Every finding on record at The Manor of Farmington Hills

This citation pertains to Intake Number 3055372. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal abuse and mistreatment by staff for two (R801 and R803) of three residents reviewed for abuse. Findings include:A review of a complaint submitted to the State Agency revealed an allegation that on 6/7/26, a Certified Nursing Assistant (CNA) told R801 to go to his room because he was sitting in the doorway of his room. (R801) was sitting in his wheelchair. The nurse's aide repeated herself. She then shoved him in his room. It is unknown if (R801) was shoved by the wheelchair or by his shoulders. (R801) defecated in his diaper. It is unknown if there was an argument. The same nurse's aide shoved the diaper with feces in (R801's) face. (R801's family member) said (R801) was upset when telling her about the incident . (R801 has a roommate in his room, and he was present during the altercation. On 7/6/26 at 12:05 PM, an interview was conducted with R801's roommate. When queried about any abuse, mistreatment, or altercations between R801 and staff, R801's roommate reported last month he heard a CNA talking to R801 not in a nice tone. R801's roommate said he could not see anything because the privacy curtain was pulled but could hear them from the other side of the curtain. R801's roommate did not recall any cussing but said the CNA sounded out of line. R801's roommate said he checked on R801 after the CNA left the room and R801's eyes appeared glassy, like he was about to cry. On 7/6/26 at 12:10 PM, an interview was conducted with R801. When queried about any altercations or mistreatment by staff the previous month, R801 reported there was an incident where he was seated in a wheelchair, half in and half out of his room. The CNA (later identified as CNA 'A') stood near the kitchen at the end of the hallway and yelled out to R801 to Get back in your room!. R801 further reported, CNA 'A' came to his doorway and pushed me into the room. When queried about what he meant by pushed, R801 gestured with his arms and hands that she had pushed him aggressively into the room in his wheelchair, not just pushed him in the wheelchair in a regular manner. R801 explained once in the room, CNA 'A' closed the door and then pushed the wheelchair against the bed. R801 said he was pushed in the wheelchair against the bed in the same manner he was pushed into the room. R801 explained his pants were soiled with urine and CNA 'A' took them off and held them in his face (R801 gestured with his hand that they were held approximately one inch from his face) and said, We don't like doing this (referring to changing R801's soiled clothing). R801 reported he was very angry and stated, She is lucky I don't have a temper like I used to and said it made him feel so badly that he felt like punching her. R801 stated, Before that, I really thought she was a nice person!. R801 further explained he reported what happened to his daughter and that he thought she called the police because the police came to talk to him. R801 did not recall being interviewed by facility staff. R801 said CNA 'A' no longer worked at the facility, and he heard she was moved to work on another hallway where she was mean to another resident. A review of R801's clinical record revealed R801 was admitted into the facility on 3/1/24 with diagnoses that included: heart disease and vascular dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition and no behaviors and was frequently incontinent of urine and stool. On 7/6/26 at 11:00 AM, an interview was attempted via the telephone with CNA 'A'. CNA 'A' was not available for interview prior to the end of the survey. A review of a Case Report from the local police department revealed, the police were contacted on 6/11/26 for suspicious circumstances. The report documented the following, On June 11, 2026, (Officer names) were dispatched to (facility address) for a resident who called his daughter who then called the facility about a dispute with a worker .Upon arrival officers made contact with the manager of the facility (The Administrator) who .was conducting her own investigation . It was documented the Administrator explained (R801's) side of the story and his roommate .(R801) stated that he was in the doorway of his room waiting for his appointment with physical therapy. When (CNA 'A') came down the hall he lives on stating he should not be in the doorway pushing his wheelchair against the bed and then proceeded to change his soiled pants and brief. Additionally, upon changing his pants (CNA 'A') took his soiled pants and put them close to (R801's) face scolding him that he should not be soiling his pants. (R801's roommate) stated that he did not definitively see anything, but he heard (CNA 'A') using foul language towards (R801) . It was documented that CNA 'B' was in the room and denied any assault, foul language, or holding R801's soiled pants near his face occurred. The report further documented, .Officers proceeded to ask (R801) his account of the events and he stated that (CNA 'A') came down the hall while he was waiting in the doorway of his room wheeled his wheelchair against the room [sic] and started changing his pants and taking his pants holding them inches from his face telling him he cannot be soiling himself. He also stated this is the first altercation they have had seeing as though she (CNA 'A') is typically nice .Officers then interviewed his roommate .he stated he did not see anything but heard (CNA 'A') being 'rough' with (R801) stating it was verbal not physical. Additionally, he stated he could see her take off his pants but could not see anything else occur . A review of an investigation conducted by the facility revealed an Investigation Summary that documented R801 denied being mistreated which was inconsistent with the above-mentioned interviews with R801 (who had intact cognition) and his roommate, the reported allegations, and the police report. A review of a Resident, Employee, and Visitor Assistance Form completed by R801's daughter revealed, My father said he was pushed in his wheelchair by the CNA and she closed the door. He also said put the brief in his face. On 7/6/26 at 11:05 AM, CNA 'B' was contacted for an interview via the telephone. When queried about what occurred on 6/7/26 with R801, CNA 'B' reported CNA 'A' was in R801's room getting ready to change him and she called CNA 'B' into the room to be a witness because she said he (R801) called her a bitch. CNA 'B' explained she went into R801's room and R801 was very upset. CNA 'B' said R801 denied calling CNA 'A' a bitch and agreed to let her change him at that time. CNA 'B' did not assist with care and was called into the room to be a witness. CNA 'B' further reported she did not know what occurred prior to being called into the room and that CNA 'A' was already in there with R801. A review of CNA 'A's personnel file revealed the following: A Disciplinary Action Record that noted CNA 'A' received a Final Warning on 6/9/26. The reason for disciplinary action was Staff member was discourteous to resident (R801). She was speaking to resident disrespectfully while providing care. The form was signed by CNA 'A' on 6/11/26. A Disciplinary Action Record that noted CNA 'A' was terminated from employment. The date of the infraction was 6/12/26. The reason for the disciplinary action was Employee was overheard speaking inappropriately to a resident while in their room by another staff member. This form was signed by the Director of Nursing (DON) and not dated. An Investigation Summary was included with the Disciplinary Action Record that revealed, in part, the following, On 6.12.26, the administrator was made aware of an allegation of a staff member engaging in verbal inappropriateness. Upon notification of this alleged allegation, the administrator conducted a complete and thorough investigation. The administrator and the DON interviewed the alleged employee (CNA 'A') with respect to this alleged allegation. (CNA 'A') denied being aware of any incident regarding her remarks. When made aware of this allegation by the DON, (CNA 'A') stated she did not say that. After interviewing this employee, she was made aware that she was being suspended, pending an investigation. The administrator interviewed the reporting staff member regarding this alleged allegation. Per the reporting staff member, she was walking down the hallway and overheard an employee said, 'get your ass up, I don't have time for this bullshit today'. The employee followed the facility's abuse policy and immediately reported this to her supervisor. The administrator asked the reporting staff member is [sic] she could identify the perpetrator, and she replied (CNA 'A'). The resident in question in non-interview-able and was unable to recall the allegation in question. A Conclusion attached to the Investigation Summary revealed, .the facility was able to substantiate that this event took place. Employee (CNA 'A') had just returned from a suspension without validation of the same allegation with respect to some of the same identical verbiage. In addition, recent disciplinary for poor customer service related to the same behavior. Therefore, it has been surmised based upon the previous pattern of this employee that this incident occurred .the facility has completed its investigation and will uphold the decision to terminate employment of (CNA 'A') . On 7/6/26 at approximately 11:30 AM, an interview was conducted with the Administrator who was the Abuse Coordinator for the facility. When queried about who the staff member was who overheard CNA 'A' verbally abusing a resident and who the resident was, the Administrator reported Housekeeper 'C' was the witness and R803 was the resident involved. When queried about the alleged mistreatment of R801 by CNA 'A', the Administrator reported they were unable to verify abuse occurred based on their investigation. They allowed CNA 'A' to return to work on 6/11/26, at which time CNA 'A' was given a disciplinary action due to being discourteous and speaking disrespectfully to R801. The Administrator was asked what was said and did not offer a response. When queried about why that was not included in the facility's investigation, the Administrator said it was separate from the abuse allegation but verified through interview with R801's roommate. The Administrator confirmed on 6/12/26, one day after CNA 'A' was brought back to work, she was overheard verbally abusing R803. The Administrator reported R803 was not able to be interviewed, but Housekeeper 'C' knew it was CNA 'A' based on her voice and R803's roommate is unable to get up on their own, so they deduced it to be R803. On 7/6/26 at 12:30 PM, an interview was conducted with Housekeeper 'C'. When queried about what they witnessed between R803 and CNA 'A', Housekeeper 'C' reported they were walking down the hallway and heard (CNA 'A') say, Don't start that shit now. We don't have time for that. Get your ass up. Housekeeper 'C' reported they did not recall the exact words, but it was very mean and was heard from the hallway. Housekeeper 'C' said they felt they needed to tell someone because what if that was your family member. Housekeeper 'C' reported they later learned from R801 and R801's roommate that CNA 'A' put R801's soiled pants in his face just a couple days before that. A review of R803's clinical record revealed R803 was admitted into the facility on 2/23/26 and discharged on 6/26/26 with diagnoses that included dementia. A review of a MDS assessment dated [DATE] revealed R803 had severely impaired cognition and no behaviors. Further review of R803's record revealed no documentation of the verbal abuse and no documented follow up to assess her psychosocial status. A review of a facility policy titled, Abuse Prohibition Policy, last revised 9/9/22, revealed, in part, the following, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation .Abuse shall include freedom from verbal, mental .physical abuse .Vermal Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the guest/resident to experience humiliation, intimidation, fear, shame, agitation, or degradation regardless of their age, ability to comprehend or disability .Mistreatment means inappropriate treatment .of a guest/resident

This citation pertains to Intake Number: 3055372. Based on interview and record review, the facility failed to report a witnessed incident of verbal abuse by staff to the State Agency and the Nurse Aide Registry, and report results of the investigation for one (R803) of three residents reviewed for abuse. Findings include:A review of Certified Nursing Assistant (CNA) 'A's personnel file revealed the following: A Disciplinary Action Record that noted CNA 'A' received a Final Warning on 6/9/26. The reason for disciplinary action was Staff member was discourteous to resident (R801). She was speaking to resident disrespectfully while providing care. The form was signed by CNA 'A' on 6/11/26. A Disciplinary Action Record that noted CNA 'A' was terminated from employment. The date of the infraction was 6/12/26. The reason for the disciplinary action was Employee was overheard speaking inappropriately to a resident while in their room by another staff member. This form was signed by the Director of Nursing (DON) and not dated. An Investigation Summary was included with the Disciplinary Action Record that revealed, in part, the following, On 6.12.26, the administrator was made aware of an allegation of a staff member engaging in verbal inappropriateness. Upon notification of this alleged allegation, the administrator conducted a complete and thorough investigation. The administrator and the DON interviewed the alleged employee (CNA 'A') with respect to this alleged allegation. (CNA 'A') denied being aware of any incident regarding her remarks. When made aware of this allegation by the DON, (CNA 'A') stated she did not say that. After interviewing this employee, she was made aware that she was being suspended, pending an investigation. The administrator interviewed the reporting staff member regarding this alleged allegation. Per the reporting staff member, she was walking down the hallway and overheard an employee said, 'get your ass up, I don't have time for this bullshit today'. The employee followed the facility's abuse policy and immediately reported this to her supervisor. The administrator asked the reporting staff member is [sic] she could identify the perpetrator, and she replied (CNA 'A'). The resident in question in non-interview-able and was unable to recall the allegation in question. A Conclusion attached to the Investigation Summary revealed, .the facility was able to substantiate that this event took place. Employee (CNA 'A') had just returned from a suspension without validation of the same allegation with respect to some of the same identical verbiage. In addition, recent disciplinary for poor customer service related to the same behavior. Therefore, it has been surmised based upon the previous pattern of this employee that this incident occurred .the facility has completed its investigation and will uphold the decision to terminate employment of (CNA 'A') . On 7/6/26 at approximately 11:30 AM, an interview was conducted with the Administrator who was the Abuse Coordinator for the facility. When queried about who the staff member was who overheard CNA 'A' verbally abusing a resident and who the resident was, the Administrator reported Housekeeper 'C' was the witness and R803 was the resident involved. When queried about the termination of employment for CNA 'A', the Administrator reported they allowed CNA 'A' to return to work on 6/11/26 after an investigation into an allegation of mistreatment, at which time CNA 'A' was given a disciplinary action due to being discourteous and speaking disrespectfully to R801. The Administrator further explained on 6/12/26, one day after CNA 'A' was brought back to work, CNA 'A' was overheard verbally abusing R803 as documented in the investigation summary. The Administrator reported R803 was not able to be interviewed, but Housekeeper 'C' knew it was CNA 'A' based on her voice and R803's roommate is unable to get up on their own, so they deduced it to be R803. When queried about whether the verbal abuse was reported to the State Agency, the Administrator reported she did not think she reported it but would look into it. On 7/6/26 at approximately 12:00 PM, the Administrator confirmed the witnessed verbal abuse toward R803 by CNA 'A' was not reported to the State Agency and acknowledged that it should have been. On 7/6/26 at 12:30 PM, an interview was conducted with Housekeeper 'C'. When queried about what they witnessed between R803 and CNA 'A', Housekeeper 'C' reported they were walking down the hallway and heard (CNA 'A') say, Don't start that shit now. We don't have time for that. Get your ass up. Housekeeper 'C' reported they did not recall the exact words, but it was very mean and was heard from the hallway. Housekeeper 'C' said they felt they needed to tell someone because what if that was your family member. Housekeeper 'C' reported they later learned from another resident that CNA 'A' put that resident's soiled pants in his face a couple days before the verbal abuse of R803. A review of R803's clinical record revealed R803 was admitted into the facility on 2/23/26 and discharged on 6/26/26 with diagnoses that included dementia. A review of a MDS assessment dated [DATE] revealed R803 had severely impaired cognition and no behaviors. Further review of R803's record revealed no documentation of the verbal abuse and no documented follow up to assess her psychosocial status. A review of the Michigan Facility Reported Incidents for Long Term Care (MI-FRI) application revealed no submitted incidents pertaining to CNA 'A verbally abusing R803.A review of a facility policy titled, Abuse Prohibition Policy, last revised 9/9/22, revealed, in part, the following, .The Administrator or designee will notify .any State or Federal agencies of allegations per state guidelines (2hours if abuse allegation .). At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action .Substantiated complaints against nurse aides for acts of guest/resident abuse .shall be reported to the state Nurse Aide Registry when the facility has knowledge .

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of residents, including R46 and R27, resulting in unmet care needs. This deficient practice had the ability to affect all residents that resided in the facility.On 9/23/25 at 10:16 AM, R46 was observed lying in bed. R46 was asked about care in the facility. R46 explained on 9/22/25 she had asked to be put back into bed around 5:00 PM, before dinner was served. was told they did not have enough staff as she required a mechanical lift and two staff members and had to wait until after dinner. was not assisted back to bed until 9:40 PM. was very tired from sitting in chair that long, and her bottom hurt.On 9/23/25 at 10:26 AM, R27 was observed lying in bed. R27 was asked about care in the facility. R27 explained she was not changed for 12 hours on 9/22/25. was changed around 4:00 PM, then was not changed again until early morning approximately 3:00 or 4:00 AM on 9/23/25. was told they were short of staff.Review of the clinical record revealed R46 was admitted into the facility on 2/26/25 with diagnoses that included: stroke, diabetes and pressure ulcer of sacral region. According to the Minimum Data Set (MDS) assessment dated [DATE], R46 was cognitively intact and dependent on staff for transfers.Review of the clinical record revealed R27 was admitted into the facility on 4/27/23 and readmitted [DATE] with diagnoses that included: heart disease, chronic obstructive pulmonary disease and diabetes. According to the MDS assessment dated [DATE], R27 was cognitively intact and was dependent on staff for toileting hygiene.Review of the four Afternoon Assignment Sheet dated 9/22/25 revealed three Certified Nursing Assistants (CNA's) assigned for Unit 1 and Unit 2. None were provided that documented Unit 3. One sheet had CNA Z' assigned to rooms 101-1 - 115-2, and another had 101-1 - 116-1. One sheet had CNA Y assigned to 116-1 - 236-1, another sheet had 226 - 236-2, another 116-2 - 123, and another had 226 - 241-1. One sheet had CNA AA assigned to 236-2 - 252-2, another had 238 - 252, and another had 241-2 - 252. On 9/25/25 at 12:22 PM, a phone call was made to CNA Y and a voicemail was left. No return call was made prior to the end of the survey.On 9/25/25 at 12:24 PM, CNA Z was interviewed by phone. CNA Z was asked how many CNA's were working the afternoon shift on 9/22/25. CNA Z explained there were four CNA's for the entire building. she had most of Unit 1, CNA Y was split between Unit 1 and Unit 2, CNA AA had the rest of Unit 2, and another CNA had Unit 3. When asked how many CNA's usually work the afternoon shift, CNA Z explained they usually had six. CNA Z was asked if there were things she could not complete on her shift. CNA Z explained she tried as hard as she could, but there were some things she could not get to, with three CNA's for 100 residents. Review of the facility daily staff postings revealed on 9/22/25 there were 98 residents.On 9/25/25 at 1:36 PM, The Administrator and Director of Nursing (DON) were interviewed and asked if the Scheduler, who was not at the facility, was working on 9/22/25. The Administrator explained the Scheduler was off on that day. When asked about only having four CNA's on the afternoon shift on 9/22/25, the DON explained they had more CNA's scheduled, but there were call-ins. The DON was asked what was done to provide care for the residents. The DON explained three managers stayed over to help with the afternoon shift. The DON was asked which managers had stayed. The DON explained it was Unit Manager (UM) C, Wound Care Coordinator (WCC) E and UM J. The DON was asked to provide the time punches for the three managers on 9/22/25.On 9/25/25 at 1:45 PM, UM J was interviewed and asked about the afternoon shift on 9/22/25. UM J explained she stayed to help on Unit 2. passed water, pass dinner trays, answered call lights and changed residents. When asked how long she stayed, UM J explained it was after 11:00 PM.On 9/25/25 at 1:55 PM, WCC E was interviewed and asked if she stayed to help out with the afternoon shift on 9/22/25. WCC E explained she did and helped out on Unit 1 to pass water, dinner trays and change residents. WCC E was informed of the resident complaints of care not being done. WCC E explained she was sure there were things that did not get done that afternoon. When asked how long she stayed, WCC E explained she stayed until 11:00 PM.Review of the time punches for the three managers revealed: UM C punched out at 7:26 PM, WCC E punched out at 7:27 PM, and UM J punched out at 7:26 PM.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in foodborne illness among all residents that consume food from the kitchen. Findings include:On 9/23/25 at 8:47 AM, during an observation of the main kitchen conducted with the Certified Dietary Manager (CDM 'G'), the following concern was observed:The reach in cooler #1 was observed to have a clear, watery liquid coming from the top fan unit (fan was not functioning). CDM 'G' reported the reach in cooler #1 was not functioning properly and someone had been out about a week ago to make repairs and they needed a new gasket part and drip pan. CDM 'G' reported the liquid was coming from the ceiling of the reach in cooler (where the fan was). Directly stored underneath this fan and surround shelving units were several food items that were visibly contaminated with the clear watery substance, including a carboard box soaked with several two pound tubs of pesto sauce, several large bags of shredded cheese, two packages of sliced cheese, a container of prepared sandwiches which had the clear liquid substance on the outside of the clear sandwich bags that were also seated in the clear, watery liquid in the bottom of the plastic bin the sandwiches were stored in. There was also a container of pre-made chicken salad that was covered in clear liquid.When asked if there should be any food items stored underneath the active draining ceiling in the reach in cooler and why they didn't utilize the several other surrounding reach-in coolers, CDM 'G' reported the food should not have been stored under that and began removing the food items from the reach in cooler to discard. CDM 'G' further reported the reach-in cooler was not leaking this bad before now. A policy titled, Food Purchasing and Storage dated 12/10/2024 did not address the issue with the leaking reach in cooler.According to the 2017 FDA Food Code section 3-305.11 Food Storage, (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview and record review, the facility failed to ensure residents' right to personal privacy during clinical assessment and provision of care for five (R14, R22, R31, R65, and R104) of five residents reviewed for privacy. Findings include:R14 On 9/23/25 at 10:09 AM, Ancillary Ear Care Nurse Practitioner (NP 'Q') was observed from the hallway providing ear care (wax removal) from the resident. They did not close the door or pull the privacy curtain to ensure personal privacy. Review of the clinical record revealed R14 was admitted into the facility on 5/27/22 and readmitted on [DATE] with diagnoses that included: vascular dementia with psychotic disturbance, unspecified dementia with other behavioral disturbance, psychotic disorder with delusions due to known physiological condition. R31 & R22 On 9/23/25 at 9:51 AM, R31 was observed from the hallway lying in bed watching their roommate (R22) receive ear care from NP 'Q'. They did not close the door or pull the curtain to ensure personal privacy. Review of the clinical record revealed R31 was admitted into the facility on [DATE], readmitted on [DATE] with diagnoses that included: cerebral infarction, abdominal aortic aneurysm ruptured, and other seizures. Review of the clinical record revealed R22 was admitted into the facility on 3/19/22 and readmitted on [DATE] with diagnoses that included: peripheral vascular disease, essential hypertension, and encounter for orthopedic aftercare following surgical amputation. R65 On 9/23/25 at 11:28 AM, Physical Medicine and Rehabilitation (PMR) NP 'R' was observed entering R65's room. NP 'R' did not close the door or pull the privacy curtain. The evaluation was heard from across the hallway, outside of R65's room, including when the resident last had a bowel movement. A review of R65's clinical record revealed R65 was admitted into the facility on 7/12/25 with diagnoses that included: femur fracture, type 2 diabetes mellitus, schizoaffective disorder, autistic disorder, and bipolar disorder. A review of a MDS (Minimal Data Set) assessment dated [DATE] revealed R65 had moderately impaired cognition. R104 On 9/23/24 at 11:32 AM, NP 'R' entered R104's room. NP 'R' did not close the door or pull the privacy curtain. The evaluation was heard from the hallway outside of R104's room. A review of R104's clinical record revealed R104 was admitted into the facility on 9/10/25 with diagnoses that included: type 2 diabetes mellitus with polyneuropathy. On 9/24/25 at 1:48 PM, an interview was conducted with the Director of Nursing (DON). When queried about privacy given to residents during medical evaluations, the DON stated, Privacy is privacy and explained all staff who provided care should close the door or pull the curtain and talk in a manner that ensures privacy. A review of a facility policy titled, Resident Dignity & Personal Privacy, revised 3/28/24, revealed, in part, the following, .Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs .Examine and treat residents in a manner that maintains their privacy .Use a closed door, a drawn curtain, or both, to shield the resident during all personal care and treatment procedures .Speak in lowered tones, as appropriate, when discussing clinical or private issues with the resident .

Based on observation, interview, and record review, the facility failed to provide a safe, homelike environment, for 14 resident rooms (Room #s 101, 103, 106, 107, 110, 116, 118, 121, 237, 243, 244, 246, and 247) and throughout the hallways on Unit 1 and Unit 2. Findings include:On 9/23/25 between 12:45 PM-1:30 PM, observations of Unit 1 and Unit 2 revealed environmental concerns with the wall corners just outside the doorways of resident rooms. There were numerous broken off plastic wall corner edges (that protected the vertical edges of the wall) that had splintered and sharp edges. Most of the broken and/or missing pieces of the plastic were at the ankle level. Additionally, the handrail outside of room [ROOM NUMBER] was observed to have a large gap (about two inches) that exposed the sharp metal bracket inside the plastic covering. On 9/24/25 at 8:56 AM, the facility was requested via email to provide documentation which included policies for maintaining equipment including handrails, wall and/or doorway wall coverings, and any documentation for maintenance repairs. On 9/24/25 at 9:10 AM, an interview was conducted with the Maintenance Director (Staff 'H') who reported they had been in their role at the facility for about seven years. When asked about how they monitored the environment for potential concerns, they reported they did audits. Staff 'H' reported when staff observed concerns, they reported that in their electronic reporting system so it could be tracked and followed up on. At that time, observations with Staff 'H' confirmed the broken, sharp edges of the protective wall edge coverings. Staff 'H' reported those areas were always getting hit by carts and were easily broken. When asked about why those areas had not been maintained or replaced to prevent potential accidents/injuries, Staff 'H' reported it usually took a while once an order was requested and parts were not always easy to get right away. They were requested to provide any documentation of past order requests including their environmental audit tools. When the handrail outside of room [ROOM NUMBER] was observed, Staff 'H' reported they were not aware of that and did not know that could happen but confirmed the sharp edges and proceeded to try to pull the handrail pieces together but was unsuccessful. Review of the documentation provided by the facility revealed only repairs for items in the kitchen and did not include the electronic reports by staff for the past six months. Review of the maintenance audits for the environment revealed no identification of the broken wall edge coverings, or the handrail. There was no documentation provided of any invoices, or requests for previous orders of the plastic wall corner edging. Review of the facility's policy titled Federal & State - Resident Rights & Facility Responsibilities dated 5/14/2024 documented, in part: .The facility must provide .A safe, clean, comfortable, and homelike environment .This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .

Based on interview and record review, the facility failed to report an allegation of mistreatment to the Abuse Coordinator and/or the State Agency within the required time frame for one (R5) of two residents reviewed for abuse. Findings include:Review of the clinical record revealed R5 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute respiratory distress syndrome, vascular dementia moderate with psychotic disturbance, delusional disorders, generalized anxiety disorder, and adult failure to thrive.According to the Minimum Data Set (MDS) assessment dated [DATE], R5 had moderately impaired cognition and was dependent on staff for most activities of daily living.Review of the progress notes included:An entry on 9/22/25 at 11:49 AM by the facility's contracted psych Nurse Practitioner (NP 'L') documented, in part: .(R5).is seen today in her room.She wants to go home, stating she does not like the facility and feels that she is being mistreated by certain people, however cannot state exactly who it is or what they are doing. She feels that they think she is crazy, for which she used the Latin word to describe this .Concerns will be forwarded to the social worker.An entry on 9/23/25 at 12:06 PM by Social Worker (SW 'K') documented, in part:SW met with (R5) today to follow up on report from Psych Nurse Practitioner (NP) of (R5) reporting to her that she felt like she was being mistreated by certain people. When SW asked (R5) if she thought that she was being mistreated by certain people she stated, I can't think right now. SW indicated that SW would come back later to meet with (R5) and she stated, I don't think that will help. SW left (R5) SW name and extension per her request to contact SW if she is feeling mistreated by others.On 9/24/25 at 1:25 PM, an interview was conducted with SW 'K'. When asked what they could explain about details of R5's allegation of mistreatment, including what had been reported following their notification of the allegation, SW 'K' reported the resident had been seen by Psych NP 'L' on Monday and both SW 'K' and the Administrator had been notified by an email about that. SW 'K' further explained they attempted to talk with R5 but the resident was asleep and yesterday they went in to talk to her and did not get many details. When asked if they were aware of whether that incident had been reported to the State Agency, SW 'K' reported they were not sure and deferred to the Administrator.On 9/24/25 at 1:35 PM, an interview was conducted with the Administrator and Director of Nursing (DON) in the presence of the Regional Clinical Director (Staff 'M'). When asked about the facility's process for reporting allegations of mistreatment, and whether they had been notified of R5's allegations of mistreatment and if that had been reported to the State Agency, the Administrator reported they were not aware of that. The Administrator was informed about the discussion with SW 'K' and that they had been notified by email from Psych NP 'L' and reported they probably had not pulled it up yet (email) and further reported because the State came in yesterday, they did not have any morning meetings which would normally have discussed that.According to the facility's policy titled, Abuse Prohibition Policy dated 8/31/22: .Staff members, volunteers, family members, and others shall immediately report incidents of abuse and suspected abuse .Injuries of unknown source - An injury should be classified as an injury of unknown source when ALL of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the guest/resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the extent of the injury, or the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time .The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator and DON immediately .The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours). At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action .

Based on observation, interview, and record review, the facility failed to ensure appropriate diet orders were entered upon admission for one (R101) of one resident reviewed for tube feeding, who was not supposed to eat anything by mouth, resulting in the potential for aspiration when the resident consumed food by mouth. Findings include:On 9/23/25 at 10:20 AM, R101 was observed lying in bed. R101 was able to say some words but had difficulty communicating. R101 reported he understood what others said but was unable to respond appropriately at times. A family member was at R101's bedside at that time. The family member explained R101 recently had a stroke and lost his ability to speak clearly and use one side of his body. On 9/24/25 at 9:00 AM, R101 was observed in bed. R101 reported his stomach hurt. When queried about whether he ate food by mouth, R101 nodded his head. When queried about whether he had a feeding tube, R101 nodded his head. On 9/24/25 at approximately 2:00 PM, R101 was observed in bed visiting with a family member. R101's family member stated, My biggest complaint is the communication between staff. Nobody knows what the other one is doing. A review of R101's clinical record revealed R101 was admitted into the facility on 9/18/25 with diagnoses that included: cerebral infarction (stroke). A review of a Nursing Summary completed upon admission on [DATE] at 4:18 PM revealed, .Resident .aphasic (difficulty speaking) r/t (related to) CVA (cerebral vascular accident). Resident is strict NPO (Nothing by mouth), bolus feed (a method of feeding through a feeding tube where large doses of the formula are given multiple times a day) .Orders and follow up appointments entered into (electronic medical record) . A review of a Nurses Note dated 9/19/25 at 3:32 PM, written by Licensed Practical Nurse (LPN) 'F', revealed, MD (medical doctor) ordered CXR (chest x-ray) .r/o (rule out) aspiration after the resident consumed a meal tray. Resident diet order is strict NPO. Diet slip updated, kitchen staff notified . A review of R101's Physician's Orders revealed an order for Nothing By Mouth was ordered on 9/19/25 in the afternoon. On 9/25/25 at 1:15 PM, an interview was conducted with LPN 'F'. When queried about what happened with R101 on 9/19/25 when he consumed a meal tray per her documentation, LPN 'F' reported R101 was a new admission. LPN 'F' reported she entered R101's admission orders and did not put in a diet order but put in the bolus tube feeding orders. LPN 'F' explained the dietary department entered a diet order for R101 on 9/19/25 and a Certified Nursing Assistant (CNA) notified her that R101 was eating a meal tray during the lunch meal. LPN 'F' asked the CNA if she gave him someone else's tray and the CNA reported R101 had a meal ticket included with the tray. LPN 'F' notified the unit manager, and it was discovered the dietary department created a meal ticket for R101. When queried about whether an order for NPO was entered upon admission, LPN 'F' reviewed R101's Physician's Orders and confirmed it was not entered until after the event of R101 consuming part of a meal tray. On 9/25/25 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). When queried about the incident of R101 receiving a meal tray on 9/19/25 when he was NPO, the DON stated, It wasn't a nursing issue. It was something dietary did. On 9/25/25 at 1:30 PM, an interview was conducted with Certified Dietary Manager (CDM 'G'), Registered Dietitian (RD) 'B', and RD 'V'. When queried about what happened with R101 on 9/19/25 and why he received a meal tray when he was not supposed to eat anything by mouth, CDM 'G' reported when she came in on 9/19/25 he did not have a diet ticket, so she put one in for him. CDM 'G' reported there was no indication R101 was NPO. R101 received a meal tray and when the error was discovered, management was notified, and an x-ray was ordered to rule out aspiration. When queried about which meal was served to R101 and on which date, a clear answer was not given by CDM 'G', RD 'B' and RD 'V'. CDM 'G' later followed up and confirmed it was the lunch tray on 9/19/25. When queried about how she would have known if a resident was NPO and not supposed to receive a meal tray, CDM 'G' reported there would be a physician's order. On 9/25/25 at 1:35 PM, the Administrator was asked to provide any incident reports and any associated investigations regarding R101. A review of an incident report completed by LPN 'F' revealed on 9/19/25 at 1:32 PM the nurse was notified R101 had a lunch meal tray at his bedside. It was documented R101 was strict NPO. The meal tray was removed from the resident's room, the resident was assessed, the unit manager and the physician were notified, and a chest x-ray was ordered to rule out aspiration. It was documented that there was miscommunication in the dietary dept. (department). No investigation was provided by the facility. A review of a facility policy titled, Physician's Order, revised on 8/20/25, revealed, in part, the following, .Physician orders are obtained to provide a clear direction in the care of the resident .Once the order is verified, the receiving licensed nurse transcribes the order in the EMR (electronic medical record) system .

This citation has two deficient practice statements (DPS).DPS #1Based on observation interview and record review the facility failed to assess and treat a skin impairment in a timely manner for one (R99) of three residents reviewed for wounds. Findings include: On 9/23/25 at 10:02 AM, R99 was observed lying in bed. When queried about the care provided in the facility, R99 reported he had pain in his left leg. R99 reported he was a victim of multiple gunshot wounds and had surgery to his left leg. R99 pulled the blanket off his leg which revealed an external fixation device that extended from the front of his left lower leg to the front of his left upper leg. R99 reported he was able to turn over a bit in bed but could not move the left leg. On 9/24/25 at 9:02 AM, R99 was observed lying in bed. R99 reported he was given pain medication an hour ago, but he was upset about a wound on the back of his left calf. R99 reported he got the wound while in the hospital due to pressure but the facility was not treating it adequately. R99 pulled back the blanket which revealed his left leg on top of a pillow that was stained with blood. R99 reported it was painful and bleeding and he had been trying to get someone to put a dressing on it since 3:00 AM. R99 reported he was concerned about it getting worse or infected if it was not covered. On 9/24/25 at approximately 9:10 AM, an observation of R99's left calf was made with the Unit Manager, Registered Nurse (RN) 'C'. RN 'C' assisted R99 to roll to the right and revealed an open area to the back of R99's left calf that was pink with two red bleeding areas in the center. There was no dressing applied to the skin impairment. R99 reported there was supposed to be a dressing on the wound, and she was going to notify the treatment nurse. On 9/24/25 at 9:53 AM, a review of R99's clinical record revealed the following:R99 was admitted into the facility on 9/19/25 with diagnoses that included: hypotension and acute embolism and thrombosis of unspecified deep veins of right lower extremity. A review of a Nursing Comprehensive Evaluation dated 9/19/25 and locked on 9/21/25 revealed R99 did not have any skin conditions.A review of a Nursing Summary dated 9/19/25 at 7:14 PM, revealed, Resident arrived at the facility via EMS (emergency medical services) at approximately (6:30 PM) on 9/19 .A skin assessment was performed by writer and aide. Writer observed a pin extrenal <sic> fixation to the LLE (left lower extremity) and resident unable to move L (left) toes. Resident appears to be in excruciating pain stating it to be in 10/10 .A review of a Nurses Note dated 9/19/25 at 7:52 PM revealed, .Resident has a pin fixation to left leg .Writer is endorsing to oncoming nurse to complete nursing comp (comprehensive evaluation) .A review of another Nurses Note (a late entry entered on 9/21/25 for 9/19/25 at 11:45 PM) revealed, .Skin tear noted to posterior aspect of L calf (lower/underside) dry dressing of gauze secured with tape in place . Further review of R99's progress notes revealed no documented assessment of the skin tear on the left calf documented on 9/19/25. A review of R99's wound assessments revealed assessments of the surgical wounds to the front of R99's left leg that included the external fixation device. A review of R99's Physician's Orders 9/19/25 to 9/24/25 revealed no order for treatment to R99's left calf. On 9/24/25 at 3:00 PM, R99 was observed lying in bed. When queried about the wound to his left calf, R99 reported a treatment was done after the observation with RN 'C' earlier that day. R99 turned his leg slightly and revealed a dressing dated 9/24/25 with RN 'C's initials. On 9/24/25 at 3:05 PM, an interview was conducted with RN 'C'. When queried about who administered the treatment to R99's left calf that day, RN 'C' reported it was the Treatment Nurse, Licensed Practical Nurse (LPN) 'S'. When queried about why there was no treatment order, RN 'C' said there was a treatment order in the Electronic Medical Record (EMR). At that time, R99's Physician's Orders were reviewed with RN 'C'. RN 'C' referred to an order for a treatment to left thigh surgical incision but there was no order for the wound to R99's left calf, which was not a surgical incision. When queried about the order, RN 'C' did not offer a response and said LPN 'S' would be the person to talk to. When queried about whether the open area to R99's left calf was assessed after it was observed that morning, RN 'C' reported it was not. On 9/24/2025 3:50 PM, an interview was conducted with LPN 'S'. When queried about her role, LPN 'S' reported she did all of the wound treatments in the facility. LPN 'S' explained if a new wound was identified, LPN 'E', the Wound Care Coordinator, assessed the wound, put in a note, entered a treatment, and contacted the wound provider. LPN 'S' further explained once the treatment order was in, she was alerted to do wound treatment for those residents. When queried about the wound to R99's left calf, LPN 'S' reported she had never seen that wound. LPN 'S' said she attempted to do the treatment on Monday (9/22/25), but R99 was in a lot of pain and he was unable to turn so she was unable to do it. When queried about if she did the treatment on that day (9/24/25), LPN 'S' said RN 'G' came to her to ask her to do it, but the order was for the night shift. LPN 'S' explained she did not administer a treatment to R99's calf (It should be noted that there was no active order for a treatment to R99's calf). On 9/24/25 at 4:12 PM, an interview was conducted with LPN 'E'. When queried about her role, LPN 'E' reported she was the wound care coordinator and was responsible for coordinating with the physician and wound nurse practitioner (NP). LPN 'E' explained when a new wound was identified, she was supposed to be notified, then she would assess the wound, and talk to the physician and NP. When queried about what was going on with R99's left calf, LPN 'E' stated, Looks like a skin tear. When queried about when she assessed the wound, LPN 'E' reported it was an abrasion. LPN 'E said she did not document an assessment of the wound anywhere, but LPN 'S' took a picture. A review of the wound assessments in R99's clinical record did not reveal any assessment or picture of the left calf, as mentioned earlier. LPN 'E' said both herself and LPN 'S' were able to assess wounds, add physician's orders, and take pictures and document the wounds. LPN 'E' followed up and reported a nurse documented a skin tear to the rear left calf on 9/19/25. When queried about why that wound was not assessed, LPN 'E' reported she was not notified. LPN 'E' confirmed she did not know about the open area to R99's left calf until that day (9/24/25). On 9/24/25 at 4:29 PM, an observation of the back of R99's left thigh was conducted with LPN 'E'. R99 reported he did not have any skin impairments on the back of his thigh. Observation revealed no skin impairment to the left thigh. When queried about the order that was in place for the left thigh surgical incision that did not exist, LPN 'E' reported she must have made a mistake and said read instead of front, referring to the surgical wound to the front of R99's thigh. LPN 'E' confirmed she did not know about the calf wound until today. A review of R99's clinical record on 9/24/25 at 4:42 PM revealed no documented assessment of the calf wound and no treatment order despite a treatment being applied to the calf. On 9/25/25 at 8:35 AM, an interview was conducted with the Director of Nursing (DON). When queried about the protocol when a skin impairment was identified, the DON reported the nurse documented the impairment, initiated a treatment, and notified the physician and wound care coordinator, LPN 'E'. When queried about LPN 'E' and LPN 'S's roles, the DON reported LPN 'E' was not wound care certified and was responsible for assessing wounds, initiating treatments, and coordinating with the wound provider. The DON reported LPN 'S' primarily did the wound treatments in the facility but could also assess and initiate treatments. The DON reported new skin impairments were supposed to be documented on a change in condition assessment. On 9/25/25 at approximately 12:30 PM, an interview was conducted with NP 'EE'. NP 'EE' reported today would be the first time evaluating R99. An observation of R99's left calf was conducted with NP 'EE'. A small amount of drainage was observed on the dressing. A pink open area was observed on the left calf. NP 'EE' stated, That's an abrasion. When asked how an abrasion could occur in that area of the body, NP 'EE' stated, From friction or shearing. NP 'EE' further stated, That's not a skin tear. A skin tear would have a flap of skin. When NP 'EE' referred to the area as a new wound, R99 stated, That's not new. I've had that longer than I've been here! On 9/25/25 at 12:35 PM, an interview was conducted with Certified Nursing Assistant (CNA) 'FF'. CNA 'FF' reported she was assigned to R99 for the past couple days. When queried about whether she noticed any skin impairments to the back of his left calf, CNA 'FF' reported she did not notice anything. A review of a Visit Report for R99, completed by NP 'EE' on 9/25/25 revealed, .Wound #1 Left, Posterior Calf is an acute Partial Thickness Abrasion .measurements are 1.6 cm (centimeters) length x (by) 0.8 cm width x 0.1 cm depth .There is a small amount of serous drainage noted . A review of a facility policy titled, Skin Management, revised 8/14/25, revealed, in part, the following, .Residents admitted with any skin impairments will have appropriate interventions implemented to prevent healing .A physician's order for treatment .Skin impairment location, measurements and characteristics documented . DPS #2 Based on observation, interview, and record review, the facility failed to administer insulin according to physician's orders and contact the physician for a hypoglycemic (low blood sugar) event. Findings include: On 9/23/25 at 10:30 AM, R102 was observed seated in a chair. R102 reported he was recently admitted into the facility and was there for antibiotics to treat a diabetic wound on his foot. R102 reported he had a hypoglycemic incident the other night and the facility did not have anything quickly available to bring his blood sugar back up. R102 said the nurse gave him two mini chocolate bars but he would typically need a large chocolate bar or glass of orange juice. R102 further reported his blood sugar level was 50 and dropping. R102 reported he received a certain type of insulin at night and stated, I should not have let them give me that amount. R102 expressed feeling lightheaded, dizzy, and was afraid he was going to die. A review of R102's clinical record revealed R102 was admitted into the facility on 9/12/25 with diagnoses of acute osteomyelitis of left ankle and foot and type 2 diabetes mellitus. A review of R102's Physician's orders revealed the following orders: Lantus (long acting) 100 unit/ml (unit per milliliter)- inject 40 unit subcutaneously (beneath the skin) at bedtime for DMInsulin Lispro (short acting) 100unit/ml inject 7 unit subcutaneously with meals for DM A review of R102's progress notes revealed the following: A Nurses Note dated 9/21/25, written by Licensed Practical Nurse (LPN) 'A', documented, During the (9:00 PM) med pass (on 9/20/25), residents BS (blood sugar) was taken and was 305 mg/dl (milligrams per deciliter). 40 units of insulin were administered per MD (physician) order. At (10:57 PM) resident c/o (complained of) feeling lightheaded, dizzy, and reported diplopia (double vision). Resident expressed concern that he could 'possible die in the night.' BS was 50 (mg/dl) at this time. Writer and aide gave resident two chocolate candy bars and 2 bottles of ensure. At (12:00 AM) blood glucose rechecked and noted to be 109 mg/dl. Resident stated that he was feeling a little better, no further c/o dizziness or visual changes at this time .Writer will reach out to MD via communication book to have the 40 Unit order reviewed and possibly changed to a lower unit or sliding scale to avoid a hypoglycemic crisis. A review of eMAR (electronic medication administration record) - Medication Administration Notes revealed R102 received different doses of Lantus than what was ordered by the physician (40 units) on multiple days as follows:On 9/12/25, 11 units were given.On 9/13/25, it was documented that R102 only accepted 20 units.On 9/14/25, R102 only accepted 30 units.On 9/15/25, 25 units per resident.On 9/16/25, 25 units given.On 9/19/25, Resident only requested half the dose of 20 units.On 9/21/25, Resident insisted on 25 units instead of 40 units.On 9/22/25, 7 units accepted.On 9/23/25, 25 units administered. A review of a Physican Note dated 9/22/25 revealed no documentation of R102's hypoglycemic event on the night of 9/20/25 and no mention of the Lantus being given at doses not consistent with the physician's orders. On 9/24/25 at 11:33 AM, an interview was conducted with LPN 'A' via the telephone. When queried about the hypoglycemic event R102 experienced on the night of 9/20/25, LPN 'A' responded with I haven't worked here that long. When queried about whether she completed training and orientation and was assigned to provide nursing care to residents, LPN 'A' reported she completed training, was licensed, and provided nursing care to residents. When queried about what type of insulin she administered to R102 on the night of the hypoglycemic event, LPN 'A' stated, I gave 40 units of lispro because his blood sugar was over 300. (It should be noted that Insulin Lispro is a short/fast acting insulin and R102's orders were to receive that insulin before meals). When queried about whether she contacted a medical provider after R102 had a hypoglycemic incident, LPN 'A' said she contacted Physician 'U'. When queried about Physician 'U's response, LPN 'A' clarified that she did not call him but wrote it in the communication book. When asked why she did not call him, LPN 'A' stated, I work on the midnight shift, and he doesn't respond. When queried about why 40 units of Insulin Lispro were given at 9:00 PM on 9/20/25 and not Lantus which was the insulin ordered to receive at bedtime, LPN 'A' stated, When you look at the orders, he only has an order for Lispro 40 units. LPN 'A' then stated, I don't really know what I gave. It's whatever is documented on the MAR. At that time LPN 'A' said she was uncomfortable answering anymore questions and hung up the phone. On 9/24/25 at11:45 AM, an interview was attempted with LPN 'D' (one of the nurses who gave Lantus at different doses than what was ordered) via the telephone. LPN 'D' was not available prior to the end of the survey. On 9/24/25 at 12:03PM, an interview was conducted with Physician 'U' via the telephone. Physician 'U' confirmed he was familiar with R102. When queried about R102's hypoglycemic event on the night of 9/20/24, Physician 'U' reported he as not notified about it and was not aware that happened. Physician 'U' reported the nurse should have called him at the time of the event. When queried about whether the nurses should administer different doses of Lantus than what was ordered (40 units), Physician 'U' stated, They can't just change it. Physician 'U' explained that if the nurses contacted him and if he was aware of the resident's noncompliance with taking that dose, he would have evaluated and educated the resident. Physician 'U' said R102 was in the facility to treat a diabetic wound and his blood sugar needed to be controlled in order to aid in wound healing. Physician 'U' reported he had never been contacted about R102 refusing the 40 units of Lantus. On 9/24/25 at 12:52 PM, an interview was conducted with Unit Manager, Registered Nurse (RN) 'C'. When queried about R102's hypoglycemic event and random doses of Lantus being given instead of the ordered 40 units, RN 'C' reported she was not aware he had a hypoglycemic event. RN 'C' reported the physician should have been called. RN 'C' reviewed R102's clinical record and said she was not sure why staff were giving R102 different doses of Lantus and explained the physician should be contacted before administering a medication outside of the orders or if the resident was refusing it. RN 'C' read the progress note regarding the hypoglycemic event on 9/20/25 and confirmed the note did not indicate what kind of insulin was administered at that time. RN 'C' said it was unlikely that it was the long-acting insulin (Lantus) if his blood sugar dropped that low, that quickly. If the nurse gave the wrong insulin, a medication error should have been reported. RN 'C' reported she would have to look into it. On 9/24/25 at 1:10 PM, an interview was conducted with the Director of Nursing (DON). When queried about whether she was aware of R102's hypoglycemic event on 9/20/25, the DON reported she would not have been notified about that. If the resident had low blood sugar, the physician should have been contacted. When queried about R102 receiving different doses of Lantus than what was ordered, the DON reported the nurses were not supposed to alter from the order said. The DON further reported that if the resident did not want that much, the nurse still should have notified the physician. A review of a facility policy titled, Diabetic Management dated 9/22/23 revealed, in part, the following, .If BG (blood glucose) is below 70 mg/dl and the resident is presenting with signs/symptoms of hypoglycemia and can swallow, administer: 4 ounces of fruit juice, or administer three (3) 5gm oral glucose tablets, or One tube of glucose gel massaged into the buccal space .Notify the physician of abnormal blood glucose test results, symptoms exhibited, and interventions implemented .

Based on observation, interview and record review, the facility failed to timely identify and treat a facility acquired pressure ulcer for one (R10) of three residents reviewed for pressure ulcers resulting in R10 acquiring a Stage 4 (full-thickness skin and tissue loss) pressure ulcer. Findings include:On 9/23/25 at 9:11 AM, R10 was observed lying in her bed flat on her back. R10 was asked if she had wounds or sores on her body. R10 explained she thought she did.Review of the clinical record revealed R10 was admitted into the facility on 8/19/22 and was readmitted on [DATE] with diagnoses that included: hypertensive urgency, fracture of left pubis and stroke. According to the Minimum Data Set (MDS) assessment dated [DATE], R10 had severely impaired cognition. The MDS assessment also indicated R10 had one facility acquired Unstageable (obscured full-thickness skin and tissue loss) pressure ulcer.Review of R10's impaired skin care plan revealed interventions that read in part, .Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 08/19/2022. Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated 08/22/2022.Review of R10's progress notes revealed a Skin/Wound Progress note dated 8/15/25 at 4:03 PM by Licensed Practical Nurse (LPN) E, who served as the Wound Care Coordinator, read in part, During skin assessment resident observed with 3 new areas, not including sacrum MASD (moisture associated skin damage) already being treated.Review of a Skin & Wound Evaluation dated 8/15/25 for R10 read in part, .Type: 15. Pressure. Stage 4: Full-thickness skin and tissue loss. Location: Right Gluteal Fold. Acquired: 1. In-House Acquired. Exact Date: 8/15/2025. Length 6.4 cm (centimeters). Width 1.8 cm. % Slough (non-viable yellow, tan, gray, green or brown tissue): 1. 100% of wound filled. Progress: 1. New. Review of the picture attached to the Skin & Wound Evaluation dated 8/15/25 revealed an open wound completely obscured by slough on R10's left gluteal fold. It should be noted the Skin & Wound Evaluation documented the wound as right gluteal fold. On 9/24/25 at 10:05 AM, R10's left gluteal fold wound was observed with LPN S, who served as the Wound Care Treatment Nurse. LPN S assisted R10 to turn on her left side and the wound was immediately observed as there was no dressing covering it. The wound appeared on the left gluteal fold, was approximately 4 cm x 3 cm and the wound bed was obscured with eschar (dead or devitalized tissue that is hard or soft in texture). LPN S then removed R10's brief to reveal a wound on R10's sacrum, that was previously identified as MASD on 8/15/25. On 9/4/25 at approximately 10:30 AM, LPN S was asked why R10's left gluteal fold wound was not identified until it was a Stage 4. LPN S explained the facility had done a skin evaluation on every resident in the facility on 8/15/25 and the wound was discovered at that time. LPN S was asked would the left gluteal fold wound be visible to the nurse providing care to R10's sacrum wound. LPN S explained the wound was visible. LPN S was asked if the Certified Nursing Assistants (CNA's) informed the nurses if they noticed any skin impairment while providing care to residents. LPN S explained sometimes they did, but sometimes they would tell her after the fact that they would just put a little cream on reddened areas.Review of R10's August 2025 Treatment Administration Record (TAR) revealed an order with a start date of 8/16/25 that read, Wound care: clean right gluteal fold with NS (normal saline), pat dry, apply medihoney gel, 4x4 gauze, border gauze . On 9/24/25 at 1:00 PM, LPN E was interviewed and asked why R10's left gluteal fold wound was first identified as a Stage 4. LPN E explained a wound should not be discovered at a Stage 4, it should be identified by staff as soon as there is a change. On 9/25/25 at 8:37 AM, the Director of Nursing (DON) was interviewed and asked about the delay in identifying R10's pressure ulcer. The DON explained pressure ulcers should be identified and treated timely Review of a facility policy titled, Skin Management revised 8/14/25 read in part, .A skin and wound total body skin evaluation is completed for each resident by the licensed nurse weekly. The licensed nurse will document findings on the skin evaluation. The CNA/STNA (state-tested nursing assistant) will report any new skin impairment to the licensed nurse that is identified during daily care.

Based on observation, interview and record review, the facility failed to store medication in a secure and safe manner and ensure proper disposal of medication for one of three medication carts observed for medication storage and labeling. Findings include:On 9/23/25 at 11:16 AM, a large green pill was observed on the hallway flooring just outside of room [ROOM NUMBER]. Nurse 'I' was observed several doors down at the medication cart. When asked to come over to room [ROOM NUMBER], Nurse 'I' confirmed the pill on the floor. When asked if they could identify what the pill was, or who it was for, Nurse 'I' used a disposable glove to wrap around the pill and picked it up to inspect and reported there were no markings, and it looked similar to a seizure pill but that was blue. Nurse 'I' then proceeded to discard the pill and disposable glove in the resident's trash can in room [ROOM NUMBER] and returned to their med cart to continue with medication administration.On 9/23/25 at 11:27 AM, an interview was conducted with Nurse Manager 'J'. When asked to about the pill that was found on the floor and discarded in the trash can inside room [ROOM NUMBER], Nurse Manager 'J' observed the pill in the trash can and reported they would have to re-educate Nurse 'I' immediately and removed the pill from the trash can.According to the facility's policy titled, Medication Storage dated 7/23/2019 documented, in part:Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members authorized to administer medications .[Name of Pharmacy] dispenses medications in packaging/containers that meet regulatory requirements. Medications shall be kept and stored in these packages/containers .

Based on observation, interview and record review, the facility failed to obtain physician ordered x-rays for one (R14) of one resident reviewed for radiology/diagnostic services. Findings include:On 9/23/25 at 10:15 AM, R14 was observed lying in bed with a visitor (Family Member/FM 'BB') seated next to the resident. The resident's left chin/jawline was observed to have dark reddish colored areas.Review of the documentation provided by the facility included:A report dated 9/15/15 12:15 PM documented, .Nursing Description: Resident <sic> noticed resident had discoloration to left side of chin.Writer notified MD (Medical Doctor). Skull xray ordered .Injury Type Bruise Injury Location 4) Face .An entry on 9/18/25 at 4:58 AM by Physician 'DD' read: .09/16/2025 .was seen today as staff reported no <sic> patient had a bruising on her chin laterally on the left side. Will order x-ray.Review of the physician orders included:An x-ray ordered 9/15/25, created 9/16/25 by Nurse 'N' for skull x-ray R/T (related to) swelling and discoloration of chin.Another x-ray ordered 9/15/25, created 9/16/25 by Nurse 'O' for facial x-ray of lower left jaw.Review of the electronic medical records (EMR) revealed there were only radiology results for the skull x-ray, and there was no documentation that the lower left jaw x-ray had been completed as ordered.There was no documentation in the EMR to explain the discrepancies of why the x-rays were documented as ordered on 9/15/25 but had created dates of 9/16/25.On 9/24/25 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). When asked about details of R14's injury of unknown origin from 9/15/25 and discrepancies in dates of the orders and notes, the DON deferred to Nurse Manager 'J' and then requested they come to join the interview.Nurse Manager 'J' was asked about R14's x-rays, they reported the x-ray had been completed. When asked to review the documentation in the EMR, Nurse Manager 'J' confirmed only the skull x-ray was completed and in the medical record. Nurse Manager 'J' further confirmed the order for the lower left jaw x-ray was not available and reported they would follow-up.On 9/24/25 at 2:00 PM, Nurse Manager 'J' reported they could not find out any more information about why the left lower jaw x-ray had not been completed.On 9/25/25 at 3:00 PM, the DON reported they didn't have a policy for radiology and would follow the policy for following physician orders.According to the policy titled, Physician's Order dated 8/20/25: .Orders must be recorded in the resident record, restated back to the ordering licensed health professional, and then signed by the person who recorded the order.It is the responsibility of the licensed nurse to follow physician orders.

This citation pertains to Complaint #2649369Based on interview and record review the facility failed to provide 1:1 feeding assistance per the resident's assessment and plan of care and thoroughly conduct a Root Cause analysis investigation for one (R701) out of one resident reviewed for accidents/choking, resulting in R701 choking on corned beef and expired shortly thereafter. Findings include:A complaint was filed with the State Agency (SA) alleged on 10/16/25 during lunch, R701 choked on corned beef while eating in the dining room and died from choking. The complainant reported R701 required 1:1 feeding assistance but believed that nobody was sitting with the resident and/or watching them eat during lunch. The complaint reported that prior to the resident's death they had informed the Administrator that R701 was not receiving 1:1 feeding assistance as needed.A review of R701's clinical record was conducted on 10/29/25 and 10/30/25. The following was revealed:R701 was initially admitted to the facility on [DATE] with diagnoses that included: dementia, psychotic disturbances, mood disturbances and need for assistance with personal care. A review of R701's Minimum Data Set (MDS) with an ARD (assessment reference date) of 9/12/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15 (severely cognitively impaired). Section GG of the MDS noted the resident as a 4 (needed supervision or touching assistance) for eating. 6/16/25: Physician order: .Details.1:1 feed with meals.Care Plan Review: Focus: R701 has alteration in nutritional and/or hydration .9/17/25 sig. wt. (significant weight) loss -15.6% x 180 days.Interventions: .provide 1:1 feeding assistance. Focus: R701 is a DNR (do not resuscitate).Focus: R701 is at risk for decline in condition.Receives Hospice services .Interventions: Adjust provisions of ADLS (activities of daily living) to compensate for resident's changing abilities.Work cooperatively with hospice so that residents.physical.needs are met.IDG (interdisciplinary group) Hospice Review (certification period - 8/25/25- 10/23/25): .Patients Name: (R701).Provider (Hospice).Meeting notes: . 9/23/25.Pt (patient) remains confused, 1:1 feed.unable to name food items that were on breakfast tray. Pt. also trying to eat nonfood items- napkins menu.Diet as tolerated, 1:1 feed .During last visit tried to get pt to name objects on her breakfast tray, but pt was unable to do so, very confused, Pt. tried eating her menu.10/14/25: Physician Note: R701.assigned on Hospice.Anticipate further unavoidable decline .impulsivity and poor safety awareness.Vital signs: BP (blood pressure) 156/86, HR (heart rate) 65, RR (respiratory rate) 20, Temperature 96.8, 02 98% .is sitting in a high back wheelchair, requires it for trunk support .frail patients are clinically challenging.encourage oral nutrition and hydration dietary to optimize nutrition. Authored by Physician/Medical Director (MD) A.10/16/25: Vitals: 9:15 AM Respirations: 18 breaths per minute.9:15 AM-O2 states: 95% .10:30 AM.Blood Pressure: 144/83.10:30 AM-83 bpm (heart rate). *It should be noted that the vitals noted above were the last vitals documented in R701's electronic record.10/16/25 (4:14 PM): Nurses Note: At approximately 1:05 PM, resident was eating lunch (corned beef) in the dining room. CNA (certified nursing assistant) alerted another nurse that resident began coughing and appeared to be choking. Unit manager on shift immediately initiated chest thrust and back blows. Resident was transferred from dining room to her bedroom with aspiration protocols being continued (finger sweeps, utilization of suction machine and 02 (oxygen) administration). Writer arrived on scene and observed MD (Medical Doctor), DON (Director of Nursing) and Unit Managers continuing care at resident's bedside. Writer observed when R701 expelled small amounts of food but continued to have labored respirations. Oxygen applied via nasal cannula and oral suctioning performed; additional food particles were cleared. Resident took a deep breath and displayed strong and bounding carotid and brachial pulses, per DON. While MD did assessment of resident, breathing became unstable and subsequently absent. Attempted to obtain vital signs-none detected. Fellow nurse called EMS (Emergency Medical Services) who arrived on the scene during aspiration protocols. Writer contacted hospice and notified attending MD who arrived on scene to complete and pronounced resident deceased at 1:16 PM. Authored by Nurse K.10/16/25: Physician Note (Late Entry-10/17/25): .Time: 1: 30 PM.REASON FOR VISIT: Aspiration/Respiratory Arrest.Resident with.dementia, hypothyroidism, hypertension, osteoarthritis, chronic pain and anxiety.signed on Hospice.Responded to code blue overhead. Nursing staff reports patient choked while eating lunch.Time of death 1:16 PM. (Authored by MD A.)A request for all Incident/Accident (IA) reports and Grievances for the past four months was requested. The documentation provided was reviewed and noted, in part, the following:IA (Incident/Accident) Investigation Form: Date 10/16/25.Time: 12:15 PM.(R701).Brief description of the incident: Resident was in dining room during lunch time. The CNA (Certified Nurse Assistant) placed the meal tray in front of the resident who then proceeded to put food into her mouth (which was unwitnessed). Resident began to choke; immediate action was taken.Resident was taken to her room where emergency care continued. 02 (oxygen) Administered, MD present. Particles were removed by suction machine. EMS (emergency medical services) arrived, resident place onto bed where she expired.Physician Findings: Resident experienced dysphasia.removal of food particles from oral cavity.Provide a brief description of the plan to avoid this situation in the future if applicable: Ensure meal tickets indicate 1:1 feed assist is r/t (related too) safety (dysphasia) or weight loss. Incident investigation summary conclusion: Resident: (701).Date of Incident: 10/16/25.Type: Choking.Conclusion:(R701).history of dementia, muscle weakness, atrophy, anxiety disorder.admitted to hospice on 8/4/25.The resident's advanced directive was DNR (Do Not Resuscitate).On 10/16/25 the resident was taken to the dining room at approximately 11:40 am for lunch, during that time the resident had an episode of dysphasia while consuming her meal that resulted in death.It was noted that the resident was a 1:1 feed assist related to poor oral intake.ST (speech therapist) also confirmed that resident did not have swallowing issues as she was observed on 10/14/25 by ST consuming 50% of her meal.During the incident, a cpr <sic>(cardiopulmonary resuscitation) certified clinical staff member was present and immediate care was rendered to dislodge the food particles from the resident's mouth. back and abdominal thrust and deep sweeping of the oral cavity and suction to remove any remaining food particles. The resident also received 02 via n/c (nasal canula) and 911 was called. Due to dnr <sic> , cpr <sic> was not administrated. In conclusion: It was determined that the staff followed the dining policy which states cpr <sic> certified clinical staff member be present during mealtimes in the dining area. Although the tray was placed in front of the resident and the resident was 1:1 feed assist, the resident had no history of dysphagia at that time, thus safety was not of concern when the tray was placed briefly in front of the resident. Further review of the investigation noted that the Corporate RD (Registered Dietician) was present in the dining room at the time of the event observing mealtimes. The RD (hereinafter CRD C) verbalized that there was an assigned CNA physically present at the table with R701.she also stated that she witnessed the staff member reacting quickly, providing CPR (*It should be noted that R701 was a DNR).At that time, she immediately alerted the administrative staff. She noted that the RN (registered nurse) UM (unit manager) entered the dining room and assisted with oral sweeps. Simultaneously, the DON and UM 2 entered the dining room and assisted with sweeps.Choking interventions continued while resident was transferred to her room across the hall from the dining room. Furthermore, the Medical Director entered the resident's room and assisted with choking interventions.resident was observed with airway clearance and breathing on her own. The Medical Director assisted with transferring resident from wheelchair onto the bed.assessment was performed by physician.he verbalized resident had a strong bounding pulse.During this assessment.first responders entered the room observed resident breathing on her own and were unable to provide additional assistance due to resident's advanced directive status. However, the Medical Director, Nurse Management and first responders remained as she transitioned.A form titled Additional Interviews was attached with the IA and listed the following staff were interviewed by the DON regarding R701: Name Interviewee #1: Corporate CRD C.CNA D.CNA E.CNA F.(10/16/25), *It should be noted that while the above employees were noted as interviewed there were no documented interviews that included statements as to what occurred on 10/16/25 and how to determine what each CNA was doing in the dining room and who was assigned to assist R701.The only written interview that was attached to the IA documents was a typed statement by Speech Therapist Manager (STM) B. The document discussed observations on 10/13/25, three days prior to the incident noting R701 was eating on their own. *It should be noted that STM B was not present in the dining room on 10/16/25 and provided no services to R701 as they were a Hospice patient.In addition to the IA notes above, the Facility provided a grievance form dated 10/6/25 that read in part, .Your name (R701's daughter hereinafter Daughter I).How can we address your issues? Per daughter, I do not like (CNA E) and do not want her taking care of mom (R701).indicated she did not like employee (CNA E) and the way they spoke to her mother.her tray was out of reach. A review of CNA Es personnel file revealed they had received one to one in-service education as follows: 10/10/25: Inservice/Education provided: Customer service and protocol for 1:1 assist feed.Reason: Employee did not stay with resident during mealtime.Expected: employee will exhibit good customer service towards residents and guest. Employee will assist resident during mealtimes and remain at bedside, dining area until resident is finished. A second Inservice for CNA E dated 10/16/25 (day of incident) read: Professionalism and Participation in relationship to providing meals at mealtime.Reason: The employee was observed by CRD C dancing in dining room during lunchtime and not assisting in passing meal trays.On 10/29/25 at approximately 11:29 AM, a phone interview was conducted with Hospice Nurse (HN) H. HN H reported that they were employed by (name redacted) hospice and had been assigned as R701's case manager. HN H was asked about R701 and the choking incident on 10/16/25. HN H reported they had been working with the resident for several months and noted that there had been some concerns regarding 1:1 feeding assistance. They noted R701 was often severely confused and often not aware of what they were eating, often non-food like objects. They noted on several occasions, they either witnessed or received reports that R701 was not receiving 1:1 assistance. HN H noted that on 10/16/25 they were notified that R701 choked and died. They did not receive clear information as to what occurred and why the resident did not have 1:1 assist with their meal due to significant decline.On 10/29/25 at approximately 11:20 AM, a phone interview was conducted with Daughter (D) I. D I reported they were very involved in R701's care and noted they were a retired nurse. They noted that on 10/16/25 they received a call from the Administrator that informed them that R701 transitioned after choking in the dining room. They were told the resident was observed as blue in the dining room, received back and abdominal thrusts and then was taken to their room and received 02 but expired in their room. D I noted that they did not receive information as to the timing of the incident and noted they were concerned as to how long R701 was without feeding assistance, how much food was consumed and how long they were choking before help was provided as choking can lead to lack of oxygen causing death. D I further reported they had expressed their concerns to the Administrator regarding 1:1 feeding on several occasions. D I noted that R701 was confused and often put utensil like putting straws and noodles in their nose. D I reported on the morning of 10/16/25 they were notified by (HN) H that a breakfast tray was found in their room about 7-8 feet away from R701 who stated they were hungry. Nobody came to the room to assist. D I stated they contacted the Administrator via phone to express their concerns and was told to lower their voice and ensured her that someone would provide 1:1 assist. D I further noted they were not sure who the aide was assigned to R701, but noted on or about 10/6/25, CNA E was reprimanded for leaving a meal tray in R701's room and did not provide assistance with eating and observed several particles of eggs all over the resident. D I stated that R701 had not received a swallow study in over a year as they were a Hospice resident.On 10/29/25 at approximately 1:43 PM, a phone interview was conducted with MD A and on 10/30/25 at approximately 10:10 AM, MD A provided additional information at the facility. MD A was asked about the incident pertaining to R701 on 10/16/25. MD A reported that they were in the building when they heard a code blue overhead and went to R701's room and was informed the resident choked while eating lunch. They noted that staff had made attempts to help with choking and R701 received 02 (*It should be noted that there was no indication as to how much supplemental 02 they received) and was placed in bed and subsequently died. When asked as to R701's cause of death, MD A noted that R701's choking was unavoidable as they were on Hospice and declining. MD A was asked about the order for 1:1 feed and would that have provided help to R701, and they responded that they were not in the dining room and was not involved in 1:1 care planning. On 10/29/25 at approximately 3:00 PM, a phone interview was conducted with CRD C. CRD C was asked if they were present when R701 choked at lunch on 10/16/25. They reported that they were in the building that day to view the facility kitchen and the large dining room. They reported that three CNAs were present in the dining room and no nurses. They recalled one CNA was passing lunch trays, one CNA was assisting with 1:1 care with another resident who was not sitting close to R701, and a third CNA was dancing and singing to the residents. With respect to R701 they stated they were not near the resident and never witnessed R701 choking until they saw a CNA running to the resident and trying to sweep food out of their mouth. They could not recall the name of the CNA who ran to assist R701. CRD C was asked as the facility/corporate procedures for leaving trays in front of residents requiring 1:1 assistance. CRD C reported that trays should not be placed in front of the resident until a staff person is able to assist them.On 10/29/25 at approximately 3:43 PM, an interview was conducted with RD J. RD J reported they were new to the facility and received their RD degree approximately two months prior to being hired by the facility. RD J was asked about R701, and they reported they recalled completing the resident's last assessment and was aware the resident was a 1:1 feed. When asked why R701 was a 1:1 feed, RD J delayed answering and then stated they were uncertain, they just knew that on her meal ticket it noted 1:1 feed. When asked if they ever communicated with Hospice services regarding eating, they replied they did not.On 10/29/25 at approximately 4:20 PM, a phone interview was conducted with CNA E. CNA E was asked if they were familiar with R701 and their 1:1 feed order. CNA E reported to their knowledge R701 was 1:1 depending on their mood. With regards to the choking incident (10/16/25) they stated they were waiting for trays to be delivered and were standing in the hallway and saw that R701 was choking and they went into the dining room and started patting them on the back, but nothing came out and they had a blank stare on their face. CNA E could not recall the time but noted nursing staff entered into the dining room to assist the resident. When asked why they received in-service write-ups 10/10/25 and again on 10/16/25, they noted that the first write up dealt with R701. They stated that they did not stay in the room while R701 was eating and the family was upset about eggs all over them. With respect to the in-service dated 10/16/25 they were written up for singing and dancing in the dining room and not passing trays.On 10/29/25 at approximately 5:14 PM, an interview was conducted with Unit Manager (UM) G. UM G reported that they started working at the facility on or about 9/8/25. When asked about the incident involving R701 on 10/16/25, they reported that they were charting behind the nurse's desk and a CNA (UM G could not recall the name of the CNA) came out of the dining room and informed them that R701 was choking. They recalled they went to get gloves, noted that the resident appeared Gray and the resident was removed from the dining room and back thrusts were performed and R701 spit out a nickel size piece of corned beef. They indicated when the resident was placed in their room, they were given 02 and additional sweeps were done to remove food. They recalled the resident had a low heart rate and MD A assessed her and their eyes rolled back and they expired.On 10/29/25 and again on 10/30/25 several attempts were made to contact CNA D. The facility reported that due to medical concerns CNA D was not available for interview. *It should be noted that CNA D was the only CNA in the dining room that had a current CPR certificate.On 10/29/25 at approximately 4:13 PM, an interview was conducted with Nurse K. Nurse K reported they had been employed by the facility for about two months. When queried as to the choking incident that occurred on 10/16/25 as they had written the note regarding the incident. Nurse K reported that they were not in the dinning room during meal pass but were notified as to the resident choking. They did not perform any care during that time but noted that Unit Manager G helped and R701 was transferred to their room to receive suctioning and 02.On 10/30/25 at approximately 1:57 PM, an interview was conducted with CNA F. CNA F reported they had been employed by the facility since 2019 and generally worked the day shift. When asked about the choking incident (10/16/25) involving R701, CNA F reported that they were not in the dining room for very long on that day and did not witness or assist with R701. They noted that they entered the dining room only to take out a resident who was scheduled for a shower. CNA F was asked if they had been interviewed regarding the incident and they reported they had not.On 10/30/25 at approximately 1:34 PM, an interview was conducted with the DON. The Administrator was also present. The DON was asked several questions pertaining to R701 and the investigation pertaining to them choking in the dining room. They reported they conducted the investigation and created the IA and Summary. The DON was asked if they had any additional documentation pertaining to the staff including signed interview statements from those noted in the dining room on 10/16/25. The DON stated that interviews were conducted with those noted in the IA. However, names of staff alleged to be in the dining room were not included and no specific documents pertaining to interviews were completed. The only exception was the one paragraph statement made by STM B who was not in the dining room on 10/16/25. The DON was asked if they were able to determine a timeline as to when R701 received their lunch tray as it was noted they entered the dining room at approximately 11:40 AM, how much food was consumed and a specific time as to when CNA staff noticed they were choking and who specifically started interventions. The DON and Administrator reported that there was no camera coverage in the dining room and could not come up with a timeline as things moved so quickly. The DON was also asked about the note that indicated CPR was started. The DON responded that no CPR was given, and the statement was written in error. They indicated that CNA D was CPR trained again, but that there was no specific statement obtained from CNA D and no indication as to what was done prior to nurses entering the dining room. The DON was also asked as to their statement in the IA that said R701 had an episode of dysphasia while consuming her meal that resulted in death. The DON noted that perhaps they did not complete a well written summary. The DON was asked if they were aware that R701 was exhibiting signs of trying to eat non-food items and confused as noted in the IDG Hospice document. The DON noted that they were not aware of that document. The Administrator noted that the IDG forms were put into the resident's electronic record by non-medical staff and as such may not have been read.The facility policy titled, Incidents and Accidents for Residents was reviewed and documented, in part: Policy: Incidents or Accidents involving a resident will be documented and reported so as to meet regulatory requirements.A Facility Incident and Accident Report must be completed by a licensed nurse.Potential witnesses shall be interviewed and the occurrence of such interviews will be documented on the Incident and Accident Investigation Form.A review of a study from the National Library of Medicine titled, Age Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk was reviewed and noted, in part, the following: .The need for supervision is an environmental risk factor for choking.sedating medication may increase choking risks that could be mitigated with supervision or assistance at meal times. In pathologic aging, cognitive impairment such as that which accompanies dementia, increase choking risk with behaviors such as eating too fast, not chewing very much, over-filling the mouth or swallowing large mouthfuls. Inadequate mealtime supervision of individuals at risk of choking has had fatal consequences.

This citation pertains to intake #2573641Based on interview and record review the facility failed to timely assess, treat, notify the physician, and facilitate a transfer to the emergency room after an acute change of condition for one resident (R905), of three residents reviewed for change of condition, resulting in a transfer to the emergency room with a diagnosis of a heart attack requiring surgical intervention. Findings include: On [DATE] at 9:45 AM, a phone call was placed to the complainant, and they reported the facility failed to appropriately treat R905 for signs and symptoms of a heart attack. They said R905 requested to go to the hospital when they experienced chest pain, but the facility did not send them in a timely manner. When R905 got to the hospital it was discovered they suffered a massive heart attack requiring surgical intervention. They went on to say R905 was placed in the intensive care unit but was alert and talking to them postoperatively, however; after the surgery R905 suffered cardiac arrest and expired.On [DATE] at 10:05 AM, a review of R905's closed clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses that included: heart disease, diabetes, pneumonia, and major depressive disorder. R905's most recent Minimum Data Set assessment indicated they had intact cognition.A review of R902's progress notes was conducted and revealed the following:A note entered into the record by Nurse ‘B' on [DATE] at 2:52 AM that read, Resident with complaint of chest pain. Nitro given x2 with no relief .Tylenol for generalized discomfort around 2100 (9 PM) .MD (medical doctor) called and voice message left. Resident requesting to go to hospital.A note entered into the record by Nurse ‘B' on [DATE] at 3:56 AM that read, NP (nurse practitioner) notified at 0339 (AM). Informed of above. Received order to transfer to ER (emergency room) for evaluation. 911 called at 0346 (3:46 AM).EMS (emergency medical services) arrived at 0355 (3:55 AM) and took over care. Transferred to ER at (Hospital Name) at 0406 (4:06 AM).A review of R905's documented vital signs did not indicate they were obtained at the time R905 complained of chest pain and requested a transfer to the emergency room.A review of R905's physician orders for nitroglycerin (a medication used for the treatment of chest pain) read, Give 1 tablet sublingually (under the tongue) every 5 minutes as needed for Chest Pain X 3 doses. If no relief, call MD). R905's MAR (medication administration record) was reviewed and revealed they only received one dose of the nitroglycerin, however; Nurse ‘B's documentation indicated they administered two.On [DATE] at 8:30 AM a review of a facility provided investigation from the Director of Nursing regarding the incident was conducted and read, .On [DATE] the Resident (R905).with history of coronary artery disease with past Percutaneous Coronary Intervention (a procedure to treat narrowed or blocked coronary arteries), CHF (congestive heart failure), Chronic <sic> kidney disease.was transferred to the hospital related to chest pain. The resident was admitted to the ICU status post STEMI (heart attack) with cardiac catheterization with 100% occlusion of the distal LAD (left anterior descending artery), angioplasty (a procedure to open blocked or occluded arteries) performed.Per hospital records, patient was placed on mechanical ventilation on [DATE] at 12:49 AM. On [DATE], the facility was informed the resident had coded and expired at 0526 am. Upon review of the resident's medical record at (Facility Name), it was noted the assigned nurse failed to: (1) Properly assess an acute change in condition of chest pain by not obtaining vital signs at the time of complaint. (2) Properly administer nitroglycerin.as ordered. (3) Documented 1 PRN (as needed) nitro (nitroglycerin) given on the MAR and documented 2 nitro given in a progress note. Order was for 3 nitro to be given 5 minutes apart, notify physician of ineffective after 3 doses. (4) Notify Physician in a timely manner, first dose of Nitro given at 0242 am, NP (Nurse Practitioner) documented as notified at 0339 am on [DATE]. (5) Transfer the resident to acute care setting immediately per resident request when administered nitroglycerin ineffective to relive chest pain.Nurse call 911 at 0346 am per her documentation.An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:10 AM and they were asked how they identified the concern to prompt their investigation. They said they routinely reviewed resident transfers to the hospital to see if anything different could have been done and they identified concerns regarding R905's documented complaints of chest pain and Nurse ‘B's response. The DON went on to say that if the nitroglycerin had been administered properly per the physician's order (three doses, five minutes apart) and the chest pain had not resolved, the physician should have been notified and R905 should have been sent to the emergency room sooner based on timing.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: (1) Suspension of Nurse ‘B' with consultation with Human resources for further recommendations, (2) Identification of residents affected and residents with the potential to be affected, (3) Chart reviews for acute changes of condition and adherence to physician's orders, (4) Re-education for all nurses on medical emergency management, significant change of condition, notification of change, medication administration and documentation expectations, (5) Review of 24 and 72 hour reports, and (6) Audits conducted to monitor the corrective actions. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake #2573641 and #1249526Based on interview and record review, the facility failed to ensure timely admission orders and assessments were completed for two residents (R#'s 902 and 905), of three residents reviewed for admissions, resulting in complaints of missed medications. Findings include: R902 On 8/5/25 a concern submitted to the State Agency for reviewed alleged R905 was not provided their medications and was not properly assessed when the day they were admitted to the facility. On 8/5/25 the medical record for R902 was reviewed and reveled the following: R902 was initially admitted to the facility on [DATE], discharged on 6/14/25 and had diagnoses including Type 2 Diabetes and Congestive heart failure. A review of R902’s census data revealed R902 was admitted to the facility on [DATE] and discharged home on 6/14/25. A review of R902’s Hospital After Visit Summary (Discharge Orders) were reviewed and revealed the following medication administration orders: BD Pen Needle Nano U/F-One each six times daily, Duloxetine 30mg (milligrams) delayed release capsule (AM), Furosemide 40 mg tablet (AM), Ibprofen 800mg tablet-TID (three times daily), Lantus SoloStar 100 unit/ml pen-injector-Inject 26 units under the skin nightly (HS), Linaclotide 145 mcg (micrograms) capsule-take one capsule by mouth daily, macitentan 10mg tabs-take one tablet by mouth once daily, Pregabalin 150 mg capsule-take one capsule by mouth two times daily (BID), Sildenafil 20 mg tablet-Take one tablet by mouth TID, carvedilol 6.25 mg tablet-take one tablet by mouth BID, metformin 500 mg tablet-take two tablets by mouth twice daily before breakfast and dinner, Omeprazole 40mg delayed-release capsule-take one capsule by mouth once daily before breakfast, rosuvastatin 20 mg tablet-take one tablet by mouth once every night (HS). A review of R902's Physican Order Summary revealed the following medications that were transcribed for administration: DULoxetine HCl Oral Capsule Delayed ReleaseSprinkle 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day for depression and Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for fluid retention A review of R902's July 2025 medication administration record revealed R902 was not administered any medications while they were at the facility. A review of R902's admission Nursing Assessments revealed R902 was never assessed by the Nurse during their admission to the facility. On 8/5/25 at approximately 3:57 p.m., during a conversation with the Director of Nursing (DON), the DON was queried why R902 did not have a Nursing assessment or the medications from the hospital transcribed timely/accurately into their record upon admission and they indicated they did not know but that it was their expectation that Nursing staff complete an initial assessment shortly after residents are admitted to the facility along with transcribing their medication list from the hospital so they can get their medications administered appropriately. R905 A complaint received by the State Agency alleged the resident did not get evening medications when they admitted to the facility on [DATE]. On 8/5/25 at 10:05 AM, a review of R905's closed clinical record was conducted and revealed they admitted to the facility on [DATE] at 6:09 PM per the census data entered into the record by Nurse 'A'. R905's diagnoses included: pneumonia, diabetes, heart disease and high blood pressure and their most recent Minimum Data Set assessment indicated they had intact cognition. A review of R905's hospital discharge medications dated 7/15/25, facility physician's orders, and medication administration records was conducted and revealed the following: An order for atorvastatin (cholesterol medication) with instructions to give the medication at night-time (per hospital discharge instructions) with the last dose given 7/14/25 in the hospital, ordered at the facility on 7/15/25 to begin on 7/16/25 at 9 PM. An order for Lantus (long acting insulin) 14 units with instructions to give the medication nightly (per hospital discharge instructions) with the last dose given on 7/14/25 in the hospital, ordered at the facility on 7/15/25 to begin on 7/16/25 at 9 PM. On 8/5/25 at 3:57 PM, an interview was conducted with the facility's Director of Nursing regarding admission orders. They said they did not know exactly why the orders were put in on 7/15/25 with start dates to begin on 7/16/25 and explained when the orders were put in the computer system it may have generated the start dates for the next day. They further went on to say given R905 admitted to the facility at 6:09 PM, they should have received their scheduled night-time medications on 7/15/25 despite the computer generated start dates.

This citation pertains to intake #1249414Based on observation, interview and record review, the facility failed to ensure a call system was operational for one resident (R901) of three residents reviewed for call systems. Findings include:On 8/5/25 a concern submitted to the State Agency was reviewed which alleged R901's call light (a system used to notify staff of the need for assistance) was not being answered. On 8/5/25 the medical record for R901 was reviewed and reveled the following: R901 was initially admitted to the facility on [DATE] and least readmitted on [DATE] and had diagnoses including Dysphagia, End stage renal disease and Congestive heart failure. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 6/18/25 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition. On 8/5/25 at approximately 11:24 a.m., R901 was observed in their room, laying up in their bed. R901 was queried regarding their call light being answered timely if they needed assistance and they reported that nobody ever answers them on time and sometimes had to wait hours or it is never answered. At that time, R901 turned on their call light for staff to refill their water cup with cold water. On 8/5/25 at approximately 12:16 p.m., R901's call light was observed to still be on with no staff having entered the room to see what R901 was requesting assistance with for the previous 45 minutes. A check to see if R901's call was functioning properly was conducted which revealed the indicator light over R901's doorway was not on. CNA C (Certified Nursing Assistant C) was queried regarding the reason nobody had assisted R901 with their request for assistance and they indicated that the call light button was working but that the light was out, so nobody knew that R901 needed help. CNA C reported that R901's call light had been broken all weekend, and nobody was available to fix it. CNA C was queried regarding the process for having Maintenace fix equipment on the weekend and they reported they weren't aware of any because there were not any maintenance personnel that work on weekends. On 8/5/25 at approximately 3:01 p.m., the Maintenance Director (MD) was queried regarding the call lights not functioning for rooms 116, 118 and 120 and they reported that the batteries on the call light system were out of energy and needed to be replaced. The MD was queried when the maintenance department had become aware of the malfunctioning call light system, and they reported that it had been that morning around 11:00AM. the MD was queried regarding maintenance being available on the weekend to fix broken essential equipment and they reported that they are on call but that nobody had called them regarding the issue. The MD indicated that had they been made aware of the issue then they could have replaced the batteries and fixed the system. The MD indicated the process is for staff to call them if they need something and nobody had notified them of the concern until that morning (8/5/25). On 8/6/25 a facility document titled Call Lights was reviewed and revealed the following: Policy-Call lights will be placed within the resident's reach and answered in a timely manner. Procedure: 1. New residents will be informed about the location of the call light at the bedside and in the bathroom/shower room. 2. Demonstrate how the call light works, 3. When a resident is in bed or confined to a chair ensure the call light is within easy reach of the resident. 4. Notify maintenance if a call light is not working .

This citation pertains to Intake MI00153376 Based on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for all residents residing on the 300 Hall on May 24, 2025, resulting in the potential for unauthorized disclosure without consent of resident protected health information. Findings include: On 5/28/25, an anonymous complaint was filed with the State Agency alleging residents' health information was not kept private as a staff member identified as Licensed Practical Nurse (LPN) D had their daughter present on 5/24/25 while preparing medications, administering medications, and taking care of residents. On 6/18/25, a record review of the facility's schedule and room assignment from 5/24/25 was reviewed. Per the Nursing Home Administrator (NHA) the 300 Unit is a short stay rehabilitation unit and LPN D was assigned to Cart 5 which assigned them to rooms 301-318. The 300 Unit resident census from 5/24/25 was compared to the 300 Unit census from 6/18/25 and no Residents were identified as still residing at the facility. On 6/18/25 at 11:48 AM, an interview with Certified Nurse assistant (CNA) C who was the assigned CNA on the 300 Unit on 5/24/25 and confirmed they were introduced to LPN D's daughter and witnessed her escorting LPN D into room [ROOM NUMBER] to administer medications. On 6/18/25 at 11:36 AM, a telephone interview with LPN E was conducted, who was assigned to Cart 5 (rooms 319-339) and confirmed they were introduced to LPN D's daughter, was told they wanted to be a Nurse, and was observed following LPN D around the Unit that evening. LPN E commented they overheard being told by LPN F they cannot have their daughter there. On 6/18/25 at 12:42 PM, LPN D arrived in the facility and inquired about the investigation being conducted. LPN D confirmed on May 24, 2025, at the end of their shift (around 6:30 PM), their [AGE] year-old daughter who wants to be a Nurse, was present while they took care of their assigned residents. LPN D acknowledged they took their daughter into a female resident's room (room [ROOM NUMBER] or 319) and inquired if they would permit her daughter to observe their blood pressure being taken. LPN D confirmed there was a male resident in the hallway, and they allowed their daughter to observe medication preparation and administration. LPN D stated another nurse named LPN F was introduced to their daughter, mentioned she (my daughter) watched me pass a medication to a resident and was told I shouldn't be doing that because it could be against HIPAA (Health Insurance Portability and Accountability Act, establishes standards for privacy and security of health information). When questioned if it was appropriate and professional for them to have their daughter present while they provided resident care, LPN D admitted it was not appropriate, it was a violation of HIPPA and apologized. On 6/18/25, a request of video footage from 5/24/25 from 5-7:30 PM was reviewed with The Director of Nursing (DON) and Nursing Home Administrator (NHA) and revealed the following: 5/24/25 at 6:39 PM, LPN D and daughter were observed standing together at the medication cart while medications were prepared. 5/24/25 at 6:42 PM, LPN D and daughter observed walking away from the medication cart and the daughter was observed standing next to LPN D as they (LPN D) administered medications to a male resident sitting in a wheelchair in the hallway. 5/24/25 at 6:45, LPN D and daughter were observed walking back then standing at the medication cart. 5/24/25 at 6:57 PM, LPN D was observed with daughter returning to the Nurse's station where the daughter was observed following LPN D behind the desk. The daughter was observed standing behind the desk, retrieved their cell phone, and holding their cell phone. The NHA acknowledged LPN D having their daughter present and observing resident care was not appropriate and had the potential to be a violation of HIPAA.

This citation pertains to intake# MI00152482 Based on observation, interview and record review, the facility failed to prevent new wounds from developing, provide wound care and complete/accurately document new skin impairments for two residents (R302 and R303) of three residents reviewed for wounds, resulting in R303's wound care not being completed per Physician's orders and R302's wounds including their right lateral hip, right heel, right toe, right lateral ankle and right lateral foot not being identified and treated in a timely manner. Findings include: On 5/15/25 a concern submitted to the State Agency was reviewed which alleged R302's wounds were not appropriately cared for and nobody knew about them. On 5/15/25 the medical record for R302 was reviewed and revealed the following: R302 was initially admitted to the facility on [DATE], discharged on [DATE] and had diagnoses including Peripheral Vascular Disease, Dementia and Protein-Calories Malnutrition. A review of R302's MDS (minimum data set) with an ARD (assessment reference date) of 4/10/25 revealed R302 needed assistance with facility staff. R302's cognition was documented as severely impaired. A review of R302's comprehensive plan of care revealed the following: Focus-[R302] is at risk for impaired skin integrity/pressure injury R/T (related to): weakness, incontinence, malnutrition,fragile skin. Date Initiated: 06/05/2023 .Interventions: Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 06/05/2023 .Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated: 06/13/2023 . A review of R302 weekly skin assessment titled Total Body Skin assessment dated [DATE] revealed R302 had no newly identified skin impairments. A review of R302's weekly skin assessment dated [DATE] revealed a struck out assessment that was entered in error. No further weekly Nursing skin assessments were noted in the record until 3/28/25. A review of R302's shower documentation for 3/26/25 indicated they had no skin impairments. A review of R302's weekly skin assessment dated [DATE] documented R302 had one newly identified skin impairment. A skin/wound progress note completed by the facility wound care coordinator dated 3/28/25 revealed the following: Skin/Wound Progress Note-Residents daughter came in to facility to speak with writer and view resident. Writer went in with daughter to complete and <sic> assessment, right foot dorsal/lateral/heel observed blackened, left outer ankle observed with non blanchable redness, right buttock observed with discolored edges and peeling skin, b/l (bilateral) hips are intact with preventative dressings in place A review of R302's shower documentation for 3/29/25 documented R302 had no skin impairments. A wound evaluation/assessment completed by the wound care medical provider on 4/3/25 revealed the following: Wound #1 Right, Lateral Hip is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5cm (centimeters) length x 3cm width x 0.1 cm depth, with an area of 15 sq cm (square centimeters) and a volume of 1.5 cubic cm There is a Moderate amount of serosanguineous drainage noted which has no odor. The patient reports a wound pain of level 0/10. The wound margin is undefined Wound bed has no, granulation, 100% slough; . Wound #2 Right Heel is an acute Partial Thickness Vasculitic Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5.3cm length x 2.3cm width with no measurable depth, with an area of 12.19 sq cm Wound #5 Right All toes is an acute Eschar covered Vasculitic Ulcer acquired on 04/01/2025 and has received a status of Not Healed. Initial wound encounter measurements are 4.2cm length x 1. lcm width with no measurable depth, with an area of 4.62 sq cm The wound margin is undefined Wound bed has no, granulation, 100% eschar; . Wound #6 Right, Lateral Ankle is an acute Eschar covered Vasculitic Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6cm length x 5cm width with no measurable depth* with an area of 30 sq cm The wound margin is attached to wound base Wound bed has no, granulation, 100% eschar; . Wound #7 Right, Lateral Foot is an acute Eschar covered Vasculitic Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 17cm length x 3.4cm width with no measurable depth, with an area of 57.8 sq cm The wound margin is attached to wound base Wound bed has no, granulation, 100% eschar; . A review of R302's weekly skin assessment dated [DATE] revealed R302 had no newly identified skin impairments. A review of R302's Physician orders revealed no treatment orders to treat any of R302's identified wounds previous to 3/28/25. A review of R302's treatment administration record (TAR) for March 2025 revealed no treatments were documented as being completed for R302's wounds until 3/29/25. On 5/16/25 at approximately 10:30 a.m., the DON (Director of Nursing) and Wound Care Nurse A (WCN A) were queried regarding R302's wounds all being initially identified on 3/28/25 with no documentation or treatments having been initiated prior and WCN A reported R302's wounds should have been identified earlier when they first started to develop. WCN A reported the facility has had problems with completing skin assessments on time and accurately. WCN A indicated that they should have been notified of the wounds so treatments could have been initiated and accurate documentation could have been completed and a wound consult been ordered for an evaluation by the medical Wound Care Provider. WCN A reported that in April they identified an issue with reporting changes of condition to management and were working to correct the deficiency. 41415 R303 On 5/15/25 at 10:57 AM, R303 was observed lying on their back in bed. A brief interview was conducted with the resident. Review of a complaint submitted to the State Agency (SA) documented concerns regarding the facility's care for R303 pressure wounds. Review of the medical record revealed R303 was admitted to the facility on [DATE], with diagnoses that included: Multiple sclerosis and was dependent on staff assistance for all ADLs (Activities of Daily Living). A review of the Skin & Wound Evaluation(s) revealed the resident had a Stage 4 pressure (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) wounds to the Sacrum and Left Gluteal Fold and a Stage 3 (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled edges are often present) pressure wounds to the Right Gluteal Fold and Left Gluteus Lateral. Review of the Medication and Treatment Administration Records (MAR/TAR) revealed the following: March 2025- 13 omitted treatments. April 2025- 11 omitted treatments. May 2025 (as of 5/15/25)- three omitted treatments. A review of a facility policy titled Skin Management revised 8/14/2024, documented in part . Resident with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing . On 5/16/25 at 10:27 AM, the Wound Nurse (WN) A and Director of Nursing (DON) were both interviewed. WN A was asked if they were the responsible staff for the wound care treatments in the facility and WN A replied they initially were responsible for all stage 3 and 4 wounds, however had most recently been responsible for all wounds with the exception of skin tears and preventative creams. WN A was asked if they were ever pulled to work the units as a floor nurse and WN A stated they were. WN A stated on the days they are pulled to work the floor, the assigned nurses to the resident with wounds are responsible for doing the wound treatment. WN A was asked if they noticed that some floor nurses were not completing the wound treatment whenever they (WN A) were unable to do them and WN A stated they had noticed that lately the nurses have not been doing the wound treatments when they were supposed to. WN A and the DON was then asked about the identified omitted treatments for March, April & May 2025 for R303. WN A stated they noticed the treatments becoming a problem lately and started putting the residents with wound treatments due on the home screen for all nurses to review and on the facility's communication board. The DON explained that the facility had recently terminated nurses they were having care issues with. No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake# MI00150024 Based on observation, interview and record review the facility failed to ensure a resident was turned properly per their needs to prevent accidents and ensure they were fully assessed following the accident for one (R702) of three residents reviewed for falls/accidents. Findings include: A complaint was filed with the State Agency (SA) that alleged the staff was turning R702 and they hit their head against the wall. On 3/4/25 at approximately 10:03 AM, R702 was observed lying in bed. The resident was alert and able to answer questions asked. When asked about the incident that occurred on or about 1/28/25, R702 reported that one Certified Nursing Assistant (CNA) pushed them against the wall when they were changing them and they hit their head. R702 further reported that the CNA pushed again and they hit their head a second time. The resident noted that they did not believe the CNA intended to hurt them, it was just that they should have used a second person to help. R702 could not recall the name of the CNA but was able to describe what they looked like and noted that the CNA is not allowed to care for them anymore. Further, R702 stated going forward they will make sure that they hold onto a large stuffed animal to ensure they protect their head. A review of the Incident/Accident (IA) report provided by the facility documented, in part, the following: .Investigation Summary .On 1/28/25 the administrator was made aware of an incident with respect to R702. Resident alleges staff member assigned hit her head on the wall .The administrator interviewed R702 .resident stated while have <care> provided, the staff member upon turning her hit her head against the wall on purpose .when asked if she <inform> the staff member that she hit her head against the wall the resident replied yes The Administrator interviewed the assigned staff member regarding this alleged incident. Per the staff member, she stated she had provided care to the resident without injury noted. Upon providing care to her roommate, she could hear R702 saying my head hurts. She said, I think you hit my head when you turned me over .Investigation Conclusion: .After completion of this investigation, the facility was able to determine the resident complained of a headache .the resident has a lot of items on her bed .bed is against the wall and turning the resident was evident of the potential for the staff member to have hit her head unintentional .One to One Inservice Record: Staff Name (CNA H) .Topic of Discussion . Providing care related to the POC (plan of care) .Employee will be able to follow the plan of care to provide care without injury . A review of R702's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: limitation of activities due to disability, weakness, and acquired absence of left leg below knee. A review of the residents most recent Minimum Data Set (MDS) revealed the resident had Brief Interview for Mental Status (BIMS) score of 13/15 (intact cognition). Continued review of R702's clinical record revealed the following: Care Plan: Focus: R702 has a functional ability deficit and requires assistance with self-care and mobility (4/13/23) Intervention:Bed Mobility: Resident requires total assistance <of> times two people to reposition and turn in bed (4/17/23) .Transfer: Resident requires Hoyer lift assistance with transfers with two person assist to operate the Hoyer lift . eMar(electronic medication administration record)Medication (1/28/25): Res c/o (complains of) headache. Social Services Note (1/28/25): SW (social worker) met with R702 today to follow-up on care concern that she reported to the nurse yesterday. [R702] informed SW what transpired last night with her CNA .SW asked [R702] if she felt safe at the facility. [R702] stated, I don't know whether I do or not . *Attempts were made to locate additional notes and assessments pertaining to the accident that occurred on 1/28/25 and possible 1/27/25 as the SW notes refers to concerns on 1/27/25. None were noted in the electronic clinical record. On 3/4/25 at approximately 2:11 PM, a phone interview was conducted with CNA H. CNA H reported that they are a part-time worker at the facility and usually work every other weekend. CNA H was queried as to the incident involving R702. CNA H reported that they turned the resident on their side during care and they then went over to assist R702's roommate with care and heard R702 complaining that their head hurt as they were turned into the wall. CNA H noted that they told Nurse I. When asked if R702 was a one person or two-person assist, CNA H noted they were a one person assist. When asked how they determined residents, including R702's, bed mobility and transfer status, they noted that they just go based on resident observation. CNA H was asked about the in-service they received and noted that they could not recall specifically, but stated it had something to do with turning and repositioning. On 3/4/25 at approximately 2:13 PM, an attempt was made to contact Nurse I via the phone. A voice message was left. No return call was received prior to the end of the Survey. On 3/5/25 at approximately 8:33 AM, an interview and record review were conduced with the Administrator and the Director of Nursing (DON) regarding R702. Both the Administrator and DON were asked as to the R702's transfer and bed mobility status. The Administrator noted that they investigated the incident involving the resident hitting their head to ensure the resident was not abused but did not fully address their bed mobility/transfer status/assessments. When asked as to the facility protocol regarding an assessment for a resident who hits their head, the Administrator/DON reported that neurological assessments should be completed and placed in the resident's record. With respect to R702 the Administrator noted the nurse did give the resident Tylenol for pain. However, they noted that no assessment documents were in R702's record. A partially completed paper document noting some neurochecks were provided at the end of the Survey. A review of the facility policy titled, documented, in part: .A neurological assessment is an indispensable tool for evaluating a resident's neurologic status .A focused neurologic assessment is necessary after a fall if the resident may have sustained a head injury .

This citation pertains to intakes #'s MI00149299 and MI00149193. Based on observation, interview and record review the facility failed to implement effective interventions including accurate wound treatments and completing accurate assessments for two residents with pressure injuries (R901 and R902) of two residents reviewed for Pressure Ulcers. R901 On 1/14/25 a concern submitted to the Stage Agency was reviewed which alleged R901's skin had broken down while at the facility. On 1/14/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted on [DATE] and had diagnoses including Diseases of biliary tract and Limitations of activities due to disability. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 12/27/24 revealed R901 needed assistance from staff with most of their activities of daily living. R901's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A facility form titled Nursing Comprehensive Evaluation dated 12/20/24 revealed the following: Section K Skin: 16. left antecubital-The fold has rashes and it pink. 14. Abdomen-Stitches from surgery in 3 places. 21. Right iliac crest (rear)-Scrabe <sic> (scrape). A progress note dated 12/20/24 revealed the following: she has scrabe at the back and sacrum on the left armfold she has rashes, at the abdomen there is stitches in three places from her surgery . A Braden Scale for Predicting Pressure Sore Risk dated 12/22/24 revealed R901 had a score of 14 indicating moderate risk of skin break down. A Skin/Wound progress note dated 12/24/24 revealed the following: Resident ADM (admitted ) 12/20/24. Resident wears reading glasses, lives alone in home, sits up to sleep in a chair at home, is incontinent of bowel and bladder. Resident required writer and additional two staff to assist with repositioning and turning, resident is unable to lift or move legs. Skin alterations noted are as follows: B/L (bilateral) arm bruising, redness in b/l folds to arms, abdomen, breast, and legs, 4 small surgical incisions with surgical tape in place, redness with no drainage or warmth observed, healed incision to right lateral foot,b/l foot/heels blanchable redness, b/l Lelymphedema, open abrasion to sacrum. Area cleaned and dressed A Skin and Wound Evaluation dated 12/24/24 revealed the following: Describe: 15. Pressure .Stage: Stage 3-Full thickness skin loss. Location: Sacrum. Acquired: Present on admission .Wound Measurements: Area-2.7 CM2 (centimeters squared). Length-3.0 CM. Width-1.3 CM .2a. % Granulation-100% of wound filled .Exudate: 1. Amount-3. Moderate. Type: 2. Type-4. Serosanguineous .Orders: 1. Goal of Care-2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration . Further review of the medical record revealed no treatment orders for R901's sacrum wound were implemented until 12/24/24 which revealed the following: Clean sacrum abrasion with NS, pat dry, apply triad foam, 4x4 gauze, foam border/ABD (abdominal) pad and secure with tape every day shift every Tue, Thu, Sat for wound care. A review of R901's treatment administration record (TAR) and medication administration record (MAR) for December 2024 revealed no treatments were documented as completed on R901's sacrum until 12/26/24. On 1/14/25 at approximately 12:45 pm., Wound Care Nurse B (WCN B) was interviewed regarding R901's pressure ulcer. WCN B reported that R901 admitted with the pressure ulcer and when they assessed it, it was a Stage 3 sacrum wound. WCN B was queried why no treatment orders were implemented for the wound upon admitting to the facility and they reported that the admitting Nurse should have had a treatment ordered for it but that they were working on educating the Nursing staff on obtaining wound treatments upon admission and not having to wait until WCN B had assessed them. WCN B reported that a treatment should have been ordered and completed after R901 had been assessed by the admitting Nurse on the day they arrived. On 1/14/25 at approximately 1:50 p.m., during a conversation with the Director of Nursing (DON), the DON as asked what the process was for ensuring wound dressing are ordered and they reported that the Nurse doing the admission assessment should be contacting the Doctor and implementing a treatment order to treat the wound until they are assessed by the wound care team. 41415 R902 Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide adequate and appropriate care to prevent a pressure wound for R902. A review of the medical record revealed R902 was readmitted to the facility on [DATE] with diagnoses that included: end stage renal disease and dependence on renal dialysis. On 1/14/25 at 10:55 AM, R902 was observed sitting up in bed eating breakfast. A brief interview was conducted with R902 at that time. At 11:17 AM, an observation of R902's buttocks was conducted with the assistance of Unit Nurse Manager (UNM) A. A pink wound dressing, no date noted was observed on the right side of R902's buttocks. On the left side was an identified open area with maceration. There was no treatment applied to the left buttocks. UNM A confirmed the left side opening and stated treatment should be applied to that area. Shortly after, an observation of the facility's treatment cart was conducted and the wound dressing observed on R902 was identified as an Allevyn dressing. A review of the medical record revealed no documentation of the identification of the left buttock skin impairment and no treatment implemented for the left buttock. A review of a Skin & Wound assessment completed 1/13/25 documented no new skin impairments identified for R902. Review of R902's January 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following order: Cleanse with Normal Saline, pat dry, apply Triad Hydrophillic Wound Dressing every shift also apply Allevyn Gentle Border dressing Q3 (every three) days and PRN (as needed) for Skin Abrasion to right upper buttocks every shift for Skin Abrasion Cleanse with NS (Normal Saline) pat dry, apply Triad Hydrophillic Wound Dressing. Start Date 1/4/25. This order was signed as completed twice a day. A second order documented: Cleanse with Normal Saline, pat dry, apply Triad Hydrophillic Wound Dressing every shift also apply Allevyn Gentle Border dressing Q3 days and PRN for Skin Abrasion to right upper buttocks every 72 hours for Skin Abrasion Cleanse with NS pat dry apply Allevyn Dry Dressing. Start Date 1/4/25. This order was signed as completed every three days. Both orders were for the same area, the right upper buttocks. A review of the medical record revealed no documentation of the identification of the duplicate orders or clarification on the correct treatment that should have been implemented for the right buttocks. On 1/14/25 at 12:44 PM, an interview was conducted with the Wound Care Nurse (WCN) B. WCN B was asked if they were informed of the skin impairment to R902's left buttocks and WCN B replied they were not. WCN B stated the staff should notify them of any skin issues identified on the residents. WCN B was asked about the two duplicate treatment orders for the right buttock area that was being applied by staff twice a day and every three days and asked to clarify what the order should be. WCN B stated they were unaware of the two implemented treatment orders but would look into it and follow back up. At 1:38 PM, WCN B returned and stated R902 was assessed and excoriation was identified on the left buttock and staff was in the process of notifying the physician for treatment orders. WCN B stated R902 orders were reviewed and is now fixed to reflect the correct order. At 1:48 PM, the Director of Nursing (DON) was interviewed and asked about R902's skin observation, the unidentified skin impairment to the left buttocks and the two treatments implemented for the right buttocks, without the error to have been identified by the staff and clarified. The DON replied that all breaks in the residents' skin should be reported to the physician and have treatment in place. The DON stated the treatment dressing that was observed on the right buttock should have been dated by the staff. The DON confirmed R902's treatment orders had been reviewed and should have been identified and clarified with the physician to reflect the correct treatment order. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: MI00146970. Based on interview and record review, the facility failed to continuously ensure orders were implemented for supplemental oxygen and for a CPAP (continuous positive airway pressure) machine, failed to implement care plans for chronic hypoxic and hypercapnic respiratory failure, failed to implement interventions for supplemental oxygen and the use of a CPAP machine, failed to provide the correct settings for the non-invasive ventilation as ordered by the Pulmonologist, failed to administer antibiotics as prescribed, and failed to provide the necessary CPAP/BiPAP (bilevel positive airway pressure) ventilation as needed for one R707 of two residents reviewed for falls, resulting in multiple incidents of respiratory distress and a change of condition that resulted in a fall, an acute corner fracture of the C5 vertebral body anteriorly and inferiorly, ultimately resulting in the residents death. Findings include: Review of a complaint submitted to the State Agency documented concerns of the care the facility provided to the resident (R707) who had a fall, fractured their back and ultimately died from their injuries. A review of the medical record revealed R707 was admitted to the facility on [DATE] with an admitting diagnosis of acute and chronic respiratory failure and additional diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. Review of the hospital referral provided to the facility upon R707's admission included the following: A Pulmonary consultation dated [DATE] at 9:42 AM, . Acute on chronic hypoxic and hypercapnic respiratory failure . Acute exacerbation of COPD . At discharge can resume home ICS (inhaled corticosteroids)/[NAME] (long-acting beta agonists)/[NAME] (long-acting muscarinic antagonist) . Would benefit from home NIV (non-invasive ventilation) given severe chronic hypercapnia. Recommend continued to use QHS (every hour of sleep) & naps . Wean fio2 (fraction of inspired oxygen) for goal SPO2 (saturation of peripheral oxygen) ,d+[DATE]%. Currently on his baseline 3L (liters) nc (nasal cannula) . appears high risk for recurrent exacerbations given severe disease at baseline . continue all aggressive care at this time . A review of the hospital After Visit Summary (dated [DATE]) provided to the facility at R707's admission documented the following: . New Pap Machine & Supplies. Follow up with CPAP facility and pulmonology. Estimated Length of Need: Lifetime . Type of machine: CPAP, Heated Humidifier?: Yes, Type of Mask: Full Face Mask 1 per 3 months. CPAP 5 cm (centimeters), Tidal volume 480, rate 18, inspiratory time 1.2, max (maximum) pressure 37, min (minimal) pressure 7 . SPECIAL DISCHARGE INSTRUCTIONS . Very important to make sure you wear CPAP during sleep and with naps. Maintain nasal cannula throughout the rest of the day . A review of the Nursing admission note dated [DATE] at 6:55 PM, documented in part . Resident arrived to the facility via ambulance . With 02 at 3 L/m (liters/minute), at 91% saturation . Resident has CPA machine brought in by RT (Respiratory Therapist) but verbalized refusal to use it . Review of the medical record revealed no documentation of a physician order for the use of a CPAP as recommended by the hospital and no orders for oxygen administration. A review of a Nursing note dated [DATE] at 7:55 PM, documented in part . RT arrived with resident's CPAP. RT verbalized that she is unable to reach prescribed IPAP calibration of 37 but put it at 30. RT verbalized that 30 is the maximum calibration and that he would need a non invasive ventilator for the prescribed CPAP dosing which would be harder to acquire. Resident however declined to use CPAP and verbalized that he does not want to use it as it is uncomfortable for him and has caused bruising and abrasion on his nose. Review of the medical record revealed no notification to the Physician or interdisciplinary team to inform them of the CPAP machine settings concern and no notification of R707's refusal to wear the CPAP. Further review revealed no documentation of discussions for interventions to help prevent the CPAP nasal discomfort and no documentation of potential alternative methods and/or treatments. There was also no documentation of education provided to the resident regarding the refusal of the CPAP as ordered by the Pulmonologist. A review of the medical record revealed no documented assessment or evaluation completed by the RT that delivered the CPAP machine. Further review of the medical record revealed no implementation of care plans/interventions for R707's CPAP machine or Oxygen administration. Review of a Nursing note dated [DATE] at 5:51 AM, documented R707 had a change of condition Respiratory Arrest and was transferred to the hospital. Review of the hospital records for [DATE] to [DATE] hospitalization revealed the following: An Internal Medicine consult dated [DATE] at 1:33 PM, documented in part . PMHX (primary history) COPD on 3L NC (nasal cannula) at baseline . presented . for hypoxia. Patient was noted to have SpO2 saturations at 60% on 10L NC, patient was then placed on a non-rebreather en route with improvement to SpO2 100%. Patient noted to initially be in respiratory distress upon arrival. Initially in ED (emergency department), patient minimally responsive, not responding to questions or commands . Active Hospital Problems . AMS (altered mental status) secondary to hypercapnia, Acute on Chronic hypoxic respiratory failure with hypercapnia, Severe emphysema/COPD . The resident was admitted to the Intensive Care Unit (ICU). Review of a Pulmonary & Critical Care Specialists consult dated [DATE] at 8:57 AM, documented in part . presented . with a complaint of hypoxia, noted as low as 60s% . has end stage COPD, recently admitted to the ICU for a severe exacerbation, requiring many days of near-total BIPAP dependence . He is conversationally dyspneic and difficult to hear while on BIPAP. He is complaining of being thirsty. Per ED/IM (emergency department/internal medicine) notes he was saturating adequately on NRB (non-rebreather) but still felt dyspneic and asked to be placed on PAP which some improvement after this . ASSESSMENT AND PLAN: Acute on chronic hypoxic and hypercapnic respiratory failure, mostly chronic but very severe COPD . Recommendations: Will need maximal nebulized bronchodilator support (schedule Xopenex+Atrovent (respiratory medications) q4 (every four hours) along with Pulmicort (respiratory medication). Needs to be maintained on triple therapy [NAME]/[NAME]/ICS in outpatient if he can ever be stable enough to be maintained there. Would continue home azithro (azithromycin- antibiotic) MWF (Monday, Wednesday, Friday) along with singular (respiratory medications). Continue NIPPV (noninvasive positive pressure ventilation) (AVAPS- average volume-assured pressure support) qHS (every hour of sleep) and with naps- need to ensure long enough breaks to avoid worsening skin breakdown on nose . Only managed to reside outside of hospital environment for 3 days, he is very dependent on NIPPV . A review of an Internal Medicine consult dated [DATE] at 10:56 AM, documented in part . showing some improvement of his condition. He is more alert. Able to answer questions although does seem weak and fatigued. He has been transitioned to nasal cannula. Continue to wear BiPAP at night as he has high propensity for CO2 (Carbon Dioxide) retention and narcosis . Review of a hospital Pulmonary Teaching Service Progress Note dated [DATE] at 8:08 AM, documented in part . Patient seen and examined . Doing fairly on 3L (3 liters of oxygen) . arrangements made for SAR (Sub Acute Rehab) at 1pm today . Recommendations . Continue home azithro (antibiotic) MWF along with singular, Continue NIPPV (AVAPS) qHS and with naps- need to ensure long enough breaks to avoid worsening skin breakdown on nose - if AVAPS not available at facility and patient still wanting to try BIPAP usage can be put on ,d+[DATE] IPAP/EPAP (otherwise if transitioning into Hospice then patient can be given nasal cannula and dyspnea can be treated with morphine primarily rather than PAP . he is very dependent of NIPPV; agree with palliative care following case given recurrence admissions with end stage disease burden, agree with taking some palliative steps such as adding morphine for air hunger. Current plan is that patient would like to try going back to SAR 1 more time, but if failing again then he would like to go to a hospice facility . instead of coming back to hospital . Overall they feel patient is reaching a better/more realistic understanding of his poor prognosis . Review of an Internal Medicine consult dated [DATE] at 9:30 AM, documented in part . awake and resting comfortably in bed on 3 L of oxygen through nasal cannula. He is aware of discharge . Patient with end-stage emphysema and would be hospice appropriate however he is not ready to partake of hospice services . We are moving him to subacute rehabilitation today . He is leaving in improved condition. A review of a Nursing note dated [DATE] at 2:22 PM, documented in part . Nurse received resident in room by 2 ems (emergency medical services) drivers from (hospital initials) . RESIDENT A&OX3 (alert and oriented times three) . Resident is total dependent 2 person assist with all adl care . Resident is a fall risk due to overseeing limits and weakness . Resident lung sounds show expiratory wheezing in bilat (bilateral) anterior and posterior lungs . Resident in room resting eyes closed with no s/s (signs/symptoms) of distress at this time . This note was documented by Registered Nurse (RN) E. Review of the referral packet provided to the facility on [DATE] at 10:30 AM, contained the pulmonologist consult that documented the recommendations of . Continue NIPPV (AVAPS) qHS (hour of sleep) and with naps - need to ensure long enough breaks to avoid worsening skin breakdown on nose . The referral also contained the Internal Medicine consult that documented in part . remains on BiPAP mask . Patient with end-stage emphysema and continues to have oxygenation issues including CO2 retention and hypoxia . Review of the medical record revealed no documentation of the recommended CPAP or BIPAP applied while the resident was resting as documented above. Further review of the medical record revealed no physician orders for a CPAP, BiPAP or oxygen administration via NC ordered for R707. Review of the [DATE] Medication and Treatment Administration Record (MAR/TAR) revealed on [DATE] at 12:56 PM, a nebulizer treatment was provided to R707 for copd/sob (shortness of breath). Further review of the [DATE] MAR/TAR revealed the facility staff failed to administer the resident's antibiotic (Azithromycin 250 mg- milligrams) on [DATE] and [DATE], as prescribed by the physician. Review of the hospital discharge documents provided to the facility on [DATE] documented in part . Azithromycin 250 mg (milligram) . take 1 tablet . 3 times per week Monday, Wednesday Friday for COPD . Last time this was given: 500 mg on [DATE] - 4:28 PM . A review of a Physician note dated [DATE] at 3:00 PM, documented in part . hospitalized at (hospital name) from [DATE] through [DATE] . The patient is status post-hospitalization for hypoxia and respiratory failure. He was noted to by hypoxic on 60% on 10 liters. The patient had a previous hospitalization from [DATE] to [DATE] for chronic obstructive pulmonary disease exacerbation and atrial fibrillation with rapid ventricular response. The patient has recurrent hypercapnia. The patient requires BiPAP and he is noncompliant . He is awake. He is alert. He is oriented x3. Insight and judgment is intact . Continue supplemental oxygen . Continue BiPAP at h.s . Azithromycin every Monday, Wednesday, and Friday . Review of the medical record revealed no ordered supplemental oxygen or an order for the BiPAP and/or CPAP to be provided. Further review of the medical record revealed no documentation of noncompliance with the CPAP or BiPAP for the second inpatient readmission. All documentation of noncompliance was identified for the residents first admission into the facility on [DATE]. The resident was sent out to the hospital on [DATE] and educated by the hospital providers on the need for the CPAP and/or BiPAP when asleep at night and for naps. The facility failed to provide these services and care as directed. A review of a Nursing note dated [DATE] at 5:51 AM, documented in part . 95%NC (oxygen saturation level via nasal cannula). Pt has a severe case of anxiety which causes him to mouth breath more frequently. No other concerns at this time . It is unknown as to the liters of oxygen that was provided to the resident on [DATE], as there was no order implemented for the supplemental oxygen. Review of a Nursing note dated [DATE] at 12:40 PM, documented in part . Writer called to room by therapy. Writer entered room and noted resident appeared short of breath and lethargic O,d+[DATE]% via nasal cannula. Writer contacted primary physician . ordered to place resident on bipap and monitor for any additional changes. Once bipap was placed resident appeared less lethargic . Further review of the record revealed no documentation of the liters of oxygen that was provided via nasal cannula and no documentation of a bipap to have been delivered to the facility and no documentation of the settings the bipap and/or CPAP was set to. The medical record revealed no order for the BiPAP/CPAP or settings for either machine. A review of a note documented a few hours later noted in part . 4:15 p.m. Summoned to room by Nurse Manager. Resident was observed lying in supine position on the floor non responsive to verbal, tactile and painful stimulus, with his head near the oxygen concentrator. Noted laceration to the right side forehead with small amount of bleeding . B/p (blood pressure) ,d+[DATE], O2 sat at 60% . 911 was called . resident was transferred out of the facility to (hospital name) . Review of a facility provided Post Fall Evaluation dated [DATE] at 4:15 PM, documented in part . Fall Description Details . Non-responsive . Lost strength/appeared weak . lying on supine position on the floor with head near the oxygen concentrator . Observed on the floor (unwitnessed) . What was the guest/resident doing during or just prior to fall? On the bed . resident's usual mental status- usually alert + responsive . Were temperature, pulse, respirations and/or O2 Sat out of normal range for this guest/resident? (not answered and left blank) . root cause- non-responsive respiratory distress . sent to the hospital for further evaluation . Review of the hospital medical record revealed the following: An Emergency Medicine consult dated [DATE] at 4:38 PM, documented in part . Chief Complaint Patient presents with - Unresponsive . arrived to ED (emergency department) . Suspected fall, Pt (patient) found on the ground unresponsive to verbal or painful stimuli . Patient on the ground at his nursing facility unresponsive to painful stimuli and saturating at 60%. Patient arrived and was being bagged by EMS in the low 90s . He is in acute distress . Noted hematoma to patient's right parietal region . Pupils equal but unreactive . Patient mechanically ventilated . Capillary refill takes more than 3 seconds . Skin is cyanotic, mottled and pale . He is unresponsive . CT Trauma Protocol Head/Brain w/o IV contrast . Impression . Right frontal soft tissue hematoma . Standard CT of the cervical spin was obtained . Impression: Acute corner fracture of the C5 vertebral body anteriorly and inferiorly Critical findings . Patient was started on fentanyl and propofol drip . Patient to remain intubated until family gets to the bedside. However, patient's family is out of town and will not be back for a couple of hours. At this time patient was admitted to ICU . A Nursing note dated [DATE] at 11:02 PM, documented in part . Decision made by family to extubate pt. See orders. Family at bedside . A Nursing note dated [DATE] at 12:25 AM, documented in part . RN (registered nurse) paged ICU resident (Doctor name) regarding declining heart rate and respirations. (Doctor name) at bedside to assess pt.(patient) TOD (Time of Death) called 0025 (12:25 AM). On [DATE] at 1:25 PM, an interview was conducted with RN E (the nurse that readmitted R707 on [DATE]) with the Director of Nursing (DON) in attendance. When asked if they were aware that R707 was supposed to be on a CPAP/BiPAP machine for naps and sleep at night, RN E replied they were not aware. RN E explained it was their first time being assigned to R707 at the facility. RN E explained they reviewed the discharge paperwork and didn't see anything on there. RN E stated they were not aware that (R707) was on a CPAP until days later when staff was looking for the CPAP machine that was located in the medication room. RN E was asked if they reviewed the referral packet sent from the hospital with the pulmonologist instructions to ensure R707 had the CPAP/BiPAP on when taking naps and at hour of sleep and RN E stated they did not receive or review the referral packet. The DON was then asked the facility's protocol on receiving and the reviewal of the referral packet to ensure the facility is equipped to provide the services and have the equipment that is needed to provide care for the resident once the resident is accepted for admission. The DON explained they have a centralized admission personnel who reviews the packet and they (the DON) also reviews the packet as well to ensure the resident is appropriate and the facility have all the required equipment and supplies. The DON was then asked if they were aware that the RT was unable to provide the settings for the CPAP/BiPAP machine as ordered by the hospital pulmonologist for R707's initial admission to the facility and the DON stated they did not recall being informed. The DON was asked if they were aware of the staff/physician failure to ensure orders were implemented for the necessary supplemental oxygen and CPAP/BiPAP for both inpatient stays for R707, the DON stated they were not aware however would look into that and follow back up. The DON stated they were able to review the readmission discharge orders for the [DATE] readmission and it did not note an order for a CPAP/BiPAP. The referral was pointed out to the DON that was provided to the facility on [DATE], which contained the documentation of R707 to be dependent on the CPAP/BiPAP and to be utilized during naps and sleeping at night. It was also brought to the DON's attention that the supplemental oxygen was not ordered on the readmission discharge orders either, however the facility staff provided it because they knew R707 required it, just as R707 required the use of a CPAP/BiPAP for naps and sleeping at night. The DON was asked why the staff provided supplemental oxygen if it wasn't on the hospital discharge orders and they did not have a current order to provide it and failed to provide the necessary CPAP/BiPAP, the DON acknowledged the concern. The DON was then asked why there was no plan of care/interventions implemented for the primary diagnosis of this resident for acute and chronic respiratory failure and the use of supplemental oxygen and CPAP/BiPAP. The DON stated they would look into it and follow back up. The DON was also asked why the resident had not received their antibiotic as ordered on [DATE] and [DATE], the DON stated they would look into it and follow back up. At 2:33 PM, the DON returned and stated they were unable to find the requested care plans and physician orders for the supplemental oxygen and CPAP/BiPAP machine. The DON acknowledged the omission of the resident's antibiotic on [DATE] and [DATE]. The DON stated they had plans to implement measures and to provide additional education to prevent this from occurring in the future. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake #'s MI00138702 and MI00144605. Based on observations, interviews and record review, the facility failed to protect the Resident's (R611) right to be free from neglect, including the provision of medical assistance, activities of daily living (ADL) assistance, medication administration and nursing supervision/monitoring for one of three reviewed for neglect, resulting in the resident to have been abandoned at a chemotherapy appointment, waiting approximately five hours for family to pick them up and having to pay for an overnight motel room until the resident was able to go to the hospital for medical care. Findings include: The immediate jeopardy (IJ) began on 5/17/24, it was identified by the survey team on 5/21/24 and the facility was notified of the IJ on 5/21/24, and a removal plan was requested. On 5/22/24, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 5/22/24, however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On 5/20/24 the State agency received a complaint in regard to R611 being abandoned at a chemo therapy appointment, not being accepted back into the facility and requiring hospitalization due to a lapse in nursing care. On 5/21/24 at 9:30AM, R611 was contacted via cell phone and asked how they were doing and where were they located, R611 responded that they were doing better and was at the hospital. R611 was then asked what happened on 5/17/24 the entire day, R611 stated that they went to their chemo appointment and when it was over they called the transportation company to come and get them and transportation stated we don't have an order to get you and hung up (the phone) on them. R611 continued and stated they then called the facility and asked them were they going to come and get them and the Nurse they spoke too stated that R611 had been discharged and couldn't come back there. R611 stated that they told the facility that they didn't have any clothes and all their items were in their room still and the nurse told R611 that they would have someone pack them up and someone could come and get it for them later. R611 then stated that they called their sister to help them, and R611's niece was then able to come and get them around 10 PM and they had to stay in a motel for the night because they had no where to go. R611 then asked could I call their sister so she could tell me the rest of what happened. On 5/21/24 at 10:00AM an interview with the Administrator was held and the Director of Nursing (DON) was present. The Administrator was asked how many residents the facility can hold and what is the current census, the Administrator stated they could hold 127 residents, and they were currently at 104. The Administrator was then asked how many beds they had available she stated about 23 or so and there was no female beds left and had about four male beds left the rest were Medicaid certified only. The Administrator was further questioned if someone was discharged could they take the resident back, the Administrator explained that they would not be able to take a female resident because they did not have any long term beds. The Administrator was asked why couldn't R611 come back to the facility after a chemo appointment and the Administrator, We don't have any female beds and she was discharged to the hospital. This Surveyor reviewed the progress note with the Administrator that stated that R611 was sent to a chemo appointment and would go to the hospital after the appointment. The admin stated, No, she was discharged to the hospital that morning due to aggressive behaviors and pain. The Administrator stated she would check with the admissions to see where R611 was and if they had been discharged (from the hospital) because that's how they had it in the system. The Administrator came back and stated that [Name of transport company] transportation was to take her to her chemo appointment and then was to take her to the hospital. The Administrator was informed that R611 stated that they were stranded at the chemo appointment and had no one to pick them up until 10PM that night because transportation stated they didn't have an order (to pick the resident back up from the chemo appointment). The Administrator then stated the transportation company should have picked them up and took them to the hospital and stated she would follow up. On 5/21/24 at 10:32AM, [Transportation company] was contacted and asked did R611 have any upcoming appointments scheduled, they replied, No. [Transportation company] was then asked can they look back and see what R611's route was for 5/17/24. FT replied that R611 had a round trip but on that morning, Nurse B called and canceled the return trip back to the facility. [Transportation company] was asked did Nurse B state why they canceled transportation, [Transportation company] stated, Because she said they were discharged . On 5/21/24 at 10:35 AM, the administrator was notified about the findings from [Transportation company] and stated she would follow up and see who that nurse was. This indicated the facility set up transportation for R611 to attend their scheduled chemotherapy appointment. The facility then canceled the return transportation and discharged the resident from the facility while they attended their chemotherapy appointment, leaving them stranded without transportation, shelter, or medical care. On 5/21/24 at 11AM, during a telephone conversation with R611's Family Member C and D, they reported they were notified by R611 that the facility had discharged them and were not going to allow them to return after their Chemotherapy (chemo) appointment had concluded (. They reported that R611 was left outside of the Chemo center in their wheelchair for almost five hours without any food, drink, medication, or medical supervision after receiving chemotherapy. Family Member C indicated they had R611's niece (Family Member D)pick R611 up after driving out of state and took R611 to a motel. At that time, R611 had an episode of incontinence and was in severe pain. Family Member C reported that R611 was in extreme pain during the night at the motel and subsequently had to go to the emergency room due to their untreated pain and not being able to receive their anticoagulant medication and was scared they would have a stroke. Family member C also stated that after she had gotten off the phone with Nurse B the morning of 5/17/24 she (Nurse B) then called R611 and told them that they were being discharged from the facility and asked R611 if they wanted to go to the emergency department. R611 stated, No after my chemo, I just want to go back to the facility and lay down. Family member D stated that she was on her way out of town when they received a call to come and pick up R611 . Family member D stated she had to turn around and come back to get R611 around 10 PM. Family Member D took R611 to their daughter's house but the apartment could not accommodate R611 needs (because of the stairs) so she got a motel room for the night and R611 stayed in the motel room with their daughter until the next morning when R611 was in so much pain she had to take them to the emergency department. On 5/21/24 at 12:15 PM, the administrator was interviewed along with the Unit Manager (UM) and asked why R611 was not permitted back to the facility if they were transported to a scheduled doctors appointment, why was the transportation canceled for the resident to return to the facility, and how they expected the resident to get back to the facility or the emergency department if their means of transportation was canceled. The Administrator replied, She was supposed to go to the hospital and because we don't have any available beds, she couldn't return. This surveyor asked for the bed hold policy and if R611 was offered one, the Administrator stated they would follow up. On 5/21/24, a record review revealed that R611 was admitted into the facility on [DATE] with the diagnoses of Malignant neoplasm of breast, cerebrovascular disease and hemiplegia and hemiparesis of the right Side. According to the most recent Minimum Data Set (MDS) assessment, R611 had a Brief Interview for Mental Status score of 12, indicating moderate cognitive deficits. On 5/22/24 at 9:47AM, an interview with Nurse B was conducted. She was asked how long they had worked at the facility and what unit did she typically work on. Nurse B replied they had been at the facility for about three weeks and usually worked on unit 1 but was on unit 2 today. Nurse B stated she was contingent (works less that part time) stated she floats (moves from unit to unit). She was then asked about the incident with R611, Nurse B explained R611 had aggressive behaviors, was following her up and down the hallway and cursed me out stating they were in pain. I asked (R611) to go to their room because I was taking care of another resident at that time. Nurse B was asked who ordered R611 to be transported to the hospital? Nurse B replied their Doctor had ordered it, but R611 had left the facility for an appointment. When I called the Doctor to make him aware of their behaviors, the doctor stated (R611) could go to the hospital once they finished the chemo appointment. Nurse B stated she was not aware that R611 had an appointment so around the time she completed the e-transfer assessment the resident was already out of the facility and at their appointment. Nurse B was asked how she didn't know that R611 was out of the facility and that they had a chemotherapy appointment since they were assigned to care for R611. Nurse B replied, Morning activities came and took [R611] to the front of the building and there is a communication located in [Electronic Medical Record] called the dashboard where all appointments and important information can be found. Nurse B was asked if they reviewed the dashboard prior to the incident with R611 and Nurse B acknowledged they had not. Nurse B was asked if she communicated with the resident about the order to send them to the hospital, Nurse B replied, No, I spoke with the family to let them know I was sending them out. Nurse B was asked why transportation for back to the facility was canceled. Nurse B was informed at that time that [Transportation company] provided this Surveyor her name stated that Nurse B had canceled the ride. Nurse B replied, Then I guess I did if that is what they told you. Nurse B was asked did she receive an education, trainings or follow up from the Administration staff regarding the incident with R611 and Nurse B replied no. Nurse B was asked why they called the physician for orders to send R611 to the hospital and Nurse B explained it was because the resident was cursing at them because they wanted their pain medication. Nurse B was asked why they didn't administer R611's pain medication to them and Nurse B stated they were going to help another resident first. Nurse B was then asked why they called the physician to send R611 to the hospital if they were not a threat to themselves and/or others and was no longer in the building and on their way to their chemotherapy appointment, and Nurse B stated at the time, they didn't know that R611 had an appointment that morning. On 5/22/24 at 10:00AM, R611 was observed resting in their bed with their eyes closed. On 5/22/24 at 10:07AM, the Social Worker (SW) was interviewed and asked did she complete a petition for R611 to be sent to hospital for a psychiatric evaluation, SW stated no. The SW was then asked what she knew in regards to R611 on 5/17/24, and the SW stated there was a new nurse that approached her with Unit Manager stated that R611 was being verbally abusive and that sounds like a situation where the administration needs to be involved. The Admin was present and stated that she would handle the situation so I did not get involved further. The SW was then asked was she aware the return transportation was canceled for R611, and the SW replied no. The SW was then asked was this a usual or typical behavior for R611. The SW stated, No, I have never experienced that behavior but there was concerns that the cancer may have spread to their brain and other parts of the body. On 5/22/24 at 10:39AM The director of Nursing(DON) was interviewed and asked what happened with R611 and Nurse B. The DON replied, [Nurse B] came to me and stated that she did not like how [R611] was speaking to her and felt that [R611] was drug seeking and that it was too early for [R611] to receive their pain medication. I told [Nurse B] not to take it personal and when it was time to administer the medication to give it to [R611]. The DON was informed that after review of the medical record, it revealed that R611 was due for their pain medication. The DON was asked if R611 was in pain and wanted their pain medication before their chemotherapy appointment, why didn't the nurse administer it to deescalate the situation with R611 and the DON stated they were not aware that R611 could receive their pain medication because they were told by Nurse B that (R611) medication was not due yet. The DON was asked how the Administrator got involved, and explained that the nurse must have went to the Administrator after we had spoken.The DON stated they saw the Administrator was handling the situation and that there was no need for both of them to handle the situation. DON stated she did receive a call from staff on Saturday to see if they could accept R611 back from the hospital. The DON stated, I contacted the Administrator to see if we could accept the resident back and that's when the Administrator told me that we did not have any more female beds available. I called the nurse back and relayed the message.The DON was then asked how a resident that goes to their chemotherapy appointment gets discharged from the facility while at the appointment, who is not informed of the discharge and/or transfer by the facility staff, and who also had their return transportation canceled, no longer has their bed/room at the facility and the DON explained they were under the understanding that R611 had returned back to the facility after their chemotherapy appointment and was transferred to (hospital name) after their return from their chemotherapy appointment. On 5/22/24 at 11:04 AM, Unit Manager(UM) A was interviewed and asked about the incident that occurred with R611 and Nurse B, UMA explained that it started on Thursday 5/16/24 and that the resident was cursing the nurse out about receiving their medications and following Nurse B from room to room. UM A stated, [R611] began to curse me out and I went ahead and gave her the medications for Nurse B. I asked the SW to come out and assist and the Administrator ended up being present and they stated that they would handle it. On 5/22/24 at 3:20PM Nurse B was re-interviewed and asked for clarification on the date of the behavior incident that occurred with themselves and R611, and Nurse B stated, It happened Thursday 5/16/24. Nurse B was then asked actually happened the next day on 5/17/24 when they called the doctor to send the resident out to the hospital and Nurse B replied, [R611] was just cursing at them on 5/17/24. Nurse B was then asked if the incident happened on 5/16/24, why did they call the physician on 5/17/24 to obtain an order to send R611 to the hospital if R611 was not a treat to themselves and/or others on 5/17/24 the day of their chemotherapy appointment and Nurse B explained that R611 was still verbally aggressive. The Immediate Jeopardy that began on was removed on when the facility took the following actions to remove the immediacy. [Facility] submits the following Credible Allegation of Compliance outlining the measures it has completed to abate the findings of immediate jeopardy. [Facility] believes that as 5/21/24 at 5:30 pm the measures it has implemented demonstrate compliance. 1. Resident identified to be affected by the alleged deficient practice. Resident # 611 is scheduled to return 5/21/24 at 5:30 pm. The Administrator has been suspended pending investigation. 2. Residents with the potential to be affected by the alleged deficient practice. The facility currently has 104 residents residing in the facility, the administrative nurses reviewed residents with scheduled appointments to ensure transportation was set/confirmed to ensure residents are returned back to the facility on 5.21.24. In addition, newly admitted residents or readmitted residents, will be reviewed M-F during the clinical meetings; to ensure residents who requires transportation to scheduled appointments are set/confirmed to ensure residents are being returned back to the facility safely. As well as, communicated on the dashboard. 3. Systematic Measures The License Professional Nurses education began on 5.21.24 at 4:14 pm and they were re-educated on the facility's Routine Resident Care Policy, Medication Administration Policy, and the Standard of Nursing Practice Policy to residents' needs are met. There are 44 Licensed Nurses who will be in-serviced on Routine Resident care Policy, Medication Administration Policy and Standards of Nursing Practice Policy. As of 5pm on 5/21/24, 40 nurses have been in-serviced and in-servicing continues. This will be on-going until all licensed nurses have been re-educated. The remaining nurses will receive education on the above policies on or before their next scheduled day. The Certified Nursing Assistances (CNA/CENA) education began on 5.21.24 at 4:14 pm and they were re-educated on the facility's Routine Resident Care Policy to ensure residents' needs are met. There are 46 CENA'S who will be in-serviced on the Routine Resident Care Policy. As of 5pm on 5/21/24, 38 CENA'S have been in-serviced and in-servicing continues. This will be on-going until all licensed nurses have been re-educated. The remaining CENA'S will receive education on the above policies on or before their next scheduled day. Scheduler, Receptionist, and Central Supply was educated on residents who have scheduled appointments will ensure transportation is set/confirmed to ensure residents are returned back to the facility. The DON/Admin Nurses reviewed the appointment book to ensure upcoming scheduled appointments, were confirmed for pick-up and return trip to the facility. Any areas of concern will be addressed. Finding will be taken to the monthly QAPI (quality assurance process improvement) meeting for further review and recommendations. The DON is responsible obtaining and maintaining compliance. DON will sustain and maintain compliance.

This citation pertains to intake #: MI00142528 Based on interview and record review facility failed to implement and revise care plan interventions timely for one (R901) of three residents reviewed for care plan, resulting in development of two stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcers, undeteced weight loss, and admission to hospital for surgical debridement of the wound and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement. Findings include: R901 R901 was admitted to the facility on [DATE] after hospitalization for fall at home. R901's admitting diagnoses included: Contusion of scalp, osteoarthritis, metabolic encephalopathy, and history of achondroplasia. R901 was living at home with their spouse prior to this fall and hospitalization . Based on Minimum Data set Assessment (MDS) dated [DATE], R901 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R901 had limited range of motion on both upper extremities, and they were totally dependant on staff assistance for eating and needed extensive assistance with their mobility in bed. R901 was transferred to hospital on 1/26/23 for further weight loss and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube and worsening wounds. A complaint received by the State Agency read in part, (R901- Name omitted) had a fall which is why he was put in a nursing home. (R901) also can 't use his hands, and he needs to be fed. (R901- Name omitted) was taken to the hospital. (Gender Omitted) had three bedsores .(R901- Name omitted) was put on three antibiotics. (R901 Gender Omitted) also had a feeding tube put in . (R901- Name omitted) is now fragile. A review of R901 ER (emergency room ) records read in part, EMS is unsure why patient was sent for PEG tube, as patient does not have one. Staff at the facility were unable to explain why they are requesting a PEG tube. Patient denies any complaints at this time and any history or complaints of dysphagia. Patient does complain of sacral decubitus ulcers. A review of admission Braden Scale (score to predict pressure sore risk) dated 11/15/23, revealed a score of 12, indicating that R901 was at higher risk for developing pressure ulcer. A review of R901's Electronic Medical Record (EMR) revealed admission nursing assessment dated [DATE]. The nursing assessment revealed R901 had weakness on both upper and lower extremities with limited range of motion. R901 was admitted with a reddened area in sacrum and the description read reddened area near coccyx. The assessment summary had a note that read, .Patient has a reddened area on (gender omitted) near coccyx will put in for wound care to look at the resident .Patient is a one-on-one feed due to limited mobility hands. Review of R901's EMR also revealed a comprehensive Minimum Data Set (MDS) assessment was completed with an Assessment Reference Date (ARD) of 11/18/23. Review of R901's comprehensive care plan revealed a care plan for skin integrity/risk for pressure sore with interventions that included: Weekly skin assessments and Braden assessments per facility protocol. No other preventative measures to maintain skin integrity were in place during this time frame. A review of admission nutrition assessment dated [DATE] revealed that R901 was at risk for alteration in nutrition and hydration and the interventions included: provide diet and supplements as ordered; offer alternates when less than 50% of meal was consumed; and observe and report significant weight changes to the physician. The facility also completed another MDS assessment (Interim Payment Assessment) with an ARRD date of 11/29/23. Further review of EMR revealed multiple progress note reveal concerns with R901's appetite and food acceptance. R90 had tested positive for Covid on 11/22/23. A rehab practioner note dated 11/22/23 at 15:43 revealed that R901 was referred to speech therapy due to modified (mechanical soft) diet. Practioner note dated 11/27/23 had the same recommendation for RD and speech therapy to follow up related to hypoalbuminemia, protein calorie malnutrition, decreased intake and resident receiving modified diet consistency. There was no speech therapy assessment/care plan on R901's clinical record and it was confirmed by the therapy program manager C that R901 did not receive any speech therapy services. A practioner progress dated 11/29/23 at 9:52 read in part, patient has not been eating or drinking well per nurse reports. (Gender Omitted) reports decreased appetite. Unit manager and patient's nurse reported today wounds have been observed on heels, buttocks, and coccyx. Practitioner assessment included poor intake, pressure sores and plan included wound care consult for multiple acquired pressure sores and RD consult. Further review of R901's wound assessment for sacrum dated 11/29/23 revealed a stage 3 pressure ulcer with the following measurements: Area of 5.7 cm2 with x 8.9 cm (length) x 1.7 cm (width) and 0.2 cm (depth). Review of R901's care plan to maintain skin integrity after stage 3 pressure ulcer, right lateral foot vascular ulcer did not have any new interventions to promote healing and prevent any further skin impairments. A care plan intervention to complete weekly skin assessments that was already in place, since 11/11/23 had a revision date of 11/29/23. EMR did not have any evidence of additional resident specific intervention/care plan implementation after R901 had developed a stage 3 pressure ulcer at the facility. A review of dietary care plan after the identification of facility acquired stage 3 pressure ulcer revealed no additional nutritional interventions to address the decreased appetite and food acceptance. R901 had lost 23.6 lbs. in approximately 45 days after admission to the facility. A dietary care plan revision dated 11/29/23 had updated goals to maintain nutrition, hydration, and monitoring labs with no additional resident specific interventions to achieve the established goals. An interview was completed with facility Dietitian B was completed on 2/27/24, at approximately 1:45 PM. Dietician B was queried about RD consult for R901. They reviewed the EMR and confirmed that R901 had an initial assessment on 11/14/23 and a consult on 1/9/24. Dietician B was queried on the communication/notification process between nursing and dietary. Dietician reported they were receiving copies of order if a Resident had an order. They also reported that they had also discussed during the morning clinical meeting if they were able to attend. Dietician was queried on they were getting notified if they no RD at clinical meeting and no further explanation a provided. Dietician was queried on there was no timely RD follow up and implementation of interventions after R901 had weight loss and had developed pressure sores. Dietician reported that based on the record review there were probably no notifications to RD completed and added that had there been a timely notification they would have followed up. An interview with wound care nurse LPN F was completed on 2/27/23 at approximately 9:30 AM. LPN F was queried about R901 and their process. LPN F explained that they had completed an initial assessment after admission, typically within 24-72 hours after the admission nurse assessment. LPN F was queried on their initial assessment and plan for R901. They reviewed EMR and reported that R901 did not have reddened area as noted on admission nursing assessment, so they did not complete a wound assessment after admission. LPN F reported that they completed wound treatments on weekdays and floor nurses were completing on weekends. LPN F was queried who was responsible to update skin/wound care plans. LPN F reported that they were updating the wound care plans if they identified any concerns. LPN F was queried what was updated for R901 after the facility had identified a stage 3 pressure ulcer on 11/29/23. LPN F reviewed the clinical record and reported that turning and repositioning frequently and to moisture barrier cream was after incontinence episodes were initiated. When queried why turning and repositioning was not in place when they were identified as high risk and no further explanation was provided. An initial interview with Director of Nursing (DON) was completed on 2/26/24, at approximately 11:30 AM. DON was queried on the facility's weight protocol. DON was queried about R901's risk on admission and timeliness with the interventions. DON reported that R901 had multiple comorbidities and had interventions in place. DON reported that they were not sure of the timeliness of the interventions, and they would check. No other information was provided prior to exit. A review of the facility provided document titled Care Planning with a revision date of 6/24/21 read in part, every resident end the facility will have a person centered plan of care developed and implemented that is consistent with the residents rights, based on comprehensive assessment that includes measurable objectives and time frames to meet a residence medical nursing and mental and psychosocial needs identified in the comprehensive assessments and prepared by the interdisciplinary team who includes but not limited to attending physician and I just to a nurse who's responsible for the resident a nurse aide a member of food or nutrition services the resident or the representative therapy staff has required and any other ancillary staff. Additional resources will be utilized to ensure that any additional needs or risk areas are identified. Procedure: 1. Residents will be assessed as they are admitted and readmitted to the nursing facility to determine their physical, psychological, emotional, medical, and psychosocial needs. The results of interdisciplinary assessment will be used to develop, review and revise resident's comprehensive care plans. 2. The care plan must be specific, resident centered, individualized and unique to each resident and may include: It should be oriented toward preventing avoidable decline. How to manage risk factors. Address/include resident strengths. Current standards of practice. Treatment objectives should have measurable outcomes. Respect the residence right to refuse treatment. If the resident has refused treatment, does the care plan reflect the facility's effort to find alternative means to address the problem? Place an interdisciplinary approach to include certified nurse aide. Involved the family\ representatives if possible. Involve and communicate the needs of the resident with the direct care staff .

This citation Pertain to Intake#: MI00142528 Based on record review and interviews facility failed to timely identify and address the nutritional needs; and monitor weights for one (R901) of three high risk residents reviewed for nutrition and weight loss. This deficient practice resulted in, undetected weight loss, further decline in nutritional status, developed two stage three pressure ulcers during their stay at the facility and transferred to hospital for PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement and surgical debridement of the wound. Findings include: R901 was admitted to the facility on [DATE] after hospitalization for fall at home. R901's admitting diagnoses included: Contusion of scalp, osteoarthritis, metabolic encephalopathy, and history of achondroplasia. R901 was living at home with their spouse prior to this fall and hospitalization . Based on Minimum Data set Assessment (MDS) dated [DATE], R901 had Brief Interview for Mental Status (BIMS) score of ,d+[DATE], indicative of intact cognition. R901 had limited range of motion on both upper extremities, and they needed moderate staff assistance for eating and extensive assistance with their mobility in bed. R901 was transferred to hospital on [DATE] for further weight loss and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube and worsening wounds. A complaint received by the State Agency read in part, (R901- Name omitted) had a fall which is why he was put in a nursing home. (R901-Name ommitted) also can 't use his hands, and he needs to be fed. (R901- Name omitted) was taken to the hospital. (Gender Omitted) had three bedsores .(R901- Name omitted) was put on three antibiotics. (R901 Gender Omitted) also had a feeding tube put in . (R901- Name omitted) is now fragile. A review of R901 ER (emergency room ) records read in part, EMS is unsure why patient was sent for PEG tube, as patient does not have one. Staff at the facility were unable to explain why they are requesting a PEG tube. Patient denies any complaints at this time and any history or complaints of dysphagia. Patient does complain of sacral decubitus ulcers. Review of R901's hospital admission records and discharge summary dated [DATE] revealed that that R901 was admitted to the hospital with advanced and infected pressure ulcer to the sacrum/coccyx (tail bone) area that extended to the bone. The infected wound needed surgical removal of unhealthy tissues. R901 had also developed another stage 3 pressure ulcer on the right hip area with exposed fat layer. R901 also had surgery for a PEG tube placement to receive nutrition and hydration due weight loss and protein calorie malnutrition. Further review of hospital records revealed a surgery note that read, depth of the wound: muscle. Size of the wound debrided 10 cm. x 14 cm. with eschar and 4 cm. undermining .3 cm. x 4 cm. wound inferior and right to the sacral wound. The infectious disease specialist note dated [DATE] revealed that R901 received three different antibiotics that were administered intravenously. Review of Nutrition consult from hospital dated [DATE] read in part, Wife reported pt with significantly decreased PO intake at nursing home . Reported pt only eat a few bites per day. Pt confirms this. States that he was previously eating regular food when he lived at home with his wife, but when he moved to a facility they placed him on pureed diet. He didn't like the food-tastes bad. Additionally he states that he tried supplements but they made him use the bathroom .'. A review of R901's code status from the facility dated [DATE] revealed that R901's wishes were to remain full code. A physician admission progress dated ,d+[DATE] at 9:46 read in part, The patient has been deemed competent to make decisions on their behalf. In the course of discussing risk benefits, and alternatives to the advance care directive options were reviewed with patient. This decision included CPR (Cardiopulmonary Resuscitation), PEG tube placement ventilator support. Patient desires to be a full code. A Review of R901's Electronic Medical Record (EMR) from the facility revealed a physician order dated [DATE] read, Transfer to hospital related to failure to thrive and worsening wounds and another order that for [DATE] that read, New order from MD to send resident to hospital for PEG tube placement and coccyx wound evaluation. Further review of physician orders and discharge summary from the hospital revealed that R901 was admitted with regular diet that was changed to mechanical soft consistency on [DATE]. A review of R901's progress notes revealed an admission nutrition assessment dated [DATE]. R901's admission weight was 115 lbs. The RD (Registered Dietician) summary and recommendations read in part, .admitted for rehab S/p hospitalization for multiple falls, failure to thrive .PO (eating by mouth) 51% - 100%, which may be suboptimal at times .will provide 2 times/day 18 gm protein. No edema noted, no open areas, coccyx red .nitration goal is for no weight loss, PO to meet >75% of nutrition needs skin to be intact. A review of R901's weight record revealed the following weight entries: [DATE] at 14:59 - 115.8 lbs. [DATE] at 10:02 - 92.2 lbs. (23.6 lb. weight loss) [DATE] at 16:24 - 96.4 lbs. The weight records did not reveal any periodic and consistent weight monitoring for R901 after admission weight. After the initial weight, the 2nd weight was completed approximately 45 days after the admission weight. A physician orders dated [DATE] read, Dietary consult, please reevaluate patient for hypoalbuminemia and another order administer 1 liter 0.9 normal saline via hypodermoclysis (administering fluids through skin for hydration) at rate of 60 ml. per hour. Further review of R901's progress note did not reveal any RD consults or follow up after the initial nutrition assessment. An RD progress note dated [DATE] at 10:09 read in part, Approached by wound nurse concerning new wound right ischial tuberosity stage 3 (pressure sores that extend past the dermis, the skin's second layer and reached the tissue fat layers beneath), continues with sacrum stage 3 and arterial R heel. Diet of mechanical soft frozen nutrition treat BID (2 times per day) and pro-stat 30 ml. QD (one time /day) .recommend ensure plus BID for additional 750 kcal (kilocalories) 26 gm protein .logged for weight loss recommendations for physician. A nursing progress note dated [DATE] revealed that R901 tested positive for COVID, and they were placed on isolation under droplet precautions. A review of the practioner note dated [DATE] revealed that R901 reported poor appetite and multiple recommendations that included Dietary to evaluate protein calorie malnutrition, push PO fluids as tolerated. The recommendations were not followed and there were no RD follow ups completed. A rehab practioner note dated [DATE] at 15:43 revealed that R901 needed 1:1 feeding assistance and referred to speech therapy due to modified diet. Practioner notes (x 2) dated [DATE] had the same recommendation for RD and speech therapy to follow up related to hypoalbuminemia, protein calorie malnutrition, decreased intake and resident receiving modified diet consistency. There was no speech therapy assessment or follow up on R901's clinical record and it was confirmed by the therapy program manager C. A practioner progress dated [DATE] at 9:52 read in part, patient has not been eating or drinking well per nurse reports. (Gender Omitted) reports decreased appetite. Unit manager and patient's nurse reported today wounds have been observed on heels, buttocks, and coccyx. Practitioner assessment included poor intake, pressure sores and plan included wound care consult for multiple acquired pressure sores and RD consult. Review of R901's Care plan revealed that R901 the following nutritional interventions implemented on admission due to their diagnoses and risk that included, observe and report to physician significant weight changes 3% in 1 week, 5% in month, 7.5% in 3 months, >10% in 6 months; offer an alternate when less than 50% of the meal is consumed; provide and serve supplements as ordered dated [DATE]. The care plan also revealed that R901 needed total staff assistance with eating due to their limited range of motion on their upper extremities. A progress note titled e-Interact SBAR Summary for providers, revealed that change in condition were reported due to weight loss and pressure ulcer and R901 was transferred to hospital. An interview with complainant was completed on [DATE] at approximately 10:10 AM. During the interview they reported that R901 was at home prior to hospitalization for the fall. R901 was using a walker, and they were assisting at home. They also reported that R901 was not getting the assistance they needed with eating. R901 did not like when the diet was changed. Complainant also reported that R901 did not have any sores prior to the admission to the facility. R901 developed multiple sores during their stay at the facility. The complainant reported that they saw the pictures of the sores and they were deep. The complainant reported that they were able to visit R901 at the facility only on weekends due to their health condition. An initial interview with Director of Nursing (DON) was completed on [DATE], at approximately 11:30 AM. DON was queried on the facility's weight protocol. DON reported that they completed weight on admission and then weekly x 4 weeks. The residents were weighed monthly after 4 weeks unless their interdisciplinary team assessment indicated otherwise. A follow-up interview was completed on [DATE] at approximately 6:20 PM. DON reported the R901 was had contractures and other comorbidities, tested positive for covid on [DATE] and lost appetite. They had RD consult and diet changes. DON was queried about R901's risk on admission and timeliness with the interventions. DON reported that they were not sure of the timeliness, and they would check. No additional information was provided prior to the exit. An interview was completed with facility Dietitian B was completed on [DATE], at approximately 1:45 PM. During the interview Dietician B was queried if they had completed the assessment and follow up for R901. They reported that Dietitian who completed the assessment no longer worked for the facility, and they were covering the facility. They also reported that they worked part time and had picked up additional days to assist and there were 2 other RD assisting. Dietician B was queried about RD consult for R901. They reviewed the EMR and confirmed that R901 had an initial assessment on [DATE] and a consult on [DATE]. They had reviewed the R901's weight record and confirmed that there were only 3 entries. Dietician B was queried on the communication/notification process between nursing and dietary. Dietician reported they were receiving copies of order if a Resident had an order. Dietician also reported that the interdisciplainary team had discussed during the morning clinical meeting, if they were able to attend the meeting. Dietician was queried on how they were getting notified if the RD did not attend the clinical meeting; no further explanation a provided. Dietician was queried on why there were no timely RD follow up after R901 had weight loss and had developed pressure sores. Dietician reported that based on the record review there were probably no timely notifications from nursing team to RD and added that if there had timely notifications dietician would have followed up. An interview with Therapy Program Manager C was completed on [DATE], at approximately 11:10 AM. During this interview Therapy Manager C reviewed EMR and confirmed that R901 did not receive any speech therapy services. A review of the facility provided document titled Weight Change with a revision date of [DATE] that read in part, Residents will be monitored for significant weight changes on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels; unless the resident clinical condition demonstrates that is not possible. Since ideal body weight charts have not been validated for institutionalized elderly, weight loss (or gain) is a guide for determining nutritional status. Therefore, the evaluation of significant weight gain or loss over a specific period of time is an important part of the evaluation process. Practice guidelines: 1. All residents will have a baseline evaluation of their nutritional status within seven days of admission/readmission. The evaluation will identify risk factors for altered nutritional status. 2. Residents will be weighed upon admission slash readmission; Weekly times 4, then monthly or as indicated by the physician and/or the medical status of the resident and document the results in the medical record .

This citation pertains to Intake(s): MI00141146 This citation has two deficient practice statements (DPS). DPS #1 Based on interview and record review, the facility failed to assess and treat a surgical wound according to physicians orders for one (R705) of one resident reviewed for non-pressure wounds, resulting in a hospital transfer when R705's foot was observed to be swollen, warm, with surgical hardware embedded into the skin. Findings include: Review of a complaint submitted to the State Survey Agency revealed an allegation that the facility neglected to change the resident's surgical bandages as ordered resulting in the resident's foot becoming swollen and the inserted pin shifting and being displaced .resident had to be sent back to the hospital as a result .bandage .was only changed one time in 11 days . Review of R705's clinical record revealed R705 was admitted into the facility on [DATE] and discharged to the hospital on 11/25/23 with diagnoses that included: displaced fracture of right foot and cutaneous abscess of right foot. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R705 had intact cognition, received intravenous antibiotics, and did not have any surgical wounds. Review of a Nurses Note dated 11/25/23 revealed the following documentation, At approximately 1030 (10:30 AM) resident (R705) stated she needed to have her dressing changed to her right foot wound. Informed resident that the dressing would be changed today by writer. Old dressing removed at approximately 1300 (1:00 PM) observed swelling from right foot to the right ankle. Sutures intact, along with 3 surgical pins. One of the pins was embedded into the skin. Resident's foot warm, not hot, pink in color, with some areas of dried blood noted. Resident stated her foot did not look like that before that it was not swollen and the pin was sticking out not embedded .Writer called resident's sister/guardian .Stated she had seen residents foot in the hospital and the pin was not embedded but sticking out like the others and the foot had not been swollen (Physician 'L' ) notified of resident's current condition, ordered to transfer resident out to the hospital . Review of R705's After Visit Summary provided to the facility by the hospital revealed the following discharge instructions: Wound/Incision Care .Wound VAC (vacuum assisted wound closure - a type of wound care that uses a suction pump, tubing, and a dressing to remove excess drainage and promote healing of complicated wounds) to be changed twice a week - 125 mmHG (millimeters of mercury - a measurement of pressure) of continuous pressure. Small black foam within dorsal medial (top inside) wound. Incision site wounds to be changed every other day consisting of flushing the wounds with saline, applying with Betadine (antiseptic), 4 x 4 gauze, Kerlix (bandage roll), and reapplying a well padded (with web roll) posterior splint . Review of R705's Physicians Orders revealed the following orders: An order dated 11/14/23 with a start date of 11/17/23 (four days after R705 was admitted into the facility) for Wound Care order: Right dorsal (medial) foot every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for Wound Cleanse with normal (saline), pat dry. Cut black foam to size of wound, apply occlusive dressing (wound dressing that seals out air, fluids, and contaminants) over the black foam to secure in place. Connect tubing. Turn on wound vac (at) 125 mmHG, low continuous suction and ensure seal is secure. Wrap over with kerlix AND as needed for Wound. If unable to maintain suction or vac malfunction: Disconnect vac. Clean area with normal saline, dry, apply saline soaked gauze to area, cover with 4 x 4 gauze and ABD pad, wrap in kerlix. An order dated 11/14/23 with a start date of 11/15/23 for Wound Care Order: Right foot (dorsal lateral - top outer and plantar medial - bottom inside) every day shift for surgical wound. Cleanse area with normal saline, dry, apply adaptic to surgical site, then betadine impregnated gauze to surgical line, cover with 4 x 4 gauze, ABD pad, wrap with kerlix and secure with tape. Apply splint and ACE wrap. The same order was also ordered on an as needed (PRN) basis. Review of R705's Treatment Administrator Record (TAR) for November 2023 revealed the wound vac treatment ordered every Mon, Wed, Fri to the right dorsal medial foot was done one time on 11/17/23 and was not administered on 11/20/23, 11/22/23, and 11/24/23. The daily treatment to the right dorsal lateral and plantar medial foot was not administered on 11/15/23, 11/16/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23, 11/22/23, and 11/24/23. Review of a Nursing Comprehensive Evaluation completed on 11/13/23 upon R705's admission revealed R705 had a right ankle (inner) wound. There was no further description of the wound. Review of R705's progress notes revealed the following: A Skin/Wound Progress Note dated 11/14/23 that documented, Skin assessment completed .The following skin alterations were noted during assessment .Right foot 3 surgical sites noted, see Skin & Wound evaluation for wound details. Dressing change completed by writer (It should be noted that there was no active wound care orders on 11/14/23) . A Nurses Notes progress note dated 11/25/23 that documented, Transfer resident out to hospital for evaluation of right foot surgical wound. There were no progress notes that documented an assessment of R705's surgical wounds to the right foot. Review of R705's Skin & Wound Evaluations revealed incomplete wound assessments started on 11/14/23 that were in progress as of 1/16/24. Review of a Skin & Wound Evaluation for R705's Right Dorsum Foot, dated 11/14/23 revealed R705 had a surgical wound to that area with dehiscence - partial or complete separation of the outer layers of the joining incision. The assessment was incomplete and was not signed. There was no documentation in R705's clinical record that indicated the dehiscence was discussed with and/or evaluated by a medical provider. Review of a second Skin & Wound Evaluation for the right dorsal foot indicated R705 had two sutures. The assessment was incomplete and not signed. Review of a Skin & Wound Evaluation for R705's right medial foot dated 11/14/23 was incomplete, unsigned and documented there were 4 sutures to the area. Further review of R705's full clinical record revealed no additional assessment or evaluation of R705's surgical wounds. Review of a care plan initiated for R705 on 11/13/23 and revised by Wound Care Nurse 'M' on 11/14/23 revealed, (R705) has actual skin impairment to skin integrity r/t (related to) surgical wound to right foot. Interventions initiated on 11/14/23 did not address the wound vac or any specifics related to the surgical wounds. On 1/17/24 at 11:42 AM, the Administrator explained Wound Care Nurse 'M' was unavailable for interview. On 1/17/24 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's skin management program, the DON reported if a resident was admitted with a wound, it was identified by the admitting nurse who conducted the head to toe skin assessment and Wound Care Nurse 'M' came behind to do a full assessment of the wound within a few days. The admitting nurse was responsible for entering the treatment order based on the hospital discharge records. The DON further explained wound assessments were completed on a weekly basis by Wound Care Nurse 'M' and the staff nurses did head to toe skin assessments weekly. When queried about who was responsible to provide wound treatments, the DON explained the staff nurses did treatments unless it was a complicated wound, then Wound Care Nurse 'M' did the treatments. When queried about how it was known if a treatment was done per the orders, the DON reported the nurse signed off on the TAR. When queried about who did wound VAC treatments, the DON reported Wound Care Nurse 'M'. When queried about how the facility ensured treatments were done according to orders, the DON reported she expected Wound Care Nurse 'M' to monitor. When queried about R705, the DON reported she did not recall that resident. When queried about the missed treatments and incomplete and missing wound assessments for R705, the DON reported they were aware the facility had some concerns with wounds and they were working on it. Review of a facility policy titled, Skin Management, last revised 7/14/21, revealed, in part, the following: .Guests/residents admitted with any skin impairment will have appropriate interventions implemented to promote healing, a physician's order for treatment, and wound location, measurements and characteristics documented . 34208 Deficient Practice #2 This deficient practice pertains to intake #MI00139866, and #MI00141946. Complaints were made to the State Agency that alleged the facility failed to appropriately monitor blood glucose levels. Based on interview and record review, the facility failed to document blood glucose readings for one resident (R702) of two residents reviewed for blood glucose monitoring resulting in the potential for unknown deviations from normal blood glucose levels. Findings include: On 1/16/23 at 11:05 AM, a review of R702's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged on [DATE]. R702's diagnoses included: heart failure, diabetes, high blood pressure, and stage IV chronic kidney disease. A review of R702's physician's orders and medication administration record (MAR) for January 2023 was conducted and revealed they received 63 units of long acting insulin every night at bedtime as well as had an order for blood sugar monitoring every eight hours at 6 AM, 2 PM, and 10 PM. The MAR revealed check marks for the blood glucose monitoring being done every 8 hours on 1/26/23 thru 1/29/23, however; there were no documented values of the blood glucose levels. Continued review of R702's closed clinical record included a review of R702's vital signs that included a section to document blood glucose levels. It was noted there was only one value documented for R702's blood glucose levels. On 1/17/23 at 10:58 AM, an interview was conducted with the Director of Nursing (DON) regarding documentation of blood glucose levels. They said the values should have been documented on the MAR underneath where it was checked off the monitoring had been done. A review of a facility provided policy titled, Diabetic Management revised 9/22/23 was conducted and read, .Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameter to follow and when to notify the physician .Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately .Documentation .Results of blood testing .

This citation pertains to Intake Number(s): MI00140078, MI00140084, and MI00141881 Based on observation, interview, and record review, the facility to assess newly developed facility acquired pressure ulcers in a timely manner, perform accurate and timely ongoing assessments of wounds and perform treatments per physician's orders for two residents (R#'s R703 and 706) of four residents reviewed for pressure ulcers, resulting in the worsening of a stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer to a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) pressure ulcer with exposed bone and suspected osteomyelitis (bone infection). Findings include: R703 Review of R703's clinical record revealed R703 was admitted into the facility on [DATE] and was discharged on [DATE] with diagnoses that included: intracerebral hemorrhage and emphysema. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R703 had severely impaired cognition, was totally dependent on staff for bed mobility, transfers, and all activities of daily living, was always incontinent of urine and stool, had significant weight loss and weighed 70 pounds, was at risk of developing pressure ulcers, and had no unhealed pressure ulcers. Review of R703's Total Body Skin Assessments revealed the following: On 8/29/23 it was documented R703 had one new wound. On 9/7/23 it was documented R703 had one new wound. On 9/14/23 it was documented R703 had one new wound. There was no documentation that described the new wounds documented on the skin assessments. Review of R703's progress notes revealed the following: A Nurses Note dated 8/25/23 that read, Resident has an open wound bed to sacrum. Resident has red area to right hip. Resident has red areas to right buttock. Writer cleaned sites with normal saline, applied santyl (a wound dressing used to remove dead tissue from a wound) ointment and border gauze for protection. Wound care notified. Tx (treatment) order placed for resident. There was no description of the wound or diagnosis of the type and stage of the wound. An Encounter progress note written by the physician on 9/4/23 (nine days after the sacral wound was first identified) revealed, .sacral wound .She usually would lay in bed need assistance with all ADL (activities of daily living) care and transfers .Staff reported pt (patient) having new sacral wound unstageable (wound is obscured by devitalized/dead tissue) . There was no documented description of the wound and no measurements. A Total Body Skin Assessment progress note dated 9/7/23 documented, Open wound bed previously reported. The location and description of the wound was not documented. A Nurses Note dated 9/10/23 documented, .Dressing on sacral area done. Writer requested a wound consult for her sacral area . A Nurses Note dated 9/11/23 documented, .Resident has a open wound bed that presents with slough (devitalized tissue) and odor .MD (Medical Doctor) stated that she would place an order for crushed (antifungal medication) to wound bed until wound care MD can assess wound . A Nurses Note dated 9/26/23 documented, Resident has new open wound bed to right elbow .Wound care notified . Review of a Skin & Wound Evaluation for R703 dated 9/19/23 revealed R703 was assessed to have a Stage 4 pressure ulcer to the sacrum that was acquired in the facility. The date the pressure ulcer was identified was not documented. It was documented the pressure ulcer was staged by Wound Care Clinic and measured 3.0 centimeters (cm) in length by 4.0 cm in width by 1.5 cm in depth with 2.5 cm of undermining (destruction of issue extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and 90 percent slough. It was documented that the primary physician was contacted and the wounds were unavoidable due to resident's decline. However, the wound was first documented on 8/25/23 with no assessment completed until 9/19/23, 25 days after it was first identified per the progress notes. Review of a Skin & Wound Evaluation for R703 dated 9/19/23 revealed R703 was assessed to have a Stage 3 pressure ulcer to the left lateral malleolus (outer ankle) that was acquired in the facility. It was documented the wound had been present since 9/19/23. It was documented the wound was staged by Wound Care Clinic and measured 1.8 cm) by 1.1 cm with 40 percent of the wound filled with slough. Review of physicians orders revealed on 9/15/23, an order to cleanse the left ankle with normal saline and cover with dry dressing was started. However, there was no documentation of when the wound was first identified or what the initial assessment of the wound was when treatment was started on 9/15/23. The first documented assessment of R703's left ankle was when the wound was a stage 3 pressure ulcer. Review of a Skin & Wound Evaluation for R703 dated 10/2/23 revealed R703 was assessed to have a Stage 3 pressure ulcer to the right elbow that was acquired in the facility, six days after it was documented in the progress notes that R703 had an open area to the elbow. There was no date documented to indicate how long the wound was present. It was documented that the wound measured 1.6 cm x 2.5 cm and was 100 percent filled with slough. Further review of the clinical record revealed no prior documentation of an assessment of the open wound to R703's right elbow prior to it being assessed with a stage 3 pressure ulcer on 10/2/23. On 1/17/24 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's process when a resident developed a new pressure ulcer, the DON reported the nurse entered a treatment order and notified Wound Care Nurse 'M'. The DON explained Wound Care Nurse 'M' was expected to assess the wound within 48 to 72 hours. R706 On 1/16/23 at 9:00 AM, a review of R706's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged on [DATE]. A review of R706's progress notes dated 9/8/23 revealed a re-opening of a stage III (Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer. A review of R706's treatment administration records (TAR) for 12/2023 was conducted and revealed missed daily treatments to the ulcer on 12/4/23, 12/7/23, 12/11/23, 12/14/23, 12/16/23, 12/20/23, 12/20/23, 12/22/23, 12/25/23, and 12/26/23. Continued review of R706's clinical record revealed only two wound care consultant forms dated 12/8/23 and 12/22/23, it was noted there was no consult for the week of 12/10/23 thru 12/16/23. It was further noted their was no evidence R706 received any assistance for turning and repositioning or had been transferred to their wheelchair. The consult dated 12/8/23 read, .Wound #1 Sacral is a chronic Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.2 cm (centimeter) length x 1.5 cm width x 1.2 cm depth .No tunneling has been noted .No undermining has been noted. There is a Moderate amount of of serous drainage noted which has no odor . The consult dated 12/22/23 read, .Wound #1 Sacral is a chronic Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) Pressure Ulcer .measurements are 2.3 cm length x 1.1 cm width x 3 cm depth .Bone is exposed. Suspected Osteomyelitis (bone infection): Awaiting Results .Undermining has been noted at 12:00 and ends at 4:00 with a maximum distance of 3 cm .The wound is deteriorating . On 1/17/24 at 1:05 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the facility's treatment of pressure ulcers with regards to missing treatments and interventions to prevent the development and worsening of pressure ulcers. The DON indicated they had recognized concerns with pressure ulcers and had been working on it. A review of a facility provided policy titled, Skin Management revised 7/14/21 was reviewed and read, .It is the policy that the facility should identify and implement interventions to prevent the development of clinically unavoidable pressure injuries .Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest resident outcomes . 34208

Based on interview and record review the facility failed to timely evaluated and implement effective and accurate treatments for one (R704) of two residents reviewed for pressure ulcers, resulting in R704 not being evaluated by wound care and/or treated for their pressure ulcer for approximately 15 days causing a worsening of the wound on the resident's coccyx and a noted increase in pain. Findings include: A Complaint was filed with the State Agency (SA) that alleged that the facility failed to treat R704's Stage IV pressure ulcer upon admission and for several weeks thereafter. The Complainant further alleged that the facility expressed to them that the ulcer was unavoidable and could not be resolved. Complaint indicated that despite a diagnosis of an unavoidable ulcer the facility failed to initiate any treatment on admission and provide a low air loss mattress to the resident for approximately two weeks. The facility policy titled, Skin Management (12/15/22) was reviewed and documented, in part: Policy: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .upon admission .all residents are evaluated for skin integrity .the Braden scale will completed upon admission .Appropriate prevention measures will be implemented and the interventions are documented on the care plan .residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, a physician's order for treatment, and wound location measurements and characteristics documented . A review of R704's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, type II diabetes, dementia and protein calorie malnutrition and obesity due to excess calories. A review of the resident's Minimum Data Set (MDS) indicated the resident was severely cognitively impaired and required extensive one to two person assist for most Activities of Daily Living (ADLs). An initial Nursing Comprehensive Evaluation dated 12/14/22 documented, in part: Is this a new admission (Yes) .Bed Mobility: Total assist .K. Skin .Does the resident have any skin conditions? (Yes) .Actual Skin Breakdown Care Plan: Interventions. Apply pressure relieving mattress .Location of skin condition .Coccyx .wound . A Braden score completed on 12/15/22 noted that the resident was at Moderate Risk for pressure sores with a score of 13. An order dated 12/14/22 noted: Wound Care Practioner to eval and treat as indicated . A Skin and Wound Evaluation dated 12/14/22 with a lock date on 12/28/22 (completion date and signed by Wound Nurse A on 12/28/22) documented, in part: .Type .15. Pressure .Unstageable .present on admission .wound measurements .Area 5.4 cm (centimeters) .length 3.1 cm .width .2.5 cm .Goal of Care. 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Heel suspension, incontinence management .Mobility .Moisture PAIN SCORE .6 .barrier .Moisture .control .Nutritional .supplementation .turning repositioning.Progress . stable . *It should be noted that there were no documents that noted the size, width, description of the wound upon entry to the building (12/14/22) until noted in the evaluation dated 12/28/22. Further there was no initial order as to a mattress either air loss or with pump noted in the evaluation. A Skin and Wound Evaluation (12/29/22) documented in part: .Type .Pressure .Stage: Unstageable .Location .Coccyx .present on admission .Area 8.9 cm .Length 4.2 cm .Width .3.3 cm .PAIN SCORE -9 .Goal of Care: Slow to heal; wound healing is slow or stalled but stable .Mattress with Pump added to Addition care. R704's Care Plan documented, in part: R704 is at risk for impaired skin integrity/pressure .Decreased mobility .(12/14/22): .interventions .conduct weekly head to toe skin assessments (12/14/22) follow policies/protocols for the preventions/treatment of impaired skin (12/14/22) .Observe dressing frequently (12/30/22) .pressure reduction cushion to w/c (12/30/22) .pressure reduction mattress to bed (low air loss) (12/30/22) .transfer/reposition every two hours(12/14/22) .Wedge .to aide in repositioning (12/14/22) . Attempts to obtain orders pertaining to the treatment of R704 wound to the coccyx were made while reviewing the clinical record. The first order found in the resident's record was as follows: Santyl Ointment 250 Unit .Apply to sacrum topically every day shift for Wound Care Sacrum .Cleanse with NS pat dry, lightly pack with Maxorb AG Santyl oint cover with 4x4 gauze securing with foam dressing . (12/29/22). A review of the residents Medication Administration (MAR)/Treatment Administration Record (TAR) documented the first treatment to the resident's wound was on 12/20/22. Physician Wound Care Note (1/3/2023) authored by Wound Nurse Practitioner (WNP) B documented, in part: .the patient was seen today as a consultation for evaluation of the patient's wounds .this information was obtained from the resident's chart .Pressure ulcer to sacral region, unspecified stage .Wound #1 sacroccyx/bilateral buttocks is a kenndy <sic> Terminal Ulcer (generally starts as a small bruise that is reddish or brown that quickly grows in a short period of hours ) encounter measurements are 10.4 cm length x 5.7 cm width x 2cm depth with an area of 59.28 sq cm and a volume of 118.56 cubic cm. There is a moderate amount of drainage noted with a strong odor .Treatment Orders .Calmoseptine QD (daily) and PRN (as needed) to the peri wound base .Crushed Flagyl (eliminates odors) and Hydrogel daily and PRN for 7 days .cleanse wound with Dakin's 1/4 strength additional orders . ROHO mattress . Physician Wound Care Note (1/10/23) authored by WNP B documented, .buttocks is a Kennedy Terminal Ulcer . measurements are 11.1cm length x 7.7 cm width x 2cm depth with an area of 85.4 sq cm and a volume of 170.95 cubic cm . An additional treatment of Triad Past QD and PRN was added to the treatment plan. On 3/14/23 at approximately 2:30 PM, an interview was conducted with Wound Nurse A. Nurse A reported that they have been working as the facility wound nurse since July 2022. When asked as to the facility protocol for residents who enter the facility with wounds, Nurse A reported that the admitting nurse is to do an initial assessment and ensure that the resident is seen by wound care including the wound physician. Nurse A indicated that the wound physician team is in the buildings on Tuesday. When asked about R704, Nurse A reported that they were out on leave when the resident was admitted on [DATE] and did not return to the facility until 12/28/22. When asked if they were not in the facility who was in charge of ensuring wound care assessments, treatments, etc. were conducted, Nurse A stated that nursing staff, including the Director of Nursing (DON), are able to assess residents and contact the wound care physician/wound nurse practitioner. When asked when the first time the wound physician was notified, Nurse A reported that the facility did not report any concerns to the wound physician and stated that they reported the concern upon their return (12/28/22). When asked if a failure to treat the resident's wound could cause the increase in size and possible increase in pain, Nurse A reported that it could. On 3/14/23 at approximately 2:45 PM, an interview was conducted with the DON. When asked why R704 did not begin treatment for their wound until Nurse A returned to the facility on or about 12/28/23, the DON reported that the facility should have initiated the order for a wound care consult to ensure treatments were in place. When asked as to why the resident did not receive a pressure reducing mattress/low-air-loss mattress until 12/30/22 as noted in the resident's care plan, the DON reported that the facility generally uses non-powered, air-filled mattresses. On 3/14/23 at approximately 3:51 PM, a phone interview was conducted with WNP B. When queried as to R704, WNP B noted that the first time they saw R704 was on 1/3/23. They noted at that time the resident's wound had a strong odor indicating infection and based on their observation noted the wound to be a Kennedy Ulcer. When asked if they were aware R704 was admitted to the facility with what was noted as a pressure sore to the coccyx noted as unstageable with significant smaller depth and width, WNP B reported that it is up to the facility to indicate a resident is to be evaluated as to their wounds. WNP B was asked if the facility should have contacted them per the 12/14/22 order for a wound consult to ensure treatment/interventions for the resident were implemented timely, WPN B noted that they should have.

Based on interview and record review the facility failed to consistently identify the root cause of a fall, review, modify and implement effective interventions to prevent further falls for one (R704) of three residents reviewed for falls, resulting in a transfer to the hospital and required multiple staples to repair a laceration to the scalp. Findings include: Review of the medical record revealed R704 was admitted to the facility on [DATE], with diagnoses that included: Parkinson's disease, bipolar disorder and anxiety disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital paperwork provided to the facility documented in part, . presenting to the ED (Emergency Department) after an unwitnessed fall today and yesterday. Patient is a poor historian . pt.(patient) is not at his baseline for mentation .seems more confused . Review of a Nursing note dated 11/30/22 at 7:41 PM, documented in part . Patient told family member that (R704) has been falling on the floor since they arrived to the facility and getting up by .self. Writer not made aware of the falls until family came and mentioned it. Patient is confused . Review of a facility Incident and Accident Report dated 11/30/22, documented in part . Patient told family member (R704) has been falling on the floor and getting up w/o (without) assistance and w/o telling somebody . Encourage resident to report falls and not get up without examination . INTERVENTIONS IMPLEMENTED . educated Pt (patient) to call for assistance and to wait for assistance. Also educated pt. that if .does fall to let a nurse or staff member know . The Intervention implemented is not effective for a confused resident. Further review of the medical record revealed multiple notes that documented the resident had some confusion. Review of a care plan titled . is at risk for fall related injury and falls R/T (related to): history of falls, Parkinson's, unaware of safety needs, impulsive Initiated 11/26/22, documented no new interventions or modification of interventions after the unwitnessed falls were reported. Review of the medical record revealed no documentation of the Interdisciplinary team to have identified the root cause of the resident falls or reviewed the interventions in R704's care plan to ensure effective and individualized interventions were implemented to prevent further falls. Review of a Nursing note dated 12/2/22 at 1:15 PM, documented in part . At approximately 1:15 PM writer was passing medications to resident and observed (R704) self ambulating with the wheelchair as a walker. Writer attempted to redirect resident to sit down as (R704) was looked <sic> unstable and was shaking, resident fell backwards and hit .head. Writer observed laceration to the back of .scalp, attempted to provide wound care . recommendation to be sent to ER (emergency room ) for further evaluation and possible stitches . Resident continued to attempt to stand and self-ambulate despite encouragement by staff to stay stationary until EMS (Emergency Medical Services) arrived . Review of an Incident and Accident Report dated 12/2/22, documented in part . Resident was walking with .wheelchair as a walker and fell on the floor. Patient hit .head . Physician requested that we send the patient to the ER (emergency room ) . INTERVENTIONS IMPLEMENTED . Educated the patient to use the walker to assist when walking. Also, educated to use the call button for assistance and to wait for assistance to come for assistance . Review of a hospital After Visit Summary dated 12/2/22, documented in part . Laceration Repair With Staples . Follow up with (Hospital name) Emergency Department in 5 days . For staple removal . Diagnoses . Fall . Laceration of scalp . Review of a physician order dated 12/3/22, documented in part Monitor scalp laceration for s/s (signs/symptoms) of Infection, notify physician of any changes . Further review of the medical record revealed the staff failed to document the number of sutures R704 received to repair the laceration to their scalp. On 1/3/23 at 1:17 PM, an interview was conducted with R704's Family Member (FA) A who stated the following, . We received a call on 12/2 saying that (R704) was at [hospital name] because (R704) had fallen and I was upset . I was there a few days before and told them about previous undocumented falls at the facility . I asked for the Incident reports from the falls . She (DON) told me I couldn't have a copy of it. I told her that I don't understand because we are just trying to understand how (R704) fell so that we can prevent it from happening again . I got two different accounts on how (R704) fell on ,d+[DATE] . (R704) had 8 staples in their head . Review of a facility policy titled Fall Management last approved on 8/18/22, documented in part . The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls . If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .

Based on observation, interview and record review, the facility failed to identify and assess behavioral changes (that included increased agitation, frustration, a decline in mental and psychosocial well-being), staff failed to follow care plan interventions and notify the physician of changes in the resident condition for one (R704) of one resident reviewed for a death, resulting in the failure of the facility staff to not have provided timely interventions and adequate supervision to R704 who was able to coordinate and carry out their suicide attempt in the facility. Findings include: Review of an Investigation Summary submitted by the facility to the State Agency (SA) documented in part, . the administrator conducted a complete and thorough investigation. The findings of the facility, the resident had a purposeful/deliberated agenda to cause/inflict self-injury. The staff had no knowledge or precursor that resident wanted to bring harm to himself. The resident's demeanor remained unchanged, (R704) was upbeat and there were no changes to their cognition or activities of daily living . The facility followed its abuse policy and self-reported this unforeseen event . Review of the medical record revealed R704 was admitted to the facility on [DATE], with diagnoses that included: Parkinson's disease, bipolar disorder and anxiety disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital paperwork provided to the facility documented the resident presented to the Emergency Department after a fall at home. Further review of the hospital paperwork revealed an Assessment PT (Physical Therapy) Forms that documented in part, . Pt (patient) presents well below baseline, unsafe for home dc (discharge), anticipate structured rehab at dc . The resident was admitted to the facility for rehab and expected to be discharged back home. Review of a Nursing note dated [DATE] at 5:31 PM, documented in part . At approximately 415pm writer observed resident self-propelling back and forth in the hallway in their wheelchair. Writer asked resident if there was anything they needed or anything that I could do for (R704) and (R704) said no. (R704) proceeded back into their room. About 15 minutes later writer was walking past residents room and saw resident on their knees in front of their closet. Writer went in to assess and observed resident with wireless phone cord wrapped around their neck and (R704) was hanging from closet bar. Writer called for help. Cut cord wrapped around residents neck and assisted to the floor. With assistance of other nurses, CPR initiated and 911 called . On [DATE] at 12:29 PM, a telephone interview was conducted with Family Member (FA) A (Family to R704) when asked if they had any concerns regarding the death of R704, FA A stated in part, . We have a lot of concerns involving (R704) death . My dad left at 2 PM (left the facility from visiting R704) . I got a call at 4:15 PM . (R704 name) is unresponsive and .is being transported to the hospital . We asked for the video and medical records from 2 PM to 4:15 PM . the police officer had been talking to us and they said in the report that he (R704) was agitated and wanted to go home and (the Director of Nursing- DON- name) denies it. It was all of this conflicting reports . On [DATE] at 2:27 PM, a message was left for the detective assigned to R704's death, however a return phone call was not received by the end of survey. On [DATE] at 3:23 PM, the administrator was asked to provide the facility's video footage for the date of [DATE] from 2 PM until the time of the incident. On [DATE] at 8:35 AM, the Administrator prepared video footage for the date of [DATE] from 2:23 PM until EMS left the facility to transfer R704 to the hospital. An observation and review of the video footage was completed and revealed the following in part: At 2:23 PM, R704 is observed in the hallway with a grey shirt on and blue pants. The resident was observed propelling and wheeling themselves in the hallway. Shortly after the resident is seen putting an object on the housekeepers cart. A staff member walks by and picked up the object from the cart and puts it back down and continued to walk down the hallway. At 2:35 PM, the housekeeping staff (later identified as housekeeping staff B) was observed to have picked up the object from their cart and gave it back to R704. From 2:37 PM until 2:49 PM, R704 is observed talking to a staff member in the hallway, going to the ice cooler in the hallway and entering and exiting their room multiple times. At 3:01 PM, a staff member enters the resident room (later identified as Physical Therapist- PT D) and exits the room with the resident. The resident appears agitated as they are observed circling in their wheelchair around this staff member in the hallway. The staff and R704 re-enters back into R704's room. At 3:02 PM, R704 is observed leaving their room with the staff member behind them. The staff member is seen talking to the resident in the hallway. R704 begins to follow the staff member to another hallway at 3:03 PM. At 3:07 PM, R704 is again observed on the hallway camera with the PT D holding the back of R704's shirt with the resident ambulating while pushing their wheelchair and entered back into R704's room. At 3:09 PM, a Certified Nursing Assistant (CNA) is observed to have enter the room and at 3:10 exited R704's room. At 3:12 PM, PT D exits R704's room. At 3:25 PM, a staff member enters in to R704's room and then exits a minute later. At 3:26 PM to 3:33 PM, the resident is again observed in their wheelchair in the hallway, talking to a staff member, going to the ice cart and standing up at the ice cart in the hallway, a staff member observes R704 standing up and briefly holds the back of R704's wheelchair up to the resident and at 3:33 PM, the resident enters into their room. A minute later at 3:34 PM, the resident wheels themselves back into the hallway and talks to a staff member. The resident re-enters their room at 3:36 PM. The resident is observed on the hallway camera a few seconds later at 3:36 PM, wheeling themselves to the middle of the hallway then re-enters into their room at 3:37 PM. At 3:41 PM, R704 is observed in their wheelchair in the hallway, two staff members are seen by the resident it appears the staff are talking to the resident. R704 is then observed propelling themselves up the hallway. At 3:45 PM, a staff member stops and talks to R704. R704 begins to propel themselves backwards in their wheelchair up the hallway and is no longer visible on the camera. At 3:46 PM, R704 is again observed on the hallway camera propelling themselves backward in their wheelchair to their room. Two minutes later at 3:48 PM, the resident exits their room and again re-enters into their room. At 3:57 PM, R704 is observed exiting their room into the hallway, with what appears to be a white towel on their lap. The resident is seen to have talked to two staff members in the hall and appears to grab another towel and propels themselves up the hallway out of the camera's view. At 4:00 PM, R704 is observed propelling themselves backwards in their wheelchair up the hall then turns the wheelchair around the correct way and uses the hallway wall bar to help wheel themselves in the hall. R704 is observed to have dropped a towel in the hallway. At 4:01 PM, a staff member picks up the towel and provides R704 with a new towel. R704 is observed in front of their room door, shaking a towel, drops a towel and covers their head with another towel. At 4:03 PM, R704 is seen propelling themselves in the hallway with a towel over their head. At 4:04 PM, a staff member stops and talks to the resident and leaves. At 4:05 PM, the resident enters their room with the staff member and the staff member exits out of the room at 4:06 PM. The staff member is then seen picking up the dropped towel from the floor. At 4:10 PM, a staff (later identified as Certified Nursing Assistant- CNA E) enters into the room and exits the room at 4:11 PM. At 4:38 PM, the nurse enters into the room and runs out of the room. The nurse re-enters the room at 4:38 PM, with another staff member and runs out again at 4:39 PM, the nurse is then observed grabbing the phone in the hallway and goes to the medication cart, bangs on the cart with their hand while reviewing the computer screen at the medication cart. The nurse is then observed running down the hall way and grabs the crash cart while running back to R704's room. From 4:39 PM from 5:18 PM, multiple staff members are observed running to R704's room, the Emergency Medical Services (EMS) arrives and at 5:18 PM, EMS is seen transporting R704 via stretcher in the hallway and out the exit door. On [DATE] at 12:16 PM, HS B was interviewed and asked about the interaction with R704 on [DATE], when R704 was observed to have put an object on HS B housekeeping cart and HS B picked up the object and handed it back to R704 as observed from the facility's video footage and HS B stated in part they were about to clean R704's room and R704 told HS B to throw the picture away. HS B stated (R704) said I don't want it (R704) used the F word . (R704) said F*** the picture . When asked what was identified on the picture, HS B stated it was a family picture with like four people in the picture . When asked if they told anyone about R704's attempting to throw away their family picture and stating F*** that picture, HS B replied no. HS B was asked if they thought it was a red flag that R704 was trying to throw away or give away their family picture and HS B stated it didn't register at the time, but the next day when they heard what happened with R704 it registered. HS B stated they did not inform anyone of the conversation with R704 until the next day when he heard what happened with the resident. When asked how R704 appeared to be that day, HS B stated usually he would see R704 in their room but this was the first day that they seen R704 was out of their room and in the hallways. HS B stated It was different. On [DATE] at 12:37 PM, Occupational Therapy Assistant (OTA) C was identified as one of the staff members that interacted with R704 in the hallway on [DATE]. OTA C was interviewed and asked about their interactions with R704 on [DATE] and OTA C stated that day the resident was pretty agitated and said (R704) had business to deal with and (R704) couldn't deal with us right now. OTA C stated they asked the resident if they wanted to go to the therapy room and they said No, I have business to deal with. OTA C stated they asked the resident if they wanted to talk and R704 replied No. OTA C then stated . (R704) was in the hallway rolling their wheelchair. (R704) was agitated about something and wouldn't tell me about it. I had not seen them like that before . OTA C stated they attempted to work with R704 twice that day but the resident refused. When asked if they told R704's nurse or anyone about the increased agitation and refusal to complete their OT exercises, OTA C stated they did not tell anyone. OTA C stated I did talk to the Certified Nursing Assistant (CNA) and asked what happened in R704's room because the nursing assistant was in the room cleaning up something and the CNA stated they didn't know but was cleaning it up. OTA C then stated they did inform their supervisor at the end of the day that they were unable to get my therapy minutes in with the resident. When asked why they didn't inform R704's nurse of the residents increased agitation, OTA C replied . (R704) was down at the nurses station and they (nurses) were standing out there, so I thought they saw (R704) and knew what the agitation was about. The nurses were just talking to (R704). (R704) was quite noticeable and very agitated . OTA C stated R704 liked a particular exercise machine in the therapy room so they tried to encourage the resident to come to the therapy room and see if it would relax (R704) and talk to them but (R704) said no, (R704) said they had business. OTA C stated this was the first time that R704 refused to do therapy with them, . (R704) kept talking about business that (R704) had to do . On [DATE] at 1:27 PM, PT D (the staff member observed on the facility's video footage holding the back of R704's shirt with the resident observed ambulating while pushing their wheelchair) was interviewed via telephone and asked about their interactions and therapy session completed with R704 on [DATE] and PT D stated they had worked with R706 the day before ([DATE]) and a little on ([DATE]) but R704 stopped at the gym door on [DATE] and said I don't want to go in there I have some business to take care of . I asked if (R704) was sure and they said yes. PT D stated R704 then jumped out of the wheelchair and ambulated while using the wheelchair which is unsafe so they held the back of the residents shirt while they walked. PT D stated the resident did not give them time to utilize a gait belt nor would R704 get back into their wheelchair. PT D stated they did see R704 a little later in the hallway but they couldn't understand what the resident was trying to say to them. PT D stated in part, . it seems like the effects of Parkinson's (R704) was having a hard time with speech and seemed frustrated . When asked if they informed R704's nurse or any administration staff of R704 frustration and refusal to complete their PT session, PT D stated in part . I tried to look for the nurse to tell her that I tried to attempt to see them and t(R704) seemed frustrated and I couldn't see them for therapy . but PT D stated they could not find R704's nurse that day. PT D stated they did talk to OTA C and told the therapist that they attempted to see them but (R704) didn't want to be seen and said they had to take care of business and OTA C stated they were trying to see R704 as well. PT D then stated . (R704)'s mood and behavior was much different that day, (R704) seemed was trying the best they could the day before doing all of the exercises that they could do and they walked back with a roll walker from the gym. It was like day and night as far as behavior . PT D then stated, . (R704) was trying to communicate, but I couldn't understand them and they seemed frustrated. I was confused because I thought it could be a side effect from Parkinson's because (R704) was real shaky . On [DATE] at 2:44 PM, Certified Nursing Assistant (CNA) E (Identified as the aide assigned to R704 on the evening of [DATE] and also the aide observed on the video footage going in and out of R704's room) was interviewed via telephone. When asked about their interactions and R704's mood on the day of [DATE], CNA E stated their shift started at three that day and they felt R704 was frustrated because they wanted to do therapy. CNA E stated prior to going to therapy R704 knocked over their food and water on their bedroom floor so they had to clean it up. CNA E stated when R704 came back from therapy they asked R704 what was wrong and R704 stated . I want to go home. CNA E stated R704 headed to the facility's exit door and they were able to talk to them and the nurse grabbed the back of the wheelchair and redirected (R704). CNA E stated . (R704) was between all of us and (R704) said I want to go home . I told (R704) let's at least eat dinner (this is one of the observations that was reviewed on the video footage when three staff members are seen around the resident, however the ice cart blocked a part of this observation on the facility's video footage). When asked if it was alarming that the resident was trying to leave, CNA E replied Yea, it was but (R704) was known for trying to leave before . I don't know what led to the agitation from dayshift, I don't know. I see them have a few episodes before were (R704) was agitated or just kind of shut down so it wasn't different for me . CNA E was asked if they were sure that R704 had other incidents of trying to leave the facility, agitation or withdrawal because there was no prior episodes documented in the record and CNA E stated that they had witnessed prior incidents. When asked about their interaction with R704 when they entered the resident's room at 4:10 PM on [DATE] (as seen on the video footage), CNA E stated . (R704) had threw water and food on the floor so I knew (R704) was agitated so I wanted to peek and see what (R704) was doing. CNA E stated the resident was observed in their wheelchair by the end of the bed watching tv. On [DATE] at 3:23 PM, Director of Social Services (DOSS) G was interviewed and asked if they talked to, assessed or had any interactions with R704 on [DATE] and DOSS G replied they did not. DOSS G stated they peeked in the resident's room after lunch and the resident was taking a nap so they didn't disturb them. When asked if they were informed of R704's increased agitation and abnormal mood and behavior on [DATE], DOSS G denied being informed. When asked if they were informed of R704 to have requested to go home, DOSS G stated they were. When asked who informed them of R704's request to go home, DOSS G could not recall. When asked if they talked to the resident to see if they wanted to be discharge DOSS G stated they did not talk to the resident but they did talk to R704's sister. When asked why they talked to R704's sister regarding the resident request to go home especially if R704 is their own responsible party and DOSS G stated they usually will talk to the family and also the resident, however the resident was sleeping when they peeked into their room. When asked if they were informed of R704 request for the second time in the evening to go home, DOSS G denied they were informed of R704's request. Review of the medical record revealed no documentation of R704 to have consented for DOSS G to have discuss with their sister their request to leave the facility and be discharged home. Review of a behavioral consult dated [DATE], documented in part . Complaint: Initial evaluation for psychiatric symptoms and medications . Pt (patient) says (R704) is tired today but mood is OK but a little anxious ,d+[DATE] currently. (R704) feels the medications help with mood and that the clonazepam helps with anxiety . Review of the CONTROLLED SUBSTANCES PROOF OF USE for R704's clonazepam 0.5 mg (milligram) tablet, give 1 tablet by mouth every 8 hours around the clock (anxiety medication which was scheduled for 9 AM, 1 PM & 9 PM) revealed on [DATE], the residents 9 AM dose was given at 11:37 AM (Two hours and thirty-seven minutes late) and their 1 PM dose was administered at 1:24 PM, not even two hours from the last dose. A medication that was needed around the clock to manage R704's anxiety was administered late on [DATE] and the behavioral consult that was conducted on the morning of [DATE] had already documented the resident's anxiety at 7 out of 10. It was verified by the facility's Director of Social Services (DOSS) G that the resident was seen by the behavioral group the morning of [DATE]. On [DATE] at 3:49 PM, Licensed Practical Nurse (LPN) F (the nurse assigned to R704 on the evening of [DATE]) was interviewed. When asked how R704 was the day of [DATE], LPN F stated in part . (R704) was antsy. I went on break and came back and (R704) was red and hot. I took their temperature but it was normal. (R704) kept going in the ice bucket and getting ice. The LPN F stated R704 was antsy even before they went on their break which they estimated was around 2:30 PM. When asked about R704 to have stated they wanted to go home, LPN F stated R704 was going up and down the hall and they redirected them a couple of times that day. When asked why R704 couldn't leave the facility if they wanted, LPN F stated they weren't sure. LPN F was asked if they notified the Social Worker, DON or Physician to inform them that the resident wanted to leave, LPN F stated No. LPN F stated . when (R704) was in the hallway they stated they wanted to go home. When asked if anyone asked R704 why they wanted to leave, LPN F stated they didn't remember why. LPN F stated R704 was not their own responsible party and would not be able to leave without family's approval. When asked why R704's anxiety medication was administered late the day of [DATE], LPN F explained it was a busy day with two discharges and wound care that had to be done before they finished administering the medications. When asked if they identified a change in R704's behavior on [DATE], LPN F stated . (R704) was off that day. (R704) was definitely off that day. Yes, I noticed changes in their behavior . At that time the typed Interview Statement which was submitted to the SA by the facility was read to LPN F, which documented in part, . [LPN F] . The administrator interviewed the charge nurse (LPN F) regarding this event . The administrator asked the charge nurse had she noticed any changes in the resident's behavior. She replied no . LPN F was asked if their statement was accurate and LPN F stated the typed statement was not accurate and LPN F stated again they had noticed changes in R704's behavior and stated . I'm pretty sure that I told the Administration that (R704) was off that day . When asked if they had informed the physician of R704's behavioral changes, LPN F stated they had not. LPN F was then asked to recall the time they found R704 unresponsive and LPN F stated in part, . I was walking by and I saw the lower part of the body. I entered the room I turned the first thing I saw was (R704) in their phone charger . (R704) was hanging from the front . and it was attached to the bar from both sides . LPN F stated with the help of other staff they lowered R704 to the floor and began CPR. Review of a care plan titled MOOD . has the potential for fluctuations in mood R/T (related to) . BiPolar DO (disorder), Adjustment D/O with mixed Anxiety and Depression Initiated [DATE], documented the following interventions . Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician . Encourage resident to express feelings and provide time to talk as needed . If resident . experiences mood fluctuations or increased anxiety; attempt to rule out potential causes . Observe and report to SW and/or physician prn acute changes in mood or behavior; feelings of sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities . diminished ability to concentrate . how resident interacts with others . Multiple facility staff failed to implement the interventions documented on the resident's care plan. Review of the medical record revealed a prescription dated [DATE], documented in part . Xanax 0.5 mg QHS (every hour of sleep) PRN (as needed) for anxiety . Further review of the medical record revealed the staff did not implement the order and there was no documentation that noted why the Xanax was prescribed. On [DATE] at 10:45 AM, the Director of Nursing (DON) was interviewed and was asked if they were informed that R704 refused OT and PT on [DATE], which was abnormal for R704 according to staff who stated all R704 wanted to do was therapy to get stronger and go home. The DON stated they were not informed. The DON was then asked if they were informed of the identified mood and behavioral changes with R704 on [DATE] and the DON stated they were not informed. When asked if they were informed that R704 requested to go home the DON stated a staff member did tell them, when asked what staff the DON could not recall. The DON stated they remember after being informed going to the resident's room and talking to the resident. The DON stated when they went to the resident's room R704's father was in the room and it was discussed that they wanted the resident to have a safe discharge and wanted to work on the goal of safely getting in and out of tub (which the resident had at home), the DON stated the resident was in agreement with staying at the facility to continue therapy and get stronger. When asked if they were informed later in the evening of the resident requesting to go home again, the DON stated they were not informed. When asked about the R704's anxiety medications to have been administered late when his anxiety level was already documented at a 7 out of 10 per the behavioral consult that was conducted on the morning of [DATE], the DON stated they were not aware that the medication had been administered late. When asked about the prescription found in the resident's chart for Xanax the DON explained when they talked to R704's sister the day of [DATE], and the sister stated if R704 doesn't get enough sleep they have changes in their behavior. The DON asked the sister what the resident took at home to help them sleep and the sister stated Xanax. The DON stated they talked to the doctor to obtain the order for the PRN Xanax. It was identified R704 requested to go home sometime before 2 PM (which is the estimated time R704's father left the facility from visiting R704) and again on evening shift when CNA E was on duty. R704 stated twice on the day of [DATE] that they wanted to go home. On [DATE] at 5:15 PM, the Administrator was interviewed and asked about the differences identified with the investigation summary submitted to the SA by the facility when compared to the staff actual interviews with multiple staff to have identified changes in R704's mood and behavior on [DATE] prior to the resident suicide attempt and the Administrator stated they had no idea why the staff would say one thing to them and another to the surveyor. The Administrator was then asked about the multiple staff to have identified the changes in R704's behavior and mood on [DATE], with the addition of the resident to have attempted to throw or give away a family portrait, decline OT and PT services which the resident had never done in the past (according to the facility staff) and the failure of staff to follow the interventions documented on the plan of care and notify the physician for additional interventions to be implemented as well as increased monitoring of the resident and the Administrator did not reply but acknowledged the concern. On [DATE] at 12:54 PM, Physician H was interviewed and asked if they were notified by the facility staff regarding the behavioral and mood changes of R704 on the day of [DATE] and Physician H replied they were not informed. Physician H was then asked if staff informed them on [DATE] that R704 requested to leave the facility and Physician H stated they could not recall having been informed. On [DATE] at 1:04 PM, the Administrator was re-interviewed and asked if they were notified by any of the facility staff regarding the mood and behavioral changes with R704 on [DATE] and the Administrator stated no. When asked if they were informed that R704 requested to leave the facility and go home twice that day, the Administrator stated they were not informed. The Administrator stated they believe their staff are remembering things in hindsight now looking back at the situation, which the Administrator believed was the reasoning for the differences noted in the investigation submitted to the SA when compared to the staff interviews with the surveyor. The Administrator stated the facility will be completing suicide education with their staff.

This Citation pertains to Intake #MI 220 Based on observation, interview and record review the facility failed to ensure fall prevention safety for one resident (R69) of four residents reviewed for accidents/falls, resulting in R69 falling forward out of their wheelchair and sustaining severe bruising and a laceration to the forehead that required nine sutures. Findings Include: A complaint was filed with the State Agency (SA) that alleged an incident occurred where Certified Nursing Assistance (CNA) Q flipped a resident who fell and sustained injury to their eye and head. The facility Fall Management Policy (revised 7/14/21) documented, in part: Policy: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls. Overview: Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls .Fall Defined: Fall refers to unintentionally coming to rest on the ground, floor . On 3/21/22 at approximately 11:02 AM, R69, who is a double above the knee [CONDITION(S)], was observed sitting in a wheelchair in their room. A scar was noted on their left forehead. When asked about falls in the facility, R69 reported that in January they were in their wheelchair in the hallway, fell forward, hit their head, and had to go to the hospital and received several stiches to their forehead and had some bruising. The resident later reported that a CNA had attempted to pull his shorts up when he was in his wheelchair causing him to fall forward out of the wheelchair on to the floor. The resident stated that his wheelchair was not locked and considered the incident an accident. A review of R69's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: acquired absence of right and left leg above knee, [CONDITION(S)], diabetes type II and hypertension. A review of the resident Minimum Data Set (MDS) noted the resident was cognitively intact and was not able to ambulate on their own. Continued review of the resident's clinical record documented, in part, the following: A progress note dated 1/25/22: Resident was in hall in his w/c. The CNA (Q) was pulled <sic>up his pants from the back of the w/c and resident fell forward onto the floor. Turned over to his back by nursing and found laceration to let side of forehead and abrasions to left hand knuckles. He was alert and oriented but very upset .EMS was called .to transfer to (name redacted) Hospital. Hospital Records dated 1/25/22: ED (emergency department) .Medical Decision Making: Patient .evaluated after a fall with forehead laceration .laceration was sutured, 9 sutures placed .Patient was instructed to return in 5 days for removal of stitches . An Encounter (physician) note dated 1/26/22: .Visit Type: Follow Up .Recent fall with laceration to the left forehead, extensive bruising laceration to the nose status post trip to ER and sutures .Patient .fell forward while pulling his pants up .he was restless and had to be sent out to the ER .Patient's face is severely bruised and has traumatic ecchymosis (discoloration of skin) . A review of the facility Incident and Accident (IA) report revealed: .Person Involved (R69) .Date of Occurrence 1/25/22 .Type of A/I: fall: Location of Injury: Laceration of L side of forehead, bleeding and swelling .sitting in hallway outside of room .Describe the nature of the Accident .Resident fell out of w/c while CNA Q was in the back of w/c and was pulling his pants up and he fell forward onto the floor- face first. Urinated on the floor @ time of fall .send to hospital .Post Fall Evaluation: 9 bil (bilateral) leg [CONDITION(S)] .Resident was up in wheelchair in hallway, wanted shorts adjusted, fell forward as assistance was provided . *It should be noted that the facility reported that there were no further investigation documents other than the I/A. On 03/23/22 at approximately 9:53 AM, an interview was conducted with CNA Q. CNA Q reported that on the morning of 1/25/22, R69 was in his w/c in the hallway and observed that his shorts were not fully pulled up and his stomach, that was large, was showing. She then asked R69 if he wanted his shorts pulled up and he told her that he did. CNA Q stated that she went behind the resident's w/c and pulled up his shorts and at the same time the resident fell forward and hit his head on the floor. When asked if she had received training on fall prevention and was familiar with R69, a double [CONDITION(S)] patient, CNA Q stated that she did receive fall prevention training and often was assigned to R69. When asked if pulling a resident's shorts from behind, especially for a double [CONDITION(S)] resident was appropriate, CNA Q stated that she probably should have asked for assistance or used a gait belt to ensure he remained stable in his w/c. On 3/23/22 at approximately 10:38 AM, an interview was conducted with the Director of Nursing (DON). When asked about R69's fall, the DON stated that if the CNA Q had asked for assistance, the fall could have been prevented. On 3/23/22 at approximately 03:23 PM and interview was conducted with Physical Therapist Manager (PT) R regarding R69's balance and the fall that occurred on 1/25/22. PT Manager R stated that as the resident is very top heavy and an [CONDITION(S)], the CNA should have requested assistance to ensure the resident's safety.

This citation pertains to MI 1364: Based on interview and record review the facility failed to perform cardiopulmonary resuscitation (CPR) and call Emergency Medical Services (EMS) for one (R#803) of three residents reviewed for CPR, resulting in an Immediate Jeopardy when CPR was not provided to R#803, who was a full code, when the resident was found without pulse and respirations and the resident expired at the facility. Findings include: The Immediate Jeopardy (IJ) started on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy electronically on [DATE] at 1:49PM. The immediacy was removed on [DATE]. Although the immediacy was removed, the facility remained out of compliance at the scope of isolated and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. A complaint was filled with the State Agency that alleged there were several deaths in the Facility due to Covid-19. Review of the clinical record for R#803 revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per the resident's minimum data set assessment dated [DATE] the resident scored 8 out of 15 on a brief interview for mental status (BIMS) exam, which indicated the resident was moderately cognitively impaired. A clinical note dated [DATE] indicated that R#803 had tested positive for Covid-19. Continued review of R#803's clinical record revealed a Nurse's Note authored by LPN 'B', effective date [DATE] at 9:00AM (created on [DATE] at 3:45PM), that documented the following: Writer was informed by the CENA (Certified Nursing Assistant) the resident was observed ambulating from the restroom back to the bed at approximately 7:20am. When Cena went to pass resident breakfast tray resident noted to be non responsive. Writer and another staff nurse went to assess resident. Noted absence of pulse no respirations resident cold and stiff. RN (Registered Nurse) in building notified time of death pronounced at 8:35 am by RN. Staff nurse notified family and NP (Nurse Practitioner) (Name Redacted) on call . Review of a physician order [REDACTED]. Per a Resident Code Status form signed by facility staff and signed on the Healthcare Legal Decision Maker Signature line on [DATE] it was documented the resident was a full code. Review of an Incident and Accident Investigation Form dated [DATE] revealed the following brief description of the incident: Don (Director of Nursing) was informed on the morning of [DATE] that resident (R#803) was deceased . The assigned LPN, (LPN 'B's) medical opinion was resident was cold and stiff, to <sic> far gone to be resuscitated an RN in the building called time of death. Per the conclusion section of the form it was documented, It was in the medical opinion of the LPN assigned to resident that she was to <sic> far gone to be resuscitated.Also per the form was the following: Nurse educated on code process and checking code status . The Quality Assurance Interview Summary of Resident Interview form revealed, in part, the following: Per an interview summary with LPN 'B' it was documented: 745 rounded and resident was lying in bed, Food carts came out around 830, CNA told (LPN 'B') resident was not responding. When I went in the room, resident was cold and stiff, no vital signs or signs of life. Per an interview summary with LPN 'A' dated [DATE] it was documented,(LPN 'A') was completing tx (treatment) <sic> across the hall from (R#803's) room, overheard CNA tell (LPN 'B') that resident was not breathing offered to assist with calling police and family. Per a CNA interview summary also dated [DATE] it was documented,Saw resident ambulate to bathroom around 720am, layed back down in bed, when passing trays noticed she was not responding and was cold to touch, went to get nurse. On [DATE] at 2:15PM, LPN 'A' was queried in regard to R#803. LPN 'A' acknowledged she was at the facility when the resident passed away, and indicated she was not the resident's nurse. LPN 'A' explained she had been doing wound care, and had been in a resident's room providing care. Per LPN 'A', a CNA had said loud enough for her to hear something like, She's not okay. LPN 'A was queried as to who the assigned nurse was for R#803, and LPN 'A' identified LPN 'B' as the resident's nurse. Per LPN 'A' she had gone in, the resident was laying straight with their feet up and the resident was not moving at all. When queried as to the time of day, LPN 'A' indicated this had occurred in the morning. LPN 'A' was queried as to whether CPR had been performed, and responded it had not been performed when LPN 'A' had been there. LPN 'A' explained she had asked what they had wanted her to do, and per LPN 'A' she was going to get the paperwork. LPN 'A' explained she did not know whether CPR had been performed for R#803, was unable to recall if emergency medical services (EMS) had responded, but did recall the police had responded. Per LPN 'A' after she looked at the paperwork she knew R#803 was a full code. On [DATE] at 3:09PM, LPN 'B' was interviewed via telephone in regard to R#803. LPN 'B' acknowledged she was the nurse on the day R#803 passed away. When queried in regard to detals of the situation, LPN 'B' explained she would have to look at her notes and would call back. On [DATE] at 3:09PM a second call was placed to LPN 'B', and a voicemail message was left at this time. A return call was not received prior to the exit of the survey. Review of a One to One Inservice Record dated [DATE] for LPN 'B' documented the following: Topic of Discussion: Checking code status and following preferences noted in the resident record. Reason: (R#803) did not recieve CPR she was a full code. Expected Outcome: CPR will be performed on all full code residents. This document was noted to have been signed on [DATE] by LPN 'B' and the facility's Director of Nursing (DON). On [DATE] at 4:17PM, the facility's DON was queried in regard to R#803. Per the DON, CPR had not been done for the resident, and the DON had completed an investigation. The DON explained the nurse (LPN 'B') who was assigned to the resident had the opinion the resident was too far gone. Per the DON the nurse explained the resident was cold to the touch and stiff. The DON was queried as to whether CPR should have been performed for the resident, and responded yes because the resident was a full code. When queried as to whether EMS had been contacted, the DON acknowledged they had not been contacted. When queried as to when EMS would be contacted, the DON explained that if a code blue was called and CPR was initiated then EMS then 911 would be called. Review of a facility policy titled, Medical Emergency Management dated ,[DATE] revealed, in part, the following: The facility ensures guests/residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the guest's/resident's Airway, Breathing, and Circulation are maintained until emergency personnel arrive. Staff is aware of each guest's/resident's code status prior to the administration of cardio-pulmonary resuscitation .4. Once a medical emergency is identified, qualified staff evaluates the guest/resident, initiates the appropriate emergency procedure(s), and calls Emergency services 911. The staff continues to provide care and monitor the guest/resident until the emergency personnel arrive. The facility submitted the following accepted plan of removal: (Facility Name) Removal of Immediate (Facility Name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F678 regarding the facility's alleged failure to perform cardiopulmonary resuscitation (CPR) on resident #803, who was a full code. 1. Resident identified to be affected by the alleged deficient practice. R#803 no longer resides in the facility. 2. Residents with the potential to be affected by the alleged deficient practice. On [DATE] the 9 residents that resided in the facility that expired in the facility were reviewed to ensure CPR was performed in accordance with resident preferences. 8 out 9 residents had CPR performed in accordance with their preferences. On [DATE] there are 77 residents currently residing in the facility and 77 out of 77 resident charts were reviewed to ensure the code status reflects the resident preferences. 3. Systemic Measures The facility policy on Emergency Medical Management and Code Status was reviewed and deemed appropriate on [DATE] and no changes were made to the policies. There are currently 25 licensed Nurses on staff at the facility. The re-education began on [DATE] at 2:00 pm with staff that was in the facility regarding the Emergency Medical Management and Code Status as of 3:30pm on [DATE] there are been 13 out 25 nurses educated. The remaining licensed nurses will be re-educated prior to the start of their next shift scheduled. 4. Quality Assurance An Ad Hoc QA meeting was held on [DATE] with the Medical Director via tele-conference and with the IDT team to review the policies on Emergency Medical Management and Code status. The administrative nurses will review residents who have expired in the facility weekly for 4 weeks and monthly for 2 months to ensure CPR was performed in accordance with the resident's preferences. Any areas of non-- compliance will be addressed immediately and will be reported to QAPI Committee for further recommendations. The Administrator is responsible for sustained compliance. Date of compliance is [DATE]

This citation pertains to Intake #MI 592 Based on observation, interview, and record review, the facility failed to timely review a radiology addendum report and timely notify the physician of a non-displaced fracture to the left ankle for one (R#503) of two residents reviewed for falls, resulting in: pain, a delay in treatment and an emergency room hospital visit. Findings Include: On 9/3/19 at 10:31 a.m., R#503 was observed sitting in a wheelchair at the bedside with a splint/cast wrapped in an ACE (All Cotton Elastic) compression bandage on the left leg. When asked what happened, R#503 stated, I can't think right now. When asked if they had a fall, R#503 stated, I can't remember falling out of the bed. At that time, R#503's Family Member 'D' was in the room visiting and stated, She (R#503) fell on the 20th of August. They (facility) finally took her to the hospital on the 26th . Family Member 'D' further stated, That was her second fall. A review of the clinical record revealed R#503 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the Minimum Data (MDS) assessment dated [DATE] revealed R#503 had a BIMS (Brief Interview of Mental Status) score of 4/15 which indicated severely impaired cognition and required extensive assistance with one to two-person physical assist with activities of daily living (ADLs). The MDS documented R#503 had one fall with one injury (not major). Further review of the facility's Incident and Accident (I&A) Report dated 8/20/19 at 3:15 p.m., revealed the following: .Called to resident's room. Upon entering, observed resident lying on floor @ (at) foot of bed. Asked what happened, stated 'I was trying to get up.' No physical injury. Able to move all extremities. Denied pain . Dr. 'G' and Family Member 'D' both were notified on 8/20/19 at 3:45 p.m . Interventions Implemented: Monitor frequently during shift change. Kept bed in lowest position. Call light in reach . A review of the Radiology Report completed by mobile x-ray (Company 'H') revealed the following: 8/23/19 at 10:16 p.m. - Reason: Pain in left foot. Pain in left ankle and joints of left foot . FOOT - Results: There is diffuse bone demineralization. There are [MEDICAL CONDITION] changes of the first metatarsophalangeal joint, mid foot and interphalangeal joints. No acute fracture, dislocation, or destructive osseous lesion. No foreign body seen. Conclusion: [MEDICAL CONDITION] changes of the left foot without acute osseous abnormality. ANKLE - Results: The ankle mortise is preserved without fracture or dislocation. There is ankle soft tissue swelling. No foreign body is seen. Conclusion: Ankle swelling but no fracture. Further review of the Addendum Radiology Report revealed the following: 8/23/19 at 11:27 p.m. - Addendum: .Subtle cortical disruption in base of left medial malleolus most likely a non-displaced fracture. Please correlate clinically and F/U (follow-up) recommended. A review of the Progress Notes revealed the following: 8/23/19 - 21:30 (9:30 p.m.) - Nurses Note: Writer, Licensed Practical Nurse (LPN - 'E'), was checking on resident and resident pushed back her covers and stated that she was trying to situate her left leg. Resident stated, 'My right leg is alright, but something is going on with my left leg.' Asked resident if it was bothering her and she stated, 'Yes.' Notified Dr. 'G' of left leg distress and new order for STAT X-RAY. 8/24/19 - 09:13 (9:13 a.m.) - eMar (electronic Medication Administration Record) - Medication Administration Note: [MEDICATION NAME] Tablet 325 MG (milligram) Give 1 tablet by mouth every 6 hours as needed for Mild Pain Left Foot Signed by LPN 'E'. 8/25/19 - 21:52 (9:52 p.m.) - Nurses Note: Without signs or symptoms of pain, respiratory distress, bleeding or new skin concerns. Resting in bed with call light within reach and refuse to turn. Will continue to monitor for any changes . Signed by LPN 'E'. 8/26/19 - 08:05 (8:05 a.m.) - Physician Note (Dr. 'G'): . Seen today in evaluation per the request of nursing regarding left ankle swelling noted on 08/25/2019 . The patient was complaining of discomfort to her left ankle. There are no reports of trauma. X-ray was obtained of her left ankle that showed ankle swelling, but no fracture. Ankle mortise is preserved without fracture or dislocation . She has swelling to her left ankle; it is tender to touch . Assessment: Left ankle contusion and [MEDICAL CONDITION]. Plan: 1. Recommend leg elevation. 2. Continue Tylenol 325 one q (every) 6h (hour) for pain as needed. 3. Physical therapy and occupational therapy to evaluate. 4. We will continue to monitor. 8/26/19 - 10:39 (10:39 a.m.) - Addendum dated 8/23/19 . Nurses Notes: An addendum added to X-RAY states: Subltle (sic) cortical disruption in base of left medial Mallelolus (sic) most likely a non-displaced fracture. Notified (Name), Dr. 'G' and new order: Transfer to (Name) Hospital 'J' ER (emergency room ) for findings on X-ray . Signed by LPN 'E'. 8/26/19 - 16:18 (4:18 p.m.) - eMar- Medication Administration Note: [MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth one time only for Pain for 1 Day Left Foot. Signed by LPN 'E'. 8/26/19 - 18:26 (6:26 p.m.) - Nurses Notes: RN (Registered Nurse) supervisor (RN 'F') in to assess resident . Resident recently medicated for pain, effects are noted . Signed by RN 'F'. 8/26/19 - 18:52 (6:52 p.m.) - Nurses Notes: Received via EMS (Emergency Medical Services) accompanied by 2 EMS staff . The facility's Pain Evaluation dated 08/23/2019 - 21:30 (9:30 p.m.) revealed R#503 exhibited occasional pain/hurting in the Left Ankle over the last 5 days with a pain intensity rate of 8 out of 10. The Evaluation further revealed the Quality of Pain included tenderness, soreness and aching. Pain has interfered with Increased Anxiety/Fear. Indicators of Pain were Vocal complaints of pain and Facial expressions. Timing and contributing Factors were Repositioning and with ADLs. Signed by LPN 'E'. The Pain Evaluation dated 08/26/2019 - 18:12 (6:12 p.m.) revealed R#503 experienced pain/hurting frequently in the Left Ankle over the last 5 days with a pain intensity rate of 8 out of 10. The Evaluation further revealed the Quality of Pain included tenderness, soreness and aching. Pain has interfered with Behavior/Mood, Increased Anxiety/Fear, Made it hard to sleep at night, and Limited day-to-day activities. Indicators of Pain were Vocal complaints of pain and Facial expressions. Timing and contributing Factors were Repositioning and with ADLs. New order post hospital: [MEDICATION NAME] 650 mg every 6 hours while awake times 3 days and follow up with Orthopedic physician. Signed by LPN 'E'. Further review of the eMAR for (MONTH) 2019 revealed the following: Physician Order: 07/29/2019 - [MEDICATION NAME] Tablet 325 MG Give 1 tablet by mouth every 6 hours as needed for Mild Pain. The eMAR revealed on 8/22/19 at 04:26 (4:26 a.m.), R#503's pain level was 8 and pain medication was administered. On 8/24/19 at 09:13 (9:13 a.m.), R#503's pain level was 6 and pain medication was administered. Physician Order: 08/26/2019 - [MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth one time only for Pain for 1 day. The eMAR revealed on 8/26/19 at 16:18 (6:18 p.m.), R#503's pain level was 8 and pain medication was administered. A review of the notes from Hospital 'J' dated 08/26/2019 - 12:01 p.m. and 12:02 p.m., revealed the following: ANKLE LEFT . Clinical Indication: status [REDACTED]. Technique: 3 views of the left ankle. Finding: There is step-off deformity of the distal tibia and linear lucency through the medial malleolus compatible with acute fracture. There is diffuse osseous demineralization. There is soft tissue swelling about the ankle. [MEDICAL CONDITION] changes of the tarsals are seen. Impression: Nondisplaced [MEDICAL CONDITION] malleolus and surrounding soft tissue swelling of the ankle . FOOT LEFT . Clinical Indication: status [REDACTED]. Technique: 3 views of the left foot. Findings: There is nondisplaced [MEDICAL CONDITION] malleolus again suggested with surrounding soft tissue swelling. There is joint space narrowing and osteophytosis of the tarsals. Joint space narrowing is noted of multiple interphalangeal articulations. There is diffuse osseous demineralization. Impression: Fracture of medial malleolus and surrounding soft tissue swelling . TIBIA AND FIBULA . Clinical Indication: status [REDACTED]. Technique: Frontal and lateral views of the left tibia and fibula. Findings: There is a buckle deformity of the medial malleolus of the ankle. There is soft tissue swelling about the ankle. There is diffuse osseous demineralization. Extensive [MEDICAL CONDITION] osteoarthritic changes of the tibiofemoral and patellofemoral articulations of the knee are seen. Impression: Buckle deformity of distal tibia compatible with fracture. Soft tissue swelling about the ankle. Diffuse osseous demineralization . On 9/4/19 at 3:40 p.m., during an interview, when asked why there was a delay in sending R#503 to the hospital for treatment after experiencing and complaining about pain on 8/23/19, LPN/Unit Manager 'B' stated, On 8/23/19, the resident (R#503) complained of pain to left lower extremity. X-rays were ordered. The initial report stated negative fracture. We didn't know there was an addendum to the report that noted there was a displaced [MEDICAL CONDITION] medial malleolus until the 26th (8/26/19) . When asked about the procedure of facility faxes for radiology results, LPN/Unit Manager 'B' stated, For stat x-rays, the nurse caring for that resident is responsible for monitoring for the results, notifying the physician of the results, and if it (results) doesn't come on that shift, then whoever is relieving that person is supposed to get the report. LPN/Unit Manager 'B' further stated, LPN 'E' noted the pain and notified the physician, and got a stat x-ray, and RN 'F' was the nurse on the next shift. On 9/4/19 at 3:58 p.m., during an interview, when queried about the process of R#503's delayed treatment after the fall on 8/20/19 and complaint of pain on 8/23/19, LPN 'E' stated, I heard that she fell from the bedside. Her bed was in the lowest position when I got there. I stayed over for another shift. I did frequent checks. She (R#503) was pushing the covers back. I thought it was her arthritis, so I asked her what's wrong and she said, 'My leg hurt.' I asked her what leg hurt? She said, 'My right leg is alright.' Then she said her left leg hurt and was really, really bothering her . I called the doctor and he said, 'I want an stat x-ray .' The stat x-rays came back negative. When asked about the addendum, LPN 'E' stated, We didn't know about the addendum on the 23rd . The doctor came in (8/26/19) and signed the order and looked at her as well. LPN 'E' was queried when did she know that R#503 had a fracture? LPN 'E' stated, When the DON (Director of Nursing) notified me. I don't go back and look at the same results, we are not used to them adding addendums . During the conversation, LPN 'E' stated, If I informed her (the nurse - RN 'F') after me that I already called, she is not going to call after me . LPN 'E' further stated, That was a delay in treatment. That is not fair to the resident or the family. The ball was dropped somewhere . On 9/4/19 at 4:30 p.m., an interview was conducted with the DON. When asked about the original fax from Mobile Radiology Company 'H', the DON stated, (Name) Radiology Company 'H' do not have a copy of the original fax. They said the original fax was sent over on 8/23/19 at 10:18 p.m., and the addendum fax was sent on 8/23/19 at 11:32 p.m. The DON was asked when the facility receive faxes from Radiology Company 'H', what is the procedure to ensure staff and physicians are notified of the results in a timely manner? The DON stated, A licensed nurse should receive and review the fax and notify the physician . The DON was then asked if that procedure was followed for R#503? The DON stated, I don't know exactly what happened . That was on Friday night (8/23/19). There was Saturday and Sunday, and we reviewed it on Monday . The DON further stated, (Name) Radiology Company 'H' did not have it set up in their file to call the facility when an addendum is faxed . At that time, there was only page one of two pages that were faxed to the facility from Radiology Company 'H' that was provided. Page two of the faxed (Addendum) revealed the results of R#503's fracture. When asked the whereabouts of page two, the DON did not have an explanation and stated, I have to call (Name) Radiology Company 'H' to see if they could fax another copy . On 9/4/19 at 4:34 p.m., a called was placed to RN 'F' for an interview. There was no answer and the voice mail box was full and could not accept messages. On 9/4/19 at 4:56 p.m., during an interview, when asked if he was notified that R#503 had a fracture, Dr. 'G' stated, I saw her on 8/23/19. On 8/23/19, the x-ray was done and did not show a fracture. I prescribed Tylenol and wrote for PT (physical Therapy) to see her. I saw her again on Monday morning (8/26/19) at 8:05 a.m. I signed off on the only report that I saw. I got a call later around 11:?? (am) that said she (R#503) had left ankle pain and they had an addendum come through that there was a fracture. Dr. 'G' further stated, The addendum never came through to me until later Monday on the 26th . On 9/4/19 at 5:40 p.m., during an interview with the Administrator and DON, when asked where the fax machine was located where R#503's radiology results would have been received, The DON stated, Station 1. When queried why Radiology Company 'H' faxed addendum results were not obtained by staff from the fax machine for three days (8/23/19 -8/26/19), and why the physician was not notified before Monday (8/26/19), the DON stated, I don't know. At that time, a policy was requested for Radiology Services and Physician Notification. The Administrator and DON stated, We don't have one . It would have to be Change in Condition. A review of the facility's policy titled Significant Change revised 11/2017 revealed the following: Purpose: Facilities have an ongoing responsibility to assess the resident's status and intervene to assist the resident to meet his or her highest practicable level of physical, mental and psychosocial well-being . Procedure: .4. A Significant Change: is a major decline or major improvement in a resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting .

This citation pertains to Intake #MI 239 Based on observation, interview and record review the facility failed to ensure a safe transfer for one (R#701) of three residents reviewed for falls/accidents, resulting in the resident sustaining an acute [MEDICAL CONDITION] fibula, pressure sores to the left heel, decline in mobility and pain. Findings include: On 2/12/19 a complaint was made to the State Agency alleging R#701 had sustained a fracture during transfer and follow-up care was not properly provided. On 3/25/19 at approximately 9:00 AM, R#701 was observed lying in bed. R#701 was alert, but had difficulty hearing and appeared confused at times causing difficulty answering questions. Soft heel protectors were observed on both the resident's left and right heels. The residents third toe on the left foot appeared bloody. A review of R#701's clinical record documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set ((MDS) dated [DATE] documented that the resident was severely cognitively impaired and required extensive one person assist for all transfers. Further review of R#701's clinical record documented, in part, the following: Progress note (1/21/19): Resident states CNA (certified nursing assistant) was helping to bed from wheelchair and her (CNA) right foot got tangled up with hers putting shoes on .resident stated it was an accident .resident C/O (complained) of pain to right ankle and visible swelling noted. Doctor notified and ordered a STAT x-ray to right ankle to r/o (rule out) fx . Progress note (1/21/19): .X-ray results for right ankle came back positive for acute fracture without dislocation. Doctor notified and ordered her to be non-weight bearing and he will see her in the morning . Progress note (1/22/19): X-ray results show fracture to RLE (right lower extremity. Resident to r/u (follow up) with orthopedics and a CAM (a boot the controls ankle movement) is to be ordered . Progress note (1/22/19) .Resident's feet became entangled with CNAs feet during transfer . Progress note (1/22/19)Resident was transferred into w/c this am for breakfast in w/c by therapy then transferred back after breakfast by same therapist (she used pivot transfer) . Progress note (1/24/19): Resident evaluated .for functional decline decreased upper body strength .unable to get in/out w/c (wheelchair). Progress note (1/29/19): Resident has SDTI (suspected deep tissue injury)/medical device related to injury to right heel. Area is 2.1x 2.8 purple tissue surrounded by pink skin. Resident has a foot/leg brace due to fracture. Informed (name redacted) New order to leave boot off and only wear boot during transfer. Resident in non-weight bearing . Progress note (2/7/19): .still c/o intermittent right ankle pain .acute fracture with pain involving distal fibula CAM walker boot was ordered but caused pressure sores to right great toes and heel. CAM walker currently discontinued .continue with (name redacted) medication which is helping pain . Progress note (2/14/19): .Patient c/o increased pain right foot. Per wound care team right heel is not better . Progress note (2/28/19): Reason for visit: uncontrolled pain .still with right foot pain . A Radiology Result Report dated 1/21/18 documented, in part: Procedure: Ankle .Reason for study: Pain in right ankle and joints of right foot Results: there is a fracture involving distal fibula with no displacement .there is associated soft tissue swelling. An Incident and Accident Report dated 1/21/19 and documented in part, the following: Person involved: R#701 .Date of Occurrence: 1/21/19 .Type of A (accident) other: twisted my foot .Location of Injury: R ankle painful to touch, slightly swollen .Describe the nature of the Accident/Incident .Resident states CNA was helping me to bed from w/c my feet got tangled up .while putting my shoe on, she twisted my foot, It was an accident . CNA assigned: CNA D Nurse G completed report . Interventions: educate staff that residents foot is planted on floor and proper placement of foot when putting on shoes on to prevent injury . On 3/25/19 at approximately 11:30 AM an interview was conducted with Wound Nurse C. When queried as to the pressure sore being treated on R#701's right heel, Nurse C reported that she had started working at the facility about one month ago, but knew that the resident had a fracture to the right ankle/fibula and was wearing a walker boot that caused an unstageable deep tissue pressure sore. Nurse C indicated that the resident's pressure sore was not healed, but was being treated. On 3/25/19 at approximately 11:45 AM an interview was conducted with CNA D. CNA D reported that she started her first job as a CNA in (MONTH) (YEAR). CNA D was queried as to the incident involving R#701. CNA D reported that she was assigned to work with R#701 and indicated that the resident was a one person assist for transfers. CNA D further indicated that she was assisting the resident from the bathroom back to bed in the wheelchair and when transferring the resident her foot got tangle up R#701's feet and the residents feet got twisted. When queried as to whether the resident had shoe on at the time or transfer and whether there was a problem either with putting on or taking off the resident's shoes, CNA D stated, I believe she had her shoes on when I transferred her. I don't remember putting them on or off, but I received some training on how to properly transfer residents. When further queried as to whether the resident reported any pain during the transfer, the CNA D stated, No. On 3/25/19 at approximately 3:20 PM an interview was conducted with Nurse G pertaining to R#701. Nurse G reported that she worked the day shift that day (1/21/19) and R#701's friend/guardian reported to her that the resident's leg was swollen and she was reported pain. When I talked to the resident she told me, she got it twisted with someone else's foot. On 3/25/19 at approximately 3:45 PM an interview was conducted with the Director of Nursing (DON). The DON was queried as to the incident the resulted in a fracture to R#701's right fibula. The DON reported that it was an accident and stated, Somehow the residents foot/leg got tangled with another staff person's leg. The resident has [MEDICAL CONDITION] and we were not sure if that is what caused the fracture. The DON did report that the CNA was trained on transferring, including foot placement and applying shoes. When further queried as to the pressure ulcer that resulted from the CAM that the resident needed to wear as a result of the fracture, the DON reported that the pressure ulcer is being treated by wound services. A request for the Facility policy(s) pertaining to transfers/accidents was requested prior to exit. A policy titled, Fall Management was provided, no policy's pertaining to accidents/transfers was provided by the end of the survey.

The citation has for deficient practices: Deficient Practice #1 Based on observation, interview, and record review, the facility failed to adequately maintain a shower chair for one (# 204) of 12 sampled residents reviewed for incidents and accident hazards from a total sample of 20, resulting in a fall with subdural hemorrhage (bleeding in the brain), contusion (bruise with swelling). Findings include: Resident #204 On 4/15/2014 at 9:15 A.M., resident #204 was observed sitting up in wheelchair at bedside. The resident had noted bruising to left hand and right upper arm and bandage to left ear. Resident #204 stated, "I hurt my head when I fell ." The resident was not verbal of specifics related to the fall, but recalled falling after having a shower. On 4/15/2014 at 10:00 A.M., employee "D"(Nurse Practitioner) was interviewed. She stated, "I heard that the shower chair broke. Resident #204 is oriented and did not try to get up on his own." On 4/15/2014 at 11:00 A.M., resident # 204's clinical record was reviewed. A review of the face sheet and nursing notes identified that the resident was originally admitted on [DATE] and returned from the hospital on [DATE] during the day shift. Diagnoses: [REDACTED]. A review of "MDS (Minimum Data Set) Resident Assessment and Care Screening" dated 2/8/2014 noted cognitive skills that were independent. The resident required total assistance with transfers and a two person physical assist. A fall risk assessment dated [DATE] noted that the resident was at risk for falls with care plan initiated. A plan of care for falls, dated 2/5/2014, noted fall risk due to decreased mobility secondary to recent trans-metatarsal amputation of right toe, needs assist with activities of daily living and transfers with two assist. Interventions noted that resident #204 needs a safe environment. On 4-16-2014 at 10:00 A.M., the facility's Incident and Accident Report dated 3/30/2014 at 12:00 P.M. were reviewed. It was identified that staff were assisting resident #204 out of the shower chair when the CNA's (certified nursing assistants) reported that the shower chair broke while transferring. Resident #204 went backwards hitting his head on the chair in the room. On the nurse assessment the resident was observed with ? dollar size hematoma at the posterior head near neckline. The resident complained of pain to area on a scale of 8 out of 10 (10 equals severe pain). The resident remained alert and verbal. The physician was notified and informed; the daughter (responsible party) was in room at time of incident. The physician ordered to send to emergency room for CT (cat scan) of head and precaution. The resident transfer form dated 3/30/14 at 12:00 P.M., noted CT, r/t (due to) hematoma. On 4/16/14 at 12:20 P.M., employee "A" Certified Nurse Aide was interviewed. Employee "A" stated, "I had just brought the resident back from his shower. I was moving the table out the way while his assigned aide, employee "B" was behind the shower chair. I turned and saw the resident falling backwards while sitting on the shower chair. The white plastic part on the back and arm of the shower chair was cracked and came apart. The resident went backwards onto the floor. We caught him but he hit the floor and head hit the room chair ...The bucket under the shower chair had been filled with water. The floor flooded so we moved the resident so he would not be lying in water, picking him up and placing him into the bed (before the nurse was called in to assess). We had not been aware that the resident had hit his head until afterwards. We saw a crack on the shower chair afterwards." On 4/16/14 at 12:20 P.M., employee"B" Certified Nurse Aide was interviewed. Employee "B" stated, "I was assisting with transferring the resident back to bed. I was setting up the chair into position when a piece, the back of the chair broke. Resident #204 went back ... I caught him and lowered him to the floor. We did not want him lying in water so we lifted him up and placed into bed ...I had not noticed a problem with the shower chair, but it was pulled off the floor and taken to maintenance." On 4/17/14 at 9:30 A.M., employee "C" the Maintenance Director was interviewed. Employee "C" stated, "I was not here when the incident happened. The shower chair was removed and placed in my office. Complaints of problems with the shower chair that had been reported. We usually try to check equipment for repairs weekly. The shower chair was thrown away and replaced with two new ones." On 4/16/14 at 3:30 P.M. and 4/18/14 at 11:00 A.M., the Director of Nursing was interviewed. She identified that the investigation was completed and that resident #204 was in room in the shower chair when the shower chair broke causing the resident to fall backwards striking his head on the room chair. The DON was queried regarding the maintenance of the shower chair and denied a history of problems with the shower chair. "It could not have been more than 2-3 years old." The DON went on to state, "The male CNA is large and possibly with the pressure of repositioning the male resident in the shower chair cause it to pop or break. We had a shower team who is supposed to report concerns with the shower chairs or equipment." The DON was unable to verify the specific age of the shower chair. It was noted that the shower chair had been thrown away and that the facility purchased two new shower chairs. A review of the "Fall Management" policy and practice guidelines dated 5/2010 note that "fall" refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). Practice guidelines: 3. when a fall occurs, the licensed nurse will assess the resident for injury. Do not move the individual until he/she has been examined by a nurse. ( ) Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to ensure that one Resident (#207), of 12 sampled Residents who were reviewed for falls out of a total sample of 20 Residents, who had been assessed as at high risk for falls and who had a history of [REDACTED]. Findings include: On 4/16/14 at 10:45 A.M., Resident #207 was observed in the room in a wheelchair. The Resident appeared calm, was alert to person and indicated that she was cold and wanted an additional blanket to cover herself with. On 4/16/14 at 10:50 A.M., Resident #207's complete clinical record was reviewed. The Resident's face sheet revealed the Resident was admitted into the facility on [DATE] and readmitted on [DATE] after a hospital stay. The [DIAGNOSES REDACTED]. Resident #207's Minimum Data Set Assessment (MDS), dated [DATE], revealed the Resident was severely cognitively impaired and was dependent on one staff person for extensive assistance with transfers, but could independently move about in the facility with the use of a wheelchair. Resident #207's most recent Minimum Data Set assessment dated [DATE] revealed the Resident was severely cognitively impaired and was totally dependent on two staff persons for transfers (i.e. from bed to wheelchair), and dependent on one person to assist with locomotion throughout the facility. Resident #207's "Resident Care Guide", dated 9/13/13, used by CNA's to direct the Resident's every day care needs, revealed "Cannot leave in BR (bathroom) alone." Resident #207's "Resident Care Guide", dated 10/25/13, revealed, "At risk for falls", "E" (extensive assist required), of 1 staff person. Resident #207's "Fall Care Plan" was reviewed and revealed: - An update dated 11/12/12 which revealed, "Keep in common areas when up in w/c (wheelchair)"; this intervention was discontinued on 6/5/13 with a note indicating "more calmer by self". - An update dated 11/7/13 which revealed, "(Resident #207) is unable to effectively use call light, secondary to impaired cognition, when needing assistance. Resident frequently has hallucination that items are on the floor and under bed and needs to pick them up. Has history of falls. Ensure that (Resident #207) is wearing non-skid footwear when ambulating or mobilizing in wheelchair." - An update dated 12/27/13 revealed, "anti-roll backs to wheelchair when available." - An updated (undated) revealed, "(Resident) propels in w/c (wheelchair), but needs to be kept in common areas when up in w/c due to increase confusion, impulsiveness and unaware of safety." This intervention was noted on being discontinued on 10/24/13 without any notation as to why intervention was discontinued. Resident #207's "Fall Risk Assessment" dated 10/16/13 indicated the Resident was at risk for falls due to a history of falls, muscle weakness, prescribed medications, impaired vision and impaired cognition. A review of "Incident and Accident Reports" (I/A's) for Resident #207 revealed the Resident fell , without injury, after attempting to self ambulate on each of the following dates: - On 5/16/13 at 8:15 A.M., the Resident fell in the room while unsupervised; the I/A report noted "Intervention Implemented: Resident removed from room to common area to be monitored by staff"; - On 5/25/13, at 7:45 A.M., the Resident fell in the room while unsupervised; the section of the I/A report "Intervention Implemented" was left blank; - On 5/25/13 at 11:15 (A.M. or P.M. not denoted on report), Resident fell while at nurses station; the section of the I/A report "Intervention Implemented" was left blank; - On 9/10/13 at 5:33 P.M., the Resident fell in the room while unsupervised; the I/A report noted "Intervention Implemented: Safety reinforced. Non-slip stockings or shoes. Position in w/c (wheelchair) to be monitored." - On 10/12/13 at 12:30 A.M., the Resident fell in the room while unsupervised; the I/A report noted "Intervention Implemented: Pt (patient) to reorientate/redirected if 0 (no) results pt is to get PRN (as needed (antianxiety medication) as ordered to calm patient." - On 10/13/13 at 12:00 P.M., the Resident fell in the room while unsupervised; the I/A report noted "Intervention Implemented: Keep floor picked up (clean)." - On 10/29/13 at 12:15 P.M., the Resident fell in the room while unsupervised; the section of the I/A report "Intervention Implemented" was left blank; - On 12/26/13 at 8:15 P.M., the Resident fell in the room while unsupervised; the I/A report noted "Intervention Implemented: staff to ensure bedside table within reach of Resident at all times." - On 12/29/13 at 9:00 P.M., Resident #207 fell in the Resident's room and sustained a skin tear to the Right forearm and a Right hip fracture. The I/A indicated that on 12/29/13 the Resident was observed on the floor by a CNA (Certified Nursing Assistant) and the Resident stated "trying to go to the bathroom." The Report indicated the Resident was wearing a "shoe and a sock on the right foot, but a gripper sock only on the left foot." The section of the I/A entitled, "Re-Creation of Last 3 Hours Before Fall" revealed, "Resident stated wasn't feeling good. Placed in bed at start of shift (3:00 P.M.). Resident attempted to get out of bed numerous times, but refused to go in chair, stating was tired." The section of the I/A entitled, "Review of Contributing Factors" (check all that apply): "footwear" and "mood or mental status" were indicated. The I/A indicated the Resident was last toileted 30 minutes before the fall. The "Incident and Accident Investigation Form" (IAIF) for the fall on 12/29/13 revealed, "At 9:00 P.M., Resident was observed laying on floor in (room) on left side; wheelchair was behind her and bleeding was noted on garment and blood was noted on the floor. Skin tear was observed to the R (right) FA (forearm) and Resident c/o (complained of) pain in R lower extremity. Resident sent to (hospital) approximately 9:15 P.M. Resident self-transferred from bed to wheelchair before 9:00 P.M., Resident then propelled self in wheelchair to bathroom and self transferred from wheelchair to toilet. Resident urinated in toilet then transferred back into wheelchair." The IAIF further indicated that the "Resident has poor short term memory and impaired decision making skills. Resident is unaware of safety needs." Resident #207's room mate and caregivers on 12/29/13 provided signed statements to account for Resident #207's fall on this date. Resident #207's roommate's signed statement, in regards to the Resident's fall on 12/29/13, was reviewed and revealed, "(Resident #207) got up and went to the bathroom. I put my call light on. (Resident #207's) CNA came in here and (Resident #207) told her to get out. I told CNA to go get the nurse. (Resident #207) got off the toilet without being helped. (Resident #207) rolled out of there (the bathroom) in her wheelchair. I pressed the call light three times for (Resident #207)'s aide. (Resident #207) then rolled her wheelchair over by the nightstand and stood up and took a few steps forward and then fell backwards." Nurse "K", a nurse who provided care to Resident #207 on 12/29/13, signed statement, regarding the Resident's fall, was reviewed and revealed, "At 6:30 P.M., while in the hallway, I observed Resident with her legs over the side of the bed. Asked Resident if wanted to go into her wheelchair, but Resident stated, "No, I'm tired." CNA "I", a CNA who provided care to Resident #207 on 12/29/13, signed statement, regarding the Resident's fall, was reviewed and revealed, "During dinner time, Resident was observed trying to get up out of bed. (Resident #207)'s legs were dangling over the side of the bed. I went into her room and put her legs in bed and assisted her to sit up in bed so she could eat. At 8:30 P.M., I went into (Resident #207's) room and I seen (the Resident) standing up by her bed, pushing the wheelchair from the front of the wheelchair. I immediately assisted her into the wheelchair and took her to the toilet and got her back into bed." CNA "J", a CNA who provided care to Resident #207 on 12/29/13, signed statement, regarding the Resident's fall on 12/29/13, was reviewed and revealed, "CNA was asked what she did when she observed the Resident trying to pick things up from the floor. CNA stated, "I told her (Resident #207) not to do that because she could fall. I helped her lay down by putting her feet in bed and assisting her to lay down." Resident #207's hospital records indicated "right hip pain s/p (status [REDACTED]. Further review of Resident #207's I/A's revealed falls without injuries on the following dates as well: - On 4/1/14 at 4:45 P.M., the Resident fell in the room while unsupervised; the I/A report noted "Intervention Implemented: Resident will be moved to common areas when not in bed." - On 4/14/14 at 4:00 P.M., the Resident fell in the room while unsupervised; the section of the I/A report "Intervention Implemented" was left blank; On 4/17/14 at 2:40 P.M., the Unit Two Nurse Manager and the facility's Director of Nursing (DON) were interviewed in regards to Resident #207's fall which resulted in a right hip fracture on 12/29/13. The Unit Two Nurse Manager was queried as to how often a Resident with a known history of falls would need to be checked on when in their rooms unsupervised. The Unit Two Nurse Manager stated, "There is no specific time period to check on (Resident #207). It would be like we'd have to be in (Resident #207)'s room checking on her every 20 minutes and that's just not possible. Normally we'd call the doctor or administer a PRN medication (to calm the Resident). The DON added, "Our first approach was to keep (Resident #207) in a common area, but found (Resident #207) was more content when alone." The DON provided no explanation for why Resident #207 was continually left in the room alone, despite the numerous falls the resident sustained [REDACTED]. The DON when queried as to if the doctor was notified of the Residents' persistent agitation on 12/29/13, indicated that the doctor was not called because this restless behavior was baseline (normal) behavior for the Resident. On 4/18/14 at 3:00 P.M., the facility's policy entitled, "Fall Management", dated 5/2010, was reviewed and revealed, "Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize 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 DON/designees is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation and monitoring of resident falls. A review of the "Fall Management" policy and practice guidelines dated 5/2010 note that "fall" refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggestion otherwise, when a resident is found on the floor, a fall is considered to have occurred. If a resident rolled off a bed or mattress that was close to the floor, this is considered a fall. ( ) Deficient Practice Statement #3: Based on observation, interview and record review, the facility failed to ensure that staff assisted transfers to the wheelchair were performed by qualified personnel, and that an injury assessment was performed by a licensed nurse prior to moving a resident after a fall, for one (#214) of 12 residents reviewed for falls out of a total sample of 20, resulting in a fall and in the potential for exacerbation of unassessed injuries. Findings include: On 4/17/14 at 12:20 P.M., Resident #214 was interviewed. The resident had a indwelling urinary catheter (tube to drain urine inserted into the bladder) and was sitting in a high back wheelchair. The resident responded to simple questions. On 4/18/14 at 10:45 A.M., Resident #214's facility Incident and Accident Reports (I&A) and clinical records were reviewed and revealed the following: A face sheet documented that Resident #214 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set assessment ((MDS) dated [DATE] documented that Resident #214 had moderately impaired cognition, needed extensive physical assistance of two staff for transfers to and from the wheelchair, did not walk, had impaired balance, was incontinent of bowel, and needed extensive staff assistance for dressing, toileting and hygiene. A prior MDS, dated [DATE], documented that Resident #214 had moderately impaired cognition, needed extensive physical assistance of one staff for transfers to and from the wheelchair, walked with extensive physical assistance from one staff, had impaired balance, was incontinent of bowel, and needed extensive staff assistance for dressing, toileting and hygiene. A Physical Therapy (PT) Discharge Summary , dated 4/26/13 documented that Resident# 214's assessed needs on discharge were, "wheelchair (w/c) management: supervised", and " 24 hour supervision and assistance for transfers and bed mobility." An I&A dated 5/30/13, documented that Resident #214 fell during a transfer into the w/c from bed, while assisted by an Activities Aide. The I&A documented, "Activity Aide attempt to assist Resident into w/c from bed. Patient fell to the floor. No injury. Maintenance Director assisted patient into w/c, Nurse was not notified." The I&A post fall interventions were documented as, "Non-nursing staff is to notify Certified Nursing Assistant (CNA) or Nurse for assistance. No one is to assist patient up until nurse is present." The attached I&A "Post Fall Evaluation", dated 5/30/13, documented contributing factors as, "mental status prior to fall: alert with some confusion." The root cause ("Fall Huddle") was documented as, "Call light (nurse call) was on and request (ed) to get out of bed, and agreed to remain in bed because (resident) was just put down (put in bed). Activity Aide then came into room to assist resident to (a) party, and incident occurred." The intervention to prevent future falls was documented as, "Only Nursing Staff is to assist residents with transfers." On 4/18/14 at 11:55 A.M., Resident #214's clinical records and I&A were reviewed with the Director of Nursing (DON). When queried, the DON reported that Resident #214 was at risk for falls, with poor balance, antiseizure medications and intermittent confusion. The DON stated, "(Resident #214)'s been at least a one person assist for transfer as long as I can remember. He has mild confusion, and his amount of confusion tends to come and go. Activity Aides are not supposed to transfer people. That Activity Aide (involved in Resident #214's fall) quit three days after the incident. The Activity Aide should have rang the call light for the nurse. A Nurse should always assess the resident for possible injuries before the resident is moved. The Maintenance Director should never have moved (Resident #214) before the Nurse assessed him." When asked if the Maintenance Director was allowed to pick residents up or to do resident transfers, the DON stated, "No. The Maintenance Director isn't really supposed to be transferring residents." When queried, the DON reported that the Maintenance Director concerned was no longer employed by the facility. The DON reported that all facility staff attended a fall prevention inservice (continuing education) given by the Inservice Director. At this time, staff sign in sheets (attendance) and class outline for an inservice entitled, "Fall Prevention", presented on 4/11/13, were reviewed with the DON and revealed that the concerned Activity Aide and Maintenance Director both attended. Review of the inservice outline revealed that there were no instructions to inform non nursing staff not to transfer residents. When asked if the Activity Aide and the Maintenance Director were trained on transferring residents, the DON stated, "No, they wouldn't be." When asked what was done after the incident to ensure that all facility non-nursing staff were aware that non nursing staff were not to transfer residents, and that a nurse must assess a resident for injuries post fall before the resident is transferred back to w/c or bed, the DON stated, "I don't believe we did any inservices. I remember the Maintenance Director signing something after a one to one counseling, but I couldn't find anything in his file to show it (was done)." At this time, the DON was requested to provide any documentation of facility measures to ensure that all non nursing staff were aware they were not to transfer residents. No further documentation of this was provided prior to survey exit. On 4/18/14 at 12:15 P.M., The DON was requested to provide facility policies on transfers of residents and the job description for Activity Aides. The following two documents were provided at 4:00 P.M., a printed copy of an online (internet) nursing journal (Lippencott Procedures- Transfer from bed to Wheelchair, http://procedures.lww.com, 4/18/14), and an undated facility Personnel policy entitled, "Activity Aide Job Description". The "Activity Aide" job description did not indicate that Activity Aides did not transfer residents, and documented the job requirements as, "certificates, licenses, registrations: none." The DON stated, "That's all we have." On 4/18/14 at 3:00 P.M., the facility's policy entitled, "Fall Management", dated 5/2010, was reviewed and revealed, "Practice guidelines: 3. when a fall occurs, the licensed nurse will assess the resident for injury. Do not move the individual until he/she has been examined by a nurse." There were no instructions regarding transfers of residents by non-nursing personnel. ( ) Deficient Practice Statement #4 Based on observation and interview the facility failed to secure three hazardous chemicals in one of two unlocked toilet rooms, for one Resident (Supplemental Sampled Resident #48) resulting in the potential for bodily injury. Findings include: On 4/16/14 at 9:40 A.M., during a general tour of the environment, Supplemental Sampled Resident #48 was observed ambulating unassisted from the toilet room located inside of the Unit #2 shower room. The door to the Unit #2 shower room was secured with a key pad entry (correct code must be entered on the pad to gain entry); however, no lock was observed on the toilet room door, nor was there a lock observed on the storage cabinet located inside the toilet room. In the toilet room, the following chemicals were observed in the storage cabinet located beneath the sink: - A 32 ounce (oz.) size spray bottle labeled "Germicidal Cleaner with Bleach"; nozzle on container noted in the "on" position; - A 32 oz. size spray bottle labeled "Pro (professional) Quaternary 1:128 Solution Health Care Germicidal"; nozzle on container noted in the "on" position; - A 32 oz. size spray bottle labeled "Super odor neutralizer"; nozzle on container noted in the "on" position. On 4/16/14 at 10:00 A.M., the Unit Two Nurse Manager was interviewed in regards to the unlocked chemicals located in the toilet room and queried as to why Supplemental Sampled Resident #48 was using the restroom unsupervised. The Unit Two Nurse Manager stated, "Really a Resident should never be in here (the toilet room). This is for employees only. (Supplemental Sampled Resident #48) is very confused. She wanders." The Unit Two Nurse Manager provided no explanation for how Supplemental Sampled Resident #48 gained entry into the shower room bypassing the code lock on the main door. On 4/16/14 at 12:15 P.M., the Material Safety Data Sheets (MSDS) were reviewed for the chemicals observed in the toilet room. The MSDS for the Germicidal Cleaner with Bleach revealed, "Exposure to vapor or mist may irritate eyes, nose, throat, and lungs. Harmful if swallowed. May cause nausea and vomiting if swallowed. The following medical conditions may be aggravated by exposure to high concentrations of vapor or mist: heart conditions or chronic respiratory problems." The MSDS for the Pro (professional) Quaternary 1:128 Solution Health Care Germicidal revealed, "Danger: Corrosive. Causes Irreversible eye damage and skin burns. May be fatal if absorbed through skin. Harmful if swallowed. May effect breathing." The MSDS for the Super odor neutralizer revealed, "Intentional inhalation of vapors from product may cause central nervous system effects and irritation of the throat and lungs with coughing. Eye irritant." On 4/16/14 at 2:10 P.M., the facility's Administrator was interviewed in regards to the Unit Two toilet room being accessible to a confused Resident who ambulated throughout the facility unassisted. The Administrator stated, "We just put those credenzas (storage cabinets) in and I guess we forgot to screw them shut so no one could put anything (i.e. hazardous chemicals) in there." On 4/17/14 at 1:00 P.M., Supplemental Sampled Resident #48's clinical record was reviewed. The Resident's face sheet revealed the Resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent Minimum Data Set Assessment ((MDS) dated [DATE] revealed the Resident was continent of bowel and bladder, usually understands, misses some part/intent of messages and comprehends most conversations. The MDS further indicated that the Resident suffered from fluctuating inattention and had a short and long term memory problem. The facility's policy on chemical storage was requested; however the policy received addressed chemical storage in food areas and did not address preventing Resident access to chemicals or address securing of chemicals in restroom areas. ( )

Based on interview and record review, the facility failed to safely assist a residents with dressing for one sampled resident (#503) out of three residents reviewed for dressing assistance from a total sample of three, resulting in a right arm fracture. Findings include: On 10/28/13 thru 10/29/13, an unannounced abbreviated survey was conducted. It was alleged that resident #503's arm was broken by a staff member while trying to dress the resident. During an interview with the residents wife conducted on 10/28/13 at 10:00 a.m., she said the resident no longer wanted to return to the facility and alternate placement was found. On 10/29/13 at 8:55 a.m., record review revealed that resident #503 was admitted into the facility on [DATE] and readmitted most recently on 7/8/13. Resident #503 was discharge from the facility on 10/8/13, and no longer resides at the facility. The resident's [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set Assessment ((MDS) dated [DATE], the resident was cognitively intact and required total assistance with one person physical assist for dressing, eating and personal hygiene. On 10/29/13 at 9:00 a.m., a review of the care plans revealed two of the following care plans; an Activities of Daily Living (ADL) care plan dated 4/7/13, that documented, "(Resident name) requires total assistance with all ADL's related to quadriplegia..He directs his own care. He does have some movement to his right arm...". Documented intervention included; "Allow to express feelings of frustration and inadequacy. Anticipate and provide for all needs....", and a care plan dated 7/8/13 which documented "resident establishes his own goals with having an individual way of living at the facility with attending dialysis 3x/week and setting his own pace with activity participation...". On 10/29/13 at 9:45 a.m., record review revealed that resident #503 attended dialysis on Tuesday, Thursday and Saturday's. On 10 /29/13 at 10:30 a.m., an interview was conducted via the phone with CNA "A" who stated that on 10/8/13 at 4:15 a.m., she was dressing resident #503 for dialysis. CNA "A" said she put resident #503's contracted left arm into the left sleeve of the shirt. She then proceed to thread the resident's contracted right arm through the right sleeve of the shirt when the arm became "stuck at the elbow". CNA "A" stated, "He told me I was too small to get him dressed, and to go get some help. I looked for someone and I couldn't find no one. I went back into the room, and he told me to 'pull' on his arm (to get it unstuck). I pulled it and I accidently broke it". On 10/29/13 at 10:45 a.m., Staff nurse "B" was queried regarding the incident with resident #503. Nurse "B" said that CNA "A" came and got me. She stated the resident was saying that she pulled his "arm out of socket". "I examined his arm and shoulder nothing seemed out of place". Nurse "B" was asked if she was able to perform Range of Motion (ROM) and she stated, "you can barley move his arms on any occasion". Nurse "B" was asked if she assessed the resident's pain and stated, "he did say he had pain, but he always has pain". On 10/29/13 at 11:25 a.m., review of the facility's "Incident and Accident Report" and the nurses notes dated 10/8/13, resident #503 was being dressed by CNA "A" and "patient claims CNA 'pulled his arm out of the socket'. ("Nurse B") examined patients arm and shoulder and could not feel like it had a brake. Two CNA's completed dressing him. Small pillow under right arm to support it-patient to dialysis." A nurses note dated 10/8/13 at 12:45 p.m. documented, "Spoke with nurse at dialysis center, stated resident complained of pain to right shoulder, nurse at center sent resident to (name of hospital) emergency room to have an x-ray". An x-ray report dated 10/8/13 documented, "Findings: Complete fracture noted through the proximal right humeral (upper arm bone) metaphysis. There is mild comminution of the fracture with tiny fracture fragments seen displaced from the main fracture. The humeral shaft is displaced inferiorly and medially. No evidence of dislocation at the shoulder joint. Impression: Displaced proximal humeral fracture". On 10/29/13 at 1:00 p.m., an attempt was made to contact resident #503 for an interview. Per the Director of Nursing at the new facility, "He was discharged to the hospital the morning". On 10/29/13 at 2:30 p.m., the Director of Nursing (DON) was interviewed regarding the incident with resident #503. The DON said that she investigated the incident by interviewing involved staff. The DON said that during the investigation it was determined that the resident "told" the CNA to pull on his arm to get it unstuck, and that the resident "directed his own care". She stated that when CNA "A" was interviewed she said "I guess I pulled his arm too hard". The DON was asked what was the facility's policy when a resident is totally dependant on staff for all activities of daily living, are vulnerable and are at risk for injury including fractures, and she said "I would hope they (the staff) would be cautious with everyone. I think she made the decision she made at the time and obviously we know she pulled too hard. But the resident knows his own body and said pull the arm. The DON said training has been provided on the following; never pulling on a resident's extremity, never take a resident past the range of motion within his/her capability, always get another person to assist you with dressing if you feel like the resident's safety would be compromised, use slow gentle stretching ans support the limb at the bony prominences when dressing, be aware of your resident's extremity limits, if uncertain, always ask for assistance, and consider selecting a different article of clothing that may be easier to don/doff (ie: button down shirts). When asked about the resident telling the CNA that she was "too small" and "get some help", the DON had no response. On 10/29/13 at 3:00 p.m., review of the facility policy "Dressing and Grooming Education", Revised 7/8/09 documented; "Putting on a Shirt...using the strong hand, first place the weak hand in the arm hole and pull the sleeve up the weak arm. Throw the rest of the garment behind the body and pull the sleeve on the weak arm all the way up. Reach behind with the strong hand and place it in the armhole. Work the sleeve into position". ( )

REFER TO INTAKE #MI 359 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE PRESSURE WOUND CARE FOR ONE (#104) OF 4 SAMPLED RESIDENTS ALL REVIEWED FOR PRESSURE ULCER DEVELOPMENT FROM A TOTAL SAMPLE OF 4, WHEN ORDERS FOR RESIDENT #104'S WOUND TREATMENTS WERE NOT TRANSCRIBED ON THE TREATMENT ADMINISTRATION RECORD (TAR) AND NOT PROVIDED, RESULTING IN DELAYED HEALING AND POSSIBLE COMPLICATIONS AND WOUND INFECTION. FINDINGS INCLUDE: RESIDENT #104 WAS admitted to the facility on [DATE]. SHE WAS admitted TO HOSPICE ON 12/18/12, DUE TO DEVELOPMENT OF GANGRENE AFFECTING MULTIPLE TOES,[MEDICAL CONDITION], AND CONFUSION IN ADDITION TO OTHER DIAGNOSES. THE MINIMUM DATA SET (MDS) assessment dated [DATE] DESCRIBED RESIDENT #104 AS BEING TOTALLY DEPENDENT ON STAFF FOR ACTIVITIES OF DAILY LIVING (ALDS) SUCH AS BED MOBILITY, TRANSFERS, TOILET USE AND PERSONAL HYGIENE. RESIDENT #104 REQUIRED ONE PERSON PHYSICAL ASSIST FOR ALL ADLS. DURING A WOUND OBSERVATION ON 2/14/13 AT 2:40 PM, RESIDENT #104 WAS OBSERVED TO HAVE A SACRAL WOUND (STAGE 3) THAT MEASURED 1.4 CM X 2.0 CM X 0.2 CM (LXWXD); A RIGHT LATERAL KNEE WOUND (STAGE 3) THAT MEASURED 1.0 CM X 1.0 CM X 0.00 CM; AND A RIGHT MEDIAL KNEE WOUND (STAGE WAS UNDETERMINED) THAT MEASURED 2.8 CM X 2.5 CM X 0.4 CM. RESIDENT #104 HAD MULTIPLE GANGRENOUS AREAS ON BOTH FEET (INCLUDING TOES AND HEEL AREA). DURING RECORD REVIEW ON 2/14/13, A WOUND CONSULT DATED 2/5/13, DESCRIBED: RIGHT LATERAL KNEE WOUND AS A SCAB (NO MEASUREMENT); SACRAL WOUND (STAGE 3) THAT MEASURED 1.0 CM X 0.8 CM X 0.3 CM; AND A RIGHT MEDIAL KNEE WOUND (UNABLE TO DETERMINE STAGE) THAT MEASURED 1.5 X 1.5 CM. THE TREATMENT ADMINISTRATION RECORD (TAR) DATED FEBRUARY 2013, SHOWED NO EVIDENCE THAT THE SACRAL WOUND (STAGE 3) AND RIGHT MEDIAL KNEE WOUND RECEIVED OR STARTED ANY WOUND TREATMENT ON 2/5/13. THERE WERE NO TREATMENT SPECIFICS FOR THE STAGE 3 SACRAL WOUND, NOR an order for [REDACTED]. NO PHYSICIAN'S ORDER WAS ENTERED ON THE TAR FOR RIGHT MEDIAL KNEE (FROM 2/1/13 TO 2/12/13). THE SACRAL WOUND (STAGE 3) DID NOT HAVE A TREATMENT ENTERED IN THE FEBRUARY 2013 TAR. A NEW ENTRY treatment for [REDACTED]. THE WOUND NURSE, LICENSED PRACTICAL NURSE (LPN) #3 DURING INTERVIEW ON 2/14/13 AT 2:40 PM COULD NOT PROVIDE AN EXPLANATION AS TO WHY THE TREATMENT RECOMMENDED BY THE WOUND CONSULTANT WAS NOT FOLLOWED AND WHY THE CONSULTANT'S RECOMMENDED ORDER WAS NOT ENTERED FOR RIGHT MEDIAL KNEE WOUND UNTIL 2/13/13. LPN #3 COULD NOT ANSWER IF THE RIGHT MEDIAL KNEE AND SACRAL WOUND TREATMENT WAS DONE PER THE WOUND CONSULT RECOMMENDATION BECAUSE THERE WAS NO TREATMENT ORDER FROM THE DOCTOR AND THERE WAS NO TREATMENT ENTERED IN THE TAR ON 2/5/13, FOR EITHER WOUND. LPN #3 STATED THAT DAILY WOUND TREATMENTS WERE THE RESPONSIBILITY OF THE NURSE ON DUTY AND THAT SHE (#3) DID NOT DO THE DAILY WOUND TREATMENTS. LPN #3 VALIDATED THAT SHE STARTED THE TREATMENT ENTRY ON 2/13/13, FOR BOTH THE SACRAL WOUND AND FOR THE RIGHT LATERAL AND MEDIAL KNEE WOUND AREA ON 2/13/13. REVIEW OF WOUND CARE RECORDS REVEALED THE FOLLOWING MEASUREMENTS FOR THE WOUND ON RESIDENT #104'S RIGHT MEDIAL KNEE AS ON 2/5/13, 1.5 CM X 1.5 CM X 0.0 CM; ON 2/12/12, 2.0 CM X 2.0 CM X 0.0 CM; AND, ON 2/14/13, 2.8 CM X 2.5 CM X 0.4 CM. REVIEW OF WOUND CARE RECORDS REVEALED THE FOLLOWING MEASUREMENTS FOR THE WOUND ON RESIDENT #104'S SACRAL AREA AS ON 1/29/13, 1.0 CM X 0.8 CM X 0.3 CM; AND, ON 2/12/13, 1.0 CM X 1.0 CM X 0.3 CM. A HAND WRITTEN (PRELIMINARY) WOUND CONSULT NOTES DATED 1/29/13, INDICATED A NEW TREATMENT ORDER FOR BOTH THE SACRAL WOUND AND THE RIGHT LATERAL KNEE WOUND AS [MEDICATION NAME] CREAM WITH [MEDICATION NAME] DRESSING, BUT THERE WAS NO TREATMENT ORDER ENTERED FOR [MEDICATION NAME] AND [MEDICATION NAME] DRESSING FOR SACRAL WOUND AND FOR RIGHT LATERAL KNEE ENTERED ON THE FEBRUARY 2013 TAR. IN WOUND CONSULT NOTES DATED 2/5/13, THE WOUND CONSULTANT NOTED RESIDENT #104'S RIGHT MEDIAL KNEE WOUND AND RECOMMENDED [MEDICATION NAME] CREAM WITH [MEDICATION NAME] DRESSING, THE SAME TREATMENT AS THE SACRAL WOUND AND THE RIGHT LATERAL KNEE SCAB. HOWEVER, THERE WAS NO NEW ENTRY FOR THE treatment for [REDACTED]. THE WOUND CONSULT WRITTEN NOTES ON 2/5/13, INDICATED TO CONTINUE treatment of [REDACTED]. THERE WAS NO EVIDENCE THAT THIS TREATMENT WAS ENTERED IN THE TAR FOR THE MONTH OF FEBRUARY 2013. A NEW WOUND TREATMENT WAS ORDERED FOR THE RIGHT LATERAL AND RIGHT MEDIAL KNEE WOUNDS ON 2/12/13, USING [MEDICATION NAME] AG THEN COVER WITH [MEDICATION NAME] DRESSING Q 2 DAYS AND PRN (AS NEEDED). THE FEBRUARY TAR SHOWED THAT treatment for [REDACTED]. WOUND CONSULT EVALUATION/PROGRESS NOTES DATED 1/29/13, 2/5/13 AND 2/12/13, WERE REVIEWED. TREATMENT ORDERS WERE COMPARED TO THE HAND WRITTEN TREATMENT ORDERS GIVEN BY THE WOUND CONSULTANT TO THE LPN #3 EVERY TUESDAY. WOUND CONSULT EVALUATION/PROGRESS NOTES DATED 1/29/13, SPECIFIED ASSESSMENT AND PLAN: #3.) RIGHT LATERAL KNEE (STAGE 3) ULCERATION AND RIGHT MEDIAL KNEE (STAGE 3) ULCERATION. WE WILL APPLY [MEDICATION NAME] AND COVER WITH [MEDICATION NAME]. #4.) SACRAL STAGE 3 ULCERATION. WE WILL APPLY [MEDICATION NAME] AND COVER WITH [MEDICATION NAME]. WOUND CONSULT EVALUATION/PROGRESS NOTES DATED 2/5/13, INDICATED IN THE ASSESSMENT AND PLAN: RIGHT MEDIAL KNEE (UTD) WE WILL START WITH [MEDICATION NAME] AG AT THIS TIME. CONTINUE TO KEEP THE AREA PADDED WITH [MEDICATION NAME]. SACRAL STAGE 3 ULCERATION. CONTINUE WITH [MEDICATION NAME] AND [MEDICATION NAME]. A TELEPHONE INTERVIEW WITH THE DIRECTOR OF NURSING (DON) WAS CONDUCTED ON 2/19/13 AT 3:30 PM. SHE AGREED THAT THE RECOMMENDED TREATMENT ORDERS FOR THE SACRAL WOUND AND THE RIGHT LATERAL AND MEDIAL KNEE DATED 1/29/13, WERE NOT TRANSCRIBED AND ENTERED ON THE TAR BY THE TREATMENT NURSE. THUS THE TREATMENT ORDERS FOR RIGHT LATERAL AND MEDIAL KNEE AND THE SACRAL WOUND DATED 1/29/13 AND 2/5/13 WAS NOT TRANSCRIBED AND THEREFORE TREATMENT WAS NOT ADMINISTERED. A TELEPHONE INTERVIEW WITH THE WOUND CONSULTANT #4 WAS CONDUCTED ON 2/19/13 AT 2:10 PM. THE WOUND CONSULTANT STATED THAT HE VISITS THE FACILITY EVERY WEEKLY ON TUESDAYS AND LEAVES A WRITTEN PRELIMINARY WOUND EVALUATION FOR THE WOUND NURSE, INDICATING WOUND MEASUREMENTS AND TREATMENT ORDERS. IN A WEEK OR SO A COMPLETED (DICTATED) EVALUATION FOR EACH OF THE VISITS IS FAXED TO THE FACILITY FOR THE RECORD. THE TREATMENT NURSE TRANSCRIBES THE ORDERS AND MAKE SURE TREATMENTS ARE DONE FOR EACH SPECIFIC WOUND. THE TAR DATED FEBRUARY 2013 SHOWED NO EVIDENCE THAT RESIDENT #104 RECEIVED THE APPROPRIATE TREATMENT AS RECOMMENDED BY THE WOUND CONSULTANT FOR RESIDENT #104'S WOUNDS FROM 2/1/13 THROUGH 2/12/13. ( )