Every finding on record at The Laurels of Hudsonville

This citation pertains to intake 3119541 Based on interview and record review, the facility failed to thoroughly investigate alleged neglect and maintain documentation that an alleged violation was thoroughly investigated for one resident (R5) out of 4 residents reviewed for abuse and/or neglect. Findings include: Review of an admission Record reflected R5 admitted to the facility on [DATE] with diagnoses that included gallbladder cancer, dementia, and was receiving hospice care. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R5 had short- and long-term memory problems.Review of a Home Care Visit note, dated [DATE], reflected that while a hospice social worker conducted a routine visit, R5 was found visibly soiled all around the groin/hip area. The note indicated the hospice social worker informed the facility charge nurse that R5 was very soiled through her clothing and left a communication note in the hospice binder at the nurse's station.During an interview on [DATE] at 10:41 AM, Power of Attorney (POA) L said the hospice social worker had informed her of how R5 had been discovered on [DATE]. POA L reported that R5 had a recent and unexpected room change on [DATE], was not being cared for by the same team of caregivers and felt that R5's condition deteriorated because of this. POA L said they reported their concerns regarding R5 being left wet and soiled for an extended period, as well as being dressed in men's clothing and lacking in basic hygiene and grooming, such as hair and toenail care. POA L said they felt R5's condition reflected neglect and hastened her death. POA L said they emailed the facility about their concerns and had a meeting with the Nursing Home Administrator (NHA) after R5 passed away, sharing photos of R5 that reflected R5 dressed in men's clothing, extremely long and broken toenails as well along with photos that reflected R5 in good condition prior to the room change. Review of an email message send by POA L to the facility's former business office manager, sent on [DATE] reflected, The room change for (R5) is not working. I (POA L) would like her moved back to 203 in the same spot. She is not getting the same care as she was before. The report today from the social worker said she sat in her urine through her pants for hours. This is unexpectable (sic) and never happened with her previous aides. (Names of 3 aides) would have never let that happen. The reply from the former business office manager was I have forwarded your request to the appropriate department.During an interview on [DATE] at 8:13 AM, the NHA reported that he met with POA L on [DATE] after R5 passed away. The NHA reported POA L reported her care concerns and gave him several pictures of R5 that were allegedly taken while R5 lived at the facility. The NHA said he completed a Guest Assistance Form indicating the reported concerns. The Guest Assistance Form and pictures of R5 were reviewed at this time. Two images reflected R5 allegedly in her former room according to the previous room number written on the image by POA L, appearing well groomed and smiling. Another picture reflected R5, allegedly after the room change, with her eyes closed and wearing a sports team logo shirt with the caption (New room number) After move.wearing man shirt - not hers (R5's). Another image was allegedly of R5's foot and showed very long and cracked toenails, the word Neglect written on the image. The last two photos showed R5 deceased . On one image (New room number) After move - Dead in 8 weeks. Change in care team; the other image, (New room number) Passed away Aug (August) 1. The NHA said he addressed the notification of room change concern but did not report an allegation of neglect, nor did he investigate the alleged neglect as the result of the meeting with POA L on [DATE].Review of the facility Abuse Prohibition Policy last revised [DATE] reflected, 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. The policy specified, Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, 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. The policy defined neglect as, the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, goods or services that a guest/ resident(s) requires but the facility fails to provide them to the guest(s)/resident(s), resulting in physical harm, pain, mental anguish or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress. The policy defines an adverse event as, an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.

This citation is related to intake # 3107907 Based on interview and record review, the facility failed to follow the five rights of medication administration for one of three residents (Resident #3) reviewed for significant medication errors. Findings:Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of Diabetes Mellitus and chronic kidney disease. Review of a nursing Progress Note dated 07/21/26 reflected that R3 .was given the wrong insulin and bedtime medication pass .R3 went to the local acute care hospital for further assessment. Review of a Medication and Treatment Error form, dated 07/22/26, noted .the nurse was preparing R3's medication and got interrupted and gave the wrong insulin. During an interview on 08/17/26 at 11:53 AM, the Director of Nursing stated that R3 had been given the wrong type of insulin on 07/21/26. Review of the facility policy and procedure Medication Administration last approved 10/17/23, reflected that nurses will .verify the medication label against the medication administration record for resident name, time, drug, dose, and route.

This citation pertains to intake 3119541Based on interview and record review, the facility failed to ensure adequate foot care was provided for 1 resident (R5) out of 1 resident reviewed for foot care. Findings include:Review of an admission Record reflected R5 admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and was receiving hospice care. During an interview on 8/17/2026 at 10:41 AM, Power of Attorney (POA) L reported they discovered R5 had extremely long and broken toenails during a visit in July 2026. POA L said they were upset R5 had not been cared for appropriately and did not understand why they had to bring the care concern to the nursing staff's attention when R5 was dependent on staff for care.Review of a Care Plan Report, initiated on 8/20/2025, reflected R5 was At risk for fluctuation in blood sugar levels R/T (related to) DM (diabetes mellitus). The goal of the care plan was to avoid complications related to diabetes. An intervention in the care plan, initiated on 8/25/2025, included Check body for breaks in skin during care/showers and treat promptly as ordered by physician. Inspect feet during care/showers for sores, pressure areas, blisters, edema or redness; Provide proper foot care as needed. Observe for changes in circulation. Observe for changes in skin integrity to the feet. Document findings and report and (sic) abnormal findings to the physician. Podiatry consult as needed. Review of weekly skin assessments from 5/10/2026 - 7/13/2026 reflected an assessment of the feet was an aspect of the weekly assessment. None of the assessments indicated R5 had overgrown and cracked toenails. During an interview on 8/17/26 at 2:27 PM, the Director of Nursing (DON) reported that it is her expectation that feet and toes are examined as a part of the weekly skin check. When asked, she reported that she was not aware of R5's toenail condition until a care conference. The DON said that she had seen R5's toenails and said they looked like talons. During an interview on 8/19/2026 at 9:45 AM, Social Worker (SW) J reported that because R5's payor source was Hospice Medicaid, she was qualified for podiatry care upon admission to the facility. SW J showed a batch (multiple residents/orders) Physician Order for Ancillary Care Service dated 11/12/2025 that reflected R5 had a physician order for podiatry. Review of R5's Electronic Medical Record (EMR) reflected R5 was only seen by a podiatrist one time, on 7/22/2026.Review of a consultant podiatrist progress note dated 7/22/2026 reflected the reason for the visit was, Facility and resident's primary care provider request evaluation of foot and toenail health. Patient (R5) presents for routine foot care, evaluation and pain in feet. The podiatrist's assessment reflected between 2mm (millimeter) and 3mm thickened, painful, and yellowed toenails. The assessment indicated R5 had onychogryphosis x 10 (all toes). Onychogryphosis is commonly known as ram's horn nails, is a nail disorder where the nail plate becomes grossly thickened, hardened, and curved into a claw-like or horn-like shape. Common causes include chronic trauma, aging, medical conditions and neglect from infrequent or improper nail trimming over long periods.

This citation pertains to intake 3119541Based on interview and record review, the facility failed to ensure the responsible party for 1 resident (R5) was notified of a room change, out of 1 resident reviewed for room changes.Findings include:Review of an admission Record reflected R5 admitted to the facility on [DATE] with diagnoses that included gallbladder cancer, dementia, and was receiving hospice care.Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R5 had short- and long-term memory problems. During an interview on 8/17/2026 at 10:41 AM, R5's Power of Attorney (POA) L reported that they arrived at the facility on 5/29/2026 and found the room previously occupied by R5 empty and being cleaned by staff who told them R5 had been moved to another room. POA L said they were not notified of the room change prior to the move.During an interview on 8/17/2026 at 1:53 PM, Social Worker (SW) J reported the process for initiating and completing a room change is to conduct a room change evaluation and complete a Notice of Room Change assessment within the Electronic Medical Record (EMR) that includes notifying the responsible party. SW J reviewed the EMR and said, We did not do this for R5. Review of a facility policy Room & Roommate Assignment, last revised 9/7/2023 reflected The facility will work with residents, resident's families, and/or the resident representative when a resident is admitted or a room move is requested by one of the parties. The facility will promptly notify the resident and the resident's designated representative when there is a change in room or roommate assignment. The policy specified, 4. When making a change in room or roommate assignment, the needs and preferences of all residents involved will be considered and, when practical, may be the determining factor when such changes are made. 5. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative may receive an explanation in writing, upon request, explaining the reason for the move. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. 6. A Notice of Room Change evaluation will be documented in the medical record. A copy of this evaluation can be provided to the resident or resident representative, if requested.

This citation pertains to intakes: 2794208, 3001098, 3005108 and 2711826 Based on interview and record review, the facility failed to 1.provide care and services to ensure abnormal laboratory values were addressed, 2. Implement resident directed care for CHF (congestive heart failure) and bacteremia sepsis (blood infection), 3. Recognize, assess, and address the resident's condition, 4. Monitor, evaluate, and revise responses to interventions as appropriate, 5. Provide appropriate physician oversight, and 6. Honor the advance directives for two (R1 and R13) of 3 residents reviewed for quality of care, resulting in the unexpected death of a resident (R31) and medication not being provided as ordered (R1). Findings include:Review of a Face Sheet revealed R13 admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, cognitive communication deficit, cardiomyopathy, enterococcus (bacterial infection) unspecified, and diabetes (as listed for primary admission). Review of an Advance Directive document signed by R13 on [DATE] and by the physician on [DATE] revealed R13 requested no CPR (cardiopulmonary resuscitation). Review of the Order Summary in the EMR for R13 revealed the resident was documented as being a Full Code. In an interview on [DATE] at 6:04 AM CNA J reported she cared for R13 during the night of [DATE] through the morning of [DATE]. She remembered that R13 had trouble breathing throughout the night. She took his vital signs several times, noted they were not good, and observed that his oxygen level was low. RN K remained in the office with the ADON most of the night, and each time CNA J knocked on the door to ask him to assess R13 and presented the latest vital signs, RN K became upset. RN K told her he would give R13 a breathing treatment and then placed his CPAP (Continuous Positive Airway Pressure machine for treating sleep apnea) mask over the nasal cannula, even though the mask would not seal properly. R13 repeatedly said he could not breathe with the CPAP on his face, and RN K told him to give it a few minutes. CNA J stayed with R13, took his vital signs again, and approached RN K to suggest sending R13 to the hospital. RN K responded that he does not send anyone out on his watch. CNA J reported that she and another CNA continued checking on R13 every 10 to 15 minutes while RN K stayed in his office. She believed R13's condition was serious, but the other nurses (RN K and the former ADON) did not treat it that way. Between 4:30 and 5:00 AM, CNA J went to check on R13 one last time before beginning her rounds on the other residents and found him unresponsive. She informed RN K and code blue was initiated at that time. Laboratory ResultsReview of the Hospital Transfer of Care Document for R13 with a discharge date of [DATE] revealed the following Hospital Problems Present: *(Principal) Bacteremia due to Enterococcus (blood infection), AKI (acute kidney injury), Aortic stenosis, Bacteremia, CAD (coronary artery disease), Chronic combined systolic and diastolic heart failure (CHF), Type II Diabetes mellitus (DM), Hypertension (HTN), Nonischemic cardiomyopathy (abnormal enlargement of the heart muscle), paroxysmal atrial fibrillation (episodes of fast irregular heart beat), Right ureteral stone. Status post right ureteral stent, . stent in appropriate position, stone in similar position; bladder appears distended, Worsening renal function, Urine [culture] positive for enterococcus faecalis, 1/2 [blood cultures] positive for enterococcus faecalis, [status post] cystoscopy . Labs on [DATE] at 7:45 AM- HGB 7.4 (low), HCT 23.1% (low), .Discharge Instructions: . Continue IV (intravenous) antibiotics that were ordered prior to his admission, 2 weeks of abx (antibiotics) from 6/8 (EOT 6/22). Review of the Order Summary for R13 revealed on [DATE] a onetime order to obtain a CBC (complete blood count) with differential, CMP (comprehensive metabolic panel), BNP, and a lipid panel. Review of the Laboratory tests collected on [DATE] for R13 revealed a potassium 4.9 mmol/L (millimole/liter) (normal 3.5-5.5), BNP of 1368.9 pg/ml (picograms/milliliter) (flagged as a double high value (normal is <100)), HBG 7.7 g/dl (grams/deciliter (normal 13.7-17.0)) and flagged as a double low value, and HCT (hematocrit) 24.5% (normal 40.5-49.7), CO2 (carbon dioxide) 22 (normal 18-33), neutrophils 82.1% (normal 43.4 - 76.2, indicating an infection). No documentation indicating the practitioner acknowledged and addressed the abnormal lab values. Review of a Practitioner Progress note dated [DATE] at 00:00 for R13 revealed it was an Acute and a new patient visit (not in person). came to the [Facility] following a hospital stay for a kidney stone and AKI (acute kidney injury) following lithotripsy. He also suffers from systolic and diastolic CHF. Normally has stage 3b kidney failure. oxygen saturation 91% (normal 95-100%) Does not address abnormal preadmission labs or the abnormal labs drawn on [DATE]. Review of a Practitioner Progress note dated [DATE] at 00:00 for R13 revealed: Visit Type: Telehealth- Asynchronous . Labs reviewed. Did not indicate which labs were reviewed or a plan/order that acknowledged the abnormal laboratory values. Review of a Practitioner Diagnostic Result Review note dated [DATE] at 00:00 for R13 revealed: Date of review [DATE]. Lab or Image Type: COMPREHENSIVE METABOLIC PANEL / LIPID PANEL / BNP / CBC/DIFF & PLT / RBC. MORPHOLOGY. Plan of Action: started strict I & O s (input and output), started triamterene (diuretic) 50mg (milligrams) . Did not specify date of labs reviewed, did not acknowledge the abnormal labs, did not order parameters for I & O's, and did not establish a goal/baseline weight. Review of a Nursing Progress note dated [DATE] at 5:43 AM for R13 revealed: Resident c/o (complains of) SOB (short of breath) at [3:30 AM], VS (vital signs) 127/79 (blood pressure), P (pulse) 103 (normal 60-100), T (temperature) 99.1 (normal 98.6 degrees Fahrenheit), SaO2 (oxygen saturations) 81% on RA (room air), placed resident on 2L O2 NC (oxygen nasal cannula), then rechecked SaO2: 92-95%, no c/o chest pains noted, [Practitioner] ordered CXR (chest Xray) and Duonebs (breathing treatments) Q4PRN (every 4 hours as needed), [Laboratory] also called and gave lab result for Hgbof (sic) 7.7. Communicated that to [Practitioner] on [communication portal]. Waiting for response. No documentation to show the low hemoglobin of 7.7 was acknowledged/addressed. Review of a Nursing Skilled Care Note dated [DATE] at 12:19 AM for R13 revealed no edema, oxygen saturation of 94% via nasal cannula (no liters of oxygen documented), no shortness of breath. res makes needs known. Cont (continue) B&B (sic). Uses urinal at bedside. Con't (continue) on IV (intravenous) abx (antibiotics)for bacteremia/UTI (urinary tract infection). Review of the Laboratory tests collected on [DATE] for R13 at midnight, the night before he passed away, was received by the Laboratory on [DATE] at 1:22 AM, and resulted on [DATE] at 11:05 AM revealed a potassium level of 5.8 (normal 3.5-5.5), BNP 1477.2, HGB 5.5, HCT 18.1%, and neutrophils 85.5%, and CO2 level was 17.0. Review of a Nursing Progress note dated [DATE] at 3:22 PM for R13 revealed a urine specimen was sent to the Hospital lab. Urine was thick, murky, and tan in color. No documentation to show the physician was notified of findings while waiting for results. Review of the Urinalysis dated [DATE] for R13 revealed a positive culture with Citrobacter [NAME], a bacteria and Candida tropicalis, a fungus. This urine culture resulted after R13 passed away. In an interview on [DATE] at 10:07 AM, the DON was asked about the laboratory report on [DATE] that reflected a low HGB and HCT as well as an elevated BNP, the DON reported the Practitioners had direct access to laboratory results and were to address them if needed and give new orders if indicated. The DON reported she would be concerned about those lab values and could not verify if the physicians were notified of the labs and if they were addressed. The DON stated an elevated BNP could mean R13 had fluid overload. The DON verified the Practitioner Progress note dated [DATE] did not show an assessment/plan, only diagnoses. When questioned about another set of labs drawn on [DATE] for R13, the DON could not find any information on who ordered them or why and verified that they resulted on [DATE] after the resident passed away. The DON verified that there was a urinalysis sent to the lab on [DATE] which revealed R13 also had a urinary tract infection (UTI) and the final result (preculture) was at 4:47 PM. The final urine culture did not result until [DATE]. The DON verified that COPD is a different disease process than CHF (congestive heart failure) and verified she could not find any documentation indicating R13 had COPD. Decreased oxygen-carrying capacity. Hemoglobin carries most of the oxygen to tissues. Anemia and inhalation of toxic substances decrease the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen. Anemia (e.g., a lower-than-normal hemoglobin level) is a result of decreased hemoglobin production, increased red blood cell destruction, and/or blood loss. Patients have fatigue, decreased activity tolerance, increased breathlessness, increased heart rate, and pallor (especially seen in the conjunctiva of the eye). Oxygenation decreases as a secondary effect with anemia. [NAME], P. A., [NAME], A. G., Stockert, P. A., Hall, A., & [NAME], W. R. (2026). Fundamentals of nursing (12th ed.) p.983. Elsevier. Medications- antibioticsReview of the Hospital Transfer of Care Document for R13 with a discharge date of [DATE] revealed:Discharge Instructions: Continue IV (intravenous) antibiotics that were ordered prior to his admission, 2 weeks of abx (antibiotics) from 6/8 (EOT 6/22).-ampicillin 2 g (grams) in sterile water 14.8 ml (milliliters), Infuse 2g over 3 minutes into a venous catheter every 12 (twelve hours. Indications: Enterococcal Bacteremia (blood infection). No cultures provided, this medication was discontinued upon admission. Review of the MAR for R13 revealed Amoxicillin Oral Tablet 500 MG (milligrams), Give 1 tablet by mouth two times a day for bacteremia for 9 Days. Ordered [DATE] and ended on [DATE]. No indication this was equivalent to the IV-ampicillin transfer of care orders and no cultures provided to show the sensitivity to the antibiotic. -Daptomycin-Sodium Chloride (antibiotic) Intravenous (IV) 350-0.9 MG/50 ML (milliliters) every 48 hours for Enterococcus infections for 10 days. Given [DATE], [DATE], and [DATE]. No cultures provided to show the sensitivity to the antibiotic. Review of a Nursing Progress note dated [DATE] at 5:43 AM for R13 revealed: Resident c/o (complains of) SOB (short of breath) at [3:30 AM], VS (vital signs) 127/79 (blood pressure), P (pulse) 103, T (temperature) 99.1, SaO2 (oxygen saturations) 81% on RA (room air), placed resident on 2L O2 NC (oxygen nasal cannula), no c/o chest pains noted, [Practitioner] ordered CXR and Duonebs (breathing treatment) Q4PRN (every 4 hours as needed). No Documentation to show the Duonebs were provided. Review of a Skilled Care Note dated [DATE] at 12:19 AM for R13 revealed no edema, oxygen saturation of 94% via nasal cannula (no liters of oxygen documented), no shortness of breath. res makes needs known. Cont B&B (sic). Uses urinal at bedside. Con't (continue) on IV (intravenous) abx (antibiotics)for bacteremia/UTI (urinary tract infection). Review of a Practitioner Progress note dated [DATE] at 00:00 for R13 revealed: Visit Type: Acute: (not in person visit) . Started daptomycin for ongoing sepsis. He came to the [Facility] s/p (status post) hospitalization for sepsis. The sepsis was caused by a ureteral stone . and came here for rehab. Are you able to obtain RoS findings Yes. But not directly from patient. Steps undertaken to obtain information. Old medical records. Spoke with nursing staff or caregivers. Respiratory Positive: CTA. ENTEROCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE: Treating with daptomycin, IV (intravenous) antibiotics. In an interview on [DATE] at 10:00 AM, the DON was questioned about R13's sepsis/bacteremia infection upon admission. The DON could not find any cultures to ensure R13 received the appropriate antibiotics. The DON reported the previous ADON was the Infection Preventionist at the time and could not find anything to show antibiotic stewardship. Medications: MidodrineReview of the Hospital Transfer of Care Document for R13 with a discharge date of [DATE] revealed:Discharge Instructions: .PRN (as needed) Midodrine added for hypotension (low blood pressure). Review of the Hospital Medication List preadmission to the facility printed [DATE] for R13 revealed:-Midodrine (ProAmatine) 10 mg tablet, take 1 tablet by mouth 4 times daily as needed for other (if SBP < 90). Indications: Blood Pressure Drop Upon Standing for diagnoses: Orthostatic hypotension. Documented in writing is scheduled Q6 (every 6 hours). No pharmacy recommendations to reflect the concern of the PRN status verses scheduled. Review of the [DATE] MAR (Medication Administration Record for R13 shows it was SHEDULED 4 times a day and documented as given 15 times with a SBP >90. Review of the Nursing Progress Notes for R13 revealed on [DATE] was the first of several warnings regarding the Midodrine Order. Physician's Order Note: This order is outside of the recommended dose or frequency. Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 10 mg by mouth every 6 hours for hypotension - The frequency of 4 times per day exceeds the usual frequency of 1 to 3 times per day. No indication the physician was notified and addressed this alert. Midodrine: Symptomatic management of refractory orthostatic hypotension in patients whose lives are impaired. Contraindicated in: Urinary retention; Severe organic heart disease; acute renal failure . Use Cautiously in: . Renal impairment (decrease initial dose); Diabetes mellitus, visual problems . Adverse Reactions/Side Effects: CV: Supine hypertension . GU (genitourinary): dysuria, urinary urge/retention/frequency. Neuro: paresthesia, anxiety, confusion, head pressure/fullness, headache, nervousness Route/Dosage: PO (oral) Adults: 10 mg three times daily, Renal Impairment PO (Adults) 2.5 mg three times daily. Assessment: Monitor supine and sitting BP (blood pressure) prior to and during therapy. Lab Test Considerations: Monitor renal and hepatic function prior to and periodically during therapy. Implementation: Because midodrine can cause marked increase of supine BP, it should be used in patients whose lives are considerably impaired despite standard clinical care. F.A. [NAME] Company. (2026). [NAME]'s drug guide for nurses (20th ed.) [Mobile app]. Unbound Medicine. https://davisdrugs.unboundmedicine.com/products/davis_drug_guide. Weights/EdemaReview of the Hospital Cardiology Consult dated [DATE] for R13 revealed a weight (wt) of 76.6 kg (kilograms/ 168.52 pounds/Lbs). No goal/ baseline weight acknowledged/established after admission to the facility. Review of the Order Summary for R13 revealed on [DATE] weekly weights were ordered. On [DATE] daily weights in the morning were ordered and to notify the physician if weight gain of 2 or more pounds in 24 hours or 4 or more pounds over 5 days. On [DATE] the daily weights continued with no specific time ordered. Review of R13's weights revealed as follows:[DATE] 187.4 Lbs at 7:28 PM (an 18.9-pound difference since [DATE])No weights from [DATE] until [DATE]/17/25 186.4 Lbs at 12:26 PM[DATE] 187.5 Lbs at 1:01 PM[DATE] 192.0 Lbs at 10:22 AM (a 4.5-pound difference in 24 hours)[DATE] 188.8 Lbs at 9:07 AM[DATE] 190.8 Lbs at 8:50 AM (a 2-pound difference in 24 hours)[DATE] 187.1 Lbs at 6:00 AM[DATE] 187.1 Lbs at 9:55 AMReview of the Nursing Progress notes reveal no indication the Practitioners were aware of the 4.5-pound weight gain on [DATE]. Review of the Medication Administration Record (MAR) R13 revealed on [DATE] Triamterene (diuretic) 50 mg twice a day was ordered for CHF with CKD (chronic kidney disease). No orders for a baseline weight/goal weight. Review of a Nursing Progress note dated [DATE] at 12:06 PM for R13 revealed: Res experienced a weight gain of 2 pounds in a 24-hour period. Increased edema to BLE (bilateral lower extremities). Currently receives Triamterene oral capsule 50mg BID. Notified on-call provider [Name] of change. Provider states that resident will be added to the rounding schedule for a provider to visit on Monday [DATE]. No changes at this time. Resident comfortable with no s/s of pain, discomfort, or dyspnea. No correlating Nursing Assessment done to reflect the grading assessment of edema. Review of the Skilled Care Notes for R13 dated [DATE] and [DATE] revealed no edema documented. Edema is present when areas of the skin become swollen or edematous from a buildup of fluid in the tissues. Direct trauma and impairment of venous return are two common causes of edema. Inspect edematous areas for location, color, and shape. Edematous skin also appears stretched and shiny. When pressure from the examiner's fingers leaves an indentation in the edematous area, it is called pitting edema. To assess the degree of pitting edema, press the edematous area firmly with the thumb for several seconds and release. The depth of pitting, documented in millimeters, determines the degree of edema (Ball et al., 2023). [NAME], P. A., [NAME], A. G., Stockert, P. A., Hall, A., & [NAME], W. R. (2026). Fundamentals of nursing (12th ed.) p.567. Elsevier. Oxygen/respiratory treatmentsReview of the Order Summary for R13 revealed no orders for a CPAP machine. Review of a Practitioner Telehealth Encounter dated [DATE] at 00:00 for R13 revealed: Nursing originally reported resident was complaining of shortness of air with O2 (oxygen) on room air at 81% (normal is 95-100%), temp 99.1, with improvement in SOA (sic) to 94-95%. Orders given for CXR (chest x-ray) and duoneb (breathing treatment) [every 4 hours as needed].Review of a Nursing Progress note dated [DATE] at 5:43 AM for R13 revealed: Resident c/o (complains of) SOB (short of breath) at [3:30 AM], VS (vital signs) 127/79 (blood pressure), P (pulse) 103, T (temperature) 99.1, SaO2 (oxygen saturations) 81% on RA (room air), placed resident on 2L O2 NC (oxygen nasal cannula), no c/o chest pains noted, [Practitioner] ordered CXR and Duonebs Q4PRN (every 4 hours as needed), [Laboratory] also called and gave lab result for Hgbof (sic) 7.7. Communicated that to [Practitioner] on [communication portal]. Waiting for response. No documentation to show a Practitioner acknowledged concerns or the laboratory values.Review of a Chest X-Ray result dated [DATE] for R13 revealed Mild opacities at both lower bases may represent infiltrates/atelectasis.Review of a LATE ENTRY Practitioner Progress note for R13 ENTERED on [DATE] to reflect the date of [DATE] at 8:00 AM for R13 revealed: Telehealth: Situation: CXR ordered due to oxygen needed since yesterday resulted: Mild opacities at both lung bases may represent infiltrates/atelectasis. Per Nurse, Mild Inspiratory wheeze to left upper lung field noted. Treatment: Continue oxygen therapy as needed. This progress note was entered 4 months after R13 passed away. Review of the MAR for R13 revealed the following orders:-Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (nebulizer breathing treatment), 3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. Ordered [DATE] and not given until [DATE] at 1:00 AM. -Oxygen, 2 Liters (L) nasal cannula related to low SaO2 (arterial oxygen saturation). Ordered [DATE] and discontinued on [DATE]. -Oxygen, 2 Liters (L) nasal cannula every night and as needed for spO2 (saturation of peripheral oxygen) <90. Every night shift for dyspnea (shortness of breath). Ordered [DATE]. Review of a Practitioner Progress note dated [DATE] at 00:00 for R13 revealed: Visit Type: Acute: (not an in person visit) . Started daptomycin for ongoing sepsis. He came to the [Facility] s/p (status post) hospitalization for sepsis. The sepsis was caused by a ureteral stone . and came here for rehab. Are you able to obtain RoS findings Yes. But not directly from patient. Steps undertaken to obtain information. Old medical records. Spoke with nursing staff or caregiversREVIEW OF SYSTEMS: Are you able to obtain RoS? Yes. But not directly from patient. Steps undertaken to obtain information: Old medical records. Spoke with nursing staff or caregivers. Cardiovascular Positive: Swelling. Positive: Back Pain, Joint Pain or Swelling. Positive: weakness. Weight 186.4 lbs . Respiratory Positive: CTA. ENTEROCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE: Treating with daptomycin, IV (intravenous) antibiotics. No acknowledgement of weight difference from preadmission weight. Review of a Skilled Care Note dated [DATE] at 12:19 AM for R13 revealed no edema, oxygen saturation of 94% via nasal cannula (no liters of oxygen documented), no shortness of breath. res makes needs known. Cont B&B (sic). Uses urinal at bedside. Con't (continue) on IV (intravenous) abx (antibiotics)for bacteremia/UTI (urinary tract infection). Review of a LATE ENTRY Nursing Progress noted ENTERED [DATE] at 10:49 AM for R13 with an EFFECTIVE DATE of [DATE] at 1:45 AM (Not the early morning of [DATE]) revealed: Res. c/o (complained of) SOB (shortness of breath), LS (lung sounds) clear and diminished in bases, SpO2 (blood oxygen) tanging between 92% and 95% with O2 at 2LPM NC (liters per minute-nasal canula). PRN Neb tx given as ordered. Post neb tx Res. States feeling better. HOB (head of bed) elevated, Res. Encouraged to exhale with pursed lips (the way a COPD patient would breathe), CPAP on with O2 NC (indicating the CPAP was placed over the NC). Review of a LATE ENTRY Nursing Progress note entered [DATE] at 10:57 AM for R13 and back dated for [DATE] at 4:45 AM revealed: Res. Observed in bed resting quietly by this nurse. CPAP on with O2. Res. Gave a thumbs up and said I'm good to go HOB elevated, call light in reach. Review of a LATE ENTRY Nursing Progress note ENTERED [DATE] at 11:43 AM for R13, back dated to [DATE] at 8:00 AM revealed: At approximately 0500, this nurse called to room [ROOM NUMBER] d/t Res. observed by CNA not breathing. Approx. 0502- CODE BLUE paged via intercom.Upon entering room with AED and Crash cart, Res. observed in bed absent of HR or Respirations. Chest compressions immediately started by this Nurse. CNA instructed to activate EMS. 2nd night Nurse XX entered room to assist with CPR. Res. transferred to floor for more effective CPR measures. AED pads applied to Res. Bare chest, shock was not advised, CPR continued. Code status documentation reviewed and code status is DNR. A copy of the advance directive handed to MDS, CPR halted . In an interview on [DATE] at 11:36 AM, RN K (former employee) reported the night of [DATE], that R13 was stable for his condition and that he checked on R13 frequently. He stated that R13's vital signs were good when he checked them, and R13 even gave him a thumbs up. RN K reported that R13's lungs were diminished but his pulse and oxygen saturations were good for him. He stated that R13 was a smoker and a COPD patient with ongoing difficulty breathing. RN K reported that he had problems documenting in the Electronic Medical Record (EMR) that night ([DATE]-[DATE]) because his notes would not save. He stated that R13 did not have any changes in condition during his shift and appeared the same as when he started his shift. He also said he was told during shift report that R13 had gone out to the hospital and returned, had labs drawn, and that lab results were pending, but he could not recall the details. RN K reported that he was told the Nurse Practitioner had seen R13 earlier that day. RN K could not recall whether there was an order for CPAP machine (Continuous Positive Airway Pressure to treat sleep apnea). He reported that he was not aware of R13's elevated BNP level or low HGB level. When asked what an elevated BNP indicated, RN K stated that it could suggest potential volume overload. No documentation in the EMR indicated R13 went out to the hospital and no documentation to indicate the Practitioner visited R13. Review of an Advance Directive document signed by R13 on [DATE] and by the physician on [DATE] revealed R13 requested no CPR. Review of the Order Summary in the EMR for R13 revealed the resident was documented as being a Full Code. In an interview on [DATE] at 10:00 AM, the DON was questioned about R13's oxygen and lack of CPAP orders, the DON reported there should have been an order for the CPAP from the physician and if there was an order, the resident's nasal cannula should have been removed so the CPAP could have a better seal for oxygen delivery. Any refusals should be documented then. Continuous positive airway pressure (CPCP) maintains a steady stream of pressure throughout a patient's breathing cycle. It benefits patients with obstructive sleep apnea (OSA), patients with heart failure, . Equipment includes a mask that fits over the nose or both nose and mouth and a CPAP machine that delivers air to the mask. The smallest mask with the proper fit is the most effective. It must be tight enough to form a seal on the face so that the air does not escape but not so tight as to cause pressure injury formation or necrosis where the mask is against the face. [NAME], P. A., [NAME], A. G., Stockert, P. A., Hall, A., & [NAME], W. R. (2026). Fundamentals of nursing (12th ed.) p. 1007-1008. Elsevier. PainReview of the Transfer of Care orders dated [DATE] for R13 revealed: .Tamsulosin 0.4 mg daily is given to help with STENT spasms. You can start using ibuprofen 800 mg three times a day starting from the day, if the two medications above are not enough you can CALL TO GET Oxycodone. You can take Pyridium for burning when you pee. Review of the [DATE] MAR for R13 revealed the following orders:_Acetaminophen 500 MG tablet every 8 hours as needed for pain for 7 days ordered [DATE] and discontinued [DATE]. Not one dose was documented as given and does not address what pain this order was for. -Acetaminophen 500 MG tablet every 8 hours as needed for pain for pain/fever. Ordered [DATE] and discontinued [DATE]. Not one dose was documented as given and did not address what pain this was for. - Hydrocodone-Acetaminophen Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 6 hours as needed for pain. Ordered [DATE]. Given [DATE] at 1:00 PM for a pain level of 2. No documentation to reflect where the pain was and the order does not address what pain this was for. Review of a Practitioner Progress note dated [DATE] at 00:00 for R13 revealed: Telehealth: Nurse reports patient has been exhibiting increased pain. Has order for Norco (opioid), needs script. Short script of Norco sent. Rounding team notified. No pain assessment available or information regarding where the pain was or why Tylenol was not given first. Review of a Nursing Skilled Care Note dated [DATE] at 10:23 AM for R13 revealed a pain assessment is documented as no pain. Examine Results: Evaluation occurs every time you have contact with a patient. It is an ongoing process that includes a comparison of before and after an intervention or a comparison with an established standard after an intervention. Once you deliver an intervention, you continuously examine results by gathering subjective and objective data from a patient, family, and health care team members (as appropriate). At the same time, you reflect on your knowledge regarding a patient's current condition, the treatment, and the resources available for recovery. [NAME], P. A., [NAME], A. G., Stockert, P. A., Hall, A., & [NAME], W. R. (2026). Fundamentals of nursing (12th ed.) p. 296. Elsevier. Care Plans:Review of the Care Plan for R13 revealed the following: Special Instructions: Meds: Whole admitted here for short term rehab following hospitalization for UTI. He also has CAD, CHF, HTN, DM, sleep Apnea and Anemia. PLEASE document on s/s's of UTI, pain, safety awareness, ability to compete ADL's and participation in therapy. TELEMED CONSENT [DATE].- Need: (R13) is at risk for cardiac complications related to multiple cardiovascular diseases: CAD (coronary artery disease), HTN (hypertension), Afib (atrial fibrillation), initiated on [DATE] and revised on [DATE]. Review of the Care Plan for R13 revealed:- Need: (R13) is at risk for pain. He generally denies any discomfort. Initiated [DATE]. Interventions included: Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician. Does not address acute verses chronic pain or the location of pain. No Care Plan with a CHF focus on interventions, no bacteremia/sepsis Care Plans, or Advance Directives. R1Review of R1's admission Record dated [DATE] revealed she was admitted to the facility on [DATE] and had diagnoses that included: Frontotemporal neurocognitive disorder, drug induced subacute dyskinesia (neurological disorder characterized by involuntary, repetitive, and purposeless muscle movement), and person history of traumatic brain injury. R1 was her own responsible party.Review of R1's Brief Interview of Mental Status (BIMS), dated [DATE] revealed she scored 15/15 (normal cognition).Review of a police report dated [DATE] at 12:11 PM revealed the police responded to the facility at on [DATE] at 12:19 PM and spoke with R1's Advocate AA, the DON (Director of Nursing) and the NHA (Nursing Home Administrator). The fire department and an ambulance service were already at the facility and R1 was transported to the hospital. The police office spoke to R1's Advocate AA. Name of AA reported that (name of R1) was supposed to receive her medications at 0700 hours, 1200 hours and 1900 hours. (Name of R1) had told AA she did not get her medication until 10:00 AM. Today at 1200 hours (Name of R1) was offered her noon medication, but she refused because she would be taking them too close. When (Name of R1) refused to take the medications facility staff stated they would deny the medication for her in the future, so (name of R1) took the medication. The DON was interviewed and confirmed R1 was supposed take her medications at 7:00 AM but she was sleeping at that time, and the nurse did not make it back to give her here 7:00 AM medications until 10:08 AM. R1 demanded her medications again at 12:00 PM and because R1 was demanding her medications the nurse allowed R1 to take her medications. The DON stated, the medication ClonazePAM would never put (name of R1) in a medical emergency. According to (name of DON), (name of R1) had been scheduled to take one ClonazePAM in the morning, one ClonazePAM in the afternoon, and three ClonazePAM in the evening. (Name of DON) stated (name of R1) would've supposedly overdosed every night if she had taken the medications like how she should've since (name of R1) scheduled to take 3 ClonazePAM in the evening and (name of R1) only took two today. After actions, revealed, With the accusations of potentially having (name of R1) overdose on her medications, I submitted a report to Michigan [NAME] (Licensing and Regulatory Affairs).Review of R1's Hospital admission (discharged ) report dated [DATE] revealed R1 went to the Emergency Department on [DATE] with a chief complaint of Altered Mental Status Pt (patient) resides at nursing facility, received an extra dose of Clonazepam at 12:30, normally oriented X4: GCS Glasgow Coma Scale (tool used to score a person's level of consciousness) of 14. A score of 13-15 indicates mild to minor brain injury/altered consciousness. Review of Medical Decision Making revealed, Suspect this behavior and extension of her conversion disorder more behavioral. Vital signs were stable. Her friend was quite pressuring about her getting her meds on a regular schedule but she is on Zanaflex with gabapentin and other meds that would alter her

This citation pertains to intakes 2794208 Based on interview and record review, the facility failed to ensure all nursing staff and nursing aides received competency training upon hire/annually. This deficient practice affects all 86 residents who reside in the facility. Findings Include: Review of 6 employee files that included 3 nurses and 3 certified nursing assistants (CNAs), revealed none of the six had skills checks completed upon hire and/or annual skills checks. Of the employee files reviewed, only one nurse was still employed at the time of this review. In an interview on 5/28/26 at 8:54 AM, the Human Resource Manager (HR) Q verified that the 6 employee files reviewed did not contain completed competency skills checks. When asked about whether the current staff had completed competencies, HR Q stated that the previous DON had not completed any competencies either, and they were trying to develop a system to ensure completion. The new Assistant Director of Nursing (ADON), who had been at the facility for only 2-3 months, would be working on this. HR Q confirmed that no current employees had verified competencies in their files.

This citation pertains to intakes 2794208. Based on interview and record review, the facility failed to ensure the appropriate antibiotic was implemented for one (R13) of one resident reviewed for antibiotics. Findings include Review of a Face Sheet revealed R13 admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, cognitive communication deficit, cardiomyopathy, enterococcus (bacterial infection) unspecified, and diabetes (as listed for primary admission). Review of the Hospital Transfer of Care Document for R13 with a discharge date of 6/13/25 revealed:Discharge Instructions: Continue IV (intravenous) antibiotics that were ordered prior to his admission, 2 weeks of abx (antibiotics) from 6/8 (EOT 6/22).-ampicillin 2 g (grams) in sterile water 14.8 ml (milliliters), Infuse 2g over 3 minutes into a venous catheter every 12 (twelve hours. Indications: Enterococcal Bacteremia (blood infection). (No cultures provided and was discontinued upon admission to the Facility.) Review of the MAR for R13 revealed Amoxicillin Oral Tablet 500 MG (milligrams), Give 1 tablet by mouth two times a day for bacteremia for 9 Days. Ordered 6/13/25 and ended on 6/22/25. No indication this was equivalent to the IV ampicillin per the transfer of care orders and no cultures provided to show the sensitivity to the antibiotic which would indicate the appropriateness. -Daptomycin-Sodium Chloride (antibiotic) Intravenous (IV) 350-0.9 MG/50 ML (milliliters) every 48 hours for Enterococcus infections for 10 days. Given 6/18/25, 6/20/25, and 6/22/25. No cultures to show the sensitivity to the antibiotic which would indicate the appropriateness.Review of the Laboratory tests collected on 6/16/25 for R13 revealed: .neutrophils 82.1% (normal 43.4 - 76.2, indicating an infection). No documentation indicating the practitioner acknowledged the abnormal lab values. Review of a Practitioner Progress note dated 6/18/25 at 00:00 for R13 revealed: Visit Type: Acute: . Started daptomycin for ongoing sepsis. He came to the [Facility] s/p (status post) hospitalization for sepsis. The sepsis was caused by a ureteral stone . and came here for rehab. Are you able to obtain RoS (sic) findings Yes. But not directly from patient. Steps undertaken to obtain information. Old medical records. Spoke with nursing staff or caregiversRespiratory Positive: CTA. ENTEROCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE: Treating with daptomycin, IV (intravenous) antibiotics. Review of a Skilled Care Note dated 6/21/25 at 12:19 AM for R13 revealed: Con't (continue) on IV (intravenous) abx (antibiotics)for bacteremia/UTI (urinary tract infection). Review of a Nursing Progress note dated 6/23/25 at 3:22 PM for R13 revealed a urine specimen was sent to the Hospital lab. Urine was thick, murky, and tan in color. No documentation to show the physician was notified of the findings before the urine specimen was sent out. Review of the Urinalysis dated 6/23/25 for R13 revealed a positive culture with Citrobacter [NAME] bacteria and Candida tropicalis, a fungus. In an interview on 6/1/26 at 10:00 AM, the DON was questioned about R13's sepsis/bacteremia infection upon admission. The DON could not find any cultures to verify and ensure R13 received the appropriate antibiotics. The DON reported that the previous ADON was the Infection Preventionist at the time and could not find anything to show antibiotic stewardship for R13 to ensure his antibiotics were appropriate.

This citation pertains to intake 2794208. Based on interview and record review, the facility failed to honor a resident's DNR (do not resuscitate) wishes for one (R13) of 3 residents reviewed for advance directives, resulting in CPR (cardiopulmonary resuscitation) attempt after found unresponsive. Findings include: Resident #13 (R13)Review of a Face Sheet revealed R13 admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, cognitive communication deficit, cardiomyopathy, enterococcus (bacterial infection) unspecified, and diabetes (listed as for primary admission). R13 passed away on [DATE]. Review of an Advance Directive document signed by R13 on [DATE] and by the physician on [DATE] revealed R13 requested no CPR (cardiopulmonary resuscitation). Review of the Order Summary in the EMR for R13 revealed the resident was documented as being a Full Code. Review of a LATE ENTRY Nursing Progress note ENTERED [DATE] at 11:43 AM for R13, back dated to [DATE] at 8:00 AM revealed: At approximately 0500, this nurse called to room [ROOM NUMBER] d/t Res. observed by CNA (Certified Nursing Assistant) not breathing. Approx. 0502- CODE BLUE paged via intercom.Upon entering room with AED (Automated External Defibrillator) and Crash cart, Res. observed in bed absent of HR (heart rate) or Respirations. Chest compressions immediately started by this Nurse. CNA instructed to activate EMS (Emergency Medical Services). 2nd night Nurse [XX] entered room to assist with CPR. Res. transferred to floor for more effective CPR measures. AED pads applied to Res. Bare chest, shock was not advised, CPR continued. Code status documentation reviewed and code status is DNR (do not resuscitate). A copy of the advance directive handed to MDS, CPR halted . In an interview on [DATE] at 11:36 AM, former Unit Manager/Registered Nurse (RN) K reported that the Electronic Medical Records (EMR) displayed R13 as a full code on the ribbon. When RN K was informed that R13 was a DNR, he searched the chart after Emergency Medical Services (EMS) took over CPR to locate the paperwork confirming R13's DNR status. EMS could not discontinue CPR without the documentation. RN K stated that the breakdown in the system occurred because the Social Workers were responsible for obtaining the consents and then updating the status in the EMR. RN K stated he should have caught the discrepancy beforehand but, as a Unit Manager, he was frequently pulled to the floor and could not adequately review charts, orders, and assist staff. In an interview on [DATE] at 12:13 PM, the Social Worker (SW) R explained that they had implemented a new system to ensure code status was updated to reflect residents' wishes. They updated it weekly and conducted audits. SW R provided the booklet and randomly selected 5 residents to review their code status, examined their Advance Directives, and confirmed the information matched what was documented in the EMR. Once the Social Workers obtained the code status documentation, the Unit Manager changed the EMR to reflect the residents' wishes. SW R stated they did not have access to officially change information in the EMR, but the Nursing staff did. After the updates were made, the Medical Records department scanned the Advance Directives into the residents' charts. Review of the Advance Directives Policy and Procedure last revised [DATE] revealed: Procedure: A. Identify: On admission, the Facility will determine whether the Resident has executed advance directives. The Facility will also determine whether there was a DNR Order issued while in the facility. A Code Status Form will be signed to reflect the decision regarding CPR/DNR under the guidance provided below.B. Obtain Documents.I. Ascertain Resident's Care/Treatment Preferences: Social Services or designee will determine to the extent possible, whether the Resident has any wishes regarding the provision of health care and treatment and/or end of life decisions, review for any inconsistencies between documents, and document the same in the record. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: The facility identified on [DATE] R13 received CPR against his wishes.On [DATE], an audit was completed to review all current residents code status and supporting documentation evident in the EMR document tab. Any concerns were addressed immediately.On [DATE], nursing staff and social workers were educated on the Advance Directive Policy and Procedure.On [DATE] the first documented weekly audit began.The facility was able to demonstrate monitoring of the corrective action and maintained compliance as of [DATE].

This citation pertains to intake number 3021098Based on interview and record review, the facility failed to formulate a safe discharge plan for 1 Resident (R12) of 3 Residents reviewed for discharge.Findings included:R12Review of R12's admission record dated 6/2/26 revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included: peripheral vascular disease, pressure ulcer of left ankle (unstageable), pressure ulcer of left heel (unstageable), frontotemporal neurocognitive disorder, diabetes mellitus 2, with diabetic neuropathy (nerve damage), and acquired absences of right leg above knee (amputation of right leg). He was listed as his own responsible party.Review of R12's Brief Interview of Mental Status (BIMS), dated 4/13/26 revealed he scored 10/15 indicating he had moderate cognitive impairment.Review of R12's 72 Hour admission Conference dated effective 4/7/26 revealed the boxes for Attendees were checked for: Responsible Party/Family, Resident/Patient, Care Manager, Social Services. 4a. revealed, Patient will be LTC (long term care). 6a. Notes/Comments: SW: Patient is a LTC patient at this facility. He is his own decision maker. Code status is full resuscitation. He is taking psychoactive medications. No observed behaviors since admission. Resident admits as a SAR (Skilled Acute Rehab guest with plans to transition to LTC if rehabilitation does not reach the goals family has set to return home. Discussed no pork or beef on trays, resident chose DNR (Do-not-Resuscitate) status, awaiting work to see if resident or advocated signs the DNR paperwork. Advocate is concerned about capacity. Provider to evaluate capacity.Review of R12's hospital discharge paperwork revealed R12 named a family member Y his DPOA, Durable Power of attorney for medical on 3/5/24.Review of the hospital discharge records in the facility records, page 1, FAX date 3/13/26 at 1:05PM revealed, History of Patient Capacity Status Changes change on 3/13/26 incapacity, changed by name of a Registered Nurse (RN) V and a second note of change on 3/13/26 incapacity, changed by a name of a LLMSW (Limited Licensed Master Social Worker) W. After these statements two statements of capacity revealed. Comment At time of this written statement, it is felt that the patient does not possess the capacity to fully understand new clinical information regarding his health status, or to direct responsible medical decision making on his own behalf. Name of the physician T. Under that statement of revealed, The patient lacks capacity to safely understand or incorporate information to make informed medical decisions. I recommend that the DDPOA (Medical Durable Power of Attorney) be activated. Name of Physician U. The next statement revealed, Comment: At time of this written statement, it is felt that the patient does not possess the capacity to fully understand new clinical information regarding his health status, or to direct responsible medical decision making on his behalf. Signed again by physician T.Review of R12's Social Services Note dated 5/8/26 at 16:59 (4:59 PM) revealed, SW made report to APS (Adult Protective Services) today at 4:45 PM about possible unsafe conditions at his home . having 12 steps that he would have to go up and down. Also, the concerns of medication management due to his diabetes with his blood glucose being extremely high.Review of R12's Adv (advanced) Discharge GG (noting section of the Minimum Data Set (MDS) assessment, Evaluation revealed, IDT (Interdisciplinary Team) Collaboration included the following: MDS (Minimum Date Set) Nurse, Eating: Discharge Performance: Shower/bathe self: discharge performance: Supervision or touching assistance, upper body dressing: discharge performance: supervision or touching assistance. Lower body dressing: discharge performance: partial/moderated assistance. Putting on /taking off footwear: Discharge performance: supervision or touching assistance. Ability to come to a standing position from sitting position form sitting in a chair, wheelchair or on the side of the bed. Discharge performance: Supervision or touching assistance. The ability to transfer to and from a bed to a chair (or wheelchair): Discharge performance: supervision or touching assistance. Toilet transfer: The ability to get on and off a toilet or commode: Discharge performance: Supervision or touch assistance. Car transfer: Discharge performance: Not attempted due to medical condition or safety.During an interview with the facility Social Worker (SW) X on 6/2/26 at 10:06 AM, SW X reviewed R12's Hospital Discharge Incapacity statements and said the facility did not honor the hospital documentation because it was signed by an RN and SW. SW X said it takes two physicians to determine incapacity. SW X did not mention the statements signed by two physicians directly under the SW and RN statements which did indicate that R12 did not have capacity to understand his clinical information. SW X could not find any documentation where the facility reviewed safety concerns or the hospital documentation of capacity with the facility physician. SW X (reported) the facility physician did not revoke R12's DPOA, as SW X believed the DPOA papers the hospital provided were not legally binding. SW X was asked why she called APS on R12 the day after discharge 5/8/26 and SW X could not recall.During an interview with Licensed Practical Nurse (LPN) Z and SW X on 6/2/26 at 10:12 AM, LPN X said she verbally reviewed R12's medications with him on 5/7/26 and provided him a bag of medications that included insulin in vials and insulin in pens. LPN Z confirmed she never witnessed R12 giving himself insulin or other medications. LPN Z recalled R12 preferred insulin pens over insulin in vials. SW X and LPN Z confirmed that R12 signed himself out and was taken to his home by the facility driver on 5/7/26. LPN Z confirmed R12 was not independent with all his ADL's (Activities of Daily Living) and R12 was noncompliant with using has call light for assistance with transfers.During a telephone interview with R12's DPOA Y on 6/2/26 at 8:42 AM, DPOA Y said the facility did not honor R12's DPOA. DPOA Y said she agreed with R12 returning home if he could be safe independently including medication management. DPOA Y said the facility informed her R12 was signing himself out on 5/7/26 and she ensured the facility that family members would meet R12 at his home. DPOA Y said the facility driver left R12 in his wheelchair at the bottom of steps to his home. R12 scooted up the steps on his butt and family had to physically help him stand and get back into his wheelchair. Family could not locate any written discharge instructions. Family continued to stay with R12 for his safety, but when he could not independently care for himself or take his own medications, they took him to a hospital emergency room. DPOA Y said the hospital was very upset that the facility did not honor R12's existing DPOA paperwork and the hospital discharged R12 to a nursing home that does honor his DPOA paperwork.Review of a hospital complaint dated 5/8/26 revealed R12 was taken to the hospital by his DPOA when he failed his home discharge. The report listed the facility name and revealed R12 was not his own DPOA; however, signed himself out of the facility and family did not agree to his discharge at that time.In an interview on 6/2/26 at 1:30 PM, the Nursing Home Administrator (NHA) confirmed that she did not locate any documentation revoking R12's DPOA or documentation where the facility reviewed R12's safety concerns with the facility physician.

This citation pertains to intakes 3021098 and 2794208. Based on interview and record review, the facility failed to develop and implement a person-centered care plan for two (R13 and R12) of 3 residents reviewed for care plans. Findings include: R12 Review of R12's admission record dated 6/2/26 revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included: peripheral vascular disease, pressure ulcer of left ankle (unstageable), pressure ulcer of left heel (unstageable), frontotemporal neurocognitive disorder, diabetes mellitus 2 with diabetic neuropathy (nerve damage), and acquired absences of right leg above knee (amputation of right leg). He was listed as his own responsible party. Review of R12's Brief Interview of Mental Status (BIMS), dated 4/13/26 revealed he scored 10/15 indicating he had moderate cognitive impairment. Review of R12's hospital discharge paperwork revealed R12 named a family member Y his DPOA, Durable Power of attorney for medical on 3/5/24. Review of the hospital discharge records in the facility records, page 1, FAX date 3/13/26 at 1:05PM revealed, History of Patient Capacity Status Changes change on 3/13/26 incapacity, changed by name of a Registered Nurse (RN) V and a second note of change on 3/13/26 incapacity, changed by a name of a LLMSW (Limited Licensed Master Social Worker) W. After these statements two statements of capacity revealed, Comment At time of this written statement, it is felt that the patient does not possess the capacity to fully understand new clinical information regarding his health status, or to direct responsible medical decision making on his own behalf. Name of the physician T. Under that statement of revealed, The patient lacks capacity to safely understand or incorporate information to make informed medical decisions. I recommend that the DDPOA (Medical Durable Power of Attorney) be activated. Name of Physician U. The next statement revealed, Comment: At time of this written statement, it is felt that the patient does not possess the capacity to fully understand new clinical information regarding his health status, or to direct responsible medical decision making on his behalf. Signed again by physician T (showing two physicians signed the document). Review of R12's 72 Hour admission Conference dated effective 4/7/26 revealed the boxes for Attendees were checked for: Responsible Party/Family, Resident/Patient, Care Manager, Social Services. 4a. revealed, Patient will be LTC (long term care). 6a. Notes/Comments: SW: Patient is a LTC patient at this facility. He is his own decision maker. Code status is full resuscitation. He is taking psychoactive medications. No observed behaviors since admission. Resident admits as a SAR (Skilled Acute Rehab guest with plans to transition to LTC if rehabilitation does not reach the goals family has set to return home. Discussed no pork or beef on trays, resident chose DNR (Do-not-Resuscitate) status, awaiting work to see if resident or advocated signs the DNR paperwork. Advocate is concerned about capacity. Provider to evaluate capacity. During an interview with the facility Social Worker (SW) X on 6/2/26 at 10:06 AM, SW X reviewed R12's hospital discharge incapacity statements and said the facility did not honor the hospital documentation because it was signed by an RN and SW. SW X said it takes two physicians to determine incapacity. SW X did not mention the statement signed by two physicians directly under the SW and RN statements which did indicate that R12 did not have capacity to understand his clinical information. SW X could not find any documentation where the facility reviewed R12's safety concerns or the hospital documentation of lack of capacity with the facility physician. SW X reported the facility physician did not revoke R12's DPOA, as SW X believed the DPOA papers the hospital provided were not legally binding. During an interview with Licensed Practical Nurse (LPN) Z and SW X on 6/2/26 at 10:12 AM, LPN X said she verbally reviewed R12's medications with him on 5/7/26 and provided him a bag of Medications the included insulin in vials and insulin in pens. LPN Z confirmed she never witnessed R12 giving himself insulin or other medications. LPN Z recalled R12 preferred insulin pens over insulin in vials. SW X and LPN Z confirmed that R12 signed himself out and was taken to his home by the facility driver on 5/7/26, LPN Z confirmed R12 was not independent with all his ADL's (Activities of Daily Living) and R12 was noncompliant with using has call light for assistance with transfers. During a telephone interview with R12's DPOA Y on 6/2/26 at 8:42 AM, DPOA Y said the facility did not honor R12's DPOA. DPOA Y said she agreed with R12 returning home if he could be safe when living independently, including medication management. DPOA Y said the facility informed her R12 was signing himself out on 5/7/26 and she ensured that family members met R12 at his home. DPOA Y said the facility driver left R12 in his wheelchair at the bottom of the steps to his home. R12 scooted up the steps on his butt and family had to physically help him stand and get back into his wheelchair. Family could not locate any written discharge instructions. Family continued to stay with R12 for his safety, but when he could not independently care for himself or take his own medications they took him to a hospital emergency room. DPOA Y said the hospital was very upset that the facility did not honor R12's existing DPOA paperwork and the hospital discharged R12 to a nursing home that does honor his DPOA paperwork. 6/2/26 at 1:30 PM, the Nursing Home Administrator (NHA) confirmed that she did not locate any documentation revoking R12's DPOA or documentation where the facility reviewed R12's safety concerns with the facility physician. Review of R12's Care Plan revealed, (Name of R12) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): recent AKA (above knee amputation). He also admitted with pressure ulcers on his left foot dated, 4/9/26. Interventions included: break tasks into smaller subtasks, encourage residents to use bell/call light for assistance, home safety visit prior to discharge, bath/shower: partial assist, ambulation/walking: resident is unable to ambulate and requires a wheelchair, for locomotion, bed mobility: supervision, dressing: supervision for upper body and partial assist for lower body, eating: set-up, personal hygiene (combing hair, shaving, applying makeup, nail care, and washing and drying face and hands): supervision, transfers:1 person slide-board transfers from wheelchair for safety, toilet hygiene: partial assist, toilet transfers, 1 assist person transfer with slide board form EOB (edge of bed) – commode with gait belt. All these interventions were still current when R12 discharged home independently on 5/7/26. There was no documentation of R12 being independent with these tasks and no documentation of a home evaluation prior to R12 discharging home independently on 5/7/26. Review of R12's care plan revealed, (Name of R12) wishes to return to the community. (name of the facility must: List any specifics that need to be accomplished before discharge can occur – especially if returning to a (group home) Discharge plan is uncertain at this time dated, 4/28/26 the only intervention was, Prepare and give resident, family member, and/or care giver contact numbers for needed community referrals as needed. There was no indication of interventions and goals related to a safe discharge home independently. R13 Review of a Face Sheet revealed R13 admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, cognitive communication deficit, cardiomyopathy, enterococcus (bacterial infection) unspecified, and diabetes (as listed for primary admission). Review of the Care Plan for R13 revealed the following: Special Instructions: Meds: Whole admitted here for short term rehab following hospitalization for UTI (urinary tract infection). he also has CAD (coronary artery disease), CHF (congestive heart failure), HTN (hypertension), DM (diabetes mellitus), sleep Apnea and Anemia. PLEASE document on s/s's (signs and symptoms) of UTI, pain, safety awareness, ability to compete ADL's and participation in therapy. TELEMED CONSENT 06/13/2025. - Need: (R13) is at risk for cardiac complications related to multiple cardiovascular diseases: CAD (coronary artery disease), HTN (hypertension), Afib (atrial fibrillation), initiated on 6/14/15 and revised on 6/24/25. Review of the Care Plan for R13 revealed: - Need: (R13) is at risk for pain. He generally denies any discomfort. Initiated 6/16/25. Interventions included: Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician. Does not address acute verses chronic pain or the location of pain. No Care Plan that addresses comorbidities for R13 including but not limited to CHF, bacteremia/sepsis, sleep apnea, anemia, or Advance Directives.

Based on interview and record review the facility failed to report an allegation of abuse to the State Agency for one of four residents (Resident #1) reviewed. Findings:Resident #1(R1)Review of an admission Record revealed R1 was a [AGE] year-old female who was admitted to the facility on [DATE].Review of a Nursing Progress Note dated 08/24/25 revealed .Resident used her phone and called 911. CNA (certified nurse aide) walking by saw her on her phone and went in to investigate and noticed 911 was talking to her. CNA explained (to 911 dispatch) that resident was confused, and the call was an accident. Dispatch stated they needed to send an officer out to do a well-check. During an interview on 08/26/25 at 12:10 PM, the Administrator/Abuse Coordinator stated that she was not aware that R1 had called 911 on 08/24/25 nor was she aware that police came to the facility to interview R1 shortly after the call to 911. During an interview on 08/26/25 at 1:35 PM, Ottawa County Sherrif Deputy G reported that the narrative of the call made by R1 to 911 on 08/24/25 included the following: the resident stated she was being held against her will, resident stated she had been assaulted by staff, resident stated staff would not allow her to make phone calls, and the resident implied that she had been sexually assaulted by staff at the facility. During an interview on 08/26/25 at 1:00 PM, CNA B indicated her recollection of events on 08/24/25 that involved R1 were as follows: she (CNA B) was walking down the hallway and saw that R1 was in her room on the phone, CNA B went into R1's room and asked who she was talking to and R1 handed CNA B the phone. CNA B stated that 911 dispatch was on the phone and dispatch told CNA B that R1 reported being abuse by a staff person in the facility. CNA B told 911 dispatch that R1 was confused, R1 was ok, and the call was a mistake. CNA B also stated that she should have notified the Abuse Coordinator but didn't. During an interview on 08/26/25 at 12:51 PM, CNA A stated that she was working the evening of 08/24/25, was aware that R1 had called 911, and was told by CNA B that R1 had told 911 dispatch that she was being abused. CNA A also stated that she did not report the allegation of abuse to the Administrator/Abuse Coordinator because I assumed the nurse would take care of it.Review of the facility policy Abuse Prohibition Policy revealed .allegations of guest/resident abuse .shall be thoroughly investigated by the Administrator and reported to appropriate state agencies .allegations by anyone .must be immediately reported to the Administrator.

Based on interview and record review, the facility failed to follow the policy and procedures and implement measures to prevent a fall for one (R10) of 4 residents reviewed for falls, resulting in a fall with a major injury.Findings include:Review of a Face Sheet revealed R10 originally admitted to the facility on [DATE] and has pertinent diagnoses of vascular dementia with behaviors, hemiplegia/hemiparesis (one sided weakness) and lack of coordination. Review of the Care Plan for R10 revealed: AMBULATION/WALKING: (R10) requires: Partial/moderate assist with THERAPY STAFF ONLY and HEMI-WALKER, initiated 2/18/25. No other modes of mobility are documented. Review of the Order Summary for R10 revealed on 5/23/25 he had orders for 5 mg (milligrams) of Warfarin/coumadin (blood thinner). Review of the last Physical Therapy discharge summary recommendations dated 12/27/24 for R10 revealed: Recommended that patient use his hemi walker at all times.Patient continues to be at high risk for falls and injury due to poor safety awareness and impulsivity. Recommended that patient ambulated with his hemi walker and assistance from a caregiver at all times.Review of a Fall Incident report dated 7/11/25 for R10 revealed a nurse, a social worker, a unit manager and a certified nursing assistant saw R10 walking in the hallway with his hemi walker. The staff encouraged the resident to get back into his wheelchair and the resident refused and continued to walk. R10 continued to walk unsupervised, which resulted in an unwitnessed fall around the corner near the cafe and ice room. The nurse heard the fall impact and saw that R10 landed on his right hip.Review of a Nursing progress note dated 7/11/25 at 4:56 PM for R10 revealed he was sent to the hospital due to a witnessed fall with head injury earlier this evening.Review of a hospital medical record dated 7/12/25 for R10 revealed he was admitted to the Surgical Intensive Care Unit with right rib fractures, respiratory monitoring, aggressive pulmonary toileting (methods used to clear mucous and secretions), a trace pneumothorax (collapsed lung), and acute pain due to trauma. The progress notes revealed: Current literature notes that every subsequent rib fracture in the elderly population is associated with a 19% increase in mortality and 27% increase in pneumonia giving this patient a high chance of mortality/pneumonia.The hospital History and Physical portion of the medical record for R10 revealed: No loss of consciousness, he is on warfarin (blood thinner), staff facility noted that he was at his baseline mentation did not appear more altered than normal. Fall was 3:30 this afternoon, hours later noted to have left-sided weakness which was abnormal for him. Injuries: Rib fractures, trace right pneumothorax, and a right pulmonary contusion (bruising of the lung).During an interview on 8/7/25 at 2:47 PM, the Director of Nursing (DON) reported R10 was to be in his wheelchair and can use a hemi-walker in his room with supervision. R10 has a history of doing what he wants to do and will just do it. The DON agreed that there was no indication in the report that R10 was being supervised while walking in his walker and no indication that any safety precautions were attempted by staff while R10 was walking which resulted in an unwitnessed fall. The DON was not aware that the care plan did not reflect R10 was to use a wheelchair for mobility. Review of a Fall Management policy dated 7/8/25 revealed: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Overview: 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. 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 managing the process for prediction, risk evaluation, treatment, evaluation, and monitoring of resident falls.Practice Guidelines: . 2. Residents identified at risk for falls will have an initial plan of care developed to meet each resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.

Based on interview and record review, the facility failed to consistently implement ordered preventative skin measures, accurately and thoroughly assess a facility acquired pressure ulcer, create and initiate new care plan interventions based on the resident's current condition, and monitor and perform weekly skin assessments for one (Resident #13) of three residents sampled for pressure injuries, resulting in an infected left hand requiring emergency room intervention and surgery. Findings:Resident #13 (R13)Review of an admission Record revealed R13 was a [AGE] year-old female, last re-admitted to the facility on [DATE], with pertinent diagnoses of dementia and Parkinson's disease with severe contractures of both hands. Review of an Order Summary for R13 reflected a physician order for (R13) to wear bilateral palm protectors during the day for 3-4 hours, start date 4/12/25. Review of an Occupational Therapy (OT) note dated 4/14/25 reflected: created hand out with visuals on proper wear of bilateral palm protectors, laminated and placed in (R13's) room at eye level. Aide reported that she was forgetful this past weekend and did not put on the palm protectors. Review of an Occupational Therapy (OT) note dated 4/15/25 reflected: Educated caregivers on importance to adhere to schedule to wear bilateral palm protectors 3-4 hours daily. Review of an OT note dated 4/16/25 reflected: provided education to certified nurse aide (CNA) on how to apply R13's bilateral palm protectors. Review of an OT note dated 4/18/25 for R13 revealed: educated unit manager on how to put on bilateral palm protectors, requested unit manager to provide more time for staff education, and educated unit manager on the visual aide as well as alternative options. Review of an OT note for R13, dated 4/21/25, revealed: R13 not wearing bilateral palm protectors. Alerted CNA that the therapist was putting on palm protectors for the resident. When asked if bilateral palm protectors were put on over the weekend, (R13) shook her head no. Review of an OT noted for R13, dated 4/22/25 reflected: provided education to multiple CNA's and Unit Manager, completed progress note with specific directions for putting on bilateral palm protectors, educated on hand hygiene, washing devices, how to apply the palm protectors, and how to assess for skin breakdown. Provided visuals and written instruction. Review of a Total Body Skin Assessment, completed by nursing on 04/30/25, reflected that R13 had normal skin conditions and no new wounds. Review of a Skin & Wound Evaluation dated 05/07/25 revealed R13 had a stage 3 pressure ulcer on the left middle finger. The evaluation also contained the information: (a) how long has the wound been present-answer unknown, (b) wound measurements- none documented, (c) evidence of infection-not answered, (d) any drainage noted-not answered, (d) odor noted after cleaning-not answered, (e) an evaluation of the surrounding skin-not answered, (f) whether there was any swelling-not answered, and (g) treatment put into place-not answered. During an interview on 8/07/25 at 9:47 AM, Wound Care Nurse (WCN) M could not locate measurements or pictures of the stage 3 pressure ulcer on the left middle finger that was noted on 5/07/25. Review of the Electronic Health Record (EHR) for R13 and verified by WCN M during the interview on 8/07/25 at 9:47 AM, revealed that weekly skin checks were not assessed between 5/07/25 and 6/05/25. Review of a Physician Progress Note for R13, dated 5/20/25, reflected: Patient has bilateral hand pain which she rates at 7 out of 10. Review of an Electronic Treatment Administration Record (Etar) for R13, dated May 2025, reflected an order for nursing to ensure that R13 wore the bilateral palm protectors daily for 3-4 hours. Documentation on the Etar reflected this was not completed on 5/07/25 and 5/17/25. Review of the Electronic Health Record (EHR) for R13 and verified by WCN M during the interview on 8/07/25 at 9:47 AM, revealed that weekly skin checks were not assessed between 6/05/25 and 7/30/25. Review of an Electronic Treatment Administration Record (Etar) for R13, dated June 2025, reflected an order for nursing to ensure that R13 wore the bilateral palm protectors daily for 3-4 hours. Documentation on the Etar reflected this was not completed on 6/10/25. Review of a Physician Progress Note for R13, dated 6/30/25, reflected: hand splints not currently on. Review of a Physician Progress Note for R13, dated 7/15/25, reflected: hand splints not currently on. Review of a Physician Progress Note for R13, dated 7/23/25, reflected: seen today for a wound to her left palm secondary to pressure from fingers from contractures. Measurements were 2 centimeters (cm) x 0.4 cm x 0.1 cm. Review of a Nurses Progress Note for R13, dated 07/23/25, revealed: left hand is contracted, the nails were long and created two wounds in her left palm, one significantly deeper than the other, there is a bad odor coming from the wound. Review of a Skin & Wound Evaluation dated 7/30/25 revealed R13 had an abrasion on her left palm. The evaluation also contained the information: (a) how long has the wound been present-answer new, (b) wound measurements-0cm x0cm x0 cm, (c) evidence of infection-not answered, (d) any drainage noted-not answered, (d) odor noted after cleaning-not answered, (e) an evaluation of the surrounding skin-not answered, (f) whether there was any swelling-not answered, and (g) treatment put into place-not answered. This assessment contradicts the nursing and physician progress notes written on 07/23/25. Review of a Nursing Comprehensive Review for sepsis screening, dated 7/30/25, reflected the following for R13: (1) Does the resident have a suspected or documented infection? Answered-No. Review of a Care Plan regarding skin integrity and risk for pressure injury for R13 revealed that no new interventions had been put into place since 4/11/25. Review of an Emar for R13 dated August 2025 reflected that no orders for daily dressing changes and wound care were in place from 8/01/25 until R13 was sent to the emergency room on 8/4/25. Review of a Therapy progress Note for R13, dated 8/04/25, reflected: Edema (swelling) noted in left hand and digits 3 through 5, left upper extremity is warm to touch, (R13) has a ring on a finger that may be posing skin integrity concerns, alerted nurse that it should be removed. Review of an Emar treatment note for R13, dated 8/04/25, reflected: left hand is swollen, red, and warm to touch, palm moist with odor, has open areas and is painful. Review of an emergency room Physician Progress Note for R13, dated 08/04/25, indicated the following: patient (R13) admitted with a temperature of 100.9, a WBC (white blood cell count) of 20.8, left hand is swollen and red. Review of a hospital Consultation Note dated 8/5/25, revealed that R13 had been prepped for surgery that day for the wound and infection in her left palm.

Based on interview and record review, the facility failed to follow standards of practice for narcotic reconciliation for three residents (Resident #21, Resident #34, Resident #51) out of 5 reviewed for pharmacy services. Findings:Resident #21 (R21) Review of an admission Record revealed R21 was a [AGE] year-old female, last re-admitted to the facility on [DATE], with pertinent diagnoses of chronic pain. Review of an Electronic Medication Administration Record (Emar) for R21 dated August 2025 reflected the following documentation for the medication Norco 7.5-325 mg (milligrams) one tab four times daily for chronic pain: (1) on 8/4/25 the medication was not administered to the resident at noon. Review of a Controlled Drug Receipt/Record/Disposition Form (CDRRDF) for R21 reflected documentation that one tablet of Norco 7.5-325 mg was signed out and administered to R21 at 1:00 PM on 8/4/25. Resident #34 (R34)Review of an admission Record revealed R34 was an [AGE] year-old-female, originally admitted to the facility on [DATE], with pertinent diagnoses of a broken left leg. Review of an Electronic Medication Administration Record (Emar) for R34 dated August 2025 reflected the following documentation for the medication Oxycodone 10 mg one tablet every 4 hours as needed for pain: (1) there was no documentation that R34 was administered the pain medication on 8/02/25 in the morning. Documentation on the CDRRDF for R34 reflected that one tablet of Oxycodone was signed out and administered to the resident at 9:57 AM on 8/02/25. Resident #51 (R51)Review of an admission Record revealed R51 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of recent cervical spine surgery. Review of an Electronic Medication Administration Record (Emar) for R51 dated July 2025 reflected the following documentation for the medication Oxycodone 5 mg one tablet every 4 hours as needed for pain: (1) there was no documentation that R51 was administered the pain medication on 7/24/25. Documentation on the CDRRDF for R51 reflected that one tablet of Oxycodone was signed out and administered to the resident on 7/23/25 at 2:24 PM, and (2) there was documentation on the Emar that one tab of Oxycodone was administered to R51 on 07/25/25 at 2:14 PM, however the medication was not signed out on the CDRRDF for that date and time. During an interview on 08/06/25 at 2:17 PM, the Director of Nursing (DON) indicated that all controlled medications must be signed out on the Emar as well as the CDRRDF.

Based on interview and record review, the facility failed to follow physician orders to obtain labs and monitor values for coumadin use, reapproach or find a root cause to a resident refusal of labs, document pertinent information, and notify the physician/guardian for 1 (R10) of 3 residents reviewed for coumadin use. Findings include:Review of a Face Sheet revealed R10 is [AGE] years old and originally admitted to the facility on [DATE] and has pertinent diagnoses of vascular dementia with behaviors, hemiplegia/hemiparesis (one sided weakness) and lack of coordination. Review of the Order Summary for R10 revealed on 5/23/25 he had orders for 5 mg (milligrams) of Warfarin/coumadin (blood thinner) and reordered again on 7/16/25 when he returned from the hospital to prevent clots. Review of the Order Summary for R10 revealed on 4/11/25 an order to check weekly PT (prothrombin time)/INR every Friday for atrial fibrillation. Document and notify the provider of the results. The time for this task is ordered for 5:00 AM. This was documented as refused on 7/11/25, 7/25/25, and 8/1/25. No documentation in R10's electronic medical record (EMR) supports why R10 refused, if he was reapproached, if the physician was notified, or if the guardian was notified. At the time of this survey, the last PT/INR lab was documented as done on 7/18/25. Review of a Coumadin Flow Sheet in a booklet at the nursing station medication cart for R10 revealed the last PT/INR value recorded was 24.3/2.0 and the Name of Doctor notified is blank. Review of a Nursing progress note dated 7/11/25 at 4:56 PM for R10 revealed he was sent to the hospital due to a witnessed fall with head injury earlier this evening.Review of a hospital medical record dated 7/12/25 for R10 revealed he was admitted to the Surgical Intensive Care Unit following a fall. The hospital History and Physical portion of the medical record for R10 revealed: No loss of consciousness, his is on warfarin (blood thinner), staff facility noted that he was at his baseline mentation did not appear more altered than normal. Fall was 3:30 this afternoon, hours later noted to have left-sided weakness which was abnormal for him. Injuries: Rib fractures, trace right pneumothorax, and a right pulmonary contusion (bruising of the lung).During an interview on 8/7/25 at 10:30 AM, the Director of nursing reported that R10's PT/INR labs have not been done on a regular basis as ordered and saw what the concern was. The DON reported that R10 will refuse at times and when he gets mad about something, he will refuse everything. The DON understood that a potential for his refusal is the timing of the lab being scheduled at 5:00 AM. The DON agreed that R10 should have been reapproached, and the physician and the guardian should have been notified, and the nurse should have documented information in the medical records. The DON reported that the in-house PT/INR testing machine is [NAME] and will need to poke a resident several times to get an accurate result. The DON acknowledged that coumadin was a high-risk medication that needs to be monitored, and the lab value of the PT/INR will determine if the coumadin dose needs to be adjusted to maintain a therapeutic level. The DON acknowledged that the risk of a high PT/INR, especially if a resident has a fall, could be potential for prolonged bleeding and if the lab value is below a therapeutic level, it can cause clotting. In an interview on 8/7/25 at 10:30 AM, the Physician P reported he told a nurse a while ago when he was informed that R10 refused the PT/INR lab that she needed to try to get it. The Physician P reported he would expect the staff to reapproach the resident and staff to follow the orders. Review of the Warfarin/Coumadin medication package insert obtained from the Food and Drug administration (https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/009218s107lbl.pdf) revealed: WARNING: BLEEDING RISK- See full prescribing information for complete boxed warning. - COUMADIN can cause major or fatal bleeding. (5.1) - Perform regular monitoring of INR (international normalized ratio) in all treated patients. (2.1) . DOSAGE AND ADMINISTRATION: -Individualize dosing regimen for each patient, and adjust based on INR response. (2.1, 2.2) . Monitoring: Obtain daily INR determinations upon initiation until stable in therapeutic range. Obtain subsequent INR determinations every 1-4 weeks (2.4) . 2.4 Monitoring to Achieve Optimal AnticoagulationCOUMADIN is a narrow therapeutic range (index) drug, and its action may be affected by factors such as other drugs and dietary vitamin K. Therefore, anticoagulation must be carefully monitored during COUMADIN therapy. Determine the INR daily after the administration of the initial dose until INR results stabilize in the therapeutic range. After stabilization, maintain dosing within the therapeutic range by performing periodic INRs. The frequency of performing INR should be based on the clinical situation but generally acceptable intervals for INR determinations are 1 to 4 weeks. Perform additional INR tests when other warfarin products are interchanged with COUMADIN, as well as whenever other medications are initiated, discontinued, or taken irregularly. Heparin, a common concomitant drug, increases the INR [see Dosage and Administration (2.8) and Drug Interactions (7)].Determinations of whole blood clotting and bleeding times are not effective measures for monitoring of COUMADIN therapy.WARNINGS AND PRECAUTIONS: 5.1 Hemorrhage: 5.1 Hemorrhage COUMADIN can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age greater than or equal to 65, history of highly variable INRs, history of gastrointestinal bleeding, hypertension, cerebrovascular disease, anemia, malignancy, trauma, renal impairment, certain genetic factors [see Clinical Pharmacology (12.5)], certain concomitant drugs [see Drug Interactions (7)], and long duration of warfarin therapy. Perform regular monitoring of INR in all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shortest duration of therapy appropriate for the clinical condition. However, maintenance of INR in the therapeutic range does not eliminate the risk of bleeding. Drugs, dietary changes, and other factors affect INR levels achieved with COUMADIN therapy. Perform more frequent INR monitoring when starting or stopping other drugs, including botanicals, or when changing dosages of other drugs [see Drug Interactions (7)]. Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding [see Patient Counseling Information (17)].

Based on interview and record review, the facility failed to follow physician ordered parameters for one resident (Resident #3) out of five reviewed for professional standards. Findings:Resident #3 (R3)Review of an admission Record revealed R3 was a [AGE] year-old female, re-admitted to the facility on [DATE] with pertinent diagnoses of chronic kidney disease and hypertensive (high blood pressure) heart disease and heart failure. Review of an Electronic Medication Administration Record (Emar) for R3, dated May 2025, reflected the following medication order: Metoprolol 25 mg (milligrams) one tablet in the morning for high blood pressure-HOLD if heart rate is less than 70. On 5/15/25 R3s heart rate was documented as 68 and the medication was administered. On 5/25/25 R3's heart rate was documented as 60 and the medication was administered. On 5/26/25 R3's heart rate was documented as 62 and the medication was administered. R3 was sent to the emergency room on [DATE] for decreased level of consciousness and a blood pressure of 93/45. Review of an 'Emar for R3, dated June 2025, reflected the following medication orders: (A) Isosorbide 10 mg one tablet every 12 hours for high blood pressure-HOLD for systolic blood pressure (the top number) of less than 100. On 06/29/23 in the evening, R3's blood pressure was documented as 94/52 and the medication was administered. (B) Midodrine 5 MG one tablet before meals for low blood pressure (start date 6/04/25) HOLD if systolic blood pressure is greater than .(no parameters for nursing to follow were entered into the order). 28 doses of the medication were administered to R3 without complete parameters. The order for Midodrine 5 MG was revised on 6/23/25 and read Midodrine 5 MG one tablet three times a day for low blood pressure HOLD if systolic blood pressure is greater than 100. On the following dates and times the medication was administered outside of physician ordered parameters: 6/24/25 at noon and at 4 PM, 6/25/25 all three doses were given outside parameters, 6/26/25 all three doses were given outside parameters, and on 6/30/25 the noon dose was given outside parameters. Review of an Emar for R3, dated July 2025, reflected the following medications orders: (A) Toprol XL (extended release) 25 MG one tablet one time daily for high blood pressure (start date 6/30/25) HOLD for systolic blood pressure less than 100. On 7/11/25 R3's blood pressure was documented as 94/64 and the medication was documented as administered. On 7/12/25 R3s blood pressure was documented as 92/66 and the medication was administered. On 7/15/25 R3's blood pressure was documented as 92/56 and the medication was administered. On 7/19/25 and 7/20/25 R3's blood pressure was documented as 92/56 and 99/62 respectively and the medication was administered. On 7/22/25, 7/23/25, and 7/24/25 R3's blood pressure was documented as 93/52, 92/58, and 98/52 respectively and the medication was administered. (B) Isosobride 10 MG one tablet every 12 hours for high blood pressure HOLD for systolic blood pressure less than 100. On 7/04/25 R3's blood pressure was documented as 95/60 and the medication was administered. On 7/07/25 R3's blood pressure was documented as 97/59 and the medication was documented as administered. On 7/08/25 and 7/09/25 R3's blood pressures were documented as 97/59 and 96/58 respectively and the medication was administered. On 7/13/25 R3's blood pressure was documented as 99/53 and the medication was documented as administered. (C) Midodrine 5 MG one tablet three times daily for low blood pressure HOLD if systolic blood pressure is greater than 100. On 07/09/25 and 07/10/25, the medication was administered outside of ordered parameters for all 3 doses on each day. On 7/17/25 two doses were administered to R3 outside of parameters. On 7/18/25, 7/30/25 and 7/31/25 one dose of Midodrine was administered to R3 on each day, outside ordered parameters. Review of an Emar for R3 dated August 2025 reflected the following medication orders: Toprol XL 25 MG one tablet once daily for high blood pressure HOLD for a heart rate less than 50 or a systolic blood pressure (top number) less than 100. On 8/1/25 and 8/06/25 R3's blood pressures were documented as 96/52 and 99/62 respectively, and the medication was administered. During an interview on 8/07/25 at 1:20 PM, the Director of Nursing stated that the facility does not audit the medications that have ordered parameters and would not know if the medications were being given outside of the ordered parameters unless another nurse reported it.

Based on observation, interview, and record review, the facility failed to implement and revise care plan interventions for 1 (Resident #88) of 5 Residents reviewed for care plans, resulting in the resident feeling scared and the increased potential for falls during self-transfers.Findings include: Resident#88 (R88)Review of an admission Record revealed Resident #88 is a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of Rheumatoid Arthritis, Muscle Weakness, Abnormalities of Gait and Mobility, asthma and vitamin D deficiency. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #88 had a Brief Interview for Mental Status (BIMS) indicating she is cognitively intact and is independent using a slide board for transfers and toileting. During an interview on 08/06/2025 at 9:57 AM, R88 stated, Since they polished the floors in my room, I fell due to them being so slippery. Resident, revealed she transfers independently using a slide board to transfer to her wheelchair (near the foot of the bed) and commode (near head of the bed.) R88 stated, I'm scared I am going to fall and get hurt due to the slippery flooring. R88 further stated, I need something down on the flooring to help prevent me from falling like a mat. I used to have strips on the flooring, but they (staff) removed them. The resident further revealed she wants something on the floor, so she does not slip and get hurt.During an observation on 8/06/2025 at 9:57 AM, revealed the floors around right side of R88's bed was clean and free of clutter/debris. The flooring was also free of any anti-slip strips and or any type of fall mat. Further observation of R88's feet revealed she was barefoot.During an interview on 08/06/2025 at 3:00 PM, DON was asked to provide information about (Name of R88's) last couple of falls. During an interview on 08/06/2025 at 3:43 PM, NHA & DON revealed (Name of R88) had 2 falls. The most recent was on 3/02/25 and the other was on 12/12/23.Review of R88's Falls Care Plan reflected (Name of Resident #88) is at risk for falls and fall related injury related to: HTN (hypertension) medication usage, weakness, limited mobility, narcotic medication usage. Date Initiated 6/06/2023, Created on: 6/06/23 with revision on 9/25/2023. An intervention included Anti-slip strips to right side of bed. Date Initiated 12/14/2023. Further review of the Fall Care Plan Intervention reflected, Educate on resident locking wheelchair brakes prior to transferring. Date Initiated 03/03/2025, Created on: 8/06/25.On 08/07/2025 at 9:00 AM, during an interview R88 revealed that she has always been in this room with her bed by the window. Residents stated the strips were removed during cleaning. R88 reiterated she was scared of falling and would like something to help prevent her from falling and getting hurt. R88 stated she had told staff, but nothing had been done. During an interview on 08/07/2025 at 9:10 AM, License Practical Nurse (LPN) R revealed (Name of R88) has expressed concerns/fears about slipping/falling in her room. LPN R also confirmed that R88 transfers independently.

Based on interviews and record reviews, the facility failed to maintain complete and accurate medical records for 2 of 19 sampled residents (R5 and R25). Findings include:R5A review of R5's admission Record, dated 8/5/25, revealed they were an [AGE] year-old resident admitted to the facility on [DATE]. R5's admission Record also revealed multiple diagnoses that included bipolar disorder and post-traumatic stress disorder (PTSD). In addition, R5's admission Record also revealed they had a guardian (someone who makes medical decisions for the resident).A review of R5's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/1/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 9 which revealed R5 was moderately cognitively impaired.A review of R5's electronic medical record, dated 9/1/24 to 8/6/25, revealed the following: - A physician's order for Ativan (a sedative-hypnotic medication for anxiety) 1 milligram (mg) every 8 hours as needed for agitation. - A second physician's order, dated 7/24/25, for Ativan 0.5 mg every 8 hours for anxiety. - R5 had received Ativan 7/12/25 (once), 7/13/25 (twice), 7/14/25 (once), 7/15/25 (once), 7/20/25 (once), 7/21/25 (twice), 7/22/25 (once), 7/24/25 (once), and 7/25/25 to 8/6/25 (three times a day as scheduled) per their Medication Administration records for July and August 2025.- A further review of R5's electronic medical record failed to reveal whether R5's guardian had been notified prior to R5 receiving the first dose of Ativan (or soon after) that R5 was receiving Ativan, the risks versus benefits of the use of Ativan, and/or the possible alternatives to treatment (interventions) the facility had used prior to the facility administering Ativan to R5. During an interview on 08/06/2025 at 1:00 PM, the Nursing Home Administrator (NHA) was notified that the surveyor could not locate any documentation in R5's electronic medical record that would indicate their guardian had been notified prior to the administration of Ativan (or soon after) that R5 had Ativan prescribed, the risks versus benefits of the use of Ativan, and/or the possible alternatives to treatment (interventions) the facility had used prior to the facility administering Ativan to R5. The NHA stated she would look through R5's electronic medical record and see if she could locate this documentation and would provide copies to the surveyor with any documentation she could find.During an interview on 08/07/2025 at 9:08 AM, Social Worker (SW) O stated the facility did not have any documentation that R5's guardian had been notified that R5 was receiving Ativan, that they had discussed the risks versus benefits of Ativan usage, and/or the possible alternatives that had been tried prior to R5 receiving Ativan. She stated she had called the hospice company that assists the facility with R5's end-of-life care yesterday and asked them if they notified R5's guardian about the risks versus benefits and alternative treatments that had been tried with R5 before Ativan was initiated. SW O stated they had e-mailed her their response which said they had provided a copy of all of R5's medications to her guardian. However, the hospice company did not send her a copy of the paperwork that they sent to the guardian. A review of an e-mail response by R5's guardian (GRD Q), dated 08/08/2025 at 9:03 AM, revealed that she was aware that the facility had started R5 on Ativan for anxiety and restlessness to help prevent falls. She stated they had also told her about the risks versus benefits and the interventions that they had tried prior to prescribing the Ativan. A second review of R5's electronic medical record, dated 9/1/24 to 8/6/25, revealed the following: - Medication Regimen Review- Pharmacy form, dated 5/13/25, revealed the pharmacist checked the box See report for any noted irregularities and/or recommendations. - A further review of R5's electronic medical record failed to reveal the pharmacist's report for 5/13/25. During a second interview on 08/06/2025 at 4:30 PM, the NHA was notified that the surveyor could not locate R5's pharmacy recommendation for 5/13/25 in the medical record. The NHA stated she would look through R5's electronic medical record and see if she could locate the pharmacy's recommendation and would provide copies to the surveyor with any documentation she could find. In addition, the surveyor requested a second time any documentation that would indicate that R5's guardian had been notified prior to the administration of Ativan (or soon after) that R5 had Ativan prescribed, the risks versus benefits of the use of Ativan, and/or the possible alternatives to treatment the facility had used prior to administering Ativan to R5.During an interview on 08/07/2025 at 10:15 AM, the Director of Nursing (DON) stated she had been unable to locate R5's pharmacy recommendation for 5/13/25 in her medical record. The DON stated she had to look in her work e-mails to find it. A third review of R5's electronic medical record, dated 5/22/24 to 8/6/25, revealed the following: - Preadmission Screening and Resident Review (PASARR) (a screening/review form used to ensure that individuals are not inappropriately placed in nursing homes for long-term care) Level I Screening, dated 5/22/24, revealed R5 required a Level II Evaluation due to having bipolar disorder, PTSD, and routinely receiving prescribed antipsychotic/antidepressant medications. - PASARR Level II Evaluation, dated 7/23/24, revealed R5 was appropriately placed in the facility and could continue to reside there and received mental health services, as needed. It also revealed that another PASARR Level II Evaluation was by 7/11/25. - A further review of R5's electronic medical record failed to reveal if a PASARR Level I Screening and/or a PASARR Level II Evaluation had been completed between 7/23/24 and 7/11/25. During an interview on 08/07/2025 at 9:17 AM, SW O stated she had completed a PASARR Level I Screening in July 2025. SW O stated she was waiting on the OBRA (Omnibus Budget Reconciliation Act) Coordinator from the county to come and complete the PASSAR Level II Evaluation. SW O confirmed that R5's PASARR I Screening was not in R5's electronic medical record. She stated she had it in a binder in her office and could not explain to the surveyor why she kept it there and did not add it to R5's electronic medical record. SW O did confirm that the binder in her office was not a part of any resident's medical record and was for her own personal use.R25A review of R25's admission Record, dated 8/6/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R25's admission Record revealed they had multiple diagnoses that included dementia, depression, anxiety, and hallucinations. A review of R25's MDS dated [DATE], revealed they had a BIMS score of 12 which indicated they were moderately cognitively impaired.A review of R25's electronic medical record, dated 6/28/25 to 8/6/25, revealed the following: - Medication Regimen Review- Pharmacy form, dated 6/30/25, revealed the pharmacist checked the box See report for any noted irregularities and/or recommendations. - A further review of R25's electronic medical record failed to reveal the pharmacist's report for 6/30/25. During an interview on 08/06/2025 at 4:30 PM, the NHA was notified that the surveyor could not locate R25's pharmacy recommendation for 6/30/25 in her medical record. The NHA stated she would look through R25's electronic medical record and see if she could locate the pharmacy's recommendation and would provide copies of any documentation that she located to the surveyor.During an interview on 08/07/2025 at 9:29 AM, the DON stated she had looked through R25's electronic medical record and could not locate the pharmacy recommendation for 6/30/25. She stated she would continue to search for the pharmacy recommendation and would provide copies to the surveyor of anything that she finds. During a second interview on 08/07/2025 at 10:34 AM, the DON stated she had found R25's pharmacy recommendation for 6/30/25. However, she stated she had found the recommendation on the pharmacy's website because it was not in R25's electronic medical record.Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Documentation is sometimes viewed as burdensome and even as a distraction from patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care . Communications with other health care professionals regarding the patient; Communication with and education of the patient, family, and the patient's designated support person and other third parties . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/25/25).

Based on interview and record review, the facility failed to implement policies and procedures for antibiotic stewardship, ensure the appropriate antibiotic was ordered and the duration of antibiotic orders was followed, promptly follow up with urinalysis, assess, monitor and document antibiotic use to ensure its efficacy, and no care plan interventions for diagnoses for 1 (R92) of 5 residents reviewed for antibiotic stewardship. Findings include:Review of a Face Sheet revealed R92 had pertinent diagnoses of urine retention and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and hypertensive chronic kidney disease with no specified stage.Review of an Order Summary for R92 dated 6/1/25 to 8/31/25 for R92 revealed the following:6/26/25- obtain UA (urinalysis) with C&S (culture and sensitivity) if indicated one time only for UA needed (sic) for 1 Day. 6/27/25- Fosfomycin 3 GM, (grams) once a day for dysuria for 1 day.6/28/25- Fosfomycin 3 GM, one time only for dysuria for 1 day. 7/1/25- obtain a urinalysis with culture and sensitivity if needed for UTI (urinary tract infection) (follow up after Fosfomycin (antibiotic) treatment) until 7/8/25. 7/1/25- Fosfomycin 3 GM, one time a day every 2 days for UTI for 6 days. 7/1/25- Fosfomycin 3 GM, STAT (statim meaning immediately) for UTI.7/17/25- UA and C&S if necessary and CMP (complete metabolic panel). 7/20/25- Cipro (antibiotic) 500 mg (milligrams), two times a day for UTI until 7/25/25 for 5 days. Review of the June 2025 Medication Administration Record (MAR) for R92 revealed Fosfomycin 3 GMs was ordered once on 6/27/25 and documented as Hold/See Nurse Notes. No notes were documented. On 6/28/25 an order for Fosfomycin 3 GM was documented as given on this day. A urinalysis is documented as done on 6/26/25.Review of a Urine Culture dated 6/29/25 for R92 revealed he had a positive urinalysis that was positive for Proteus mirabilis. The susceptibility report did not list Fosfomycin as a suitable treatment for this strain of bacteria. Review of a Urinalysis collected on 7/17/25 and resulted on 7/18/25 for R92 revealed a culture was not done. The urine sample was orange and extra turbid with white blood cells and the red blood cells were TNTC (too numerous to count, and normal is negative), and leukocytes were elevated (normal is negative). Started Cipro per on call on 7/20/25 was written at the bottom of the form. Review of the July 2025 MAR for R92 revealed he received Fosfomycin 3 GM on 7/2/25, 7/2/25, 7/4/25, and 7/6/25. On 7/20/25 he received Cipro 5 mg (that was ordered twice a day for 5 days) once on 7/20/25, twice on 7/21/25 and 7/22/25, and once on 7/23/25 (equivalent to 3 days) and was discontinued on 7/23/25.Review of the Nursing Progress notes for R92 revealed the following:7/1/25 at 1:11 PM- the resident was given 1000 mg of extra strength Tylenol that was ordered for headaches but documented it was given for pain in his left side and lower abdomen. 7/4/24 at 8:08 PM- the resident was given 1000 mg of extra strength Tylenol that was ordered for headaches, but complained of lower back pain. 7/7/25 at 8:47 AM- the resident was given 1000 mg of extra strength Tylenol that was ordered for headaches and was given for bladder pain, states more painful during the night.7/16/25 at 5:26 PM- 7 Day Status- resident's VS (vital signs) unremarkable. [resident complains of] having pain/discomfort while urinating, res also stated he's stressed and anxious. Res also is worried about having low appetite. Res was able to talk to this nurse in Spanish. Res hopes to talk to provider tomorrow. There was no thorough continuous monitoring for signs and symptoms of infection during and after antibiotic use. Review of the Physician Progress note dated 7/17/25 for R92 revealed: Asked to see the [AGE] year-old for 60 day regulatory visit. He complained of low back pain which radiated around to his abdomen, but had no other complaints. No new orders or updated plan for R92's care was documented. Review of a Physician Progress note dated 7/18/25 for R92 revealed: Diagnostic Result Review. Urinalysis complete with micro. Plan of Action: Looks like a dirty catch and apparent active UTI.Review of a Practitioner Progress note dated 7/20/25 at 8:00 AM for R92 revealed an order for Cipro 500 mg twice a day for 5 days was ordered. This was ordered 2 days after the urinalysis was resulted. Review of Physician Progress note dated 7/22/25 for R92 revealed he was asked to see R92 due to persistent frequency and burning and urination. He does have a UTI and I will provide Cipro 500 mg twice a day for the UTI and perineum for the burning. This was already ordered on 7/20/25 and discontinued on 7/23/35 the day after this visit. Review of a Nursing Progress note dated 7/22/25 for R92 revealed: Continues on antibiotic therapy for UTI, continues to [complain of] pain in lower abdomen.Review of a Nursing Progress note dated 8/1/25 for R92 revealed: resident states mild pain to abdomen area and groin. Review of the Care Plan for R92 revealed no focus for urinary retention, urinary infection or benign prostatic hyperplasia.In an interview on 8/6/25 at 1:08 PM, the Assistant Director of Nursing (ADON)/Infection Control Preventionist A reported they have an antibiotic stewardship program and follow the McGeer's criteria for infections. If an antibiotic is needed prior to receiving a positive diagnostic lab, the physician is really good at writing a risk verses benefit. The physician is really good at not prescribing antibiotics prematurely and will do so once in a while to get a head start if there is a great concern. When questioned about R92 starting on Fosfomycin on 6/27/25 and continued after the urine culture resulted on 6/29/25 without changing to a more susceptible antibiotic, the ADON did a google search and reported that Fosfomycin does treat proteus mirabilis. When questioned about the urinalysis collected on 7/17/25 that did not have a culture and sensitivity done, but R92 was ordered Cipro for 5 days but only took it for 3 days, the ADON reported it may have been because they realized he did not have a positive culture. Review of a policy titled Infection Control Antibiotic Stewardship & MDRO's (multidrug resistant organisms) last revised 4/17/25 revealed: Antibiotic stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials, by promoting the selection of the optimal antimicrobial drug regimen, dose duration of therapy, and route of administration. 4. The medical director, primary care providers and pharmacy consultants will be utilized for their drug expertise and/or training in improving antibiotic use. This includes the selection, dosing, appropriate route of administration and days of therapy. 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.

This citation pertains to intake # MI00149246 Based on observation, interview, and record review, the facility failed to follow professional guidelines for three residents (Resident #4, Resident #5, and Resident #9) out of 4 residents reviewed for tube feeding. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year old female, last admitted to the facility on [DATE] with pertinent diagnoses of cerebral palsy. R4 was completely dependent on staff to have all of her needs met and received nutrition and hydration through a tube feed. During an observation on 03/26/25 at 8:30 AM, R4 laid in bed resting with her eyes closed with the tube feed running. R4's lips were dry and cracked and the head of the bed was positioned at 20 degrees with the resident slid down in the bed and R4's head was positioned at 10 degrees. During an observation on 03/27/25 at 8:03 AM, R4 laid in bed with her eyes closed and the tube feed running. The head of the bed was elevated to 12 degrees. During an observation on 03/27/25 at 8:35 AM, certified nurse aide (CNA) M exited R4's room. R4 was observed laying in bed resting with her eyes closed and the head of the bed remained at 12 degrees. During an interview at the same time, CNA M reported having been in the room to check on R4. When asked at what level the head of the bed should be. CNA M stated that she did not know. Review of a Care Plan for R4 reflected .elevate head of bed to 30 degrees during and 30 minutes after tube feed. Resident #5 (R5) Review of an Admission Record revealed R5 was an [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of cognitive communication deficit, pneumonitis due to inhalation of food and vomit, and acute respiratory failure. R5 received nutrition and hydration through a tube feed. During an observation on 03/26/25 at 8:35 AM, R5 laid in bed resting with his eyes closed and the tube feed was running. The head of the bed was raised to 22 degrees and the Osmolite 1.5 did not have a time on the label indicating when it was initiated. During an observation on 03/27/25 at 8:15 AM, R5 laid in bed resting with his eyes closed and the tube feed was running. R5's head was elevated to 20 degrees and the kangaroo flush bag that was dated 03/26/25 did not have a start time indicated. Review of a Care Plan for R5 revealed .elevate the head of bed to semi-Fowlers position (head of the bed position at 30 to 45 degrees) during and 30 minutes after tube feed. Resident #9 (R9) Review of an Admission Record revealed R9 was an [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's Disease, cancer of the mouth and throat, and Alzheimer's. During an observation on 03/26/25 at 8:20 AM, R9 laid in bed resting with his eyes closed and the tube feed running. The kangaroo flush bag that provided hydration to R9 was not labeled with a date and time that it was initiated. During an interview on 03/27/25 at 9:00 AM, the Director of Nursing indicated that the standard of practice for the facility regarding tube feeding practices was to (a) elevate the head of the bed to 30-45 degrees when the tube feed was running, (b) to label the tube feed solution and kangaroo flush bag with the date and time each was initiated. Review of the facility policy Enteral Nutrition reflected .(8) the resident should be in the semi-Fowlers position during administration and for 30 minutes to one hour afterward to prevent aspiration.

This citation pertains to intake MI00147718 Based on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure injuries for one resident (Resident #1) out of 4 residents reviewed for pressure injury, resulting in worsening of pressure injury, serious infection, and delayed wound healing. Findings include: Resident #1 (R1) Review of an Admission Record reflected R1 admitted to the facility on [DATE] with diagnoses that included enterovirus, anemia, high blood pressure, chronic kidney disease, chronic congestive heart failure (CHF), atrial fibrillation with the presence of automatic (implantable) cardiac defibrillator, history of stroke, cognitive communication deficit, and muscle weakness. Review of a Minimum Data Set (MDS) admission assessment dated [DATE] reflected R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15. R1 required partial to moderate assistance with rolling left and right, sitting to lying, lying to sitting on the side of the bed. R1 needed substantial/maximal assistance (helper does more than half of the effort) for sitting to standing and chair/bed-to-chair transfer. Section M - Skin Conditions reflected R1 was at risk for development of pressure ulcers and did not have any unhealed pressure ulcers or other skin conditions. Review of a Nursing Comprehensive Evaluation dated 9/12/24 (admission assessment) reflected R1 admitted to the facility with scattered bruising to the back of the right hand, a dark purple dot under an unspecified right toe, recent left arm cellulitis per hospital report. Swelling noted, no pain, no redness. No other skin alterations were noted in the admission assessment. Review of a Care Plan initiated on 9/12/24 reflected R1 was AT RISK for impaired skin integrity/pressure injury. The goal was to Minimize risk in an effort to reduce likelihood of pressure injury development. Interventions included cueing R1 to reposition self as needed and Follow facility policies/protocols for the prevention/treatment of impaired skin integrity. During an interview on 11/13/24 at 10:43 AM, R1 reported he had some difficulty at the facility. R1 explained that he had gout, cellulitis and wounds on his feet which impacted his ability to participate with physical therapy. During an observation on 11/13/24 at 1:14 PM, R1 was lying in bed on a standard mattress, a standard pillow under his feet, however, the pillow had compressed and R1's feet were resting on the mattress. RN C assembled supplies and explained the dressing change to R1, who agreed to the observation. RN C removed the dressings, dated 11/11/24, on R1's left foot which were saturated with serosanguinous drainage. Three separate areas were noted along the lateral aspect of R1's left foot and heel which presented as unstageable wounds due to eschar covered most of the wound beds, with slough at the rolled edges. RN C cleansed and redressed each wound. RN C then removed the dressing on R1's right heel, dated 11/11/24, with moderate serous exudate present. The right heel wound was also unstageable due to the presence of eschar and slough. R1 winced in pain during the procedure. It was noted that the sheet at the foot of the bed was streaked with what appeared to be dried bloody/serous drainage. During the observation of wound care on 11/13/24 at 1:14 PM, R1 reported that he tried to elevate his feet off the bed, but the pillow kept slipping away. R1 again reported he was having a hard time working with physical therapy due to the wounds on his feet which was a frustrating set-back as he was looking forward to going home. During an observation on 11/13/24 at 3:27 PM, R1 was observed resting in bed, his heels resting directly on the mattress. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] (the day after R1 admitted to the facility) reflected R1's did not have any wounds. Review of Progress Notes dated 9/25/24, documented by CNS A reflected Per nursing, back wound noted, and excoriation noted on bottom. For back care, cleanse with wound cleanser daily and cover with border gauze. For excoriation: do pericare daily with mild soap and water, apply zinc barrier cream BID (twice a day) and PRN (as needed). Swelling persists in LLE (left lower extremity). The extremity appears shiny and swollen with redness discoloration noted near the posterior malleolus. Encouraged patient to elevate. Continue with torsemide (diuretic) 20 mg (milligrams) daily. As previously mentioned, patient states he thinks he has gout but has never been evaluated by his primary care provider for this condition. Symptoms do appear to be consistent with gout diagnosis. If no improvement noted with consistent elevation, will consider trialing of indomethacin or colchicine and monitor for improvement. Uric acid level and BMP (basic metabolic panel) level due on 9/30 (2024). Will continue to monitor. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] (13 days after the previous assessment) reflected R1 had 4 New Wounds. Review of a Nurses Notes dated 9/26/24 reflects, (R1) has four new wounds to his feet. To his left heel he had a popped (open) blister that measures 3.7 x 2.0 cm (centimeters). He has blisters on the lateral side of his right foot that go from heel to toes. The heel measures 4.9 x 3.5, mid lateral foot is 3.3 x 2.2 cm and toward the toes was 2.2 x 2.2 cm. (Note: this progress notes incorrectly identified the location of R1's wounds, clarified with CNS A during an interview on 11/14/24 at 8:30 AM. R1 has one wound on his RIGHT heel, and three wounds on his LEFT foot.) Review of Progress Notes dated 9/27/24 documented by Clinical Nurse Specialist (CNS) A reflected (R1) seen for a possible gout (a type of arthritis that occurs when the body has too much uric acid, which causes crystals to form in the joints. Gout causes sudden, severe pain, swelling, redness, and warmth in the affected joint) flare, pain, and PT/OT (Physical Therapy/Occupational Therapy) tolerance. Patient stated he is having a hard time working with therapy because of his chronic left foot and left knee pain. Patient stated it was gout today and not arthritis. Had at length conversation to clarify if patient had ever formally been diagnosed with gout. Patient stated no. LLE (left lower extremity) does appear consistent with gout with swelling, erythema (redness), and shiny skin. Some blisters noted on LLE, hard to distinguish if blisters are related to tophi (a deposit of uric acid crystals that form under the skin in joints, tendons, and soft tissues). Will continue to monitor and order wound care . The progress note did not mention the opened blister on the right foot. Review of R1's September 2024 Treatment Administration Record (TAR) reflected the order L (left) foot blister care: daily for night shift. Cleanse foot daily with mild soap and water. If blisters are intact apply skin prep. If not intact, apply A & D and cover with gauze. May apply roll gauze to keep in place every night shift for L foot blister care. -Start Date- 9/28/24 11:00 PM. Further review of the September 2024 TAR did NOT reflect a treatment order to treat the open blister on R1's right foot. Review of a Skin & Wound - Total Body Skin assessment dated [DATE] reflected R1 had 3 New Wounds. No further documentation related to the new wounds were found in the clinical record. Review of a Progress Notes dated 10/01/24 documented by CNS A reflected Foot examined. 1+ swelling noted, nonpitting, three blood blisters present and intact. The note indicates R1 is still being evaluated for gout and is having trouble tolerating therapy due to pain in foot. The progress note does not address the condition of R1's right heel. Review of Progress Notes dated 10/03/24 documented by CNS A reflects New unstageable pressure wound found on R (right heel). Unsure of origin. Slough (dead tissue that can impede wound healing and increase risk of infection) and Eschar (a collection of dry, dead tissue within the wound) present at base. Wound consult updated. Wound care ordered as Right heel pressure ulcer care: Cleanse daily with wound cleanser, apply calcium alginate cut to fit area, and cover with bordered gauze daily. Date and initial. Weight bearing as tolerated for RLE (right lower extremity) to promote wound healing. Wound (wound care consultant) to see 10/07 (2024) . Review of the EMR reflected R1 signed a consent to be treated by the wound care consultant upon admission as evidenced by a Wound Care Patient Consent Form document signed by R1 on 9/12/24. Review of Progress Notes dated 10/28/24 for Wound Care indicates Wound care consulted for follow-up, evaluation, and treatment on bilateral foot wounds. The note revealed 1. (1) Right Heel Pressure Unstageable - This wound measures 3.18 x 1.84 cm with a depth of 0.1 cm. This wound is full thickness. There is a moderate amount of serous drainage from the area. Wound bed consists of 50% eschar and 50% slough tissue. Edges are attached and there is no tunneling, undermining, or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain induration or sign of infection. 2. (2) Left Lateral Midfoot Blister - This wound measures 12.48 x 2.68 centimeters with a depth of 0.1 centimeters. This wound is partial thickness. There is a moderate amount of serosanguinous drainage from this area. Wound bed consists of 90% epithelial and 10% granulation tissue. Edges are attached and there is no slough, eschar, tunneling, undermining or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection. The wound care note does not specify R1 had three blistered areas on the left foot as had been previously documented. This note indicates the first time R1 is evaluated by the wound care consultant, three weeks from the time CNS A indicated R1 would be seen. Review of Nurses Notes dated 10/29/24 reflects Wound an R (right) heel noted to have strong foul odor and excessive amount of purulent drainage. (R1) c/o (complains of) chills. Res (resident) noted to have fever, elevated pulse, and BP (blood pressure) lower than baseline. On-call provider notified and orders were obtained for midodrine (treats low blood pressure) and Rocephin (broad-spectrum antibiotic). Orders administered. On-call provider then told this nurse that she would like the res sent to ED (Emergency Department) for eval (evaluation). Res refusing to go to the hospital at this time-on-call provider notified of refusal. Review of Progress Notes dated 10/30/24 reflected .Patient is lethargic. Blood pressure is still running in 90s this morning. Educated patient that he did meet all the criteria for sepsis and is may have been beneficial for patient to go to hospital for further evaluation. R heel wound examined, purulent and foul odor drainage noted. Wound base with eschar spreading around site. I will order a wound culture and empiric antibiotic treatment until wound culture results. Per up-to-date recommendations, empiric antibiotic therapy stated into Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG BID for 5 days and doxycycline 1-mg tablet BID for 5 days or longer pending result of wound culture. As patient was meeting criteria for sepsis, the benefit of starting empiric antibiotic therapy outweighs the risk to prevent hospitalization or further deterioration. Review of an Order Recap Report for all R1's orders from admission to 11/13/2024 did not reflect a wound culture had been ordered. During an interview on 11/14/24 at 8:30 AM, CNS A reported she had been following R1's wounds and acknowledged the first order in place to treat the blister was for closed blisters, not open wounds. CNS A said she did not know R1 had an open wound on the right heel. CNS A said when R1 developed signs and symptoms of sepsis she was very worried and wanted R1 to go to the hospital. When R1 refused hospitalization , CNS A ordered medication to support his blood pressure, an empiric antibiotic and wanted a wound culture to ensure the antibiotic therapy ordered was appropriate. CNS A said she kept looking for the wound culture results, and it was discovered the wound culture was never ordered or obtained. CNS A said she was concerned R1 may have MRSA (Methicillin-resistant Staphylococcus aureus) which would not have been treated with the antibiotic ordered. CNS A reported she did not know why the wound care consultant did not evaluate, treat and monitor R1's wounds until 10/28/24 (three weeks after the consultation was requested). According to CNS A, regardless of how the wounds developed, the lack of pressure reducing interventions did not promote healing. Review of Skin & Wound Evaluation reports, dated 11/11/2024 (entered 2 weeks after the wounds were assessed) reflected R1's wounds were first evaluated on 10/28/24. As of 11/14/2024 NO other wound measurements and descriptions were found in the EMR. The wounds were described as follows: 1. Left lateral midfoot, pressure, unstageable: obscured full-thickness skin and tissue loss due to slough and/or eschar, in house acquired; Length 2.2 cm, Width 1.2 cm, Depth 0.1 cm; wound bed-slough, 50% of wound filled, eschar, 50% of wound filled. Additional Care specified R1 needed Heel Suspension/Protection device, mattress with pump, nutritional/dietary supplementation. 2. Left Lateral Foot, pressure, unstageable: obscured full-thickness skin and tissue loss due to slough and/or eschar, in house acquired; Length 3.8 cm, Width 2.7 cm, Depth 0.1 cm; Wound bed-slough 10% of wound filled, Eschar, 50% of wound filled. Additional Care specified R1 needed Heel Suspension/Protection device, mattress with pump, nutritional/dietary supplementation. 3. Left Lateral Foot, Distal, pressure, unstageable: obscured full-thickness skin and tissue loss due to slough and/or eschar, in house acquired; Length 1.0 cm, Width 0.9 cm, Depth 0.1 cm; Wound bed 100% eschar. Additional Care specified R1 needed Heel Suspension/Protection device, mattress with pump, nutritional/dietary supplementation. 4. Right Heel, pressure, present on admission (this is incorrect, as evidenced by the admission assessment and subsequent total body skin assessments); Length 2.0 cm, Width 1.4 cm, Depth 0.2 cm, wound bed-slough 50%, eschar 50%. Additional Care specified R1 needed Heel Suspension/Protection device, mattress with pump, nutritional/dietary supplementation.

Based on interview and record review the facility failed to consistently implement physicians orders for 1 of 3 residents (Resident #101) reviewed for quality of care, resulting in facility staff not recognizing the risk of low blood pressure prior to administering blood pressure medications which placed Resident #101 at risk for serious health conditions. Findings include: Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Review of the Functional Status revealed that Resident #101 required limited assistance of 1 person for eating. Review of Resident #101's Progress Note dated 3/27/22 at 10:04 A.M. revealed, Spoke with resident's spouse regarding her condition being that she is very tired and lethargic. Wanted to update spouse on this. Also to let spouse know that due to her lethargy a [MEDICATION(S)] (pain medication) was held so only 1 pill was given instead of 2 to see if this made a difference, but noted it did not help her lethargy. Resident is hardly eating or drinking her ensures (supplement) at the moment . Review of Resident #101's Progress Note dated 3/27/22 at 13:34 (1:34 P.M.) revealed, Resident was found in her room setting (sic) in her chair with her head down and food coming out of her mouth. Therapist came to this nurse stating resident was not doing well. Could not get resident to respond to touch or stimuli. Called for help in resident's room. Crash cart was brought to residents room. Vital Signs were taken BP was 79/49, 02 (oxygen) was 49% on room air. Pulse was 48. 02 mask placed on resident's face. 02 back up to 100% on 02. 911 was called and spouse was called. Review of the Ambulance Prehospital Care Report Summary dated 3/27/22 at 1:26 pm, Resident #101 was found to have a blood pressure of 63/37 and a pulse of 69. At 1:34 pm, Resident #101's blood pressure was 68/37 with a pulse of 74 with continued severe [CONDITION(S)] despite fluid administration. At 1:44 pm, Resident #101's blood pressure was 72/41 with a pulse of 66. It was documented that The pt (patient) began to show some increase in LOC (level of consciouness) and when asked if the pt was feeling better, the pt gave a deliberate thumbs up to EMS 2 times. Review of the hospital note dated 3/27/22 at 3:46 pm revealed, [AGE] year-old female who presents from her living facility with reports of altered mental status. After receiving IV fluids prior to arrival, EMS reports improvement in her mental status and vital signs. On arrival her blood pressure is soft improved to the 90 systolic. She is saturating 94% on room air. She is at her neurologic baseline . During an interview on 3/30/22 at 11:46 A.M., Certified Occupational Therapy Assistant (COTA) B reported that she entered Resident #101's room on 3/27/22 and observed Resident #101 in her wheelchair, with her head slumped over, drooling, and unable to lift her head up. COTA B reported that she alerted LPN F due to Resident #101 being unresponsive. During an interview on 3/30/22 at 10:51 A.M., Licensed Practical Nurse (LPN) F reported that on 3/27/22, Resident #101 had not been her normal self all day and stated, .she was very lethargic .I had never seen her like that before . LPN F reported that she had thought the lethargy was a side effect of Resident #101's pain medications, therefore she held a dose of [MEDICATION(S)] (pain medication). LPN F reported that after lunch Certified Occupational Therapy Assistant (COTA) B, alerted her to Resident #101 being unresponsive and stated, .(Resident #101's) head was slumped forward .she was drooling .she did not respond .I lifted her head and she tried to open her eyes .her oxygen level was really low, like 50 . LPN F reported that at first she had thought Resident #101 was choking and stated, .but there was no food in her mouth .we sat her up and gave her oxygen .she came back around real fast . LPN F reported that Resident #101 was transferred to the hospital by ambulance and stated, .she was alert and talking clearly when she left . Review of Resident #101's Blood Pressure Record indicated on 3/27/22 at 10:31 a BP of 89/52 mm/Hg (manual). Previous to that the BP findings were: 135/79 on 3/26/22, 178/94 on 3/25/22, 137/82 on 3/24/22, 125/76 on 3/23/22, and 128/80 on 3/22/22. There were no findings with the SBP (systolic blood pressure: the top number) below 90 within the previous 15 months that were available for review. Review of Resident #101's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated a BP reading of 89/52 and LPN F's initials indicating that the medication was administered, regardless of BP results outside of parameters. During a subsequent interview on 3/30/22 at 3:32 P.M., LPN F reported that she did not hold Resident #101's [MEDICATION(S)], did not recheck her blood pressure, and did not contact the physician until Resident #101 became unresponsive after lunch and stated, .when blood pressure is outside of parameters we are supposed to notify the physician . During an interview on 3/31/22 at 8:44 A.M., Medical Doctor (MD) C reported that he would have expected a call from the nurse on 3/27/22 when Resident #101 was lethargic and had low blood pressure and stated, .that is a change of condition .they should have held the [MEDICATION(S)] and called the on-call doctor . During an interview on 3/30/22 at 3:59 P.M., Unit Manager (UM) E reported that nursing concerns with blood pressure level would be based on the resident's normal levels and stated, .if the top number is less than 90 or over 170 .we would hold the medication .recheck blood pressure .then call physician . During an interview on 3/30/22 at 4:30 P.M., DON reported that a blood pressure reading of 89/52 would not be concerning for someone like Resident #101, because she normally runs on the low side and stated, .we wouldn't contact the physician for that (despite the physician orders to call) .the nurse should have held the [MEDICATION(S)] and rechecked the blood pressure . DON reported that LPN F contacted her on 3/27/22 regarding Resident #101 being lethargic and stated, I told her to call (Resident #101's husband), because he would want to know . Review of the facility policy Change of Condition: When to report to MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant) dated (not date) revealed, Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed .Report Immediately: Blood Pressure: Systolic BP > 200 mmHg or < 90 mmHg . Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, [CONDITION(S)] is present when the systolic BP (blood pressure) falls to 90 mmHg or below .record any signs of BP alteration in nurses notes. Report abnormal findings to nurse in charge or health care provider. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 461 and 465.

This citation pertains to intake M 5065 Based on observation, interview and record review, the facility failed to assess, communicate, and address pain and injury post fall for 1 (Resident #6), resulting in delayed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Resident #6 (R6) Review of a Face Sheet Revealed R6 originally admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed R6 was cognitively intact and independent for transfers and cares. Review of a Facility Reported Incident (FRI) submitted to the State Agency on 12/8/21 revealed R6 had an injury of unknown source in the form of a fracture. On 12/7/21 a portable xray of R6's hip was done that concluded R6 had acute fractures in the right hip region. Guest was noted to have fallen and had injuries on bilateral elbows although was noted walking and transferring without concern days after. Where and when did the alleged incident occur? Unknown although the guest did have a fall on November 29th, 2021, with no noted hip injuries at that time. Guest was noted to have fallen and had injuries on bilateral elbows although was noted walking and transferring without concern days after. Removed cords plugged into wall and removed shoes that guest received from another guest that were too big for his feet. Review of an Incident and Accident Report dated 11/29/21 for R6 revealed he had an unwitnessed fall at 2:00 p.m. and sustained skin tears on his bilateral elbows. R6 was walking in his room toward his bed and tripped over cords that were on the floor near the bathroom door. He also had shoes on that were too big. The facility removed the items that were plugged in and removed the shoes that were too big. R6 was found laying on his back with his legs stretched out and his arms were at his side. Review of a Radiology Results Report dated 12/7/21 revealed R6 had ACUTE PAIN DUE TO TRAUMA and revealed he had a right subcapital fracture with no displacement. Review of an x-ray dated 12/14/21 for R6 revealed: Known right hip FX (fracture) eval for possible SX. PT (patient) states falling on November 29 and fracturing his right hip. Impression: There appears to be a probably acute fracture of the right inferior pubic ramus . Review of a Nursing Progress Note dated 11/29/21 at 3:35 p.m. revealed at (1:55 p.m.) heard a loud crash, resident observed on the floor on his back in front of the bathroom door with walker tipped over. Full range of mother performed on upper and lower extremities, resident painful but able to stand and raise his arms. Skin assessed noted to have skin tears on outer bilateral elbows, resident stated he hit his head, scalp assessed, and forehead assessed, no open areas or raised bumps.tiger text to (Nurse Practitioner). Resident stated he tripped over the cords that were plugged in near the bathroom, there was noted to be a black cell phone on the ground that had been pulled out the wall during the fall and also a white humidifier fan that was plugged in. Resident also noted to have on black Velcro tennis shoes that were floppy at the toes, shoes measured 12.5 inches residents feet measured 10 inches. Items unplugged and removed out of the path/walkway. Review of a Nursing Progress note dated 11/30/21 at 1:32 p.m. for R6 revealed: Fall reviewed with IDT (interdisciplinary team); resident observed on the floor in his room. Stated he tripped over cords. Resident noted to have pair of shoes too large for him. Cell phones moves to another area in room to charge and guardian notified to see if she could get him the right size in shoes. Review of a Physical Therapy Progress Note dated 11/30/21 for R6 revealed: Pre-tx (Pretreatment): Is skilled therapy needed to address pain? = Nursing to address. Barriers impacting treatment? = Yes. Barriers Impacting Treatment: Pt (patient) fell on to R (right) side last night causing increases in pain with ex's (exercises) and activity. Clarified accuracy of fall w/ (with) nursing. Review of a Physical Therapy Progress Note dated 12/1/21 for R6 revealed: Pre tx: Is skilled therapy needed to address pian? = Nursing to address. Pt able to sit EOB (edge of bed) for approx. 1 min before R hip pain increased and pt had to lay back down. Barriers impacting treatment? = Yes. Barriers Impacting Treatment: confusion, increased R hip pain. Review of a Physical Therapy Progress Note dated 12/2/21 for R6 revealed: Pre tx: Is skilled therapy needed to address pain? = Nursing to address. SLR 2x10 on L LE (left lower extremity) only due to increased pain on R LE (right lower extremity) when attempted. Pt demo'd (demonstrated) decreased ROM (range of motion) on R LE compared to L LE 2* increases in pain from fall that occurred earlier this week. Pt able to stand and shift wt (weight) over to L LE to help decrease pain in R LE, however pt c/o (complained of) nausea after standing for approx. 10 sec and had to return to supine. Review of a Physical Therapy Progress Note dated 12/3/21 for R6 revealed: Pre tx: Is skilled therapy needed to address pian? = Nursing to address.pt stated his RLE would hurt too much to perform PROM (passive range of motion) on RLE. Review of a Physical Therapy Progress Note dated 12/6/21 for R6 revealed: Pre tx: Is skilled therapy needed to address pian? = Nursing to address. LAQ and marches 2 x 15 on L only 2* increased pain when attempted on R LE. Review of a Nursing Progress Note dated 12/7/21 at 2:18 p.m. for R6 revealed: Therapy stating resident having increased pain in his right hip since fall. NP (Nurse Practitioner) notified. Order for X-ray obtained. Review of a Nursing Progress Note dated 12/7/21 at 7:39 p.m. for R6 revealed: (Nurse Practitioner) notified of x-ray results. Resident to be NWB (non-weight bearing.) Review of a Physical Therapy Progress Note dated 12/7/21 for R6 revealed: Pre tx: Is skilled therapy needed to address pian? = Nursing to address.Pt had increases in R LE pain when WB (weigh bearing) for longer than approx. 3 sec. Pt had fall a couple weeks ago and has made improvements with abilities and pain, however is still experiencing increased pain with WB and some activity. Barriers impacting treatment? = Yes. Barriers Impacting Treatment: increased RLE pain with WB and MMT. Review of a Physical Therapy Progress Note dated 12/8/21 for R6 revealed: Pre tx: Is skilled therapy needed to address pian? = Nursing to address. Pt (educated) about new NWB status on RLE not bearing any weight at all through R leg, avoiding laying on R side when in bed since fx (fracture) is at hip. Spoke with nursing staff about x-ray results from yesterday, fx on RLE was reported with new NWB status on R LE. Pt ed about new WB status and importance in healing process. Review of the Electronic Medical Records (EHR) do not reflect the communication and pain assessment for R6's right lower extremity. In an interview on 12/21/21 at 12:45 p.m., R6 reported he remembered falling on 11/29/21 and had extreme pain the first day of the fall and was wondering why it took 4-5 days to get an x-ray done and was concerned about the delay in his care. He reported when he finally went to the hospital, his fracture was already starting to heal. In an interview on 12/21/21 at 1:45 p.m., Licensed Practical Nurse (LPN) J reported she was working the day R6 fell , and it happened around shift change when she heard a loud crash. When she entered his room, he was laying flat on the floor with his walker tipped over. A cell phone was plugged in the wall along the walking pathway and an air humidifier was on the floor and the plugs were pulled out of the wall from R6 tripping over them. She was unclear if he hit his head. LPN J reported the resident was instructed to see if he could move his arms and legs and he eventually was able to move. R6 stood with no problems and sat in his wheelchair. R6 complained of pain but not sure where the pain was or remembered if he was able to rate it. LPN J reported R6 is a good historian most days. LPN J reported the fall was charted and the Nurse Practitioner (NP) was notified via Tiger Text. LPN J could not remember if the NP called back and verified the Electronic Medical Record (EMR) did not reflect it. The EMR reflected the NP acknowledged the incident the next day on 11/30/21 in the EMR. LPN J reported R6 usually had a baseline pain in his left hip and left shoulder prior to this incident and was unaware he had pain in his right hip until the x-ray showed where the fracture was. LPN J was aware R6 had increase pain when walking with Physical Therapy. In an interview on 12/22/21 at 8:15 a.m., Nurse Practitioner (NP) L reported as soon as the nurses reached out to her about R6 having pain, she immediately ordered an x-ray. NP L reported she was unaware of R6 having any pain until then (12/7/21). When she saw R6 the day after his fall on 11/30/21, he only complained of pain in his [NAME]. In an interview on 12/22/21 at 8:23, the Assistant Director of Nursing (ADON) reported she was one of the nurses that responded when she heard R6 fall on 11/29/21. When she entered the room, R6 was on the floor in a sitting position facing the window. His roommate had a cell phone plugged into a wall socket near the floor that the resident tripped over. The ADON reported R6 was able to move his extremities and get up off the floor. She did not recall the resident complaining of pain until a week later when the Unit Manager (UM) M made her aware of his pain and then x-rays were ordered. The ADON reported R6 had chronic pain on his left side and denied R6 had pain at the time of the fall. The ADON reported she is not sure if the staff were putting the pieces together regarding the residents' fall incident and his pain. In an interview on 12/22/21 at 8:35 a.m. UM M reported she heard about R6 falling the next day after it happened and alerted the NP when she came in to the facility that day. UM M reported the facility utilizes a Tiger Text system to notify healthcare practitioners of any resident concerns. UM M reported she remembers talking to R6 who was up walking with his walker and denied any pain. She knew therapy was working with the resident and when she became aware of the resident refusing therapy because of pain, she notified the NP right away and an x-ray were ordered. R6 rated his pain at a 1-3/10 scale on his backside and buttocks. In an interview on 12/22/21 at 9:00 a.m., the Rehabilitation Director (RD) N reported she is unaware of R6 refusing therapy and expects the therapy staff to notify the nursing staff if a resident is having pain. When queried how the therapy staff communicates resident concerns with the nursing staff, RD N reported they will utilize a Tiger Text but could not elaborate how the system worked. RD N reported they have an Interdisciplinary Team (IDT) meeting on Tuesdays to discuss residents who are getting therapy. On 1/7/21 they had an IDT meeting and discussed R6s' complaints of pain in his groin with UM M. When queried about the therapy documentation for Pre tx: Is skilled therapy needed to address pain? = Nursing to address and what that meant, RD N reported that meant it was communicated to the nursing staff about the residents pain. Review of a policy titled Pain Management last revised 7/2021 revealed: The facility will evaluate and identify guests/residents for pain, determine the type, location and severity and develop a care plan for pain management. Review of a policy titled Fall Management last revised 7/2021 revealed: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize fall and risk of injury related to falls.

This citation pertains to intakes: MI 055 and MI 191. Based on interview and record review, the facility failed to assess and monitor one Resident (Resident #31) of 1 Resident reviewed for diabetes management, resulting in Resident #31's lack of necessary care and subsequent death, and the potential for other Residents with medical conditions like diabetes mellitus to not be assessed and monitored according to medical standards. Findings include: Resident #31 Review of Resident #31's face sheet, dated [DATE] revealed he was a [AGE] year old male admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #31 was not his own responsible party. During an interview with the Director of Nursing (DON) on [DATE] at 12:50 PM, the facility investigation on Resident #31 that was submitted to the State on [DATE] at 4:30 PM was reviewed. The DON said she was not aware of a concern of neglect until the afternoon of [DATE] when Certified Nurse Aide (CNA) A made the allegation. The DON said CNA A was given a written warning on [DATE] for not meeting job expectations during an emergency on that happened on [DATE]. The DON said she was not aware of any care concerns or delay in the treatment of [REDACTED]. The Surveyor requested information on Resident #31's assessments, care and condition for the 24 hours prior to Resident #31 passing on [DATE]. During a telephone interview with CNA A on [DATE] at 6:10 PM, CNA A said she started work on [DATE] at 6:00 PM but was not assigned to Resident #31 at that time. At 10:00 PM CNA A assignment changed, and Resident #31 was in her group and was in bed at that time. CNA A said she did not know for sure when she had provided care prior to finding Resident #31 during last rounds around 4:00 AM, covered in sweat and unable to speak. CNA A said CNA F came in the room and stayed with Resident #31 while she went to get Licensed Practical Nurse (LPN) H. LPN H did not come, so CNA F tried to get LPN H to come. When LPN H did not come, CNA F got the nurse from the other side LPN D to come help. LPN D got her CNA C to help. CNA A said CNA T tried to get LPN H to come help and when LPN H did not come over CNA T Text the DON. CNA A said the DON did not come into interview staff. CNA A said the DON called her on the telephone to asked what happened. CNA A said she told the DON that LPN H was doing her routine medications and would not come when she asked for help with Resident #31. CNA A was very upset and said in her [AGE] years of being a caregiver she had never had and nurse refuse to help. CNA A said the DON twisted her statement and on [DATE] the DON wrote her ups and said she should have called a code. CNA A said that did not make any sense because LPN H was right down the hall. CNA A said the facility did not take her written statement. The statement the facility took CNA A did not sign. During an interview with the DON on [DATE] at 8:15 AM, the DON said she did an initial investigation on [DATE] and provided a typed copy that started out, [DATE], DON received text from UM (unit manager name) LPN I, at 4:50 am that (name of Resident #31) had passed away, [DATE]. DON received a text from (name of CNA T) stating that something was wrong with (name of resident #31) and responded immediately, CNA T responded and then CNA T ended text thread asking me to contact CNA F and CNA A. 0600 DON arrived to the facility and first met with CNA F The DON was asked for a copy of the texted that CNA T sent her the morning of [DATE]. The DON said she did not have that text. The DON's investigation confirmed that CNA F was aware Resident #31 did not look right and after that CNA F went to get a resident ready for [MEDICAL TREATMENT]. During a telephone interview with CNA T on [DATE] at 9:50 AM, CNA T confirmed she text the DON on [DATE] at 4:51 AM. CNA T said she had the text on her old phone but could not send it as it was not currently active. CNA T plugged in the old phone and read the text. Name of Resident #31 looks like he stroked out or something and (name of LPN H) is not doing anything about it because she is doing her meds first aide went to get the nurse from the other side by the time LPN H went in he past. DON texted back, name of LPN I just texted me do you mean you alerted her an emergency and he wasn't dead yet and she did not come right away. CNA T responded, that's right. The DON responded, will investigate that right away. DON questioned, where was she when you tried to get her, CNA T responded, check with CNA A, CNA F and LPN D. The DON responded, ok. CNA T said she went home at 6:00 AM and the DON did not come in to investigate. The DON and NHA did not interview her about Resident #31's death. The facility investigation confirmed CNA T was not interviewed during the facility investigation. The DON's initial investigation included, DON and Assistant Director of Nursing (ADON) met with LPN H. She states that she was at her med cart with medications when she was approached by CNA A who asked her to check Resident #31. She said she stood there thinking that she was told in report that his blood sugar was low, but she had proactively checked a blood sugar since then. She was trying to process what would be going on with Resident #31 and quickly complete what she was doing. She did know based on the information she was given, that he was unresponsive. DON then had a coaching session with LPN H asking questions and providing immediate feedback on how to respond in situations of emergency. This discussion was completed by 6:45 am. DON determined at this point that this incident was not reportable in nature and that education would be the only required follow up. However, based on the text CNA T had sent on [DATE] the DON was aware of an allegation of neglect for Resident #31 at 4:51 AM. According to the DON's initial investigation [DATE], she spoke to CNA A at 7:12 AM and CNA A said LPN H was at her medication cart when she reported something was wrong with Resident #31. CNA A said she had to get the other side and when they got to the room it was too late. This was another allegation of delayed treatment or neglect the morning of [DATE]. According to the DON's initial investigation [DATE], LPN D confirmed staff had her responded to Resident #31 medical needs and LPN H was not in the room. The morning of [DATE] the DON had received concerns from CNA A and CNA T that LPN H did not respond to their request of emergency care for Resident #31. LPN D confirmed she responded prior to LPN H. CNA F confirmed when CNA A first went to get help for Resident #31 he had a change in condition. The DON did not see this information as an allegation of neglect and did not report this incident to the police or the State Agency on [DATE]. According to the facility reported incident dated [DATE] at 4:30 PM the facility became aware of an allegation of neglect for Resident #31 on [DATE] when the DON, ADON E were doing a disciplinary action and education for CNA A. (The DON's initial investigation showed CNA A was upset the morning of [DATE] and had to get the nurse from the other side to care for Resident #31 after she had already approached LPN H. The investigation also indicated the DON was aware of delays in treatment and other staff confirming LPN H did not respond to the initial requests for help). The facility waited 5 days after the initial investigation to report the allegation of neglect to the State Agency and the facility did not report this allegation to the police. The Surveyor confirmed Resident #31 was alive when CNA A, CNA T, and CNA F all assisted Resident #31. Multiple attempts to get LPN H to come provide urgent care failed and LPN D was asked to assist with the care of Resident. LPN D indicated Resident #31 had passed when she arrived. LPN H indicated in her facility interview Resident #31 had passed before she arrived. Facility interviews with LPN D and LPN H do not indicated they provided any medical care. The Surveyor was unable to determine how much time passed between CNA A first identifying Resident #31 was covered in sweat and not responding as normal to LPN D and H pronouncing Resident #31 dead. Review of the Facility Reported Incident (FRI) dated [DATE] revealed, CNA F Reported to the NHA that CNA A said she tried to get LPN H to come for over 30 minutes and she wouldn't come. Surveyor interviews indicated all CNA's reported Resident #31 was breathing and alive when they first attempted to get help for Resident #31. Review of Resident #31's progress note dated [DATE] at 4:40 AM revealed, CENA (nurse aide) reported patient unresponsive blood sugar 53 [MEDICATION NAME] given patient had no pulse or heartbeat observed by both nurses. On call nurse notified, family and on call dr notified. The facility investigation does not indicate anyone took a blood sugar or gave a [MEDICATION NAME] injection just prior to death. During an interview with LPN H on the phone on [DATE] at 2:00 PM she confirmed she did not respond right away when CNA A requested because she did not realize it was an emergency. LPN H did not indicate any other staff were involved with trying to get her to respond to care request for Resident #31. LPN H said when she got to Resident #31's room LPN D was already there and said Resident #31's blood sugar was 50. LPN H said she gave the [MEDICATION NAME] injection and they checked for a pulse and Resident #31 was gone. During a telephone interview with LPN D on [DATE] at 9:00 AM, she confirmed she was not working on Resident #31's unit on [DATE]. LPN D said CNA A told her, I need you right now. LPN D said she was aware resident had a history of [REDACTED]. LPN D said she got the blood sugar and LPN H gave the [MEDICATION NAME] injection. LPN D was not sure if Resident #31 was alive when LPN H gave the [MEDICATION NAME] injection. LPN D said after the [MEDICATION NAME] injection was given both nurses confirmed Resident #31 did not have a pulse or respirations. LPN D said one of the CNA's got the code status and Resident #31 was a no code. LPN D could not recall if the DON interviewed her that morning but recalled she was educated that they need to respond timely, call a code and how CNA's need to respond to a change in condition. During and interview with Resident #31's physician MD X on [DATE] at 9:15 AM. MD X said he was not aware until today that there was a delay in providing medical care for Resident #31 on [DATE]. MD X had a copy of Resident #31's Medical Certificate of Death with him and provided a copy. The manner of death was, NATURAL and the first cause of death was DIABETES MELLITUS. MD X was asked if he knew Resident #53's blood sugar was 53 that morning and the delay in treating his blood sugar may have been 30 minutes or more. MD X said he was not aware of this information. MD X was asked if this information would that change the cause of death? MD X responded he would not change the cause of death. During a telephone interview with Corporate Nurse (CN) Z on [DATE] at 3:15 PM, CN Z confirmed she co-signed the Employee Disciplinary Records for CNA A and CNA F. CNA A's discipline, Rule Violation, Job expectations in an emergency. Supervisor's Remarks, On [DATE] you failed to respond/communicate effectively when a emergency or potential emergency arises. Counseling/Discussion/Agreement: #1 call code overhead page, obtain vitals, obtain crash cart and notify clinical team of emergency with clear messaging. Also talking about incidents with people not involved could be a HIPPA violation. Employee's Remarks: This statement is not turn (sp) (name of CNA A) was right their (sp) I know the true. (signed by CNA A) signed [DATE]. CNA F's discipline: Rule Violation: Job expectation in an emergency. Supervisor's Remarks: On [DATE] you failed to respond communicate effectively when a emergency or potential emergency Aries. Counseling/Discussion/Agreement: Call code overhead page, obtain vital, obtain crash cart and notify clinical team of emergency with clear messaging. Be aware of potential HIPPA violations with talking about incident with people not involved. This was discussed over the phone, signed [DATE]. During a telephone interview with CNA F on [DATE] with the DON, CN Y listening on a telephone and Regional Consultant (RC) Z present. CNA F confirmed her interview with the NHA in the facility investigation (no date or time) was accurate. In the interview CNA F said she was bringing supplies to the area when CNA A asked her to enter Resident #31's room and CNA A stated, he didn't seem right. CNA F stated she grabbed Resident #31's arm and it fell and told CNA A. No, he doesn't seem right. CNA A left the room to assist a resident to get ready for an upcoming appointment. The Surveyor asked CNA F why she did not stay to help. CNA F said she stayed until CNA A got back from asking LPN H for help. CNA F thought LPN H was coming. Resident #31 was not in distress, so she got her resident ready for [MEDICAL TREATMENT]. CNA F said she did not know Resident #31 had died until the next day. After CNA F was off the telephone the Surveyor asked CN Y if CNA F should have been disciplined for her response to Resident #31's care needs on [DATE]. CN Y said she did not know that. RC Z confirmed with CN Y that CN Y's signature was on CNA F disciplined dated [DATE]. Review of LPN D facility interview dated [DATE] (8 days after Resident #31 died ) revealed, LPN D recalls being in the very end room from her hallway, close to Resident #31's room where a CNA approached her to ask if she would look at someone. LPN D stated she was just finishing up with her guest, so she was able to go into the room that she was asked to. Upon entering the room of Resident #31, she identified that he was unresponsive, LPN D stated she believes he was deceased upon entering, she asked the CNA to grab the [MEDICATION NAME] and began to assess vitals. No vitals were present and LPN H entered the room both nurses confirmed that he was deceased . LPN D then offered to call the doctor service and asked LPN H to contact the family. LPN D stated there was no sense of urgency that she identified by staff and does not recall hearing panic or yelling in the hallway during this timeframe. There is no indication that LPN D took Resident #31's blood sugar at this time or that LPN H gave Resident #31 a [MEDICATION NAME] injection. Review of the facility interview with LPN H (no date) revealed, Interview with (name of LPN H) by NHA. LPN H stated has been having a difficult time since that night occurred. Stated she keeps going through her mind to see if she missed something, as the staff has been very mean to her since the incident occurred. LPN H stated she did not recognize any change of behavior than normal from CNA A and did not think that there was a sense of urgency to the situation. LPN H did state that at one point during the shift that(NAME)called for the nurse and when LPN H responded CNA A stated, just forget it. LPN H stated I don't know how to take her sometimes. LPN H did know that Resident #31 was having issues with his blood sugars and was investigating that, she had been in the room earlier that shift.(NAME)denies hearing CNA A calling for her in an urgent matter identifying and (sp) emergent situation. LPN H reviewed the code status on Resident #31 (which was DNR) and upon entering the room, where the other nurse was, it was apparent that Resident #31 was deceased . LPN H notified Resident #31's sister after leaving the room. LPN H did not indicate she gave Resident #31 a [MEDICATION NAME] injection. Resident #31's last progress notes in his medical record written by LPN H revealed, CENA (certified nurse aide) reported patient unresponsive blood sugar 53 [MEDICATION NAME] given patient had no pulse or heartbeat observed by both nurses. On call nurse notified, family and on call dr notified. When LPN H and D were interviewed by the Surveyor they both confirmed LPN D took Resident #31's blood sugar and LPN H gave the [MEDICATION NAME] injection. LPN D and LPN H could not answer why they would have taken a blood sugar or provided [MEDICATION NAME] to a Resident that was dead. Based on the facility interviews and the Surveyors interview it is clear Resident #31 was viewed alive with a change in condition by multiple CNA's prior to LPN D and H entering the room. One facility interview revealed it could have been more than 30 minutes before the LPN's responded to Resident #31's change in condition. The facility did provide a facility wide Inservice on how staff are to respond to a resident change in condition. It is clear staff did not respond appropriately to Resident #31's change in condition. The medical record did not contain any information on how the facility was monitoring Resident #31 the night of [DATE] when he was known to have a blood sugar of 51 on [DATE] at 5:00 PM and required juice and a [MEDICATION NAME] injection to get his blood sugar to 111. There is no record of staff taking another blood sugar until [DATE] at 4:40 AM. At 4:40 AM his blood sugar was 53 he received a [MEDICATION NAME] inject and was declared dead. According to the American Diabetes Association. https://diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/[DIAGNOSES REDACTED]. A low blood sugar is less than 70 mg/dL. Some of the signs and symptoms of low blood sugar are: Sweating, chills and clamminess, confusion, and color draining from skin. The only sure way to know whether you are experiencing low blood sugar is to check your blood sugar, if possible. If you are experiencing symptoms and you are unable to check your blood sugar for any reason treat the [DIAGNOSES REDACTED] (low blood sugar). Steps for treating a person with symptoms keeping them from being able to treat themselves. 1. Inject [MEDICATION NAME] into the buttock, arm or thigh, following the instructions in the kit. 2. When the person regains consciousness (usually in ,[DATE] minutes), they may experience nausea and vomiting. 3. If you have needed [MEDICATION NAME], let your doctor know so you can discuss ways to prevent severe [DIAGNOSES REDACTED] in the future. Don't hesitate to call 911. If someone is unconscious and [MEDICATION NAME] is not available or someone does not know how to use it, call 911 immediately. According to CNA interviews during this investigation Resident #31 presented with symptoms of low blood sugar. The Surveyor and the facility investigation could not determine how much time passed from the onset of low blood sugar symptoms to treatment with [MEDICATION NAME]. 911 was not called when staff that knew how to inject did not immediately respond to Resident #31's change in condition. Assessment of Resident #31, known to have had a low blood sugar and treatment/services for a Resident with a low blood sugar were not delivered in a timely manner and Resident #31 died . During a telephone interview with CNA A on [DATE] at 6:10 PM, CNA A said she frequently cared for Resident #31 prior to his death on [DATE]. CNA A was still very distraught about the night Resident #31 died and the fact that she could not get LPN H to respond to caring for Resident #31 when she noticed he was covered in sweat, and could not respond to her verbally. CNA A was asked what Resident #31 was normally like at night. CNA A said he would normally be in bed sleeping at 10:00 PM when she would make first rounds and she would check on him frequently. If Resident #31 would need to use the bathroom he would call out Hey I need to use the bathroom. CNA A Resident #31 was blind but could walk to the bathroom with hand hold assistance. Resident #31 often would wake up between 1:30 AM and 3:00 AM. When he was awake at these times, she would get him out of bed, and he would sit and eat sandwich, cookie, and drink at the nurse's station. When he was done eating, he would usually go back to bed and sleep the rest of his shift. The facility investigation and medical record did not indicate what Resident #31's care or response to care was on 3rd shift until he was noted to have a change in condition, blood sugar of 53 and died at 4:40 AM. Review of Resident #31's food acceptance record revealed Resident #31 ate ,[DATE]% of his meals on [DATE] and a snack at bedtime on [DATE]. There was no indication how many calories or carbohydrates he ate on [DATE] and he was found to have a low blood sugar of 51 on [DATE] at 5:00 PM and required juice and a [MEDICATION NAME] injection to get his blood sugar to 111. There is no record of staff taking another blood sugar until [DATE] at 4:40 AM. At 4:40 AM his blood sugar was 53 he received a [MEDICATION NAME] inject and was declared dead. Review of Resident #31's food acceptance record revealed it did not count calories or carbohydrates. Food acceptance only accounted for a percentage of a meal accepted and indicated if he took his evening snack. This record did not account for 4 meals that Resident #31 would eat if he was awake between 1:00 and 3:00 AM. The record did not indicate how many calories or carbohydrates Resident #31 ate after [DATE] at 5:00 PM when is blood sugar went from 51 to 111. During an interview with LPN I on [DATE] at 9:40 AM, LPN I said she was the unit manager for Resident #31's unit. LPN I assisted with Resident #31's care plan and care conference. LPN I said she was not aware Resident #31 was frequently awake between 1:00 and 3:00 AM and when awake he ate a sandwich, cookie and drink. LPN I was not able to locate any calorie counts or carbohydrate counts for Resident #31 in his medical record. LPN I said Resident #31 had a history of [REDACTED]. LPN I said if the juice did not work, he did need [MEDICATION NAME]. LPN I was not sure how often this happened. Resident #31's Nutritional Evaluation, dated [DATE] revealed, Weights are stable (no sign wt (weight) changes in 6 mo (months) meds as above no changes except [MEDICATION NAME] (long acting insulin) was decreased last mo (month) for low BS's (blood sugars). LPN I confirmed Resident #31's morning blood sugar would most likely be high if he ate a sandwich, cookie and drink between ,[DATE] am. This would give a false sense of a routine high blood sugar. Review of Resident #31's blood Sugar Summary from April, 2020 to [DATE] revealed he had 5 blood sugar readings over 300 which were all taken in the morning. Resident #31 had 3, blood sugars below 70 from April to [DATE] and low readings were also in the morning. Occasionally eating a meal between 1:00 and 3:00 AM can affect the morning blood sugar. Review of Resident #31's physician orders [REDACTED]. One day later [DATE] Resident #31 was also started on [MEDICATION NAME] 100 unit/ML, 35 units at 8:00 AM, which was a total of 30 units more long acting insulin than he had been on prior to [DATE].

This citation pertains to intakes: MI 055 and MI 191. Based on interview and record review, the facility failed to ensure 1 resident (Resident #31) out of 10 residents reviewed for abuse and neglect, was free from neglect when staff failed to recognize and treat an acute change in condition for an unknown period of time ([DIAGNOSES REDACTED]) resulting in death. Findings include: Resident #31 Review of Resident #31's face sheet, dated [DATE] revealed he was a [AGE] year old male admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #31 was not his own responsible party. During an interview on [DATE] at 12:50 PM, the Director of Nursing (DON) reviewed a Facility Reported Incident (FRI) that was submitted to the State Agency on [DATE] related to Resident #31. The DON said she was not aware of a concern of neglect until the afternoon of [DATE] when Certified Nurse Aide (CNA) A made the allegation. The DON said CNA A was given a written warning on [DATE] for not meeting job expectations during an emergency that happened on [DATE]. The Surveyor requested information on Resident #31's assessments, care and condition for the 24 hours prior to Resident #31 passing on [DATE]. The facility investigation and the medical record did not contain any interviews revealing who provided care for Resident #31 after 5:00 PM, [DATE] up to the time he was found dead on [DATE] at 4:40 AM. During a telephone interview on [DATE] at 6:10 PM, CNA A said she started work on [DATE] at 6:00 PM but was not assigned to Resident #31 at that time. At 10:00 PM CNA A's assignment changed, and Resident #31 was in her group and was in bed at that time. CNA A said she did not know for sure when she had provided care prior to finding Resident #31 during last rounds around 4:00 AM covered in sweat and unable to speak. CNA A said CNA F came in the room and stayed with Resident #31 while she went to get Licensed Practical Nurse (LPN) H. LPN H did not come, so CNA F tried to get LPN H to come. When LPN H did not come CNA F got the nurse from the other side of the building (LPN D) to come help. LPN D got her CNA C to help. CNA A said CNA T tried to get LPN H to come help and when LPN H did not come over CNA T sent a text message to the DON. CNA A said the DON did not come to the facility to interview staff and begin an investigation before she went home at 6:00 AM. CNA A said the DON called her on the telephone to ask what happened. CNA A said she told the DON that LPN H was doing her routine medications and would not come when she asked for help with Resident #31. CNA A was very upset and said in her [AGE] years of being a caregiver she had never had a nurse refuse to help in an emergency. CNA A said the DON twisted her statement and on [DATE] the DON wrote her up and said she should have called a code. CNA A said that did not make any sense because LPN H was right down the hall. CNA A said the facility did not take her written statement or have her sign the statement they provided for CNA A (no date or time). During an interview with the DON on [DATE] at 8:15 AM, the DON said she did an initial investigation on [DATE] and provided a typed copy that started out, [DATE], DON received text from UM (unit manager name) LPN I, at 4:50 am that (name of Resident #31) had passed away, [DATE]. DON received a text from (name of CNA T) stating that something was wrong with (name of resident #31) and responded immediately, CNA T responded and then CNA T ended text thread asking me to contact CNA F and CNA A. 0600 DON arrived to the facility and first met with CNA F The Surveyor asked the DON for a copy of the (text messages) that CNA T sent her the morning of [DATE]. The DON said she did not have that text. Review of the facility, Abuse Prohibition, Investigation, and Reporting policy (no date), The Administrator is responsible for ensuring that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately reported to the State Agency and other officials in accordance with federal regulation and sate guidelines. The facility waited 5 days to report this incident to the State Agency and did not report this incident to the police. Neglect is defined as the failure of the facility, its employees, ore service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #31 did not receive timely emergency care on [DATE] and died . The facility report on Resident #31 dated [DATE], It is the conclusion of the facility through a detailed investigation that the finding of the fist initial investigation stand firm. The facility was not able to identify that there was neglect on on behave (sic) the death that occurred on [DATE] with Resident #31. The facility was able to determine that after the event occurred staff began to talk and make altered perceptions of the actual incident occurrence. Staff have been educated on reporting and possible HIPPA violations with reaching out to staff members who not involved in the incidents. LPN H, the nurse in question was not reprimanded for this occurrence as the DON immediately investigated this occurrence without concerns. CNA A and CNA F were both educated on appropriate steps when concerned about a guest and drills have been performed for off shifts to further build comfort in higher acuity situations. Spoke with staff who were identified throughout this investigation to be involved although were not here when the incident occurred. Reiterated to these staff member proper conduct and expectation of their jobs and roles. The facility did not report the incident that was identified on [DATE] to the State. The initial investigation documented concerns of how staff responded when Resident #31 had a change in condition. (possible neglect). The initial investigation did not contain the full text message the DON received from CNA T and showed no indication they asked staff what time Resident #31 was last observed alive, what care was provided, what time care was last provided, the time of the change in condition or time the nurses responded to his change in condition. During a telephone interview on [DATE] at 9:50 AM, CNA T confirmed she sent a text message to the DON on [DATE] at 4:51 AM. CNA T said she could read the text message exchange from her old phone but could not forward the message due to the mobile device did not have service. CNA T read the following exchange: CNA T: (Resident #31) looks like he stroked out or something and (LPN H) is not doing anything about it because she is doing her meds first aide went to get the nurse from the other side by the time LPN H went in he past. DON: (LPN I) just texted me do you mean you alerted her an emergency and he wasn't dead yet and she did not come right away. CNA T: that's right DON: Will investigate that right away. Where was she (LPN H) when you tried to get her CNA T: Check with CNA A, CNA F and LPN D. DON: OK The DON's initial investigation included, DON and Assistant Director of Nursing (ADON) met with LPN H. She states that she was at her med cart with medications when she was approached by CNA A who asked her to check Resident #31. She said she stood there thinking that she was told in report that his blood sugar was low, but she had proactively checked a blood sugar since then. She was trying to process what would be going on with Resident #31 and quickly complete what she was doing. She did know based on the information she was given, that he was unresponsive. DON then had a coaching session with LPN H asking questions and providing immediate feedback on how to respond in situations of emergency. This discussion was completed by 6:45 am. DON determined at this point that this incident was not reportable in nature and that education would be the only required follow up. However, based on the text CNA T had sent on [DATE] the DON was aware of an allegation of neglect for Resident #31 at 4:51 AM. According to the DON's initial investigation [DATE], she spoke to CNA A at 7:12 AM and CNA A said LPN H was at her medication cart when she reported something was wrong with Resident #31. CNA A said she had to get the nurse from the other side and when they got to the room it was too late, Resident #31 had already died . According to the DON's initial investigation [DATE], LPN D confirmed staff had her respond to Resident #31's medical needs and LPN H was not in the room. The morning of [DATE] the DON had received concerns from CNA A and CNA T that LPN H did not respond to their request of emergency care for Resident #31. LPN D confirmed she responded prior to LPN H. CNA F confirmed when CNA A first went to get help for Resident #31 he had a change in condition. The DON did not see this information as an allegation of neglect, did not report this incident to the police or the State Agency on [DATE], and did not conduct a complete investigation into the allegations of neglect. According to the facility reported incident dated [DATE] at 4:30 PM, the facility became aware of an allegation of neglect for Resident #31 on [DATE] when the DON and ADON E were doing a disciplinary action and education for CNA A. (The DON's initial investigation showed CNA A was upset the morning of [DATE] and had to get the nurse from the other side to care for Resident #31 after she had already approached LPN H. The investigation also indicated the DON was aware of delays in treatment and other staff confirming LPN H did not respond to the initial requests for help). The facility waited 5 days after the initial investigation to report the allegation of neglect to the State Agency and the facility did not report this allegation to the police. The Surveyor confirmed Resident #31 was alive (unknown time) when CNA A, CNA T, and CNA F all assisted Resident #31 the morning of [DATE]. CNA A, CNA F and CNA T made attempts to get LPN H to come provide urgent care for Resident #31. LPN D was asked to assist with the care of Resident 31 when LPN H failed to respond. LPN D indicated Resident #31 was already deceased when she arrived in the room (unknown time morning of [DATE]). LPN H indicated in her facility interview Resident #31 had passed before she arrived. Facility interviews with LPN D and LPN H do not indicate they provided any medical care. The Surveyor was unable to determine how much time passed between CNA A first identifying Resident #31 was covered in sweat and not responding as normal to LPN D and H pronouncing Resident #31 dead. Review of the Facility Reported Incident (FRI) dated [DATE] revealed, CNA F Reported to the NHA that CNA A said she tried to get LPN H to come for over 30 minutes and she wouldn't come. Surveyor interviews indicated all 3 CNA's reported Resident #31 was breathing and alive when they first attempted to get help for Resident #31. Review of Resident #31's progress note dated [DATE] at 4:40 AM revealed, CENA (nurse aide) reported patient unresponsive blood sugar 53 [MEDICATION NAME] given patient had no pulse or heartbeat observed by both nurses. On call nurse notified, family and on call dr notified. The facility investigation does not indicate anyone took a blood sugar or gave a [MEDICATION NAME] injection just prior to death. Review of Resident #31's [DATE] Medication Administration Record [REDACTED]. During a telephone interview on [DATE] at 2:00 PM, LPN H confirmed she did not respond right away when CNA A requested assistance for Resident #31 because she did not realize it was an emergency. LPN H did not indicate any other staff were involved with trying to get her to respond to care request for Resident #31. LPN H said when she got to Resident #31's room LPN D was already there and said Resident #31's blood sugar was 50. LPN H said she gave the [MEDICATION NAME] injection and they checked for a pulse and Resident #31 was gone (deceased ). LPN H said she was aware Resident #31 had a low blood sugar prior to her starting at 6:00 PM on [DATE]. LPN H was asked if she took Resident #31's blood sugar before she gave his insulin that night and where she documented it. LPN H said the facility took away the place to document it but I would have taken it and believed it was 308. (This was not in the investigation or the medical record, more than 2 months had passed when LPN H gave this information to the Surveyor.) Review of Resident #31's June MAR indicated [REDACTED]. There was no indication a blood sugar level was checked. Resident #31's blood sugar had dropped to 51 on [DATE] at 5:00 PM and he required juice and a [MEDICATION NAME] injection to get his blood sugar to 111. The next blood sugar was recorded at 4:40 AM and was 53 in the same note that indicated Resident #31 had died . During a telephone interview on [DATE] at 9:00 AM, LPN D confirmed she was not working on Resident #31's unit on [DATE]. LPN D said CNA A told her, I need you right now. LPN D said she was aware Resident #31 had a history of [REDACTED]. LPN D said she got the blood sugar and LPN H gave the [MEDICATION NAME] injection. LPN D was not sure if Resident #31 was alive when LPN H gave the [MEDICATION NAME] injection. LPN D said after the [MEDICATION NAME] injection was given both nurses confirmed Resident #31 did not have a pulse or respirations. LPN D said one of the CNA's got the code status and Resident #31 was a no code. LPN D could not recall if the DON interviewed her that morning but recalled she was educated that they need to respond timely, call a code and how CNA's need to respond to a change in condition. During an interview on [DATE] at 9:15 AM, Resident #31's Medical Doctor (MD) X said he was not aware until today that there was a delay in providing medical care for Resident #31 on [DATE]. MD X had a copy of Resident #31's Medical Certificate of Death with him and provided a copy. The manner of death was, NATURAL and the first cause of death was DIABETES MELLITUS. MD X was asked if he knew Resident #31's blood sugar was 53 that morning and the delay in treating his blood sugar may have been 30 minutes or more. MD X said he was not aware of this information. MD X was asked if this information would that change the cause of death? MD X responded he would not change the cause of death. During a telephone on [DATE] at 3:15 PM, Corporate Nurse (CN) Z confirmed she co-signed the Employee Disciplinary Records for CNA A and CNA F. Review of a facility discipline record reflected CNA A's Discipline, Rule Violation, 'Job expectations in an emergency'. Supervisor's Remarks, On [DATE] you failed to respond/communicate effectively when a emergency or potential emergency arises. Counseling/Discussion/Agreement: #1 call code overhead page, obtain vitals, obtain crash cart and notify clinical team of emergency with clear messaging. Also talking about incidents with people not involved could be a HIPPA violation. Employee's Remarks: This statement is not turn (sic) (name of CNA A) was right their (sic) I know the true. (signed by CNA A) signed [DATE]. CNA F's discipline: Rule Violation: Job expectation in an emergency. Supervisor's Remarks: On [DATE] you failed to respond communicate effectively when an emergency or potential emergency Arises. Counseling/Discussion/Agreement: Call code overhead page, obtain vital, obtain crash cart and notify clinical team of emergency with clear messaging. Be aware of potential HIPPA violations with talking about incident with people not involved. This was discussed over the phone, signed [DATE]. During a telephone interview with CNA F on [DATE] with the DON, CN Y listening on a telephone and Regional Consultant (RC) Z present. CNA F confirmed her interview with the NHA in the facility investigation (no date or time) was accurate. In the interview CNA F said she was bringing supplies to the area when CNA A asked her to enter Resident #31's room and CNA A stated, he didn't seem right. CNA F stated she grabbed Resident #31's arm and it fell and told CNA A. No, he doesn't seem right. CNA A left the room to assist a resident to get ready for an upcoming appointment. The Surveyor asked CNA F why she did not stay to help. CNA F said she stayed until CNA A got back from asking LPN H for help. CNA F thought LPN H was coming. Resident #31 was not in distress, so she got her resident ready for [MEDICAL TREATMENT]. CNA F said she did not know Resident #31 had died until the next day. After CNA F was off the telephone the Surveyor asked CN Y if CNA F should have been disciplined for her response to Resident #31's care needs on [DATE]. CN Y said she did not know that. RC Z confirmed with CN Y that CN Y's signature was on CNA F disciplined dated [DATE]. Review of LPN D facility interview dated [DATE] (8 days after Resident #31 died ) revealed, LPN D recalls being in the very end room from her hallway, close to Resident #31's room where a CNA approached her to ask if she would look at someone. LPN D stated she was just finishing up with her guest, so she was able to go into the room that she was asked to. Upon entering the room of Resident #31, she identified that he was unresponsive, LPN D stated she believes he was deceased upon entering, she asked the CNA to grab the [MEDICATION NAME] and began to assess vitals. No vitals were present and LPN H entered the room both nurses confirmed that he was deceased . LPN D then offered to call the doctor service and asked LPN H to contact the family. LPN D stated there was no sense of urgency that she identified by staff and does not recall hearing panic or yelling in the hallway during this timeframe. There is no indication that LPN D took Resident #31's blood sugar at this time or that LPN H gave Resident #31 a [MEDICATION NAME] injection. Review of the facility interview with LPN H (no date) revealed, Interview with (name of LPN H) by NHA. LPN H stated has been having a difficult time since that night occurred. Stated she keeps going through her mind to see if she missed something, as the staff has been very mean to her since the incident occurred. LPN H stated she did not recognize any change of behavior than normal from CNA A and did not think that there was a sense of urgency to the situation. LPN H did state that at one point during the shift that CNA A called for the nurse and when LPN H responded CNA A stated, just forget it. LPN H stated I don't know how to take her sometimes. LPN H did know that Resident #31 was having issues with his blood sugars and was investigating that, she had been in the room earlier that shift. Heather denies hearing CNA A calling for her in an urgent matter identifying and (sic) emergent situation. LPN H reviewed the code status on Resident #31 (which was DNR) and upon entering the room, where the other nurse was, it was apparent that Resident #31 was deceased . LPN H notified Resident #31's sister after leaving the room. LPN H did not indicate she gave Resident #31 a [MEDICATION NAME] injection. According to documentation in the Electronic Medical Record (EMR), on [DATE] at 5:00 PM (less than 12 hours before Resident #31 died ), Resident #31 was hypoglycemic with a blood glucose reading of 51, requiring [MEDICATION NAME] and juice to get his blood glucose level to 111. The medical record did not reflect additional follow-up (notification to the physician, increased supervision or blood glucose monitoring etc.) after this hypoglycemic episode. Resident #31's last progress note dated [DATE] at 4:40 AM written by LPN H revealed, CENA (certified nurse aide) reported patient unresponsive blood sugar 53 [MEDICATION NAME] given patient had no pulse or heartbeat observed by both nurses. On call nurse notified, family and on call dr notified. When LPN H and D were interviewed by the Surveyor they both confirmed LPN D took Resident #31's blood sugar and LPN H gave the [MEDICATION NAME] injection. LPN D and LPN H could not answer why they would have taken a blood sugar or provided [MEDICATION NAME] to a Resident that was dead. Based on the facility interviews and the Surveyors interview it is clear Resident #31 was viewed alive with a change in condition by multiple CNA's prior to LPN D and H entering the room. One facility interview revealed it could have been more than 30 minutes before the LPN's responded to Resident #31's change in condition. The facility did provide a facility wide Inservice on how staff are to respond to a resident change in condition. It is clear staff did not respond appropriately to Resident #31's change in condition. The medical record did not contain any information on how the facility was monitoring Resident #31 the night of [DATE] when he was known to have a blood sugar of 51 on [DATE] at 5:00 PM and required juice and a [MEDICATION NAME] injection to get his blood sugar to 111. There is no record of staff taking another blood sugar until [DATE] at 4:40 AM. At 4:40 AM his blood sugar was 53 he received a [MEDICATION NAME] inject and was declared dead. It remains unclear what care Resident #31 was provided from 6:00 PM on [DATE] to 6//,[DATE] at 4:40 AM when he was declared dead. According to the American Diabetes Association. https://diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/[DIAGNOSES REDACTED]. A low blood sugar is less than 70 mg/dL. Some of the signs and symptoms of low blood sugar are: Sweating, chills and clamminess, confusion, and color draining from skin. The only sure way to know whether you are experiencing low blood sugar is to check you blood sugar, if possible. If you are experiencing symptoms and you are unable to check your blood sugar for any reason treat the [DIAGNOSES REDACTED] (low blood sugar). Steps for treating a person with symptoms keeping them from being able to treat themselves. 1. Inject [MEDICATION NAME] into the buttock, arm or thigh, following the instructions in the kit. 2. When the person regains consciousness (usually in ,[DATE] minutes), they may experience nausea and vomiting. 3. If you have needed [MEDICATION NAME], let your doctor know so you can discuss ways to prevent severe [DIAGNOSES REDACTED] in the future. Don't hesitate to call 911. If someone is unconscious and [MEDICATION NAME] is not available or someone does not know how to use it, call 911 immediately.

Based on interview and record review, the facility failed to provide supervision to prevent accidents and falls for 1 resident (Resident #88), of 3 residents reviewed for falls, resulting in skin tears and lacerations requiring treatment at a hospital and repeated falls. Findings include: Review of a facility Admission Record dated 3/29/19 reflected Resident #88 was a resident of the facility with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 needed extensive assistance from two people for bed mobility, transfers, walking in room, dressing, toilet use and personal hygiene. Review of Fall Risk Assessments for the date range 1/16/2019-3/02/2019 reflected Resident #88 was a high risk for falls. Review of a Care Plan initiated on 12/13/2018 reflected, (Resident #88) is at risk for falls related to: [MEDICAL CONDITION] with upper body tremors and shuffling of feet, impulse control issues, hallucinations, poor safety awareness, limited range of motion (ROM) right arm status [REDACTED]. He has a history of falls at home prior to recent hospital stay. Chooses not to use call light, right arm hinge brace, wheelchair, stands unassisted/unsafely, places himself on all fours and wanders. The goal of the care plan was for Resident #88 to Be free from injury related to falls through review date and Will be free from side effects of antipsychotic and/or antidepressant daily such as: drowsiness, dizziness, rapid heart beat, tardive dyskinesia, nausea/vomiting, fatigue, gastrointestinal distress, blurred vision, constipation, dry mouth, weight gain, headache, nervousness, and/or agitation. Interventions included AIMS (Abnormal, Involuntary Movement Scale) every 6 months (initiated 1/24/2019), Assist (Resident #88) with activity when restless (initiated 3/6/19), Assist (Resident #88) with walking TID, to and from meals as he is able (initiated 1/25/19), Attempt dose reduction as needed when appropriate (initiated 1/24/19), Bed by wall for increased floor space (initiated 1/11/19), Behavior Management per protocol (initiated 1/24/19), Complete fall risk per protocol (initiated 1/24/19), Encourage resident to wear shoes and/or non-skid socks when out of bed, non-skid socks when out of bed, non-skid socks when in bed, provide extensive assistance (initiated 1/24/19), Encourage to be in common area while awake and during shift change as tolerated (1/17/19), give medications as ordered (initiated 1/23/19) , labs as ordered to rule [MEDICAL CONDITION] (initiated 1/23/19), neurology appointment as needed (initiated 1/25/19), observe for fatigue and/or unsteadiness and encourage rest periods as needed (initiated 1/24/19), observe for ineffectiveness and side effects related to [MEDICAL CONDITION] drug use, report abnormal findings to the physician (initiated 1/24/19), offer toileting every 2 hours (initiated 3/4/19), posey roll to left side of bed to remind (Resident #88) of bed boundaries (initiated 1/28/19), Post fall medication review (initiated on 1/24/19), provide assistive devices as needed: wheelchair, geri-chair (revised on 2/20/19), provide geri-chair for sleep with cushion, for comfort as (Resident #88) tolerates (revised 2/21/19), provide safety devices as ordered anti-tippers to back of chair (initiated 1/24/19), psych consult as needed (initiated 1/24/19), PT/OT evaluate and treat as ordered PRN (initiated 1/24/19), (Resident #88) evaluated by neurology and dose reduction [MEDICATION NAME] (an anti-anxiety drug) trial (initiated 3/14/19), (Resident #88) requires extensive assist of 1 person with gait belt for all transitional movements (initiated 12/08/18), wear gait belt during the day for safety (initiated 2/21/19). Review of a Fall Timeline, undated, reflected Resident #88 had total of 37 falls from 1/15/19-3/21/19. The Fall Timeline was compared with incident reports and the care plan as well as progress notes. New and pertinent interventions were not added to the care plan to avoid falls and prevent injury from 1/28/19-2/21/19. Review of an Incident Report dated 1/24/19 at 8:45 p.m., reflected Resident #88 had an unwitnessed fall and was discovered in the middle of his bedroom doorway with a large skin tear to his left arm and an abrasion on his left knee. The incident reported indicated staff assisted (Resident #88) to his chair and kept him near staff, one on one supervision. The intervention of one to one supervision was not added to the care plan and it is not clear in the progress notes when the one on one supervision was discontinued. Review of a Wound/Skin Healing Note dated 1/24/19 at 9:22 p.m. reflected (Resident #88) had a wound noted on 1/24/19 .left arm skin tear: Length 10.0, (no unit of measure specified), Width = 3.0 (no unit of measure specified) . The note indicated a care plan update was not performed. Review of a Nurses Notes dated 1/24/19 reflected (Resident #88) was observed on the floor in the doorway to his bedroom. This nurse assisted resident to bed after dinner per his request. At 2045 (8:45 p.m.) staff observed him sitting on his butt on the floor. It was noted that he had a very large skin tear to his left arm and had apparently hit the door jam and the floor with the left side of his body .no further injuries observed at this time. Steri strips (a suture like bandage) placed to skin tear and then area wrapped with gauze wrap .staff will continue to monitor. Review of a Nurses Note dated 1/26/19 at 10:15 a.m. reflected Spoke with (Resident #88's wife) about guest concerns related to his behaviors. Discussed sending (Resident #88) to (a psychiatric hospital), where he could be observed on a 24-hour basis and his meds can be adjusted, also talked about sending (Resident #88) to a dementia unit, where it's a smaller unit with less stimulation. It was noted when (Resident #88) was in the conference room with little stimulation and one on one care, on 1/23/19, he seemed calmer, less anxious. The concern is that (Resident #88) continues to get up from his chair and walk around, and he has had several falls, he may fall and hurt himself. (Resident #88's wife) voiced understanding of the discussion and verbalized she will call the (psychiatric hospital) and make a referral, as she voiced this might be a good option for (Resident #88). Review of an Incident Report dated 1/30/19 reflected Resident #88 had a witnessed fall in the activity room at the facility when he leaned out of his wheelchair and fell to his knees. The Immediate intervention to prevent recurrence was for staff to stay near resident in close proximity of (Resident #88's) wheelchair during activities. Additional follow-up was for Resident #88 to be sent to a psychiatric hospital for observation and recommendation. The intervention mentioned in the incident report was not added to the care plan. Review of the Fall Timeline (undated) reflected that Resident #88 was sent to a psychiatric hospital from 2/1/19-2/13/19. According to the timeline, on 2/13/19, Resident #88 fell again, three hours after return from the psychiatric hospital and the intervention mentioned on the timeline to prevent another fall was for the resident to be taken to the nurses station for increased supervision, but was not added to the care plan. Review of an Incident Report dated 2/14/19 at 12:10 p.m. indicated Resident #88 was witnessed rising from his chair in the hallway, lost his balance and fell to the floor on his right side .(Resident #88) was placed in front of the nurses station for supervision. New interventions were not added to the care plan as a result of the fall. Review of the Fall Timeline (undated) reflected Resident #88 fell again on 2/15/19, twice on 2/16/19, and three times on 2/17/19. No incident reports were available for the falls mentioned in the timeline on 2/17/19 were provided. No updates to the care plan was made following these incidents. Review of an Incident Report dated 2/18/19 at 3:57 p.m., reflected Resident #88 was observed on his knees in front of his wheelchair near the nurses desk. The incident report indicated the fall was unwitnessed and the intervention put into place to prevent another fall was to place the resident at the nurses station with a puzzle, however, the intervention was not added to the care plan. Review of Nurses Notes dated 2/18/19 at 7:03 p.m. reflected (Resident #88) fell at 6:05 p.m. onto buttocks, witnessed, no injury noted. Again witnessed fall at 6:20 onto right hip and elbow, both site examined by this nurse and no notable injury at this time. (Resident #88) denies any pain and is able to stand upright. Nurse Practitioner (NP) was notified about this fall and states to monitor. (Resident #88) fell again at 6:45 p.m. onto his knees, slid out of chair, no injury. There were no incident reports for the falls mentioned. No care plan updates or increased supervision noted in the progress notes. Review of an Incident Report dated 2/21/19 at 10:30 a.m. reflected Resident #88 had a witnessed fall in the doorway of his room, hitting his head on a trash can and dresser resulting in an open area needing stitches in the emergency department. Review of a Nurses Note dated 2/21/19 at 10:51 a.m. reflected At 10:30 a.m., this nurse was heading to resident room and when resident was observed on the floor with left elbow area was open and blood noted. Resident wound was dressed, wife and team health was notified, resident being transported to (hospital) via (paramedics). Review of Nurses Note dated 2/21/19 at 5:47 p.m. reflected (Resident #88) returned to facility at 3:00 p.m. with dressing to left elbow area. Resident has 6 staples to that area which need to stay in place for the next 10 days . (Resident #88) at 5:00 p.m. was observed standing at nurses station, this nurse was not able to reach resident in time prior to him falling. No incident report for the fall that occurred at 5:00 p.m. was provided, no interventions to prevent another fall was noted and no updates to the care plan were made outside of placing the resident in a geri-chair and the application of a gait belt to be worn at all times. Review of an Incident Report dated 2/23/19 at 1:55 p.m. reflected Resident #88 had a witnessed fall when he went from his chair to his knees. No additional information was mentioned in the incident report except that the immediate intervention to prevent another fall was Supervision. No update to the care plan was made and no specifics about who was to supervise the resident was noted. Review of an Incident Report dated 2/26/19 at 1:30 p.m. reflected Resident #88 was found on the floor after an unwitnessed fall, no injury noted. The intervention to prevent another fall was to place Resident #88 near the nurse station for observation and was not a new intervention. Review of an Incident Report dated 2/26/19 at 2:00 p.m., 30 minutes after the previous fall, reflected Resident #88 had a witnessed fall when he stood from his wheel chair and fell to the floor and sustained a laceration above the left eye. Initially, the resident was treated for [REDACTED]. Review of Nurses Notes dated 2/26/19 indicated (Resident #88) returned from the emergency department .with stitches to his left temple, these are to be removed after 5 days . Review of an Incident Report dated 3/2/19 at 11:10 a.m. reflected Resident #88 had a witnessed fall at the nurse's desk. The intervention mentioned in the incident report was to assist the resident back into his wheelchair and toilet the resident. Review of an Incident Report dated 3/2/19 at 4:30 p.m. reflected Resident #88 had another fall, apparently witnessed hitting his head against the wall before landing in his wheelchair and sustaining a laceration to his right eye. The wound was treated with a pressure dressing and the intervention attempted was to assist the resident with an activity when restless and was not new. Review of an Incident Report dated 3/8/19 at 11:00 a.m. indicated Resident #88 stood up from his wheelchair unassisted and fell to the floor. The intervention to prevent another fall was to Keep supervised in common areas as much as possible and was not a new intervention. Review of an Incident Report dated 3/18/19 at 1:20 p.m. reflected Resident #88 was witnessed leaning over in his wheelchair, causing it to tip over and fell on to floor. The intervention mentioned to prevent the incident from happening again was to keep resident in a common area and was not a new intervention. Resident #88 had another fall on 3/18/19 at 3:00 p.m. The Incident Report dated 3/18/19 at 3:00 p.m. indicated Resident #88 stood up unassisted and fell to his knees before staff would intervene. The intervention mentioned on the incident report was to remain in common areas and was not a new intervention. Review of an Incident Report dated 3/21/19 at 7:20 p.m. reflected Resident #88 had a witnessed fall from his wheelchair. The intervention mentioned on the incident report to prevent another fall was for the resident to be supervised and was not a new intervention. Follow up intervention included having Resident #88 evaluated for a lap tray to prevent the resident from rising. During an interview on 3/29/19 at 10:04 a.m., the MDS Coordinator, Registered Nurse (RN) K reported that falls are reviewed in the morning interdisciplinary team (IDT) meeting. RN K said the incident reports are reviewed and compared to nurses notes and then interventions are reviewed. RN K said the unit manager does the post fall analysis, then the Director of Nursing and the Administrator sign off on the report. When asked why increased supervision and one on one supervision (as mentioned in the incident reports) were not added to the care plan, RN K did not have an answer. RN K said that Resident #88 had never been a 1:1 while at the facility. RN K reported that Resident #88 had been sent to the psychiatric hospital in another state with the hope they would change his medication to decrease his impulsiveness, but the hospital did not change any of Resident #88's medication. RN K said that while Resident #88 was in the other hospital, he was a constant 1:1. When asked, RN K reported that Resident #88 did not have any falls while on 1:1 supervision in the psychiatric hospital.

This citation pertains to intake MI 1531 Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on observation, interview, and record review, the facility failed to prevent the elopement of 1 resident (Resident #5), of 5 residents reviewed for elopement, resulting in an Immediate Jeopardy when (Resident #5) who had been assessed as an elopement risk and wore a WanderGuard bracelet, and who eloped from the facility, unbeknownst to staff, after an unknown system malfunction, allowing Resident #5 to elope from the facility on 2/10/19 at approximately 12:30 p.m. and was brought back to the facility about a half hour later when a family member of the resident located the resident outside a grocery store a half a mile from the facility. This deficient practice placed Resident #5 and 4 other residents who were assessed as being at risk for elopement, at risk for serious harm, injury and or death from hazards outside the facility. Findings: Review of a facility Admission Record, dated 2/12/2019, indicated Resident #5 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #5 was moderately cognitively impaired with periods of inattention and disorganized thinking and who exhibited wandering behavior at times. Resident #5 was assessed as being independent, needing set up help only for bed mobility, transfers and walking in her room. Resident #5 needed supervision and set up help for ambulation on and off the unit while using a walker. On 3/01/19 at 7:40 a.m., the likely route Resident #5 walked was observed. The distance traveled was approximately half a mile over snow-covered and icy sidewalks adjacent to a 25 mile per hour residential street that led to a crosswalk and traffic signal at a 45 mph four-lane thoroughfare in a highly trafficked area near stores, restaurants and parking lots. Review of a Facility Reported Incident submitted to the State Agency on 2/10/19 reflected the following: At approximately 12:40 p.m., (Resident #5's) (Guardian/Power of Attorney (POA) D) informed facility that she could not find her mom, notified (Registered Nurse (RN) K). Staff attempted to locate guest and called a code W for a missing resident. Guest was not found in room and staff began to search the area. Administrator notified of the incident at 12:48 p.m. and instructed (RN K) to call 911. Additional staff members were instructed to look outside and (Resident #5's) son-in-law, who was here visiting guest, left in his car to search and found (Resident #5) ambulating on the sidewalk behind (grocery store). Resident was returned to the facility in son-in-law's personal vehicle. Review of a Facility Investigation Summary dated 2/11/19 indicated On 2/10/19 at 12:40 p.m., (Facility) identified that (Resident #5) was not present in the facility at the time family came to visit her at lunch hour. She was last seen in the facility at approximately 12:30 p.m. Facility staff, family and (Sheriff's Department) notified and staff conducted a search of the interior and exterior of the property per policy. Family sighted the guest down the street walking on the sidewalk and returned guest to the facility. (911 operator) was still on the phone when guest was found. Guest was located at approximately 1:00 p.m. and brought back to the facility at 1:05 p.m. (Resident #5) was evaluated by (paramedics) at the time of returning to the facility and vitals were taken by the EMS and facility within the initial entrance back into the facility. (Resident #5) was assessed with [REDACTED]. (Resident #5) was placed on 1:1 with family initially and 15 minutes checks when family left for the first hour per facility policy and 30 minute checks thereafter. Later that evening guest was placed on 1:1 again due to emotional concerns and packing her belongings. Wanderguard replaced on right ankle and noted that previous Wanderguard was functional and working with door alarms, expiration date was (MONTH) 2020. Additional details in the report indicated that no alarm or door function malfunction was discovered and when asked, Resident #5 said she exited the facility via the front doors after an unknown person asked if it was all right for her to leave. Review of the Summary Report of Facilities Conclusion reflected .The facility is able to substantiate that (Resident #5) did exit the building without staff knowledge . The Nursing Home Administrator and the Director of Nursing were informed on 3/1/19 at 3:30 p.m. that Immediate Jeopardy had been identified, starting on 2/10/19 at 12:30 p.m. when (Resident #5) who had been assessed as an elopement risk and wore a WanderGuard bracelet, and who eloped from the facility, unbeknownst to staff, after an unknown system malfunction, allowing Resident #5 to elope from the facility on 2/10/19 at approximately 12:30 p.m. and was brought back to the facility about a half hour later when a family member of the resident located the resident outside a grocery store a half a mile from the facility. This deficient practice placed Resident #5 and 4 other residents who were assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. On 3/01/19 the surveyor verified the following interventions were put into place and were effective to remove the immediacy: 1. As of 2/10/19, Resident #5 received 1:1 with family initially and 15 minutes checks when family left and 30-minute checks thereafter. 8:48 p.m. that evening guest was placed on 1:1 again due to emotional concerns and packing her belongings. Immediately upon returning to facility, staff checked WanderGuard and found device properly working. It was also determined that device was attached properly to guest right ankle. WanderGuard replaced on right ankle and noted that previous WanderGuard was functional and working with door alarms, expiration date was (MONTH) 2020. 2. On 2/10/19, Nurse Managers re-assessed the 7 current residents who have a WanderGuard device. As of 2/10/19, all 7 current residents remain at risk for elopement and a WanderGuard device remains in place. 3. On 2/10/19, the Director of Nursing & Unit Managers audited the 7 current residents with WanderGuards to ensure placement and proper functioning were documented in each residents Treatment Administration Record. Licensed Nurses continue to check for placement every shift and functionality daily and document on the Treatment Administration record per facility's policy. 4. On 2/10/19, the Administrator reviewed the facility Missing Guest policy and it was deemed appropriate. 5. On 2/10/19, the Maintenance Director and/or designee validated that all Secure Care doors throughout the facility were functioning properly. The Maintenance Director and/or designee will continue checking all Secure Care doors for proper functioning on a daily basis per facility policy and document findings daily. 6. On 2/10/19, DON reviewed the elopement books and they were found to be up-to-date. Social service will continue to update each book with any changes as needed the per facility policy. 7. On 2/10/19, DON/designee immediately began re-educating staff; 115 of 116 facility staff members re-educate regarding missing guest policy. The remaining staff member will be educated by the DON and Managers prior to the start of their next scheduled shift. 8. On 2/11/19, Nurse Managers reassessed the other 81 current residents for elopement risk; no other residents were identified as a risk. 9. On 2/11/19, the facility relocated Resident #5 to a room farther away from the front door with Guardian consent. 10. On 2/11/19, the Maintenance Director changed passcode to alarm device to the Secure Care doors; will change passcode on a monthly basis. Code will not be given to guests. 11. On 2/14/19 Secure Care came in and completed an annual maintenance of all doors. On 3/01/19 this surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 2/14/19.

Based on observation, interview and record review, the facility failed to provide functioning assistive devices to prevent the fall for 1 resident (Resident #8) out of 5 residents reviewed for falls, from a total sample of 19 residents, resulting in Resident #8 sustaining a left humeral fracture (upper arm), pain, and decreased range of motion. Findings include: Review of Resident #8's medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she was severely cognitively impaired, required limited assistance of one person for transfers and dressing and, no limitation in her range of motion for all for extremities (arms and legs), and no complaints of pain. Her MDS dated [DATE] (after the fall of 11/5/14) indicated she required extensive assistance of two persons for transfers, extensive assistance of one person for dressing, had decreased range of motion in one upper extremity, and frequently complained of pain which was rated as 7 out of 10. Review of facility incident report for Resident #8, dated 11/5/14 at 2:00 pm, revealed Resident #8 was found on the floor, sitting next to the bed. The incident report (signed by Licensed Practical Nurse "M") indicated Resident #8's auto lock brakes on her wheelchair were not functioning and her alarming seatbelt was not activated. The report indicated Resident #8 had pain in her left upper arm, which she was unable to lift. Review of a radiology report for Resident #8, dated 11/5/14 revealed "Exam: Shoulder complete, Min. 2V (2 view) left" with "Conclusion: Acute fracture of the humeral head" (upper arm bone). Review of physician orders [REDACTED]. Review of medication administration records for Resident #8 for the month of November 2014 revealed on 11/6/14, 11/7/14, 11//8/14, 11/9/14, 11/10/14, 11/12/14, 11/13/14, 11/15/14, and 11/16/14 Resident #8 was given Tramadol 50 mg (pain medication) for left arm pain. Review of medication administration records for Resident #8 for the month of November 2014 revealed on 11/21/14 at 5:00 pm and 7:45 pm, Resident #8 was given Morphine (narcotic pain medication) for arm pain. Review of Resident #8's falls care plan (dated 11/15/13) revealed she had been identified to be at risk for fall related injury related to impaired mobility, history of fall with left hip fracture and incontinence with interventions listed to include provide assistive devices as needed, supervise and assist with transfers, self releasing seat belt alarm to wheelchair (all interventions dated 11/15/13). Review of physician orders [REDACTED]. Review of facility repair requisition (dated 11/5/14) for Resident #8's room, revealed a request to repair auto lock brakes "immediately". In an interview on 2/26/15 at 3:00 pm, Licensed Practical Nurse (LPN) "M" stated on 11/5/14 she was at the nurse's desk when Resident #8's roommate peeked out of Resident #8's room door and stated there was a lady on the floor. LPN "M" stated she went to Resident #8's room and observed Resident #8 sitting on the floor with her back to her bed. LPN "M" stated the alarming seatbelt on Resident #8's wheelchair was open, but not alarming and the anti-lock brakes on Resident #8's wheelchair were not functioning. LPN "M" stated Resident #8 immediately complained of pain in her left arm, would not allow any movement of her left arm, so her physician was called and an order for [REDACTED]. LPN "M" stated the Xray showed a fracture of Resident #8's arm, so Resident #8 was sent to the hospital. LPN "M" stated she wasn't sure what happened, or how Resident #8 got on the floor, so she just wrote what she observed on the incident report. In an interview on 2/27/15 at 8:35 pm, facility Director of Nursing (DON) "B" stated upon the facility investigation, no staff had been identified to have assisted Resident #8 to bed prior to her fall. DON "B" stated Resident #8 attempted to self transfer, her auto lock brakes didn't work and her alarming seatbelt did not alarm when she fell . When the surveyor asked why the seatbelt did not alarm, DON "B" stated Resident #8's roommate had a history of [REDACTED].#8's alarms because the noise bothered her. #

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY TREATMENT AND SERVICES, TO PROMOTE HEALING OF A STAGE THREE PRESSURE ULCER, AND FAILED TO PREVENT NEW PRESSURE ULCERS FROM DEVELOPING IN 1 (# 3 ) OF 5 RESIDENT ' S REVIEWED FOR PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 20 RESIDENT'S RESULTING IN THE DEVELOPMENT OF NEW PRESSURE ULCERS, INCREASED PAIN, AND THE POTENTIAL FOR INFECTION. FINDINGS INCLUDE: ACCORDING TO A FACILITY FACE SHEET DATED 8/26/12, RESIDENT #3 WAS A [AGE] year OLD MALE WHOSE [DIAGNOSES REDACTED]. ACCORDING TO A DOCUMENT TITLED "FAITH HOSPICE SERVICES" RESIDENT #3 WAS admitted TO FAITH HOSPICE WITH THE [DIAGNOSES REDACTED]. ACCORDING TO A PHYSICIANS PROGRESS NOTE DATED 8/28/12 RESIDENT #3'S [DIAGNOSES REDACTED]. ACCORDING TO A FACILITY DOCUMENT TITLED "BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK" DATED 12/5/12 REFLECTED THAT RESIDENT #3 HAD A TOTAL SCORE OF 16. A TOTAL SCORE OF 17 OR LESS INDICATES THAT THE INDIVIDUAL IS AT RISK FOR DEVELOPING A PRESSURE ULCER. RESIDENT #3'S BRADEN SCALE SCORE FOR 2/18/13 WAS 15 INDICATING THAT RESIDENT #3 WAS AT RISK FOR DEVELOPING A PRESSURE ULCER. ACCORDING TO A FACILITY DOCUMENT TITLED "WEEKLY SKIN ASSESSMENT" DATED 3/11 (NO YEAR), RESIDENT #3 BEGAN TO HAVE SKIN BREAK DOWN FIRST NOTED TO "UNDER SCROTUM, EXCORIATION." RESIDENT #3'S SCROTAL WOUND WAS DOCUMENTED ON A FACILITY ASSESSMENT TITLED "WOUND AND SKIN CONDITION RECORD" ON 3/11/(NO YEAR) THE SCROTAL WOUND WAS A "PARTIAL (SKIN) THICKNESS WOUND (LOSS OF EPIDERMIS AND PARTIAL LOSS OF DERMIS)." MEASUREMENTS OF THIS SCROTAL WOUND WAS 0.1 CM BY 0.1 CM NO ODOR, NO DRAINAGE, COLOR: WHITE AND RED." RESIDENT #3 DOES NOT HAVE ANY DOCUMENTATION ABOUT THIS SCROTAL WOUND BEING HEALED. ACCORDING TO A FACILITY DOCUMENT TITLED "WEEKLY SKIN ASSESSMENT" DATED 3/11/13 FOR RESIDENT #3 THE DOCUMENT REFLECTS A WOUND "BELOW THE SCROTUM AND ON THE RIGHT BUTTOCK." THERE IS NO WOUND MEASUREMENT SHEET FOR RESIDENT #3 FOR THE RIGHT BUTTOCK WOUND. ACCORDING TO A FACILITY DOCUMENT TITLED "WEEKLY SKIN ASSESSMENT" DATED 3/11/13 FOR RESIDENT #3, THE DOCUMENT REFLECTS "AREA ON RIGHT BUTTOCKS IS NOW OPEN. NEW AREA ON LEFT BUTTOCKS NOTED WITH SMALL OPEN AREAS." THERE IS NO WOUND MEASUREMENT SHEET FOR RESIDENT #3 FOR THE RIGHT BUTTOCK WOUND OR LEFT BUTTOCK WOUND. RESIDENT #3 EXPERIENCED MULTIPLE SKIN BREAK DOWN AREAS BEGINNING 10/17/12 AND ACCORDING TO THE BRADEN SCALE COMPLETED BY THE FACILITY FOR PREDICTING PRESSURE SORE RISK, THE FACILITY IDENTIFIED THAT RESIDENT #3 WAS A RISK FOR DEVELOPING PRESSURE ULCERS. A FACILITY "NURSING CARE CARD" (NO DATE NOTED) FOR RESIDENT #3 INDICATED THAT THE INTERVENTIONS FOR RESIDENT #3'S RISK FOR PRESSURE ULCERS WERE "BED MOBILITY/SKIN CARE: ? ASSIST OF 1. ? TURNING AND POSITIONING SCHEDULE: EVERY 2 HOURS, ? BEDREST, ? SIDE TO SIDE, KEEP OFF COCCYX (BACK)." THE SAME INTERVENTIONS, DATED 3/11/13, WAS NOTED ON RESIDENT #3'S CARE PLAN. DURING AN OBSERVATION ON 3/26/13 AT APPROXIMATELY 2:10 PM IN RESIDENT #3'S ROOM, RESIDENT #3 WAS NOTED TO BE IN BED, LYING ON HIS BACK, WHICH WAS CONTRADICTORY TO THE PLAN OF CARE. DURING AN OBSERVATION ON 3/27/13 AT APPROXIMATELY 9:42 AM IN RESIDENT #3'S ROOM, RESIDENT #3 WAS NOTED TO BE IN BED, LYING ON HIS BACK, WHICH WAS CONTRADICTORY TO THE PLAN OF CARE. DURING AN OBSERVATION ON 3/27/13 AT APPROXIMATELY 11:30 AM IN RESIDENT #3'S ROOM, RESIDENT WAS NOTED TO BE IN BED, LYING ON HIS BACK,WHICH WAS CONTRADICTORY TO THE PLAN OF CARE. DURING AN INTERVIEW WITH CERTIFIED NURSES AID (CNA) "AA" ON 3/27/13 AT APPROXIMATELY 3:25 PM OUTSIDE OF RESIDENT #3'S ROOM IN HALL, CNA "AA" WAS ASKED WHAT SPECIAL CONSIDERATIONS RESIDENT #3 HAD FOR HIS WOUNDS ON HIS BUTTOCKS. CNA "AA" STATED RESIDENT #3 HAD A TURNING SCHEDULE. CNA "AA" WAS ASKED WHAT RESIDENT #3'S TURNING SCHEDULE WAS. CNA "AA" STATED RESIDENT #3 WAS TURNED FROM HIS LEFT SIDE, TO RIGHT SIDE TO BACK. DURING AN INTERVIEW ON 3/28/13 AT APPROXIMATELY 1:30 PM OUTSIDE RESIDENT' #3'S ROOM IN HALL WITH CNA "S", CNA "S" WAS ASKED WHAT RESIDENT #3'S TURNING SCHEDULE WAS TODAY. CNA "S" INDICATED RESIDENT #3 WAS FACING THE WALL(RIGHT SIDE) AFTER BREAKFAST. CNA "S" THEN STATED BREAKFAST WAS APPROXIMATELY 8:00 TO 9:30 AM. CNA "S" STATED SHE HASN'T TURNED RESIDENT #3 SINCE AFTER BREAKFAST. IT IS NOW APPROXIMATELY 1:30 PM, 4 HOURS OR MORE SINCE BREAKFAST WHEN RESIDENT #3 WAS TURNED FACING THE WALL (RIGHT SIDE). DURING AN OBSERVATION OF A DRESSING CHANGE FOR RESIDENT #3 IN HIS ROOM ON 3/27/13 AT APPROXIMATELY 11:30 AM WITH LPN "F" AND ASSISTANT DIRECTOR OF NURSING (ADON) "B" TO OBSERVE "EXCORIATIONS" (SUPERFICIAL LOSS OF SUBSTANCE) ON COCCYX AREA AND DRESSING CHANGE OF COCCYX WOUNDS. LPN "F" WAS ASKED WHEN RESIDENT #'3'S WOUNDS TO THE COCCYX BEGAN. LPN "F" STATED THE COCCYX WOUNDS STARTED AS A DARKENED AREA A COUPLE OF MONTHS AGO. ADON "B" STATED RESIDENT #3'S OPEN WOUNDS BEGAN "A FEW WEEKS" AGO BUT ADON "B" STATED SHE WOULD HAVE TO LOOK AT THE RECORDS FOR AN EXACT DATE. DURING THE OBSERVATION OF RESIDENT #3'S COCCYX, THERE WERE 3 OPEN AREAS NOTED BY LPN "F" AND ADON "B". AS LPN "F" AND ADON "B" TURNED RESIDENT #3 FURTHER ONTO HIS RIGHT SIDE TO REMOVE HIS BRIEF, ANOTHER OPEN AREA WAS DISCOVERED ON HIS LEFT UPPER BUTTOCK. LPN "F" STATED, "LOOKS LIKE IT'S NEW." REGARDING THE AREA ON RESIDENTS LEFT UPPER BUTTOCK. THE AREA WAS PURPLE IN THE CENTER WITH SURROUNDING RED THAT WAS UNBLANCHABLE (DIDN'T TURN WHITE WHEN PRESSED INDICATING THERE IS TISSUE DAMAGE). LPN "F" FINISHED RESIDENT #3'S COCCYX WOUND'S CLEANSING AND DRESSSING. LPN "F" STATED SHE WAS GOING TO LEAVE RESIDENT #3 ON HIS BACK FOR LUNCH. DURING AN OBSERVATION ON 3/28/13 AT APPROXIMATELY 11:30 AM OF RESIDENT "3'S COCCYX WOUNDS ASSESSMENT BY PHYSICIAN "N" IN RESIDENT #3'S ROOM, PHYSICIAN "N" MEASURED RESIDENT #3'S COCCYX WOUNDS: 1) SACRAL (BASE OF SPINE) TO COCCYX (TAILBONE AREA) TO MEDIAL (TOWARDS THE MIDDLE) BUTTOCK "WOUND AREA 70 % EXCORIATION", STAGE 1 OR 2 SCATTERED, 40 % SLOUGHING (SHEDDING) EPIDERMIS, DENUDED (MISSING FIRST LAYER OF SKIN) EPIDERMIS" MEASURING 9 CM BY 9.5 CM. PHYSICIAN "N" CONSIDERED THE 3 AREAS LPN "F" IDENTIFIED AS A "WOUND AREA". 2) RIGHT UPPER BUTTOCK. PHYSICIAN "N" STATED DARK BLOOD, SLOUGHING EPIDERMIS, VERY IRREGULAR AREA 4.5 CM BY 3.4 CM , A DUSKY DISCOLORATION THAT IS 2.5 CM BY 2.5 CM, AND A PINK VS TAN AREA THAT IS 1.0 CM BY 0.7 CM DENUDED (LACKING COVERING) AREA WITH NO DEPTH. THIS RIGHT UPPER BUTTOCK WOUND WAS THE NEWLY DISCOVERED WOUND BY LPN "F" ON RESIDENT #3 ON 3/27/13 AT APPROXIMATELY 11:30 AM. PHYSICIAN "N" RATED RESIDENT #3'S RIGHT UPPER BUTTOCK WOUND AS A STAGE 2 PRESSURE ULCER. PHYSICIAN "N" STATED THAT RESIDENT #3'S NECROTIC DERMIS IN DENUDED AREA OF RIGHT UPPER BUTTOCK WOUND MEASURING 1 CM BY 0.7 CM MAY INCREASE TO STAGE 3 (PRESSURE WOUND) BECAUSE OF DEEP TISSUE INJURY. DURING AN INTERVIEW IN RESIDENT #3'S ROOM ON 3/28/13 AT APPROXIMATELY 12:15 PM WITH PHYSICIAN "N" REGARDING RESIDENT #3'S NURSING CONSIDERATION FOR PREVENTING AND HEALING COCCYX WOUNDS HE STATED RESIDENT #3 NEEDS TO BE TURNED (ON HIS SIDE) AT A 40 TO 45 DEGREE ANGLE. RESIDENT #3 WAS OBSERVED TO BE POSITIONED ON HIS BACK MULTIPLE TIMES WHEN RESIDENT #3'S CARE PLAN INDICATED POSITIONING WAS TO BE "TURNING AND POSITIONING SCHEDULE: EVERY 2 HOURS, BEDREST, SIDE TO SIDE, KEEP OFF COCCYX". NURSING (CNA AND NURSE) STAFF WAS NOT AWARE OF RESIDENT #3'S CARE IN REGARDS TO POSITIONING FOR PREVENTION AND HEALING OF PRESSURE ULCERS. RESIDENT #3 DEVELOPED A NEW STAGE 2 PRESSURE WOUND ON HIS RIGHT UPPER BUTTOCK. ( )

This citation pertains to intake MI 398 Based on observation, interview, and record review the facility failed to prevent the elopement and ensure the safety of 1 (Resident #102) of 3 residents, out of a total sample of 7 residents, resulting in an Immediate Jeopardy when Resident #102, who had been identified as an elopement risk and who exited the facility on 9/15/11 at approximately 3:45 p.m., unbeknownst to facility staff, was found by Physical Therapy Assistant (PTA) #3, at approximately 4:00 p.m., lying on his side in his wheelchair, with a seatbelt restraint on, in front of a loading dock beside a dumpster. This deficient practice placed 32 additional residents, identified as an elopement risk, at risk for serious harm, injury, and/or death. Findings include: Record review of a "Record of Admission", dated 8/25/11 and a Minimum Data Set ((MDS) dated [DATE], indicated Resident #102 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 76). Resident #102 had short and long term memory problems, exhibited wandering behavior daily and required extensive assistance from staff for transfers, walking, dressing, eating, toileting and personal hygiene. An "Elopement Risk Assessment", dated 8/25/11, identified Resident #102 at a high risk for elopement and wandering. An "Admission Care Plan", dated 8/24/11, indicated Resident #102 was to wear a WanderGuard, have a sensor mat (alarm) in his wheelchair, and an alarming seatbelt as the resident was assessed to have "no safety awareness", per a "Determination of Device Usage" and "Restraint Consent Statement," dated 9/07/11. Record review of an "Incident Report," dated 9/15/11 at 4:10 p.m., revealed Resident #102 was "observed on ground, wheelchair on side...by dumpster at 4:10 p.m." An "Incident Report Questionnaire," dated 9/16/11, revealed Resident #102 was found by PTA #3 as he was leaving an employee parking lot. During an interview on 11/03/11 at 2:00 p.m., PTA #3 demonstrated and retraced his steps with this surveyor, revealing he had just punched out for the day and walked across a 25 mph street to an employee parking lot and did not observe any other staff members or residents outside at that time. As he was driving out of the parking lot, he noticed Resident #102, still in his wheelchair tipped on its side with a "seatbelt" on. PTA #3 got out of his car, ran to the resident, and then went inside the facility to get help. PTA #3 did not hear any door or safety device alarms sounding. Licensed Practical Nurse (LPN) #6 and Certified Nursing Aides (CNA's) #7 and #8 responded. During an interview on 11/03/11 at 3:30 p.m., LPN #6 stated she observed Resident #102 lying on the ground in his wheelchair. LPN #6 did not recall hearing any alarms inside the facility, and did not hear any alarms sounding from a sensor pad on the wheelchair. She stated she was not assigned to the resident that day, but documented an assessment indicating no injuries were noted. LPN #6 recalled Resident #102 was talking nonsensically. LPN #6 could not recall the last time she had seen Resident #102 prior to finding him outside. During an interview on 11/03/11 at 3:35 p.m., CNA #6 recalled PTA #3 running into the facility "looking like he was going to have a heart attack" saying Resident #102 had fallen outside. She recalled rushing through the service hall from the nursing unit to the loading dock and seeing Resident #102 belted into his wheelchair which was tipped onto its side. CNA #6 stated it looked like Resident #102 has fallen off the loading dock. CNA #6 was not assigned to care for Resident #102 that day and was not sure of the last time she had seen him inside the facility. During an interview on 11/03/11 at 2:25 p.m., CNA #7 revealed she had worked a double shift that day and could not recall the last time she had seen Resident #102 before he eloped. CNA #7 said she recalled seeing Resident #102 lying on his back on the ground, LPN #6 was assessing Resident #102 who was on his back "babbling". An interview, on 11/04/11 at 8:45 a.m., LPN #5 revealed she was the nurse assigned to care for Resident #102, but had been busy with an admission and a transfer at the time of the incident. LPN #5 stated Resident #102 was wearing a WanderGuard, and did not recall hearing any door alarms inside the building. LPN #5 thought the last time she had seen Resident #102 was approximately 15 minutes before he was found outside, lying on his side in his wheelchair, with a seatbelt restraint on, in front of a loading dock beside a dumpster. An observation on 11/03/11 at 2:10 p.m., of the location where Resident #102 was found revealed a loading dock, approximately 2 feet high. A dumpster used for cardboard was positioned to the left of the driveway and a second dumpster for garbage flanked loading dock on the right. Facing the loading dock from the road were empty oxygen tanks stored to the left of the loading dock on the ground against the side of the building between the cardboard dumpster and the facility wall. The door leading into the facility from the loading dock was secured with a keypad combination lock from the outside. The door was unlocked from the inside, no combination was required to open it. A service hall with vending machines and storage closets, as well as an entrance to the facility kitchen led to a door which opened onto a nursing unit. The door from the nursing unit in the facility to the service hall was secured with a keypad combination lock. An interview on 11/03/11 at 1:20 p.m., Maintenance Supervisor #1 revealed he was instructed to change the combination key lock on the door that led from the nursing unit to the service hall that led to the vending machines, kitchen, storage rooms, and loading dock on 9/16/11, a day after Resident #102 eloped from the facility. Maintenance Supervisor #1 stated, during an earlier interview on 11/03/11 at 12:40 p.m., that the combination key locks were installed on doors within the facility and on doors to employee areas and there was not a universal code. All other entrances were secured with a "Secure Care" magnetic locking system controlled with a keypad. During an interview on 11/03/11 at 3:00 p.m., Resident #102 said he was not able to recall eloping from the facility. He denied knowing a universal combination to any keypad in the facility. The Director of Nursing (DON) and Corporate Nurse Consultant #11 were informed on 11/4/11 at 4:17 p.m. of the Immediate Jeopardy (IJ) which began on 9/15/11 and was identified on 11/3/11 when Resident #102 (identified as an elopement risk) exited the facility unbeknownst to facility staff on 9/15/11 at approximately 3:45 p.m. then was found by Physical Therapy Assistant (PTA) #3, at approximately 4:00 p.m., lying on his side in his wheelchair, with a seatbelt restrain on, in front of a loading dock beside a dumpster. On 11/7/11, this surveyor verified the facility implemented the following measures to remove the Immediate Jeopardy: 1.) All Nursing Staff on duty 11/4/11 during the survey were immediately inserviced on investigating and ensuring adequate supervision to prevent recurrence of an incident of exiting behavior. In-servicing included documentation of frequent visual checks, investigating contributing factors to an incident and implementation of immediate interventions. The maintenance director will change the alarm code monthly and immediately whenever the facility staff becomes aware of a resident knowing a door code. In a case where a resident exits an automatic self locking door after learning an entering the passcode, the maintenance director will be called immediately to assist with changing the code. 2.) 12 of 12 CNA's and 9 of 9 Nurses were inserviced on 11/3/11. 20 of 20 CNA's and 5 of 5 nurses had been inserviced on 11/4/11. 3.) The 33 remaining nursing staff will be in-serviced on the prevention of accidents, investigation and implementation of interventions to prevent recurrence prior to working their next scheduled shift. 4.) The Administrator and Director of Nursing have been provided additional education on 11/3/11 by the Regional Operator and Regional Quality Assurance relating to conducting a thorough investigation of incidents, timely intervention implementation and reporting incidents to the State Agency per the requirements. 5.) 105 of 105 current residents were reviewed on 11/3/11 and 33 were identified to be at risk for exiting and were reviewed by the Nurse Managers and designees on 11/3/11 to ensure interventions are in place to prevent unsupervised exiting. 6.) The facility will conduct an elopement drill at least quarterly to ensure appropriate and timely response by staff. 7.) All incidents are reviewed during the morning clinical meeting to ensure incidents are thoroughly investigated and interventions are implemented to prevent recurrence, continuing as of 9/15/11. 8.) The Quality Assurance Committee will review all trends during the monthly meeting for the next (3) three months to ensure policies and procedures have been followed. Additional education and monitoring will be initiated for any identified concerns. 9.) Accident prevention is presented during new employee orientation and is part of the facility's nursing education calendar, continuing as of 9/15/2011. 10.) All WanderGuard door alarm codes were changed on 11/3/11. 11.) All personal alarms have been checked for placement and function on 9/16/11 and on 11/4/11. 12.) An elopement drill was completed on 11/4/11. Although the Immediate Jeopardy was removed on 11/4/11, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm, due to all staff had not received education and sustained compliance had not been verified by the State Agency. ( )