Physician R said he would not have a record of that and had DON B look in the medical record for a nursing note. DON B said yes a nurse had called about Resident #10 being confused and Physician R ordered a urinalysis to check for a UTI. Physician R was asked if the nurse told him Resident #10 was seeing bugs and people that were not there. Physician R said no and even if he had known that he would not have done anything more at that point. Physician R proceeded to provide the Surveyor with a copy of Resident #10's hospital Neurological Surgery report dated 2/16/18 that documented, Resident #10 had been transferred to the hospital with an altered mental status after a fall. Resident #10 had a neurological decline and was incubated (breathing tube was placed). The CT (radiological test) showed a large left intraparenchymal hematoma (area of brain bleed). Surgery was not recommended because of the extent of the injury and poor prognosis. On page 6 of this report documented under plan was, ICH (intracrainial hemorage) is likely conversion of [MEDICAL CONDITION] primary Physician R pointed out this high lighted line and said it was his opinion based on this information that Resident #10 fell because of a stroke.

This citation pertains to intake number MI 212. Based on observation, interviews, and records review, the facility failed to prevent Resident (#102) from slapping Resident (#106) and failed to prevent Resident # 102 from repeated incidents of verbal and mental abuse for 4 (#'s 101,103,104, and 105) of 6 sampled residents from a total sample of 6 residents, resulting in, fear, anger, pain, and frustration. Findings include: Review of the facesheet revealed Resident #102 was an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets dated 6/27/2014 revealed Resident #102 was severely cognitively impaired, experienced both long- and short-term memory loss, and required supervision from facility staff to perform activities of daily living (ADL's), including wandering/ambulation. Resident #102 was identified with verbal behaviors (including threatening others, screaming at others, cursing at others) and other behaviors not directed at others (such as rummaging; searching through the belongings of others) all of which were assessed to have occurred "four to six days per week, but less than daily." The Physician order [REDACTED].#102 was to wear a wanderguard device (monitoring bracelet) on her left ankle. According to the Psychiatric Follow-up Evaluation dated 6/9/2014 (untimed), Resident #102 continued daily medical management of her condition (dementia complicated by anxiety) with administration of [MEDICATION NAME] (initiated 3/21/2014) and [MEDICATION NAME] (initiated 4/8/2014). The Mood Care Plan initiated 4/3/2014, identified Resident #102 had experienced conditions such as depression, anxiety, and memory impairment. This care plan was revised on 6/23/2014 to include "increase of behaviors at sundown," though there were no specific behaviors identified until a revision of the care plan, dated 7/25/2014 (date of State Surveyor's entrance to the facility), that specified behaviors included "agitative behaviors such as hitting, threatening statements, slapping, verbal statements of frustrations regarding others." Interventions included psychiatric consultation, diversion activities, administration of medications, interacting with the Resident in a calm, reassuring manner, and allowing the Resident to express her fears/concerns. Review of Resident #102's Nurses Notes for the period 5/8/2014 through 7/25/2014 included the Resident "yelled at staff and other guests, and often used inappropriate language while entering other guests rooms, both day and night, without being invited, and is difficult to redirect at times" for the dates 5/8/2014, 5/15/2014, 5/22/2014, 6/5/2014, 6/8/2014, 6/9/2014, 6/12/2014, 6/14/2014, 6/15/2014, 6/18/2014, 6/19/2014, 6/20/2014, 6/25/2014, 6/27/2014, 6/30/2014, 7/4/2014, 7/16/2014, 7/18/2014, and 7/21/2014. Resident #101 The facesheet revealed Resident #101 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #101 was cognitively intact and required supervision with ADL's. During an interview on 7/25/2014 at 9:55 AM, Resident #101 said, "They (facility staff) have put Velcro "stop" signs over our doors to keep her (identified as Resident #102) out. Those signs mean nothing to her; she rips 'em off. She comes in my room daily. She's shown me her fist. She uses a lot of profanity. She screams at me. She wanders all the time. She's free to roam; no one is with her. I saw her hit him (identified as Resident #106); he's in a wheelchair and can't defend himself; makes me angry." Resident #103 The facesheet revealed Resident #103 was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #103 was cognitively intact and required minimal assist from facility staff with ADL's. During an interview on 7/25/2014 at 8:55 AM, Resident #103 said, "She (identified as Resident #102) wanders into everyone's rooms here. She argues with you and uses four-letter words. She's all whacked out. Makes me angry they just let her go like that. She just wanders in and stays awhile. She irritates the hell out of me." Resident #104 The facesheet revealed Resident #104 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #104 was cognitively intact and required extensive assist with ADL's. During an interview on 7/25/2014 at 9:35 AM, Resident #104 said, "She (identified as Resident #102) gets mad. She says 'son of a [***] .' She scares me. She yells. Comes daytime, night. Stop sign doesn't work; pulls it back. Comes in. She's mean. She slapped him (identified as Resident #106)." Resident #104 was observed to cry, inconsolably, during the interview with the State Surveyor and say she was "afraid" of Resident #102. Resident #104 was observed by the State Surveyor to watch the doorway to her room, repeatedly, and plead with the State Surveyor to "keep her (Resident #102) out of here." Resident #105 The facesheet revealed Resident #105 was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed Resident #105 was mildly cognitively impaired, and required extensive assist from facility staff with ADL's. During an interview on 7/25/2014 at 1:20 PM, Resident #105 said, "I've got a stop sign on my door to keep a certain person (identified as Resident #102) out of here. She comes in here one or two times a week. She looks at my stuff; thinks it's her's. Hasn't taken anything. She's threatened to hurt me. She screams and yells obscenities at me. She scares me. She stays in here about 10 minutes before anybody comes to get her out of here. They're not doing enough to keep her out of my room; makes me angry. She's even wandered in here at night; it scared me. The velcro stop sign doesn't stop her; she takes it down. I worry about her hurting me; she gets very angry, yells, and threatens. She's unsafe." Resident #106 The facesheet revealed Resident #106 was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #106 was severely cognitively impaired and required extensive assist with ADL's. According to the Incident Report dated 7/21/2014 (untimed), and the Narrative Nursing Note dated 7/18/2014 at 5:00 PM, Resident #106 was observed by facility staff to have been "smacked in the mouth" on 7/18/2014 at 4:00 PM by Resident #102 as he was putting a puzzle together. Both Residents were separated. Resident #106 was reported to have sustained no injury. Unsuccessful attempts were made to interview Resident #106 on 7/25/2014 at 1:05 PM, and again on 7/28/2014 at 11:40 AM. During a phone interview on 7/28/2014 at 2:28 PM, LPN "C" said, "She's (identified as Resident #102) a wanderer, all the time. Almost daily other residents complain she's wandering into their rooms. I'd heard her tell Resident #106 she wanted to smack him; she eventually did. Residents have said they're fearful of her. She goes into other residents' rooms, even at night. Some residents (identified as Resident #101 and Resident #103) have complained and so have we. I've told the Director of Nursing and also the Administrator here, that she (Resident #102) didn't fit here and that other residents aren't protected." During an interview on 7/28/2014 at 10:40 AM, Certified Nurse Aide (CNA) "D" said, "She (identified as Resident #102) yells at other residents. She needs to be in a special dementia unit." During an interview on 7/28/2014 at 1:30 PM, LPN "B" said,"She's (identified as Resident #102) is a wanderer. We get complaints about her daily. She wanders into other's rooms all the time. I saw her smack him (identified as Resident #106) in the mouth. Many residents are upset with her. She's impulsive. It doesn't surprise me that she hit him (Resident #106). She's not appropriate for this facility; she needs more one on one care." During an interview on 7/28/2014 at 2:10 PM, Social Work Director "E" said, "I've received complaints about her (identified as Resident #102). She wanders into other residents' rooms. We put up velcro stop signs across residents' doors. I didn't receive any complaints of aggression by her until recently. I'd heard she had slapped a male resident (identified as Resident #106). I didn't do follow up with him because he's mentally retarded, and probably wouldn't have remembered the event. To protect other residents, we have put up the stop signs and keep her in our vision at all times; we try to watch her." On 7/25/2014 at 9:55 AM, Resident #102 was observed by the State Surveyor to enter the main dining room where she sat with the surveyor, and no other facility attendants, until 10:17 AM when two facility staff members entered the dining room. During an unannounced, on site complaint investigation conducted 7/28/2014, care plans for Residents #101, #103, #104, #105, and #106 were reviewed; there were no care plans developed, with interventions, to protect these identified residents from verbal and/or physical abuse. On 7/25/2014 at 10:50 AM, resident rooms #16, #17, #19, and #21 were observed with velcro stop signs across the doorways. Review of Resident Council Meeting minutes for April 2014, May 2014, June 2014, and July 2014 revealed residents' concerns with Resident #102's wandering into other residents' rooms, after removing velcro stop signs from doorways, where she rummaged through others' possessions, used foul language, and was rude. During an interview on 7/28/2014 at 4:55 PM, the Director of Nursing said interventions to protect other residents from Resident 102 were "stop signs, but she takes them down and goes in other's rooms anyway, and our staff are on alert when she wanders, including direct visualization at all times; we try to at all times." During an interview on 7/28/2014 at 5:15 PM, the Nursing Home Administrator said the "goal of care to all residents, when another resident wanders and is aggressive both verbally and physically, is to reassure affected residents of interventions, educate guests who may not understand the wandering resident's diagnoses, provide safety in this facility, and make sure all residents understand this is a safe place." ( )

This citation pertains to intake MI 999. Based on observation, interview and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 13 sampled residents (Resident #100) reviewed for elopement, from a total facility census of 42 residents, resulting in an Immediate Jeopardy when, on two separate occasions, Tuesday, June 17, 2014 at 6:20 p.m. and on Monday, July 7, 2014 at 6:00 p.m., Resident #100 who was a known elopement risk and had a secure care monitoring bracelet on his ankle (an elopement monitor activated by the wander system on the door), eloped from the facility unbeknownst to facility staff. This deficient practice placed 12 residents at risk for serious harm, injury, and/or death. The immediate jeopardy began on or before 6/17/14 at 6:20 p.m., based on review of the incident report dated 6/17/14, which revealed Resident #100 was observed outside of the facility on the picnic table in back of the facility, out of sight of staff alone and unsupervised. The area where he was located lead to open fields, the parking lot and the road. Per interview done on 7/10/14 at 2:15 p.m., the Director of Nursing (DON) said when the resident first came to the facility on [DATE] (his original admission), he was assessed to be at risk for elopement and a secure care monitoring bracelet was put on him and it was kept on him through his last 2 admissions (3/28/13 and 4/6/13), due to his continued risk for elopement. Review of Resident #100's Admission Care Plan dated 1/4/13, revealed "Wander Guard (secure care monitoring bracelet) to L (left) ankle." During an interview done in the Admission office on 7/10/14 at 1:40 p.m. with staff member "H" (Charge Nurse, LPN), she stated "He (the resident) just loves to go outside, he got out (on 6/17/14) when he followed me out the employee door by himself. I saw him in the hall, I said I'll see you and he went out the door behind me, I didn't see him go out the door, I did not know about it until I got back to work. He needs to be somewhere we can see him." In an interview done in the Admission office on 7/10/14 at 3:55 p.m., with staff member "N" (Maintenance), he revealed the resident was able to walk out the employee door without the door alarm sounding because the door did not have a secure care monitoring system alarm on it and there was a 30 second delay from the door opening to completely shutting. The door alarm would have activated when the door bar was pushed to open it, however the door did not have the chance to close completely after staff member "H" left before the resident caught the door and walked out without the alarm sounding. The immediate jeopardy was identified at approximately 3:00 p.m. on 7/10/13, based on staff interviews done in the Admissions office on 7/10/14 (at 1:40 p.m., 2:03 p.m. and 2:10 p.m.) with staff members "H", "J" (Housekeeper) and "K" (Nursing Assistant/CNA) and review of the facility incident reports dated 6/17/14 and again on 7/7/14. Review of the incident report, dated 6/17/14, revealed Resident #100 had eloped from the facility on 6/17/14 at 6:20 p.m., through the employee entrance/exit door, following staff member "H". Review of the incident report dated 7/7/14, revealed on 7/7/14 at approximately 6:00 p.m., Resident #100 was observed by staff member "L" (Therapist) as she was driving past the facility, walking on the side of the a 2 lane, winding road with large trees blocking drivers view from a short distance, out of sight of the facility, alone and unsupervised. Facility staff were not aware Resident #100 had left the facility; his secure care monitoring bracelet had not activated the front door he went out, which was equipped with a secure care monitoring alarm system. The Administrator was notified on 7/11/14 at 11:05 a.m. of the immediate jeopardy that began on 6/17/14 at 6:20 p.m., due to the facility's failure to recognize, monitor and intervene in a timely manner for Resident #100, who was NPO (nothing by mouth) and on tube feedings and who had a known pattern of not going to the dining room at meal times (due to being NPO and not eating) and known behaviors of wandering and wanting to go for a walk outside at or around diner time (5:30 p.m. to 6:00 p.m.). Findings include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 3/20/14 and 4/24/14, [DIAGNOSES REDACTED].#100 was a [AGE] year old male, admitted to the facility on [DATE], was moderately cognitively impaired, dependent on staff assistance with Activities of Daily Living (ADL's), had right sided impaired vision, unclear speech with difficulty understanding and making himself understood, had dysphagia (difficulty swallowing), was NPO and receiving tube feedings and had a history of [REDACTED].#100's [DIAGNOSES REDACTED]. Resident #100 was assessed by the facility to be at risk for elopement upon admission and had a secure care monitoring bracelet applied to his ankle due to his elopement risk, was independent with mobility, had wandering activity and communication to staff of wanting to leave the facility and go to Lansing (where his family member lived). Review of Resident #100's physician order [REDACTED]. A side effect of Zyprexa is sedation; with the decrease in dose the resident would become more alert. Observation of Resident #100 was done throughout the investigation on 7/10/14 (at 8:30 a.m. to 4:00 p.m.), on 7/11/14 (at 7:30 a.m. to 4:00 p.m.) and on 7/14/14 (at 8:00 a.m. to 11:00 a.m.). Resident #100 was not able to be interviewed due to [DIAGNOSES REDACTED].#100 was observed to be neat, clean, well groomed, dressed appropriately and had a secure care monitoring bracelet on his right ankle. He was observed during the investigation (7/10/14 to 7/14/14) to stay to himself most of the time, walking independently around the facility and frequently sitting at or near the front door watching staff and visitors go by. During meal times (at 7:45 a.m. and 12:00 p.m.), he was observed in his room or sitting near the front door by himself. Review of the Physician order [REDACTED]." Review of the Cognitive Care Plan dated 1/8/14, revealed "Provide safe environment for wandering." Review of the Wander Care Plan dated 7/1/14, revealed "at risk for elopement due to his independent mobility and statements of wanting to go shopping or go to Lansing. Redirect away from exit doors, observe whereabouts frequently." Review of the Behavior Care Plan dated 1/8/14, revealed "Potential for behavior problems related to [DIAGNOSES REDACTED]. He (Resident #100) also has a [DIAGNOSES REDACTED]. He also has a dx (diagnosis) of TBI (Traumatic Brain Injury) and recent CVA (stroke) which has effected his cognitive status." Review of the mental status evaluation (BIMS) dated 7/3/14; Resident #100 was moderately cognitively impaired. Review of the PT evaluation dated 4/23/13, revealed "Gait Analysis Deviations: Patient exhibits forward lean of trunk and knee wobble which are associated with the underlying causes of abnormal tone. Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for anxiety and falls." Review of the MDS dated [DATE], revealed the resident required supervision with locomotion on unit. An interview was done in the Admission office on 7/10/14 at 3:10 p.m., with staff member "M" (Restorative staff). Staff member "M" stated "I walk him (Resident #100) daily, we walk in the employee parking lot and go around in circles. He likes to sit at the picnic table. He walks faster than me." When asked by this surveyor if she would trust the resident outside of the facility by himself she stated " no, I don't think he knows what to do outside." An interview was done in the Admission office on 7/10/14 at 1:55 p.m., with staff member "I" (Social Service and Activity Director). Staff member "I" stated "We don't have any activities going on at dinner time (approximately 5:30 p.m. to 6:30 p.m.). Sometimes I take him (Resident #100) out on break with me, between 5:30 p.m. and 6:00 p.m.; he sits on the picnic table." Review of the 6/14 Activity Calendar revealed on 6/17/14 at 5:00 p.m., "Reminiscing" was offered and on 7/7/14, no activity was offered between 5:00 p.m. and 7:00 p.m. During an interview done in the Admission office on 7/14/14 at 8:15 a.m., staff member "I" said on 6/17/14, the activity was ended by "5:30 p.m." Resident #100 Elopement on 6/17/14: Review of the incident report and staff statements dated 6/17/14, revealed staff member "J" (Housekeeper) was on break when she saw Resident #100 walking outside in the courtyard, open the courtyard gait, enter the employee parking lot and sit on the picnic table behind the facility, out of sight of staff, alone and unsupervised. During an interview done in the Admissions office on 7/10/14 at 2:03 p.m., staff member "J" stated she "went inside and (staff member "O", Charge Nurse, RN) was there, she did not know he was outside." Staff member "J" left Resident #100 outside alone while she went in the facility and reported to staff member "O" that he was outside alone. In a telephone interview done on 7/11/14 at 10:05 a.m., staff member "J" stated, "I didn't see him walk through the courtyard (out the employee door, down steps and into the courtyard)" and stated "I don't know how long he was in the courtyard." Observation of the facility employee door, the courtyard, employee parking lot and the picnic table was made on 7/10/14 at 2:15 p.m., accompanied by the Director of Nursing (DON). The employee door was at the end of a long hallway out of sight of the nursing station and opened to steps going down into the courtyard. A white fence surrounded the courtyard which had 3 non-locked singled latched doors which this surveyor easily opened with one hand. In the courtyard there were 2 rusty metal pipes approximately 4 feet in length each sitting by the sidewalk on the grass and a black grill scraper with a razor blade-like on the end of it sitting in sight on the side of the grill, which the DON promptly removed and said it should not have been left out. The employee parking lot and facility grounds had no fence, was surrounded by wooded areas and lead to the sides of the building, into the front parking lot and directly to the road. Per interview done in the Admission office on 7/11/14 at 11:20 a.m. with staff member "Q" (Certified Nurse Aide/CNA) and per review of staff member "Q's" hand written statement dated 6/17/14 revealed she had seen the resident outside on 6/17/14 at 6:00 p.m. alone by the courtyard fence. Staff member "Q" stated, "I was in the main dining room feeding about 6:00 p.m., I looked up and saw (Resident #100) walking by himself. I had my eyes on him for 5 to 7 minutes, I didn't tell anybody, (supplemental resident #109) said "(the resident) was outside without anyone with him." (Resident #109) went up to tell a nurse (unable to recall name)." When this surveyor asked staff member "Q" why she did not tell someone immediately Resident #100 was alone outside, she stated, "because if I leave the dining room while people were eating, I will get in trouble." An interview was done in private in Resident #109's room on 7/11/14 at 11:30 a.m. Resident #109 stated, "I saw him (Resident #100) walk by my window (from her table in the dining room on 6/17/14). I walked to find somebody to tell." Resident #109 informed staff (she was unable to recall the staff's name) she had seen Resident #100 outside alone. Review of Resident #109's BIMS assessment dated [DATE] revealed she was "cognitively intact." Review of Resident 109's physician note (un-dated), stated "she is mentally competent." During an interview done in the Admission office on 7/11/14 at 7:50 a.m. and per hand written statement dated 7/11/14, staff member "O" (Charge Nurse/Registered Nurse/RN) stated "(Resident #109) came and told me he (Resident #100) was outside alone about 6:30 p.m. (on 6/17/14). I went out the front door, didn't see him, I walked around the back and he was sitting at the picnic table by himself. The employee door did not alarm when he went out it, if you push on the bar the alarm should go off. I called the DON and told her, she said she would call me back. The DON called and asked if (Resident #100) was in sight of staff at all times, I said 'no, I wish I could tell you he was but, he wasn't.' She (the DON) told me to chart "Guest observed outside, staff alerted nurse, guest brought back inside. Guest was in sight at all times." I was told to chart this in the nurse's notes (on 6/17/14, after the resident's elopement). On 6/21/14, I came back to work that day, the charting clarification dated 6/18/14, was written by the DON not me. I didn't talk to the DON about the charting and she didn't talk to me until 7/10/14 (the first day of the investigation)." Review of the nurse's notes dated 6/17/14 at 9:47 p.m., (signed by staff member "O") revealed, "Guest observed outside. Staff alerted nurse. Guest brought back inside. Wanderguard (secure care monitoring bracelet) assessed and evaluated to be in place and in working condition." Review of the nurses notes dated 6/18/14 at 5:08 p.m. (electronically signed by staff member "O" and the DON) revealed, "Clarification for charting 6/17/14-Guest was within site (Sic, sight) of staff at all times while outside. Guest stated he didn't know what the problem was with going outside. Guest was guided willingly back into the building and educated on being accompanied with staff when sitting outside " Review of the physician progress notes [REDACTED]." An interview was done in the Admission office on 7/11/14 at 9:10 a.m., with the Administrator and the DON. The Administrator stated, "we did not report the elopement (on 6/17/14) because based on our investigation and statements; he was within staff's sight." The Administrator reviewed the incident report and all staff statements regarding the elopement on 6/17/14 that were given to this surveyor and it was agreed by the Administrator that this surveyor had the same incident report and all staff statements she had. The Administrator stated "maybe I should have reported it" and added that she was not done interviewing all staff yet regarding her investigation of the elopement on 6/17/14 (23 days prior). An interview was done in the Admission office on 7/11/14 at 10:40 a.m., with the DON. The DON confirmed she had electronically entered the nurses notes dated 6/18/14, regarding the clarification of the notes written on 6/17/14 and stated, "I was told that someone saw him (Resident #100) the whole time outside, I don't remember who. I looked at the statements (staff written accounts of the elopement of 6/17/14) yesterday (on 7/10/14) for the first time." The DON said the incident report and staff statements were not made available to her until 7/10/14. Review of the facility Incident Reporting for Incidents Involving Facility Guests (Residents) policy dated 2/12, revealed, "The Administrator will oversee the investigation of the incident and will notify the Home Office, if appropriate, according to the (Facility) policy, and will notify the Licensing Entity if appropriate." Resident Elopement on 7/7/14: Review of the incident report and staff statements dated 7/7/14, revealed on 7/7/14 at 6:00 p.m., staff member "L" (Therapist) was driving past the facility and saw Resident #100 hitch hiking on the side of a winding country road with large trees blocking his full view from drivers alone and unsupervised. Staff member "L" called the facility and informed them she had seen Resident #100 hitch hiking on the side of the road, out of sight of the facility and by himself. Facility staff were not aware Resident #100 had left the facility and no door alarms had been activated when he left the building. Staff went looking for Resident #100 and found him alone and out of sight of the facility, on the side of the road past the stop sign, hitch hiking with cars going by. Review of the nurse's notes dated 7/7/14 at 7:10 p.m. revealed, "Received an outside call from (staff member "L") in therapy stating she observed guest (Resident #100) ambulating down the road. Guest was retrieved via personal vehicle by this nurse (staff member "O") at (road past the stop sign) and (second road) near stop sign with thumb out hitch hiking, front door assessed and found to not be locking properly." An interview was done in the Admission office on 7/10/14 at 2:45 p.m., with staff member "L". Staff member "L" (Therapist) stated, "I was off work. I was coming around the corner (near the facility) and I saw the resident (#100) on the grass on the right side of the road, he was hitch hiking. I didn't talk to him (Resident #100) at all. I called the facility about 6:00 p.m., I told the staff where to go to find him. I saw a CNA (unable to recall name), picked her up and the nurse (staff member "O") followed me (in staff member "L's" car), the nurse told him to get in her car and he did." Staff member "L" confirmed on 7/7/14, cars were driving past Resident #100 when she saw him. An interview was done in the Admission office on 7/11/14 at 7:50 a.m., with staff member "O" (Charge Nurse/RN). Staff member "O" stated, "I punched in (on 7/7/14) and answered the phone call from (staff member "L") about 6:00 p.m. She called and said (Resident #100) was hitch hiking down around the corner. I told (staff member "A"/Charge Nurse/LPN) that he (#100) was out of the building. He ("A") said 'I'm going to get him.' I ran to the stop sign and I couldn't see him, I ran back to the building, got my keys and went to get him. I drove to the stop sign and turned left and he was on the grass at the side of the road hitch hiking, he had his thumb out. I put him in my car and took him back to the facility. All the staff is in the dining rooms feeding at 6:00 p.m., except for 1 CNA for South and East halls." Observation of the location where Resident #100 was found on 7/7/14 was done by this surveyor accompanied by staff member "L" on 7/10/14 at 2:45 p.m., during her interview. The location he was found at was past the corner stop sign to the left, on the grass at the edge of a two lane curvy road with large trees on both sides blocking full view of the sides of the road, out of sight of the facility, a total of 0.2 miles from the facility driveway. An interview was done in the Admission office on 7/10/14 at 12:15 p.m., with staff member "A" (Charge Nurse/LPN). Staff member "A" confirmed Resident #100 had eloped out the front facility door on 7/7/14 and was found out of sight of the facility on the side of the road, alone and hitch hiking. Staff member "A" stated, "We (staff) got in a vehicle and went to look for him, he came back with us. I checked the front door, there was a nipple bumper on the door, it was holding the door open, one of the screws was coming out and it caused the door to not close fully (a small square metal piece with 4 screw holes that was attached to the top of the front door, part of the door frame). I took it off and gave it to (an office staff member, he was unable to recall name)." An interview was done in the Admission office on 7/10/14 at 3:55 p.m. with staff member "N" (Maintenance). Staff member "N" was asked by this surveyor if on 7/7/14, if there was a small metal piece on the facility front door that was preventing the door from completely closing, Staff member "N" said, "yes" and pulled it out of his pocket and showed it to this surveyor. It was a small square-like shape with 4 holes for screws on each corner, with a rounded piece of metal about ? inch in length in the middle. Staff member "N" stated "it was keeping the door (front door) open about a ? inch, you couldn't see it with your eyes, the nurse (staff member "A") took it off (on 7/7/14). The issue with the door was his (Resident #100's) wander guard alarm (secure care monitoring sensor bracelet) did not go off and the door did not completely close." Resident #100 had a secure care monitoring sensor bracelet on his ankle and the facility front door was equipped with a secure care monitoring system that should have activated when a sensor bracelet was within a 3 to 4 feet range of the door and thus causing the door to automatically lock preventing any resident wearing a wandering device to not be able to leave the facility. An interview was done in the Admission office on 7/10/14 at 1:30 p.m., with staff member "G" (CNA). Staff member "G" stated, "I was here, I didn't hear any alarms (door alarms) go off. (Staff member "A") tried to fix it (the front door). It could have been prevented if the door alarm had been working, maybe if activities could take him (Resident #100) on a walk during dinner." An interview was done in the Admissions office on 7/10/14 at 1:40 p.m., with staff member "H" (Charge Nurse/LPN). Staff member "H" stated, "I was (Resident #100's) nurse on 7/7/14. He just loves to go outside, it was around 5:15 p.m., he was sitting by the front door. I checked his ankle wander guard earlier that day." Resident #100's secure care monitoring sensor bracelet was found to be in working condition by staff member "H" on 7/7/14. Staff member "H" said she had checked the residents secure care monitoring bracelet by using a hand held electronic sensor monitor/tester; it was not checked for proper functioning at the front door. An interview was done in the Admission office on 7/10/14 at 1:25 p.m., with staff member "F" (Charge Nurse/LPN). Staff member "F" stated, "He's (Resident #100) always attempting to push open the doors, the back door and employee door, about once every other day he tries to go out the doors." Review of the "Know Your Rights, Your Medicaid Care And Coverage In A Nursing Facility" dated 12/11 revealed, "You have a right to live in a safe, clean, comfortable, and home-like nursing home." (Michigan Department of Community Health, page 5) On 7/10/14 at 10:00 a.m., this surveyor confirmed that the facility implemented the following to remove the immediate jeopardy. 1. On 6/17/14 at 6:20 a.m., Resident #100 was assessed with [REDACTED]. All exterior facility doors were assessed, with no malfunctions identified. 2. On 6/17/14 at 6:30 p.m., the facility initiated 15 minute checks of Resident #100 until 6:30 a.m. on 6/18/14. 3. On 6/18/14, the facility changed all five exit doors alarm systems to signal at 15 seconds from the 30 second previous time (delayed door closing time). 4. On 6/18/14 education via a typed sign was posted on the importance of closing all exit doors after leaving the building and maintaining all courtyard gates in a closed position. 5. On 7/7/14 Resident #100 was returned to the facility and assessed, with no injuries found. 6. On 7/7/14, upon return of the resident to the facility, he was put on one-to-one observation while out of bed and 15 minutes checks while sleeping until 7/8/14 at 7:00 a.m. 7. On 7/7/14, all facility residents were put on 15 minute checks until 7/8/14 at 7:00 a.m. 8. On 7/7/14, upon return to the facility, Resident #100's secure care bracelet was checked and found to be functioning properly. 9. On 7/7/14, the front door secure care system was checked and found to be malfunctioning. The facility placed a staff member at the front door and remained at the door until 7/7/14 at 11:30 p.m., when the door alarm company repair staff arrived at the facility. Repairs were made including replacement of the door magnets, the right antennae, door closure mechanism and key pad. A facility staff member remained at the front door to monitor function until 7/8/14 at 7:00 a.m. 10. On 7/8/14 at 7:00 a.m., a facility staff member has checked the front door for proper function every 15 minutes and continued until 7/10/14. 11. On 7/8/14 a total of 52 of 56 staff members had been educated by the Administrator, Director of Nursing or designees on proper function of all alarmed doors and what to do if they notice the alarms are not working. This included 12 of 13 Licensed Nurses, 21 of 21 Nursing Assistants/CNA's, 3 of 4 Therapy staff, 6 of 6 Environmental staff, 4 of 6 Dietary staff and 6 of 6 ancillary staff. All 4 remaining staff will be educated prior to beginning their next scheduled shift by the Administrator, Director of Nursing or designated staff with documentation of training. 12. On 7/8/14, additional upgrades were made to the facility front door (replace the right antennae) by Secure Care staff. 13. On 7/9/14, the facility installed an additional secure care monitoring system to the Dietary Manager's office exit door for added security. 14. The Maintenance supervisor or designee monitored the facility front door for proper function daily for 3 consecutive days (from 7/8/14 through 7/10/14) and monitoring will continue 3 times/week for 30 days then weekly. The 4 other facility doors will continue to be checked and monitored weekly. 15. On 7/10/14 at 5:00 p.m., the facility front door antennas were adjusted; the door alarm system was tested and found to be functioning properly. 16. On 7/10/14, all facility residents with secure care monitoring sensors (bracelets) were re-assessed for on-going use of the devices. One resident upon reassessment was deemed to no longer require a secure care monitoring sensor. 17. On 7/10/14, the facility reviewed policy's regarding elopement and no changes were made. 18. On 7/10/14 and 7/11/14, the facility courtyard was assessed for potential dangerous items and all were removed. The courtyard will be monitored by the Maintenance supervisor or designee. 19. The facility will continue to monitor 12 of 12 residents assessed (on 7/10/14) to be at risk for elopements bracelet sensors for placement by the charge nurses every shift and their function daily. Documentation of the checks will in each resident's clinical record. This documentation begins with application of the bracelets and continues until discharge. 20. New employee's orientation will continue with education on supervision to prevent resident elopements and proper function of the secure care system will be added. On-going education is provided through the facility's annual in service calendar. 21. On-going monitoring and compliance will be conducted by the facility Licensed Administrator and reported to the Quality Assurance Committee for oversight. Although the immediate jeopardy was removed on 7/10/14, the facility remained out of compliance at a scope pattern and severity of no actual harm with the potential for more than minimal harm due to all nursing staff having not yet been in serviced and the facility's ability to sustain compliance pending verification by the State Agency. ( )